The first rule about infantile hemangiomas: Make sure they’re actually infantile hemangiomas, a pediatric dermatologist urged colleagues. Then watch patients closely, refer to specialists when appropriate, and consider propranolol in complicated or high-risk cases, Andrea L. Zaenglein, MD, said at MedscapeLive’s Women’s & Pediatric Dermatology Seminar.

“In my career as a pediatric dermatologist, propranolol has been a life changer for us more than any other medicine,” said Dr. Zaenglein, professor of dermatology and pediatric dermatology, Penn State University, Hershey.

Before the point where propranolol is prescribed, confirm the diagnosis and use the correct terminology, she advised. It’s still appropriate to use the International Society for the Study of Vascular Anomalies (ISSVA) vascular lesion classification system released in 1982. “For most people, it serves the purpose well,” she said. Another option is an updated and more complex classification system from 2015.

Dr. Zaenglein highlighted two studies – one published in 2011 and the other published in 2020 – that revealed high levels of misclassification of vascular malformations in research reports. The earlier study found that 21% of patients with misclassified lesions were mistreated, compared with none of those who were classified using ISSVA terminology.

“I cannot stress [proper classification] enough when you’re dealing with babies and children with vascular lesions. If not sure, be vague. Say ‘a vascular tumor’ or a ‘vascular malformation.’ But only reserve ‘infantile hemangioma’ for that very diagnosis,” she said.

As Dr. Zaenglein noted, infantile hemangiomas affect 5%-10% of 1-year-olds, of whom 20% have multiple lesions. They’re more common in females by a 3-to-1 margin, and also seen more in premature infants, and in cases of multiple births, higher maternal age, and low birth weight.

The pathogenesis of these lesions is unclear, she said, although there are hints about genetic components and tissue hypoxia, among other possible causes. “Importantly, you get 80% of the growth by 3-4 months of age. Then it’ll slow in its growth and kind of slowly go away over time, but it’s not linear regression. It’s more that you get more improvement up front, usually until about 5, and then you can get some continued gradual evolution up until about 7 or 10 years of age.”

Complications can include ulceration, infection and – in rare cases – hemorrhage and high-output cardiac failure, she said. “Knowing which ones are at high risk for complications is important, and also there are systemic associations that we have to be mindful of. We also want to think about aesthetic outcomes as well when we talk about management of infantile hemangiomas.”

High-risk infantile hemangiomas include those with the following features:

• Extensive facial involvement. Dr. Zaenglein highlighted a case of a 2-year-old baby with a large, bulky hemangioma that distorted facial features around the eye. “This would be a medical emergency” requiring immediate evaluation and treatment, she said.
• Periocular involvement. Refer to ophthalmology, she recommended. “Even smaller hemangiomas can cause refractive errors or amblyopia, and oftentimes need to be treated with either systemic or topical therapy depending on the size and extent,” she said.
• PHACE syndrome (Posterior fossa malformations, hemangiomas, arterial anomalies, coarctation of the aorta and cardiac defects, eye abnormalities). “Propranolol has been safely used in PHACE, but every patient is different,” she said. “You need to make sure to do a good risk assessment before starting because if they have narrowed blood flow or limited blood flow, there is a question of whether there is potential risk for stroke if you drop a baby’s blood pressure. Make sure that the vasculature is evaluated before started on propranolol. Also, there are recent reports of risk of long-term risk of stroke with PHACE syndrome as patients are getting into their adulthood.”
• Beard distribution. Be aware of possible airway involvement that can be revealed by biphasic stridor. In those cases, immediate treatment – perhaps even with tracheostomy – is needed to avoid mortality, she said.
• Multiple sites: Patients with five or more hemangiomas may have liver involvement, she said, and should undergo hepatic evaluation. Consider evaluating if this is suspected, even if the number of hemangiomas is under five, she said.
• Perineal/lumbosacral involvement: A third of these cases are associated with spinal dysraphism. Refer to neurosurgery, she recommended.

Dr. Zaenglein highlighted a report on the use of propranolol published in 2008 and noted that clinical practice guidelines for managing infantile hemangiomas published in 2019 are also helpful.

Flat hemangiomas, meanwhile, can benefit from timolol maleate 0.5% solution or gel-forming solution – 1 drop twice daily or 2 drops once daily, she said. This treatment should be avoided in thick hemangiomas, she said.

MedscapeLive and this news organization are owned by the same parent company. Dr. Zaenglein disclosed consulting fees (Dermata, Cassiopea, and Regeneron), and fees for contracted research support (Incyte).

The first rule about infantile hemangiomas: Make sure they’re actually infantile hemangiomas, a pediatric dermatologist urged colleagues. Then watch patients closely, refer to specialists when appropriate, and consider propranolol in complicated or high-risk cases, Andrea L. Zaenglein, MD, said at MedscapeLive’s Women’s & Pediatric Dermatology Seminar.

“In my career as a pediatric dermatologist, propranolol has been a life changer for us more than any other medicine,” said Dr. Zaenglein, professor of dermatology and pediatric dermatology, Penn State University, Hershey.

Before the point where propranolol is prescribed, confirm the diagnosis and use the correct terminology, she advised. It’s still appropriate to use the International Society for the Study of Vascular Anomalies (ISSVA) vascular lesion classification system released in 1982. “For most people, it serves the purpose well,” she said. Another option is an updated and more complex classification system from 2015.

Dr. Zaenglein highlighted two studies – one published in 2011 and the other published in 2020 – that revealed high levels of misclassification of vascular malformations in research reports. The earlier study found that 21% of patients with misclassified lesions were mistreated, compared with none of those who were classified using ISSVA terminology.

“I cannot stress [proper classification] enough when you’re dealing with babies and children with vascular lesions. If not sure, be vague. Say ‘a vascular tumor’ or a ‘vascular malformation.’ But only reserve ‘infantile hemangioma’ for that very diagnosis,” she said.

As Dr. Zaenglein noted, infantile hemangiomas affect 5%-10% of 1-year-olds, of whom 20% have multiple lesions. They’re more common in females by a 3-to-1 margin, and also seen more in premature infants, and in cases of multiple births, higher maternal age, and low birth weight.

The pathogenesis of these lesions is unclear, she said, although there are hints about genetic components and tissue hypoxia, among other possible causes. “Importantly, you get 80% of the growth by 3-4 months of age. Then it’ll slow in its growth and kind of slowly go away over time, but it’s not linear regression. It’s more that you get more improvement up front, usually until about 5, and then you can get some continued gradual evolution up until about 7 or 10 years of age.”

Complications can include ulceration, infection and – in rare cases – hemorrhage and high-output cardiac failure, she said. “Knowing which ones are at high risk for complications is important, and also there are systemic associations that we have to be mindful of. We also want to think about aesthetic outcomes as well when we talk about management of infantile hemangiomas.”

High-risk infantile hemangiomas include those with the following features:

• Extensive facial involvement. Dr. Zaenglein highlighted a case of a 2-year-old baby with a large, bulky hemangioma that distorted facial features around the eye. “This would be a medical emergency” requiring immediate evaluation and treatment, she said.
• Periocular involvement. Refer to ophthalmology, she recommended. “Even smaller hemangiomas can cause refractive errors or amblyopia, and oftentimes need to be treated with either systemic or topical therapy depending on the size and extent,” she said.
• PHACE syndrome (Posterior fossa malformations, hemangiomas, arterial anomalies, coarctation of the aorta and cardiac defects, eye abnormalities). “Propranolol has been safely used in PHACE, but every patient is different,” she said. “You need to make sure to do a good risk assessment before starting because if they have narrowed blood flow or limited blood flow, there is a question of whether there is potential risk for stroke if you drop a baby’s blood pressure. Make sure that the vasculature is evaluated before started on propranolol. Also, there are recent reports of risk of long-term risk of stroke with PHACE syndrome as patients are getting into their adulthood.”
• Beard distribution. Be aware of possible airway involvement that can be revealed by biphasic stridor. In those cases, immediate treatment – perhaps even with tracheostomy – is needed to avoid mortality, she said.
• Multiple sites: Patients with five or more hemangiomas may have liver involvement, she said, and should undergo hepatic evaluation. Consider evaluating if this is suspected, even if the number of hemangiomas is under five, she said.
• Perineal/lumbosacral involvement: A third of these cases are associated with spinal dysraphism. Refer to neurosurgery, she recommended.

Dr. Zaenglein highlighted a report on the use of propranolol published in 2008 and noted that clinical practice guidelines for managing infantile hemangiomas published in 2019 are also helpful.

Flat hemangiomas, meanwhile, can benefit from timolol maleate 0.5% solution or gel-forming solution – 1 drop twice daily or 2 drops once daily, she said. This treatment should be avoided in thick hemangiomas, she said.

MedscapeLive and this news organization are owned by the same parent company. Dr. Zaenglein disclosed consulting fees (Dermata, Cassiopea, and Regeneron), and fees for contracted research support (Incyte).

The first rule about infantile hemangiomas: Make sure they’re actually infantile hemangiomas, a pediatric dermatologist urged colleagues. Then watch patients closely, refer to specialists when appropriate, and consider propranolol in complicated or high-risk cases, Andrea L. Zaenglein, MD, said at MedscapeLive’s Women’s & Pediatric Dermatology Seminar.

“In my career as a pediatric dermatologist, propranolol has been a life changer for us more than any other medicine,” said Dr. Zaenglein, professor of dermatology and pediatric dermatology, Penn State University, Hershey.

Before the point where propranolol is prescribed, confirm the diagnosis and use the correct terminology, she advised. It’s still appropriate to use the International Society for the Study of Vascular Anomalies (ISSVA) vascular lesion classification system released in 1982. “For most people, it serves the purpose well,” she said. Another option is an updated and more complex classification system from 2015.

Dr. Zaenglein highlighted two studies – one published in 2011 and the other published in 2020 – that revealed high levels of misclassification of vascular malformations in research reports. The earlier study found that 21% of patients with misclassified lesions were mistreated, compared with none of those who were classified using ISSVA terminology.

“I cannot stress [proper classification] enough when you’re dealing with babies and children with vascular lesions. If not sure, be vague. Say ‘a vascular tumor’ or a ‘vascular malformation.’ But only reserve ‘infantile hemangioma’ for that very diagnosis,” she said.

As Dr. Zaenglein noted, infantile hemangiomas affect 5%-10% of 1-year-olds, of whom 20% have multiple lesions. They’re more common in females by a 3-to-1 margin, and also seen more in premature infants, and in cases of multiple births, higher maternal age, and low birth weight.

The pathogenesis of these lesions is unclear, she said, although there are hints about genetic components and tissue hypoxia, among other possible causes. “Importantly, you get 80% of the growth by 3-4 months of age. Then it’ll slow in its growth and kind of slowly go away over time, but it’s not linear regression. It’s more that you get more improvement up front, usually until about 5, and then you can get some continued gradual evolution up until about 7 or 10 years of age.”

Complications can include ulceration, infection and – in rare cases – hemorrhage and high-output cardiac failure, she said. “Knowing which ones are at high risk for complications is important, and also there are systemic associations that we have to be mindful of. We also want to think about aesthetic outcomes as well when we talk about management of infantile hemangiomas.”

High-risk infantile hemangiomas include those with the following features:

• Extensive facial involvement. Dr. Zaenglein highlighted a case of a 2-year-old baby with a large, bulky hemangioma that distorted facial features around the eye. “This would be a medical emergency” requiring immediate evaluation and treatment, she said.
• Periocular involvement. Refer to ophthalmology, she recommended. “Even smaller hemangiomas can cause refractive errors or amblyopia, and oftentimes need to be treated with either systemic or topical therapy depending on the size and extent,” she said.
• PHACE syndrome (Posterior fossa malformations, hemangiomas, arterial anomalies, coarctation of the aorta and cardiac defects, eye abnormalities). “Propranolol has been safely used in PHACE, but every patient is different,” she said. “You need to make sure to do a good risk assessment before starting because if they have narrowed blood flow or limited blood flow, there is a question of whether there is potential risk for stroke if you drop a baby’s blood pressure. Make sure that the vasculature is evaluated before started on propranolol. Also, there are recent reports of risk of long-term risk of stroke with PHACE syndrome as patients are getting into their adulthood.”
• Beard distribution. Be aware of possible airway involvement that can be revealed by biphasic stridor. In those cases, immediate treatment – perhaps even with tracheostomy – is needed to avoid mortality, she said.
• Multiple sites: Patients with five or more hemangiomas may have liver involvement, she said, and should undergo hepatic evaluation. Consider evaluating if this is suspected, even if the number of hemangiomas is under five, she said.
• Perineal/lumbosacral involvement: A third of these cases are associated with spinal dysraphism. Refer to neurosurgery, she recommended.

Dr. Zaenglein highlighted a report on the use of propranolol published in 2008 and noted that clinical practice guidelines for managing infantile hemangiomas published in 2019 are also helpful.

Flat hemangiomas, meanwhile, can benefit from timolol maleate 0.5% solution or gel-forming solution – 1 drop twice daily or 2 drops once daily, she said. This treatment should be avoided in thick hemangiomas, she said.

MedscapeLive and this news organization are owned by the same parent company. Dr. Zaenglein disclosed consulting fees (Dermata, Cassiopea, and Regeneron), and fees for contracted research support (Incyte).

This spring may bring an unusual transition for families: a return to in-person school after nearly a year in a virtual classroom. This will undoubtedly come as a welcome relief to many parents worried about their children’s education and development and struggling with running school from home. But it is important for parents to remember that transitions, even happy ones, are difficult. You can help parents to anticipate what may be challenging about this transition for their children so that they are all prepared and can diminish struggles and support their children’s mastery.

Be curious about their children’s thoughts and feelings

Parents should adopt a truly curious and open-minded approach with their children. Remind parents that, while they are experts on their own children, they should not assume they know what their children are thinking or feeling about the return to school. Some children, especially ones struggling with learning problems or difficulty with peers, will have grown very comfortable being at home with parents or siblings. Some children, especially pre- and early teens, may have changed substantially in the year and might feel uncertain about returning to a prior team or group of friends. Some children may feel concerned about leaving a pet at home alone. Some children may be going to a new school and be anxious about facing such a big transition without the usual planning and supports. Those on a college track may be worried they are “behind” academically or in college preparation.

Parents can show up when and where their children are most likely to talk, perhaps bath time or bedtime for younger children or in the car together with their adolescents. They can ask: “Have you been thinking about what it might be like to go back to school? Have your friends been chatting about it?” They might be curious together about what might have changed in a year. What might be really great about being back in a classroom? What might they miss about home school? And what might be new? Are you worried about the work, any of your friends, or not being home? If children can begin to anticipate both the good and the difficult, they will be better equipped to face and manage the challenges and appreciate the delights.

Children in elementary school are built to master new situations but are also prone to anxiety about new expectations and demands. Parents can be calmly curious about what their thoughts, feelings, and questions are and look for answers together. Often all they need is to see parents being calm in the face of uncertainty, bearing the strong feelings that may come, and preserving curiosity and compassion. Adolescents may be grieving the things they have missed, or they may have concerns about relationships and practical matters such as the implications for applying to college. Parents can offer compassion and validation and help them to devise their own strategies to face the practical challenges they are concerned about.
 

Be mindful of their children’s vulnerabilities

While most children will find the transition back to school easier than they may anticipate, there will be some for whom the transition will be very challenging. Children who have been bullied at school may have found themselves able to concentrate and learn free of the fear and stress of a classmate’s taunts or stares. Children with learning disabilities or ADHD have probably struggled with online school, but they have also likely established strategies and supports during the year that have enabled them to get enough individualized help to get their work done. These children are vulnerable to falling behind and getting discouraged when these supports are lost, and possibly not replaced with new ones in the chaos of transition. Parents should reassure their children that they will work with the school to make sure that they can succeed in the classroom as they did at home.

Children with an inhibited or shy temperament might have found that it was easier to focus and listen in the comfortable setting of home than in a busy, stimulating classroom. Children who suffer from anxiety disorders that may make separating from parents or managing the performance and social demands of school extra difficult will find the return to school especially challenging. Some younger children may have experienced the emergence of an anxiety disorder during the past year, and the return to school may mark the challenge that brings heretofore quiet symptoms into full relief.

These children have all enjoyed being able to avoid the discomfort of certain anxiety-provoking situations, and they may be particularly stressed by anticipating a return to school. Younger children may begin to have stomach aches and other physical complaints as the return to school gets close, older children may seem more withdrawn or irritable or begin discussing ways to continue school from home. Parents should help their children try to identify and describe their worries. For anxious children, having a chance to practice may be very helpful. Visiting their school, especially if it is a new school, or having a planned hangout with a friend (with appropriate precautions) is the kind of exposure that can lessen anticipatory anxiety. If this is not enough, parents should not hesitate to bring in other caring, supportive adults, such as school counselors or therapists that may be essential to helping their children face and manage what may be intense anxiety.
 

Consider routines to support their transition

Just as parents begin to return their children to an earlier bedtime toward the end of summer, it will be helpful to consider how changing certain routines will support their children now. If children will need to get up earlier to be ready for a bus or a team practice, they should start moving bedtime and wake-up time earlier gradually. Uniforms or backpacks that have not been seen for a year should be dug out. Children who are planning a return to a sport may benefit from gradually increasing their exercise or starting training now. This will have the added benefit of improving sleep and energy and fortifying children for the challenges of change. Parents might consider reaching out to other parents in the same class as their children and having a virtual conversation to share their thoughts.

If their family has developed some new “COVID routines” that they have come to enjoy, they should find a way to preserve them. Perhaps they are having dinner together more often or have established a family game night or Netflix night. Help parents consider how to avoid falling back into overscheduling their children and themselves. If they created a time to Zoom with distant or vulnerable loved ones, they might decide to continue this. School may determine some of their routines, but they should also prioritize their family connections and well-being in deciding how to schedule their days.
 

Find opportunity for mastery and meaning

As parents are listening, validating, and planning with their children, they might use this time to reflect on valuable lessons. They might point out the value of patience: Adjusting to change takes time and happens in fits and starts. It has been 12 months since many of the pandemic changes started and it will take more than a few days to adjust as schools reopen. They might point out how proud they are of what their children have been able to learn, build, or do during this year, what they admire about them. It may be a time to consider what their family may have lost and gained during the past year, what they are eager to leave behind, and what they might like to keep. And it is also a chance for parents to observe that change is an inevitable part of life (especially when growing up). It is always challenging, and often brings loss and sadness. But if we pay attention, there are also the green shoots of what is new and possible.

Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].

This spring may bring an unusual transition for families: a return to in-person school after nearly a year in a virtual classroom. This will undoubtedly come as a welcome relief to many parents worried about their children’s education and development and struggling with running school from home. But it is important for parents to remember that transitions, even happy ones, are difficult. You can help parents to anticipate what may be challenging about this transition for their children so that they are all prepared and can diminish struggles and support their children’s mastery.

Be curious about their children’s thoughts and feelings

Parents should adopt a truly curious and open-minded approach with their children. Remind parents that, while they are experts on their own children, they should not assume they know what their children are thinking or feeling about the return to school. Some children, especially ones struggling with learning problems or difficulty with peers, will have grown very comfortable being at home with parents or siblings. Some children, especially pre- and early teens, may have changed substantially in the year and might feel uncertain about returning to a prior team or group of friends. Some children may feel concerned about leaving a pet at home alone. Some children may be going to a new school and be anxious about facing such a big transition without the usual planning and supports. Those on a college track may be worried they are “behind” academically or in college preparation.

Parents can show up when and where their children are most likely to talk, perhaps bath time or bedtime for younger children or in the car together with their adolescents. They can ask: “Have you been thinking about what it might be like to go back to school? Have your friends been chatting about it?” They might be curious together about what might have changed in a year. What might be really great about being back in a classroom? What might they miss about home school? And what might be new? Are you worried about the work, any of your friends, or not being home? If children can begin to anticipate both the good and the difficult, they will be better equipped to face and manage the challenges and appreciate the delights.

Children in elementary school are built to master new situations but are also prone to anxiety about new expectations and demands. Parents can be calmly curious about what their thoughts, feelings, and questions are and look for answers together. Often all they need is to see parents being calm in the face of uncertainty, bearing the strong feelings that may come, and preserving curiosity and compassion. Adolescents may be grieving the things they have missed, or they may have concerns about relationships and practical matters such as the implications for applying to college. Parents can offer compassion and validation and help them to devise their own strategies to face the practical challenges they are concerned about.
 

Be mindful of their children’s vulnerabilities

While most children will find the transition back to school easier than they may anticipate, there will be some for whom the transition will be very challenging. Children who have been bullied at school may have found themselves able to concentrate and learn free of the fear and stress of a classmate’s taunts or stares. Children with learning disabilities or ADHD have probably struggled with online school, but they have also likely established strategies and supports during the year that have enabled them to get enough individualized help to get their work done. These children are vulnerable to falling behind and getting discouraged when these supports are lost, and possibly not replaced with new ones in the chaos of transition. Parents should reassure their children that they will work with the school to make sure that they can succeed in the classroom as they did at home.

Children with an inhibited or shy temperament might have found that it was easier to focus and listen in the comfortable setting of home than in a busy, stimulating classroom. Children who suffer from anxiety disorders that may make separating from parents or managing the performance and social demands of school extra difficult will find the return to school especially challenging. Some younger children may have experienced the emergence of an anxiety disorder during the past year, and the return to school may mark the challenge that brings heretofore quiet symptoms into full relief.

These children have all enjoyed being able to avoid the discomfort of certain anxiety-provoking situations, and they may be particularly stressed by anticipating a return to school. Younger children may begin to have stomach aches and other physical complaints as the return to school gets close, older children may seem more withdrawn or irritable or begin discussing ways to continue school from home. Parents should help their children try to identify and describe their worries. For anxious children, having a chance to practice may be very helpful. Visiting their school, especially if it is a new school, or having a planned hangout with a friend (with appropriate precautions) is the kind of exposure that can lessen anticipatory anxiety. If this is not enough, parents should not hesitate to bring in other caring, supportive adults, such as school counselors or therapists that may be essential to helping their children face and manage what may be intense anxiety.
 

Consider routines to support their transition

Just as parents begin to return their children to an earlier bedtime toward the end of summer, it will be helpful to consider how changing certain routines will support their children now. If children will need to get up earlier to be ready for a bus or a team practice, they should start moving bedtime and wake-up time earlier gradually. Uniforms or backpacks that have not been seen for a year should be dug out. Children who are planning a return to a sport may benefit from gradually increasing their exercise or starting training now. This will have the added benefit of improving sleep and energy and fortifying children for the challenges of change. Parents might consider reaching out to other parents in the same class as their children and having a virtual conversation to share their thoughts.

If their family has developed some new “COVID routines” that they have come to enjoy, they should find a way to preserve them. Perhaps they are having dinner together more often or have established a family game night or Netflix night. Help parents consider how to avoid falling back into overscheduling their children and themselves. If they created a time to Zoom with distant or vulnerable loved ones, they might decide to continue this. School may determine some of their routines, but they should also prioritize their family connections and well-being in deciding how to schedule their days.
 

Find opportunity for mastery and meaning

As parents are listening, validating, and planning with their children, they might use this time to reflect on valuable lessons. They might point out the value of patience: Adjusting to change takes time and happens in fits and starts. It has been 12 months since many of the pandemic changes started and it will take more than a few days to adjust as schools reopen. They might point out how proud they are of what their children have been able to learn, build, or do during this year, what they admire about them. It may be a time to consider what their family may have lost and gained during the past year, what they are eager to leave behind, and what they might like to keep. And it is also a chance for parents to observe that change is an inevitable part of life (especially when growing up). It is always challenging, and often brings loss and sadness. But if we pay attention, there are also the green shoots of what is new and possible.

Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].

This spring may bring an unusual transition for families: a return to in-person school after nearly a year in a virtual classroom. This will undoubtedly come as a welcome relief to many parents worried about their children’s education and development and struggling with running school from home. But it is important for parents to remember that transitions, even happy ones, are difficult. You can help parents to anticipate what may be challenging about this transition for their children so that they are all prepared and can diminish struggles and support their children’s mastery.

Be curious about their children’s thoughts and feelings

Parents should adopt a truly curious and open-minded approach with their children. Remind parents that, while they are experts on their own children, they should not assume they know what their children are thinking or feeling about the return to school. Some children, especially ones struggling with learning problems or difficulty with peers, will have grown very comfortable being at home with parents or siblings. Some children, especially pre- and early teens, may have changed substantially in the year and might feel uncertain about returning to a prior team or group of friends. Some children may feel concerned about leaving a pet at home alone. Some children may be going to a new school and be anxious about facing such a big transition without the usual planning and supports. Those on a college track may be worried they are “behind” academically or in college preparation.

Parents can show up when and where their children are most likely to talk, perhaps bath time or bedtime for younger children or in the car together with their adolescents. They can ask: “Have you been thinking about what it might be like to go back to school? Have your friends been chatting about it?” They might be curious together about what might have changed in a year. What might be really great about being back in a classroom? What might they miss about home school? And what might be new? Are you worried about the work, any of your friends, or not being home? If children can begin to anticipate both the good and the difficult, they will be better equipped to face and manage the challenges and appreciate the delights.

Children in elementary school are built to master new situations but are also prone to anxiety about new expectations and demands. Parents can be calmly curious about what their thoughts, feelings, and questions are and look for answers together. Often all they need is to see parents being calm in the face of uncertainty, bearing the strong feelings that may come, and preserving curiosity and compassion. Adolescents may be grieving the things they have missed, or they may have concerns about relationships and practical matters such as the implications for applying to college. Parents can offer compassion and validation and help them to devise their own strategies to face the practical challenges they are concerned about.
 

Be mindful of their children’s vulnerabilities

While most children will find the transition back to school easier than they may anticipate, there will be some for whom the transition will be very challenging. Children who have been bullied at school may have found themselves able to concentrate and learn free of the fear and stress of a classmate’s taunts or stares. Children with learning disabilities or ADHD have probably struggled with online school, but they have also likely established strategies and supports during the year that have enabled them to get enough individualized help to get their work done. These children are vulnerable to falling behind and getting discouraged when these supports are lost, and possibly not replaced with new ones in the chaos of transition. Parents should reassure their children that they will work with the school to make sure that they can succeed in the classroom as they did at home.

Children with an inhibited or shy temperament might have found that it was easier to focus and listen in the comfortable setting of home than in a busy, stimulating classroom. Children who suffer from anxiety disorders that may make separating from parents or managing the performance and social demands of school extra difficult will find the return to school especially challenging. Some younger children may have experienced the emergence of an anxiety disorder during the past year, and the return to school may mark the challenge that brings heretofore quiet symptoms into full relief.

These children have all enjoyed being able to avoid the discomfort of certain anxiety-provoking situations, and they may be particularly stressed by anticipating a return to school. Younger children may begin to have stomach aches and other physical complaints as the return to school gets close, older children may seem more withdrawn or irritable or begin discussing ways to continue school from home. Parents should help their children try to identify and describe their worries. For anxious children, having a chance to practice may be very helpful. Visiting their school, especially if it is a new school, or having a planned hangout with a friend (with appropriate precautions) is the kind of exposure that can lessen anticipatory anxiety. If this is not enough, parents should not hesitate to bring in other caring, supportive adults, such as school counselors or therapists that may be essential to helping their children face and manage what may be intense anxiety.
 

Consider routines to support their transition

Just as parents begin to return their children to an earlier bedtime toward the end of summer, it will be helpful to consider how changing certain routines will support their children now. If children will need to get up earlier to be ready for a bus or a team practice, they should start moving bedtime and wake-up time earlier gradually. Uniforms or backpacks that have not been seen for a year should be dug out. Children who are planning a return to a sport may benefit from gradually increasing their exercise or starting training now. This will have the added benefit of improving sleep and energy and fortifying children for the challenges of change. Parents might consider reaching out to other parents in the same class as their children and having a virtual conversation to share their thoughts.

If their family has developed some new “COVID routines” that they have come to enjoy, they should find a way to preserve them. Perhaps they are having dinner together more often or have established a family game night or Netflix night. Help parents consider how to avoid falling back into overscheduling their children and themselves. If they created a time to Zoom with distant or vulnerable loved ones, they might decide to continue this. School may determine some of their routines, but they should also prioritize their family connections and well-being in deciding how to schedule their days.
 

Find opportunity for mastery and meaning

As parents are listening, validating, and planning with their children, they might use this time to reflect on valuable lessons. They might point out the value of patience: Adjusting to change takes time and happens in fits and starts. It has been 12 months since many of the pandemic changes started and it will take more than a few days to adjust as schools reopen. They might point out how proud they are of what their children have been able to learn, build, or do during this year, what they admire about them. It may be a time to consider what their family may have lost and gained during the past year, what they are eager to leave behind, and what they might like to keep. And it is also a chance for parents to observe that change is an inevitable part of life (especially when growing up). It is always challenging, and often brings loss and sadness. But if we pay attention, there are also the green shoots of what is new and possible.

Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].

A miniature camera the size of a capsule that is swallowed and then transmits images of the inside of the gut can reveal cancer and gastrointestinal diseases. The device, which will be studied in a trial conducted by the National Health Service in England, is used by patients at home as a substitute for endoscopy.

“What sounds like sci-fi is now becoming a reality,” said Sir Simon Stevens, chief executive of NHS England. “These minute cameras pass through your body. They take two pictures per second, checking for signs of cancer and other conditions like Crohn’s disease.”

The trial, announced on March 11, 2021, will initially involve 11,000 patients from 40 regions in England. Participants will be sent the colon capsule endoscopy to use at home.

The capsule typically takes 5-8 hours to pass through the digestive system. As the capsule passes through the bowel, images are sent to a data recorder in a shoulder bag.

The trial is being conducted by the University College London Hospitals NHS Foundation Trust. The investigators have created a guide on using the device at home.

“Not only does colon capsule increase our diagnostic capacity, because it doesn’t require the resources of a dedicated hospital space to do the examination, it also allows us to do the examination in the patient’s home, so patients who may be shielding or cautious about going to a hospital can perform the procedure in the comfort of their own homes,” commented Ed Seward, MD, PhD, endoscopy lead at UCL.

The move is in response to a surge in patients coming forward for cancer checks after the slowdown in cancer services caused by the COVID-19 pandemic. In December 2020, more than 200,000 people came forward, an increase of 13,000 over the same month the previous year.

Traditional endoscopy services are still being offered, although endoscopies take longer to conduct because of infection control measures that must be employed to ensure that patients who undergo endoscopies do not develop COVID-19. This, in turn, means fewer people can undergo endoscopies over a given period.

“We welcome any initiative that seeks to simplify and improve the early diagnosis of gastrointestinal disease and, in particular, colorectal cancer, which unfortunately is still responsible for many avoidable deaths,” said Alastair McKinlay, MD, president of the British Society of Gastroenterology.

“Colon capsule is a promising new technology that may offer a real advantage for some patients. For this reason, we welcome the opportunity for a proper service evaluation so that both the limitations and advantages of this technique can be properly assessed,” he said.

“This has the potential to make a huge difference for people with bowel cancer symptoms and could help the NHS to prioritize those who urgently need further tests,” added Genevieve Edwards, chief executive at Bowel Cancer UK.

No funding for the study has been disclosed. No relevant financial relationships have been disclosed.

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

A miniature camera the size of a capsule that is swallowed and then transmits images of the inside of the gut can reveal cancer and gastrointestinal diseases. The device, which will be studied in a trial conducted by the National Health Service in England, is used by patients at home as a substitute for endoscopy.

“What sounds like sci-fi is now becoming a reality,” said Sir Simon Stevens, chief executive of NHS England. “These minute cameras pass through your body. They take two pictures per second, checking for signs of cancer and other conditions like Crohn’s disease.”

The trial, announced on March 11, 2021, will initially involve 11,000 patients from 40 regions in England. Participants will be sent the colon capsule endoscopy to use at home.

The capsule typically takes 5-8 hours to pass through the digestive system. As the capsule passes through the bowel, images are sent to a data recorder in a shoulder bag.

The trial is being conducted by the University College London Hospitals NHS Foundation Trust. The investigators have created a guide on using the device at home.

“Not only does colon capsule increase our diagnostic capacity, because it doesn’t require the resources of a dedicated hospital space to do the examination, it also allows us to do the examination in the patient’s home, so patients who may be shielding or cautious about going to a hospital can perform the procedure in the comfort of their own homes,” commented Ed Seward, MD, PhD, endoscopy lead at UCL.

The move is in response to a surge in patients coming forward for cancer checks after the slowdown in cancer services caused by the COVID-19 pandemic. In December 2020, more than 200,000 people came forward, an increase of 13,000 over the same month the previous year.

Traditional endoscopy services are still being offered, although endoscopies take longer to conduct because of infection control measures that must be employed to ensure that patients who undergo endoscopies do not develop COVID-19. This, in turn, means fewer people can undergo endoscopies over a given period.

“We welcome any initiative that seeks to simplify and improve the early diagnosis of gastrointestinal disease and, in particular, colorectal cancer, which unfortunately is still responsible for many avoidable deaths,” said Alastair McKinlay, MD, president of the British Society of Gastroenterology.

“Colon capsule is a promising new technology that may offer a real advantage for some patients. For this reason, we welcome the opportunity for a proper service evaluation so that both the limitations and advantages of this technique can be properly assessed,” he said.

“This has the potential to make a huge difference for people with bowel cancer symptoms and could help the NHS to prioritize those who urgently need further tests,” added Genevieve Edwards, chief executive at Bowel Cancer UK.

No funding for the study has been disclosed. No relevant financial relationships have been disclosed.

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

A miniature camera the size of a capsule that is swallowed and then transmits images of the inside of the gut can reveal cancer and gastrointestinal diseases. The device, which will be studied in a trial conducted by the National Health Service in England, is used by patients at home as a substitute for endoscopy.

“What sounds like sci-fi is now becoming a reality,” said Sir Simon Stevens, chief executive of NHS England. “These minute cameras pass through your body. They take two pictures per second, checking for signs of cancer and other conditions like Crohn’s disease.”

The trial, announced on March 11, 2021, will initially involve 11,000 patients from 40 regions in England. Participants will be sent the colon capsule endoscopy to use at home.

The capsule typically takes 5-8 hours to pass through the digestive system. As the capsule passes through the bowel, images are sent to a data recorder in a shoulder bag.

The trial is being conducted by the University College London Hospitals NHS Foundation Trust. The investigators have created a guide on using the device at home.

“Not only does colon capsule increase our diagnostic capacity, because it doesn’t require the resources of a dedicated hospital space to do the examination, it also allows us to do the examination in the patient’s home, so patients who may be shielding or cautious about going to a hospital can perform the procedure in the comfort of their own homes,” commented Ed Seward, MD, PhD, endoscopy lead at UCL.

The move is in response to a surge in patients coming forward for cancer checks after the slowdown in cancer services caused by the COVID-19 pandemic. In December 2020, more than 200,000 people came forward, an increase of 13,000 over the same month the previous year.

Traditional endoscopy services are still being offered, although endoscopies take longer to conduct because of infection control measures that must be employed to ensure that patients who undergo endoscopies do not develop COVID-19. This, in turn, means fewer people can undergo endoscopies over a given period.

“We welcome any initiative that seeks to simplify and improve the early diagnosis of gastrointestinal disease and, in particular, colorectal cancer, which unfortunately is still responsible for many avoidable deaths,” said Alastair McKinlay, MD, president of the British Society of Gastroenterology.

“Colon capsule is a promising new technology that may offer a real advantage for some patients. For this reason, we welcome the opportunity for a proper service evaluation so that both the limitations and advantages of this technique can be properly assessed,” he said.

“This has the potential to make a huge difference for people with bowel cancer symptoms and could help the NHS to prioritize those who urgently need further tests,” added Genevieve Edwards, chief executive at Bowel Cancer UK.

No funding for the study has been disclosed. No relevant financial relationships have been disclosed.

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

Colorectal cancer (CRC) screening is now recommended for average-risk individuals starting at age 45 years, according to the American College of Gastroenterology’s updated guideline.

The starting age was previously 50 years for most patients. However, for Black patients, the starting age was lowered to 45 years in 2005.

The new guidance brings the ACG in line with recommendations of the American Cancer Society, which lowered the starting age to 45 years for average-risk individuals in 2018.

However, the U.S. Preventive Services Task Force, the Multi-Specialty Task Force, and the American College of Physicians still recommend that CRC screening begin at the age of 50.

The new ACG guideline were published in March 2021 in the American Journal of Gastroenterology. The last time they were updated was in 2009.

The ACG said that the move was made in light of reports of an increase in the incidence of CRC in adults younger than 50.

“It has been estimated that [in the United States] persons born around 1990 have twice the risk of colon cancer and four times the risk of rectal cancer, compared with those born around 1950,” guideline author Aasma Shaukat, MD, MPH, University of Minnesota, Minneapolis, and colleagues pointed out.

“The fact that other developed countries are reporting similar increases in early-onset CRC and birth-cohort effects suggests that the Western lifestyle (especially exemplified by the obesity epidemic) is a significant contributor,” the authors added.

The new ACG guideline emphasize the importance of initiating CRC screening for average-risk patients aged 50-75 years. “Given that current rates of screening uptake are close to 60% (57.9% ages 50-64 and 62.4% ages 50-75), expanding the population to be screened may reduce these rates as emphasis shifts to screening 45- to 49-year-olds at the expense of efforts to screen the unscreened 50- to 75-year-olds,” the authors commented.

Now, however, the guideline suggests that the decision to continue screening after age 75 should be individualized. It notes that the benefits of screening are limited for those who are not expected to live for another 7-10 years. For patients with a family history of CRC, the guideline authors recommended initiating CRC screening at the age of 40 for patients with one or two first-degree relatives with either CRC or advanced colorectal polyps.

They also recommend screening colonoscopy over any other screening modality if the first-degree relative is younger than 60 or if two or more first-degree relatives of any age have CRC or advanced colorectal polyps. For such patients, screening should be repeated every 5 years.

For screening average-risk individuals, either colonoscopy or fecal immunochemical testing (FIT) is recommended. If colonoscopy is used, it should be repeated every 10 years. FIT should be conducted on an annual basis.

This is somewhat in contrast to recent changes proposed by the American Gastroenterological Association. The AGA recommends greater use of noninvasive testing, such as with fecal occult blood tests, initially. It recommends that initial colonoscopy be used only for patients at high risk for CRC.

For individuals unwilling or unable to undergo colonoscopy or FIT, the ACG suggests flexible sigmoidoscopy, multitarget stool DNA testing, CT colonography, or colon capsule. Only colonoscopy is a single-step test; all other screening modalities require a follow-up colonoscopy if test results are positive.

“We recommend against the use of aspirin as a substitute for CRC screening,” the ACG members emphasized. Rather, they suggest that the use of low-dose aspirin be considered only for patients aged 50-69 years whose risk for cardiovascular disease over the next 10 years is at least 10% and who are at low risk for bleeding.

To reduce their risk for CRC, patients need to take aspirin for at least 10 years, they pointed out.
 

Quality indicators

For endoscopists who perform colonoscopy, the ACG recommended that all operators determine their individual cecal intubation rates, adenoma detection rates, and withdrawal times. They also recommended that endoscopists spend at least 6 minutes inspecting the mucosa during withdrawal and achieve a cecal intubation rate of at least 95% for all patients screened.

The ACG recommended remedial training for any provider whose adenoma detection rate is less than 25%.
 

Screening rates dropped during pandemic

The authors of the new recommendations also pointed out that, despite public health initiatives to boost CRC screening in the United States and the availability of multiple screening modalities, almost one-third of individuals who are eligible for CRC screening do not undergo screening.

Moreover, the proportion of individuals not being screened has reportedly increased during the pandemic. In one report, claims data for colonoscopies dropped by 90% during April. “Colorectal cancer screening rates must be optimized to reach the aspirational target of >80%,” the authors emphasized.

“A recommendation to be screened by a PCP [primary care provider] – who is known and trusted by the person – is clearly effective in raising participation,” they added.

Dr. Shaukat has served as a scientific consultant for Iterative Scopes and Freenome. Other ACG guideline authors reported numerous financial relationships.

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

Colorectal cancer (CRC) screening is now recommended for average-risk individuals starting at age 45 years, according to the American College of Gastroenterology’s updated guideline.

The starting age was previously 50 years for most patients. However, for Black patients, the starting age was lowered to 45 years in 2005.

The new guidance brings the ACG in line with recommendations of the American Cancer Society, which lowered the starting age to 45 years for average-risk individuals in 2018.

However, the U.S. Preventive Services Task Force, the Multi-Specialty Task Force, and the American College of Physicians still recommend that CRC screening begin at the age of 50.

The new ACG guideline were published in March 2021 in the American Journal of Gastroenterology. The last time they were updated was in 2009.

The ACG said that the move was made in light of reports of an increase in the incidence of CRC in adults younger than 50.

“It has been estimated that [in the United States] persons born around 1990 have twice the risk of colon cancer and four times the risk of rectal cancer, compared with those born around 1950,” guideline author Aasma Shaukat, MD, MPH, University of Minnesota, Minneapolis, and colleagues pointed out.

“The fact that other developed countries are reporting similar increases in early-onset CRC and birth-cohort effects suggests that the Western lifestyle (especially exemplified by the obesity epidemic) is a significant contributor,” the authors added.

The new ACG guideline emphasize the importance of initiating CRC screening for average-risk patients aged 50-75 years. “Given that current rates of screening uptake are close to 60% (57.9% ages 50-64 and 62.4% ages 50-75), expanding the population to be screened may reduce these rates as emphasis shifts to screening 45- to 49-year-olds at the expense of efforts to screen the unscreened 50- to 75-year-olds,” the authors commented.

Now, however, the guideline suggests that the decision to continue screening after age 75 should be individualized. It notes that the benefits of screening are limited for those who are not expected to live for another 7-10 years. For patients with a family history of CRC, the guideline authors recommended initiating CRC screening at the age of 40 for patients with one or two first-degree relatives with either CRC or advanced colorectal polyps.

They also recommend screening colonoscopy over any other screening modality if the first-degree relative is younger than 60 or if two or more first-degree relatives of any age have CRC or advanced colorectal polyps. For such patients, screening should be repeated every 5 years.

For screening average-risk individuals, either colonoscopy or fecal immunochemical testing (FIT) is recommended. If colonoscopy is used, it should be repeated every 10 years. FIT should be conducted on an annual basis.

This is somewhat in contrast to recent changes proposed by the American Gastroenterological Association. The AGA recommends greater use of noninvasive testing, such as with fecal occult blood tests, initially. It recommends that initial colonoscopy be used only for patients at high risk for CRC.

For individuals unwilling or unable to undergo colonoscopy or FIT, the ACG suggests flexible sigmoidoscopy, multitarget stool DNA testing, CT colonography, or colon capsule. Only colonoscopy is a single-step test; all other screening modalities require a follow-up colonoscopy if test results are positive.

“We recommend against the use of aspirin as a substitute for CRC screening,” the ACG members emphasized. Rather, they suggest that the use of low-dose aspirin be considered only for patients aged 50-69 years whose risk for cardiovascular disease over the next 10 years is at least 10% and who are at low risk for bleeding.

To reduce their risk for CRC, patients need to take aspirin for at least 10 years, they pointed out.
 

Quality indicators

For endoscopists who perform colonoscopy, the ACG recommended that all operators determine their individual cecal intubation rates, adenoma detection rates, and withdrawal times. They also recommended that endoscopists spend at least 6 minutes inspecting the mucosa during withdrawal and achieve a cecal intubation rate of at least 95% for all patients screened.

The ACG recommended remedial training for any provider whose adenoma detection rate is less than 25%.
 

Screening rates dropped during pandemic

The authors of the new recommendations also pointed out that, despite public health initiatives to boost CRC screening in the United States and the availability of multiple screening modalities, almost one-third of individuals who are eligible for CRC screening do not undergo screening.

Moreover, the proportion of individuals not being screened has reportedly increased during the pandemic. In one report, claims data for colonoscopies dropped by 90% during April. “Colorectal cancer screening rates must be optimized to reach the aspirational target of >80%,” the authors emphasized.

“A recommendation to be screened by a PCP [primary care provider] – who is known and trusted by the person – is clearly effective in raising participation,” they added.

Dr. Shaukat has served as a scientific consultant for Iterative Scopes and Freenome. Other ACG guideline authors reported numerous financial relationships.

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

Colorectal cancer (CRC) screening is now recommended for average-risk individuals starting at age 45 years, according to the American College of Gastroenterology’s updated guideline.

The starting age was previously 50 years for most patients. However, for Black patients, the starting age was lowered to 45 years in 2005.

The new guidance brings the ACG in line with recommendations of the American Cancer Society, which lowered the starting age to 45 years for average-risk individuals in 2018.

However, the U.S. Preventive Services Task Force, the Multi-Specialty Task Force, and the American College of Physicians still recommend that CRC screening begin at the age of 50.

The new ACG guideline were published in March 2021 in the American Journal of Gastroenterology. The last time they were updated was in 2009.

The ACG said that the move was made in light of reports of an increase in the incidence of CRC in adults younger than 50.

“It has been estimated that [in the United States] persons born around 1990 have twice the risk of colon cancer and four times the risk of rectal cancer, compared with those born around 1950,” guideline author Aasma Shaukat, MD, MPH, University of Minnesota, Minneapolis, and colleagues pointed out.

“The fact that other developed countries are reporting similar increases in early-onset CRC and birth-cohort effects suggests that the Western lifestyle (especially exemplified by the obesity epidemic) is a significant contributor,” the authors added.

The new ACG guideline emphasize the importance of initiating CRC screening for average-risk patients aged 50-75 years. “Given that current rates of screening uptake are close to 60% (57.9% ages 50-64 and 62.4% ages 50-75), expanding the population to be screened may reduce these rates as emphasis shifts to screening 45- to 49-year-olds at the expense of efforts to screen the unscreened 50- to 75-year-olds,” the authors commented.

Now, however, the guideline suggests that the decision to continue screening after age 75 should be individualized. It notes that the benefits of screening are limited for those who are not expected to live for another 7-10 years. For patients with a family history of CRC, the guideline authors recommended initiating CRC screening at the age of 40 for patients with one or two first-degree relatives with either CRC or advanced colorectal polyps.

They also recommend screening colonoscopy over any other screening modality if the first-degree relative is younger than 60 or if two or more first-degree relatives of any age have CRC or advanced colorectal polyps. For such patients, screening should be repeated every 5 years.

For screening average-risk individuals, either colonoscopy or fecal immunochemical testing (FIT) is recommended. If colonoscopy is used, it should be repeated every 10 years. FIT should be conducted on an annual basis.

This is somewhat in contrast to recent changes proposed by the American Gastroenterological Association. The AGA recommends greater use of noninvasive testing, such as with fecal occult blood tests, initially. It recommends that initial colonoscopy be used only for patients at high risk for CRC.

For individuals unwilling or unable to undergo colonoscopy or FIT, the ACG suggests flexible sigmoidoscopy, multitarget stool DNA testing, CT colonography, or colon capsule. Only colonoscopy is a single-step test; all other screening modalities require a follow-up colonoscopy if test results are positive.

“We recommend against the use of aspirin as a substitute for CRC screening,” the ACG members emphasized. Rather, they suggest that the use of low-dose aspirin be considered only for patients aged 50-69 years whose risk for cardiovascular disease over the next 10 years is at least 10% and who are at low risk for bleeding.

To reduce their risk for CRC, patients need to take aspirin for at least 10 years, they pointed out.
 

Quality indicators

For endoscopists who perform colonoscopy, the ACG recommended that all operators determine their individual cecal intubation rates, adenoma detection rates, and withdrawal times. They also recommended that endoscopists spend at least 6 minutes inspecting the mucosa during withdrawal and achieve a cecal intubation rate of at least 95% for all patients screened.

The ACG recommended remedial training for any provider whose adenoma detection rate is less than 25%.
 

Screening rates dropped during pandemic

The authors of the new recommendations also pointed out that, despite public health initiatives to boost CRC screening in the United States and the availability of multiple screening modalities, almost one-third of individuals who are eligible for CRC screening do not undergo screening.

Moreover, the proportion of individuals not being screened has reportedly increased during the pandemic. In one report, claims data for colonoscopies dropped by 90% during April. “Colorectal cancer screening rates must be optimized to reach the aspirational target of >80%,” the authors emphasized.

“A recommendation to be screened by a PCP [primary care provider] – who is known and trusted by the person – is clearly effective in raising participation,” they added.

Dr. Shaukat has served as a scientific consultant for Iterative Scopes and Freenome. Other ACG guideline authors reported numerous financial relationships.

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

A mitochondrial DNA variant may increase the risk of gallstone disease more than fourfold, according to investigators.

wir0man/GettyImages

Mitochondrial DNA 827A>G disrupts mitochondrial function and leads to abnormal cholesterol transport, which increases gallstone development, reported Dayan Sun, of Fudan University, Shanghai, China, and colleagues.

The investigators noted that the findings add support to a genetic role in gallstone development, which could allow for identification of at-risk individuals and implementation of preventive measures.

“The etiology of gallstone disease is multifactorial; age, sex, pregnancy, diet (macronutrients, alcohol, and coffee), and other factors are involved,” the investigators wrote in Cellular and Molecular Gastroenterology and Hepatology. “Moreover, the significant familial predisposition and ethnic differences in prevalence of this disease indicate the potential influences of genetic factors.”

In 2002, Nakeeb and colleagues reported that at least 30% of gallstone disease cases stemmed from genetic factors. And genetics may play an even greater role in certain populations, such as Native Americans, among whom more than 70% of women have gallstone disease, based on a study by Everhart and colleagues.

According to Ms. Sun and colleagues, a variety of genetic drivers of gallstone disease have been identified, such as ABCG8, identified as the most common genetic risk factor by at least one study, along with a list of other rare mutations, such as one affecting CFTR that leads to altered bile composition.

Based on previous research that linked mitochondrial DNA variants with metabolic defects and, more specifically, aberrations in lipid metabolism, as well as an observed “maternal bias in the maternal transmission of gallstone disease” that suggest mitochondrial influence, the investigators looked for patterns specifically in mitochondrial DNA variants among patients with gallstones.

The study enrolled 104 probands with confirmed gallstone disease and 300 unrelated controls. After collecting DNA samples from all participants, the investigators sequenced mitochondrial DNA HVS1 regions. A comparison of haplogroups showed that B4b’d’e’j was more common among patients with gallstone disease than among controls (odds ratio, 4.428; P = .00012), and further analysis pinpointed 827A>G, a variant in 12S ribosomal RNA.

“During the evolutionary history of modern humans, haplogroup B4 might have originated in East Asia approximately 40,000 years ago,” the investigators wrote, noting that B2, a subhaplogroup of B4, “was a founder haplogroup and expanded in the Americas after the Last Glacial Maximum (approximately 20,000 years ago).”

According to the investigators, this may explain why Native Americans have a higher prevalence of gallstones than East Asians (14%-35% vs. 3%-12%) because they are more often carriers of B4 (14%-44% vs. 2%-8%).

The investigators sought to characterize the impact that the 827A>G variant has on mitochondrial function and found effects ranging from lower respiratory chain complex activity, diminished mitochondrial function, activated mitochondrial protein quality control and retrograde signaling pathways, abnormal lipid metabolism, and abnormal cholesterol transport processes.

For example, the investigators investigated respiratory chain complex activity by creating two sister branch haplogroup cell models, including six cybrids for 827A and six more for 827G, which is how they detected the lower activity. Another step the investigators took was corroborating this finding by detecting OXPHOS function in the 827A and 827G cybrids to determine mitochondrial function.

“In summary, our study demonstrates a potential link between mitochondrial DNA 827A>G and gallstone disease,” the investigators wrote. “Our findings provide a significant biological basis for the clinical diagnosis and prevention of gallstone disease in the future.”

The study was funded by the National Natural Science Foundation of China, the 111 Project, the Shanghai Municipal Science and Technology Major Project, the Scientific and Technology Committee of Shanghai Municipality, and the CAMS Innovation Fund for Medical Sciences. The investigators reported no conflicts of interest.

A mitochondrial DNA variant may increase the risk of gallstone disease more than fourfold, according to investigators.

wir0man/GettyImages

Mitochondrial DNA 827A>G disrupts mitochondrial function and leads to abnormal cholesterol transport, which increases gallstone development, reported Dayan Sun, of Fudan University, Shanghai, China, and colleagues.

The investigators noted that the findings add support to a genetic role in gallstone development, which could allow for identification of at-risk individuals and implementation of preventive measures.

“The etiology of gallstone disease is multifactorial; age, sex, pregnancy, diet (macronutrients, alcohol, and coffee), and other factors are involved,” the investigators wrote in Cellular and Molecular Gastroenterology and Hepatology. “Moreover, the significant familial predisposition and ethnic differences in prevalence of this disease indicate the potential influences of genetic factors.”

In 2002, Nakeeb and colleagues reported that at least 30% of gallstone disease cases stemmed from genetic factors. And genetics may play an even greater role in certain populations, such as Native Americans, among whom more than 70% of women have gallstone disease, based on a study by Everhart and colleagues.

According to Ms. Sun and colleagues, a variety of genetic drivers of gallstone disease have been identified, such as ABCG8, identified as the most common genetic risk factor by at least one study, along with a list of other rare mutations, such as one affecting CFTR that leads to altered bile composition.

Based on previous research that linked mitochondrial DNA variants with metabolic defects and, more specifically, aberrations in lipid metabolism, as well as an observed “maternal bias in the maternal transmission of gallstone disease” that suggest mitochondrial influence, the investigators looked for patterns specifically in mitochondrial DNA variants among patients with gallstones.

The study enrolled 104 probands with confirmed gallstone disease and 300 unrelated controls. After collecting DNA samples from all participants, the investigators sequenced mitochondrial DNA HVS1 regions. A comparison of haplogroups showed that B4b’d’e’j was more common among patients with gallstone disease than among controls (odds ratio, 4.428; P = .00012), and further analysis pinpointed 827A>G, a variant in 12S ribosomal RNA.

“During the evolutionary history of modern humans, haplogroup B4 might have originated in East Asia approximately 40,000 years ago,” the investigators wrote, noting that B2, a subhaplogroup of B4, “was a founder haplogroup and expanded in the Americas after the Last Glacial Maximum (approximately 20,000 years ago).”

According to the investigators, this may explain why Native Americans have a higher prevalence of gallstones than East Asians (14%-35% vs. 3%-12%) because they are more often carriers of B4 (14%-44% vs. 2%-8%).

The investigators sought to characterize the impact that the 827A>G variant has on mitochondrial function and found effects ranging from lower respiratory chain complex activity, diminished mitochondrial function, activated mitochondrial protein quality control and retrograde signaling pathways, abnormal lipid metabolism, and abnormal cholesterol transport processes.

For example, the investigators investigated respiratory chain complex activity by creating two sister branch haplogroup cell models, including six cybrids for 827A and six more for 827G, which is how they detected the lower activity. Another step the investigators took was corroborating this finding by detecting OXPHOS function in the 827A and 827G cybrids to determine mitochondrial function.

“In summary, our study demonstrates a potential link between mitochondrial DNA 827A>G and gallstone disease,” the investigators wrote. “Our findings provide a significant biological basis for the clinical diagnosis and prevention of gallstone disease in the future.”

The study was funded by the National Natural Science Foundation of China, the 111 Project, the Shanghai Municipal Science and Technology Major Project, the Scientific and Technology Committee of Shanghai Municipality, and the CAMS Innovation Fund for Medical Sciences. The investigators reported no conflicts of interest.

A mitochondrial DNA variant may increase the risk of gallstone disease more than fourfold, according to investigators.

wir0man/GettyImages

Mitochondrial DNA 827A>G disrupts mitochondrial function and leads to abnormal cholesterol transport, which increases gallstone development, reported Dayan Sun, of Fudan University, Shanghai, China, and colleagues.

The investigators noted that the findings add support to a genetic role in gallstone development, which could allow for identification of at-risk individuals and implementation of preventive measures.

“The etiology of gallstone disease is multifactorial; age, sex, pregnancy, diet (macronutrients, alcohol, and coffee), and other factors are involved,” the investigators wrote in Cellular and Molecular Gastroenterology and Hepatology. “Moreover, the significant familial predisposition and ethnic differences in prevalence of this disease indicate the potential influences of genetic factors.”

In 2002, Nakeeb and colleagues reported that at least 30% of gallstone disease cases stemmed from genetic factors. And genetics may play an even greater role in certain populations, such as Native Americans, among whom more than 70% of women have gallstone disease, based on a study by Everhart and colleagues.

According to Ms. Sun and colleagues, a variety of genetic drivers of gallstone disease have been identified, such as ABCG8, identified as the most common genetic risk factor by at least one study, along with a list of other rare mutations, such as one affecting CFTR that leads to altered bile composition.

Based on previous research that linked mitochondrial DNA variants with metabolic defects and, more specifically, aberrations in lipid metabolism, as well as an observed “maternal bias in the maternal transmission of gallstone disease” that suggest mitochondrial influence, the investigators looked for patterns specifically in mitochondrial DNA variants among patients with gallstones.

The study enrolled 104 probands with confirmed gallstone disease and 300 unrelated controls. After collecting DNA samples from all participants, the investigators sequenced mitochondrial DNA HVS1 regions. A comparison of haplogroups showed that B4b’d’e’j was more common among patients with gallstone disease than among controls (odds ratio, 4.428; P = .00012), and further analysis pinpointed 827A>G, a variant in 12S ribosomal RNA.

“During the evolutionary history of modern humans, haplogroup B4 might have originated in East Asia approximately 40,000 years ago,” the investigators wrote, noting that B2, a subhaplogroup of B4, “was a founder haplogroup and expanded in the Americas after the Last Glacial Maximum (approximately 20,000 years ago).”

According to the investigators, this may explain why Native Americans have a higher prevalence of gallstones than East Asians (14%-35% vs. 3%-12%) because they are more often carriers of B4 (14%-44% vs. 2%-8%).

The investigators sought to characterize the impact that the 827A>G variant has on mitochondrial function and found effects ranging from lower respiratory chain complex activity, diminished mitochondrial function, activated mitochondrial protein quality control and retrograde signaling pathways, abnormal lipid metabolism, and abnormal cholesterol transport processes.

For example, the investigators investigated respiratory chain complex activity by creating two sister branch haplogroup cell models, including six cybrids for 827A and six more for 827G, which is how they detected the lower activity. Another step the investigators took was corroborating this finding by detecting OXPHOS function in the 827A and 827G cybrids to determine mitochondrial function.

“In summary, our study demonstrates a potential link between mitochondrial DNA 827A>G and gallstone disease,” the investigators wrote. “Our findings provide a significant biological basis for the clinical diagnosis and prevention of gallstone disease in the future.”

The study was funded by the National Natural Science Foundation of China, the 111 Project, the Shanghai Municipal Science and Technology Major Project, the Scientific and Technology Committee of Shanghai Municipality, and the CAMS Innovation Fund for Medical Sciences. The investigators reported no conflicts of interest.

Because of significant reduction in delivery of recommended childhood immunization during the pandemic, there is a risk for resurgence of vaccine preventable infections, including measles, pertussis, and polio, which can result in significant morbidity and mortality in children, reported Amy G. Feldman, MD, of Children’s Hospital Colorado, Aurora, and associates.

Yangna/Thinkstock

Will loss of herd immunity lead to vaccine deserts?

When asked to comment, pediatric infectious disease specialist Christopher J. Harrison, MD, said, “My concern is that we may see expansion of what I call ‘vaccine deserts.’ Vaccine deserts occur in underserved communities, areas with pockets of vaccine-hesitant families or among selected groups with difficult access to health care. These vaccine deserts have held a higher density of vulnerables due to low vaccine uptake, often giving rise to outbreaks of vaccine-preventable diseases, e.g., measles, mumps, pertussis. They are usually due to an index case arriving from another vaccine desert (a developing country or a developed country, U.S. or foreign) where the disease is still endemic or pockets of vaccine hesitancy/refusal exist. When detected, local outbreaks result in rapid responses from public/private health collaborations that limit the outbreak. But what if vaccine deserts became more generalized in the U.S. because of loss of vaccine-induced herd immunity in many more or larger areas of our communities because of pandemic-driven lack of vaccinations? That pandemic-driven indirect damage would further stress the health care system and the economy. And it may first show up in the older children whose vaccines were deferred in the first 4-6 months of the pandemic.”

Dr. Feldman and associates cited findings from a collaborative survey conducted by UNICEF, the World Health Organization, Gavi the Vaccine Alliance, the CDC, the Sabin Vaccine Institute, and the Johns Hopkins Bloomberg School of Public Health, which found that immunization programs experienced moderate to severe disruptions or terminations in at least 68 of 129 low and middle-income countries surveyed. According to the WHO, CDC, Red Cross, and GAVI, 94 million people presently are estimated to be at risk as a consequence of not receiving their measles vaccines following the suspensions.

“These national and international declines in routine immunizations have placed the global community at significant risk for outbreaks of vaccine-preventable infections (VPIs) including measles, polio, and pertussis, diseases which are more deadly, more contagious and have a higher reproductive factor (R0) amongst children than COVID-19,” the authors observed.

Dr. Feldman and associates outlined the horrible devastation that these VPI can cause in children, including significantly higher morbidity and mortality than adults, especially among those with immunodeficiencies. Neurologic deficits, paralysis, intellectual disabilities, and vision and hearing loss are just some of the permanent effects conveyed. “It is concerning to imagine how measles could spread across the United States when social distancing restriction[s] are relaxed and unvaccinated children return to school and usual community engagement,” they noted.
 

Collaborative engagement key to course correction

The authors found that primary care providers and public health communities are working not only to restore vaccine administration but also to restore confidence that vaccine delivery is safe in spite of COVID. In addition to recommending specific risk mitigation strategies for clinicians, they also suggested individual practitioners use electronic health records to identify patients with COVID-related lapses in vaccination, employ electronic health record–based parent notification of overdue immunizations, and offer distance-friendly vaccination options that include parking lot or drive-up window vaccine delivery.

Additionally, Dr. Feldman and colleagues recommended that local, state, regional, and national health systems use public service announcements via television and digital as well as social media platforms to convey important messages about the considerable health risks associated with vaccine avoidance and the availability of free or reduced-cost vaccination programs through the federally funded Vaccines For Children program for parents out of work or without insurance. Equally important is messaging around encouraging vaccine opportunities during all health care visits, whether they be subspecialty, urgent care, emergency room, or inpatient visits. In areas where access to clinics is limited, they urged the use of mobile clinics as well as additional focus on providing medical homes to children with poor access to care.

“A partial but expanding safety net may be developing spontaneously, i.e., practices and clinics based on a patient-centered medical home (PCMH) model,” noted Dr. Harrison, professor of pediatrics, University of Missouri-Kansas City, in an interview. “When lagging vaccinations were reported in mid-2020, we checked with a local hospital–based urban clinic and two suburban private practices modeled on PCMH. Each had noted a drastic drop in well checks in the first months of the pandemic. But with ill visits nearly nonexistent, they doubled down on maintaining health maintenance visits. Even though staff and provider work hours were limited, and families were less enthusiastic about well checks, momentum appears to have grown so that, by later in 2020, vaccine uptake rates were again comparable to 2019. So, some already seem to have answered the call, but practices/clinics remain hampered by months of reduced revenue needed to support staff, providers, PPE supplies, and added infection control needs,” he said.The study was funded by the Agency for Healthcare Research Quality. Dr. Isakov disclosed relationships with various pharmaceutical companies outside the submitted work. The other authors had no relevant disclosures. Dr. Harrison’s institution receives grant funding from GSK, Merck, and Pfizer for pediatric vaccine trials and pneumococcal seroprevalence studies on which he is an investigator.

[email protected]

Because of significant reduction in delivery of recommended childhood immunization during the pandemic, there is a risk for resurgence of vaccine preventable infections, including measles, pertussis, and polio, which can result in significant morbidity and mortality in children, reported Amy G. Feldman, MD, of Children’s Hospital Colorado, Aurora, and associates.

Yangna/Thinkstock

Will loss of herd immunity lead to vaccine deserts?

When asked to comment, pediatric infectious disease specialist Christopher J. Harrison, MD, said, “My concern is that we may see expansion of what I call ‘vaccine deserts.’ Vaccine deserts occur in underserved communities, areas with pockets of vaccine-hesitant families or among selected groups with difficult access to health care. These vaccine deserts have held a higher density of vulnerables due to low vaccine uptake, often giving rise to outbreaks of vaccine-preventable diseases, e.g., measles, mumps, pertussis. They are usually due to an index case arriving from another vaccine desert (a developing country or a developed country, U.S. or foreign) where the disease is still endemic or pockets of vaccine hesitancy/refusal exist. When detected, local outbreaks result in rapid responses from public/private health collaborations that limit the outbreak. But what if vaccine deserts became more generalized in the U.S. because of loss of vaccine-induced herd immunity in many more or larger areas of our communities because of pandemic-driven lack of vaccinations? That pandemic-driven indirect damage would further stress the health care system and the economy. And it may first show up in the older children whose vaccines were deferred in the first 4-6 months of the pandemic.”

Dr. Feldman and associates cited findings from a collaborative survey conducted by UNICEF, the World Health Organization, Gavi the Vaccine Alliance, the CDC, the Sabin Vaccine Institute, and the Johns Hopkins Bloomberg School of Public Health, which found that immunization programs experienced moderate to severe disruptions or terminations in at least 68 of 129 low and middle-income countries surveyed. According to the WHO, CDC, Red Cross, and GAVI, 94 million people presently are estimated to be at risk as a consequence of not receiving their measles vaccines following the suspensions.

“These national and international declines in routine immunizations have placed the global community at significant risk for outbreaks of vaccine-preventable infections (VPIs) including measles, polio, and pertussis, diseases which are more deadly, more contagious and have a higher reproductive factor (R0) amongst children than COVID-19,” the authors observed.

Dr. Feldman and associates outlined the horrible devastation that these VPI can cause in children, including significantly higher morbidity and mortality than adults, especially among those with immunodeficiencies. Neurologic deficits, paralysis, intellectual disabilities, and vision and hearing loss are just some of the permanent effects conveyed. “It is concerning to imagine how measles could spread across the United States when social distancing restriction[s] are relaxed and unvaccinated children return to school and usual community engagement,” they noted.
 

Collaborative engagement key to course correction

The authors found that primary care providers and public health communities are working not only to restore vaccine administration but also to restore confidence that vaccine delivery is safe in spite of COVID. In addition to recommending specific risk mitigation strategies for clinicians, they also suggested individual practitioners use electronic health records to identify patients with COVID-related lapses in vaccination, employ electronic health record–based parent notification of overdue immunizations, and offer distance-friendly vaccination options that include parking lot or drive-up window vaccine delivery.

Additionally, Dr. Feldman and colleagues recommended that local, state, regional, and national health systems use public service announcements via television and digital as well as social media platforms to convey important messages about the considerable health risks associated with vaccine avoidance and the availability of free or reduced-cost vaccination programs through the federally funded Vaccines For Children program for parents out of work or without insurance. Equally important is messaging around encouraging vaccine opportunities during all health care visits, whether they be subspecialty, urgent care, emergency room, or inpatient visits. In areas where access to clinics is limited, they urged the use of mobile clinics as well as additional focus on providing medical homes to children with poor access to care.

“A partial but expanding safety net may be developing spontaneously, i.e., practices and clinics based on a patient-centered medical home (PCMH) model,” noted Dr. Harrison, professor of pediatrics, University of Missouri-Kansas City, in an interview. “When lagging vaccinations were reported in mid-2020, we checked with a local hospital–based urban clinic and two suburban private practices modeled on PCMH. Each had noted a drastic drop in well checks in the first months of the pandemic. But with ill visits nearly nonexistent, they doubled down on maintaining health maintenance visits. Even though staff and provider work hours were limited, and families were less enthusiastic about well checks, momentum appears to have grown so that, by later in 2020, vaccine uptake rates were again comparable to 2019. So, some already seem to have answered the call, but practices/clinics remain hampered by months of reduced revenue needed to support staff, providers, PPE supplies, and added infection control needs,” he said.The study was funded by the Agency for Healthcare Research Quality. Dr. Isakov disclosed relationships with various pharmaceutical companies outside the submitted work. The other authors had no relevant disclosures. Dr. Harrison’s institution receives grant funding from GSK, Merck, and Pfizer for pediatric vaccine trials and pneumococcal seroprevalence studies on which he is an investigator.

[email protected]

Because of significant reduction in delivery of recommended childhood immunization during the pandemic, there is a risk for resurgence of vaccine preventable infections, including measles, pertussis, and polio, which can result in significant morbidity and mortality in children, reported Amy G. Feldman, MD, of Children’s Hospital Colorado, Aurora, and associates.

Yangna/Thinkstock

Will loss of herd immunity lead to vaccine deserts?

When asked to comment, pediatric infectious disease specialist Christopher J. Harrison, MD, said, “My concern is that we may see expansion of what I call ‘vaccine deserts.’ Vaccine deserts occur in underserved communities, areas with pockets of vaccine-hesitant families or among selected groups with difficult access to health care. These vaccine deserts have held a higher density of vulnerables due to low vaccine uptake, often giving rise to outbreaks of vaccine-preventable diseases, e.g., measles, mumps, pertussis. They are usually due to an index case arriving from another vaccine desert (a developing country or a developed country, U.S. or foreign) where the disease is still endemic or pockets of vaccine hesitancy/refusal exist. When detected, local outbreaks result in rapid responses from public/private health collaborations that limit the outbreak. But what if vaccine deserts became more generalized in the U.S. because of loss of vaccine-induced herd immunity in many more or larger areas of our communities because of pandemic-driven lack of vaccinations? That pandemic-driven indirect damage would further stress the health care system and the economy. And it may first show up in the older children whose vaccines were deferred in the first 4-6 months of the pandemic.”

Dr. Feldman and associates cited findings from a collaborative survey conducted by UNICEF, the World Health Organization, Gavi the Vaccine Alliance, the CDC, the Sabin Vaccine Institute, and the Johns Hopkins Bloomberg School of Public Health, which found that immunization programs experienced moderate to severe disruptions or terminations in at least 68 of 129 low and middle-income countries surveyed. According to the WHO, CDC, Red Cross, and GAVI, 94 million people presently are estimated to be at risk as a consequence of not receiving their measles vaccines following the suspensions.

“These national and international declines in routine immunizations have placed the global community at significant risk for outbreaks of vaccine-preventable infections (VPIs) including measles, polio, and pertussis, diseases which are more deadly, more contagious and have a higher reproductive factor (R0) amongst children than COVID-19,” the authors observed.

Dr. Feldman and associates outlined the horrible devastation that these VPI can cause in children, including significantly higher morbidity and mortality than adults, especially among those with immunodeficiencies. Neurologic deficits, paralysis, intellectual disabilities, and vision and hearing loss are just some of the permanent effects conveyed. “It is concerning to imagine how measles could spread across the United States when social distancing restriction[s] are relaxed and unvaccinated children return to school and usual community engagement,” they noted.
 

Collaborative engagement key to course correction

The authors found that primary care providers and public health communities are working not only to restore vaccine administration but also to restore confidence that vaccine delivery is safe in spite of COVID. In addition to recommending specific risk mitigation strategies for clinicians, they also suggested individual practitioners use electronic health records to identify patients with COVID-related lapses in vaccination, employ electronic health record–based parent notification of overdue immunizations, and offer distance-friendly vaccination options that include parking lot or drive-up window vaccine delivery.

Additionally, Dr. Feldman and colleagues recommended that local, state, regional, and national health systems use public service announcements via television and digital as well as social media platforms to convey important messages about the considerable health risks associated with vaccine avoidance and the availability of free or reduced-cost vaccination programs through the federally funded Vaccines For Children program for parents out of work or without insurance. Equally important is messaging around encouraging vaccine opportunities during all health care visits, whether they be subspecialty, urgent care, emergency room, or inpatient visits. In areas where access to clinics is limited, they urged the use of mobile clinics as well as additional focus on providing medical homes to children with poor access to care.

“A partial but expanding safety net may be developing spontaneously, i.e., practices and clinics based on a patient-centered medical home (PCMH) model,” noted Dr. Harrison, professor of pediatrics, University of Missouri-Kansas City, in an interview. “When lagging vaccinations were reported in mid-2020, we checked with a local hospital–based urban clinic and two suburban private practices modeled on PCMH. Each had noted a drastic drop in well checks in the first months of the pandemic. But with ill visits nearly nonexistent, they doubled down on maintaining health maintenance visits. Even though staff and provider work hours were limited, and families were less enthusiastic about well checks, momentum appears to have grown so that, by later in 2020, vaccine uptake rates were again comparable to 2019. So, some already seem to have answered the call, but practices/clinics remain hampered by months of reduced revenue needed to support staff, providers, PPE supplies, and added infection control needs,” he said.The study was funded by the Agency for Healthcare Research Quality. Dr. Isakov disclosed relationships with various pharmaceutical companies outside the submitted work. The other authors had no relevant disclosures. Dr. Harrison’s institution receives grant funding from GSK, Merck, and Pfizer for pediatric vaccine trials and pneumococcal seroprevalence studies on which he is an investigator.

[email protected]

The Diagnosis: Cutaneous Collagenous Vasculopathy 

Cutaneous collagenous vasculopathy (CCV) is an idiopathic microangiopathy of the small vessels in the superficial dermis. A condition first identified by Salama and Rosenthal¹ in 2000, CCV likely is underreported, as its clinical mimickers are not routinely biopsied.² It presents as asymptomatic telangiectatic macules, initially on the lower extremities and often spreading to the trunk. Cutaneous collagenous vasculopathy often is seen in middle-aged adults, and most patients have comorbidities such as hypertension, diabetes mellitus, or cardiovascular disease. The exact etiology of this disease is unknown.^3,4 

Histopathologically, CCV is characterized by dilated superficial vessels with thickened eosinophilic walls. The eosinophilic material is composed of hyalinized type IV collagen, which is periodic acid-Schiff positive and diastase resistant (Figure 1).^3,4 Stains for amyloid are negative.  

Generalized essential telangiectasia (GET) is a condition that presents with symmetric, blanchable, erythematous telangiectases.⁵ These lesions can occur alone or can accompany systemic diseases. Similar to CCV, the telangiectases tend to begin on the legs before gradually spreading to the trunk; however, this process more often is seen in females and occurs at an earlier age. Unlike CCV, GET can occur on mucosal surfaces, with cases of conjunctival and oral involvement reported.⁶ Generalized essential telangiectasia usually is a diagnosis of exclusion.^7,8 It is thought that many CCV lesions have been misclassified clinically as GET, which highlights the importance of biopsy. Microscopically, GET is distinct from CCV in that the superficial dermis lacks thick-walled vessels.^5,7 Although usually not associated with systemic diseases or progressive morbidity, treatment options are limited.⁸ 

Livedoid vasculopathy, also known as atrophie blanche, is caused by fibrin thrombi occlusion of dermal vessels. Clinically, patients have recurrent telangiectatic papules and painful ulcers on the lower extremities that gradually heal, leaving behind white stellate scars. It is caused by an underlying prothrombotic state with a superimposed inflammatory response.⁹ Livedoid vasculopathy primarily affects middle-aged women, and many patients have comorbidities such as scleroderma or systemic lupus erythematosus. Histologically, the epidermis often is ulcerated, and thrombi are visualized within small vessels. Eosinophilic fibrinoid material is deposited in vessel walls, including but not confined to vessels at the base of the epidermal ulcer (Figure 2). The fibrinoid material is periodic acid-Schiff positive and diastase resistant and can be highlighted with immunofluorescence, which may help to distinguish this entity from CCV.^1,9 As the disease progresses, vessels are diffusely hyalinized, and there is epidermal atrophy and dermal sclerosis. Treatment options include antiplatelet and fibrinolytic drugs with a multidisciplinary approach to resolve pain and scarring.⁹ 

Primary systemic amyloidosis is a rare condition, and cutaneous manifestations are seen in approximately one-third of affected individuals. Amyloid deposition results in waxy papules that predominantly affect the face and periorbital areas but also may occur on the neck, flexural areas, and genitalia.⁵ Because the amyloid deposits also can be found within vessel walls, hemorrhagic lesions may occur. Microscopically, amorphous eosinophilic material can be found within the vessel walls, similar to CCV (Figure 3A); however, when stained with Congo red, cutaneous amyloidosis shows waxy red-orange material involving the vessel walls and exhibits apple green birefringence under polarization (Figure 3B).¹⁰ Amyloid also will be negative for type IV collagen, fibronectin, and laminin, whereas CCV will be positive.⁵

The Diagnosis: Cutaneous Collagenous Vasculopathy 

Cutaneous collagenous vasculopathy (CCV) is an idiopathic microangiopathy of the small vessels in the superficial dermis. A condition first identified by Salama and Rosenthal¹ in 2000, CCV likely is underreported, as its clinical mimickers are not routinely biopsied.² It presents as asymptomatic telangiectatic macules, initially on the lower extremities and often spreading to the trunk. Cutaneous collagenous vasculopathy often is seen in middle-aged adults, and most patients have comorbidities such as hypertension, diabetes mellitus, or cardiovascular disease. The exact etiology of this disease is unknown.^3,4 

Histopathologically, CCV is characterized by dilated superficial vessels with thickened eosinophilic walls. The eosinophilic material is composed of hyalinized type IV collagen, which is periodic acid-Schiff positive and diastase resistant (Figure 1).^3,4 Stains for amyloid are negative.  

Generalized essential telangiectasia (GET) is a condition that presents with symmetric, blanchable, erythematous telangiectases.⁵ These lesions can occur alone or can accompany systemic diseases. Similar to CCV, the telangiectases tend to begin on the legs before gradually spreading to the trunk; however, this process more often is seen in females and occurs at an earlier age. Unlike CCV, GET can occur on mucosal surfaces, with cases of conjunctival and oral involvement reported.⁶ Generalized essential telangiectasia usually is a diagnosis of exclusion.^7,8 It is thought that many CCV lesions have been misclassified clinically as GET, which highlights the importance of biopsy. Microscopically, GET is distinct from CCV in that the superficial dermis lacks thick-walled vessels.^5,7 Although usually not associated with systemic diseases or progressive morbidity, treatment options are limited.⁸ 

Livedoid vasculopathy, also known as atrophie blanche, is caused by fibrin thrombi occlusion of dermal vessels. Clinically, patients have recurrent telangiectatic papules and painful ulcers on the lower extremities that gradually heal, leaving behind white stellate scars. It is caused by an underlying prothrombotic state with a superimposed inflammatory response.⁹ Livedoid vasculopathy primarily affects middle-aged women, and many patients have comorbidities such as scleroderma or systemic lupus erythematosus. Histologically, the epidermis often is ulcerated, and thrombi are visualized within small vessels. Eosinophilic fibrinoid material is deposited in vessel walls, including but not confined to vessels at the base of the epidermal ulcer (Figure 2). The fibrinoid material is periodic acid-Schiff positive and diastase resistant and can be highlighted with immunofluorescence, which may help to distinguish this entity from CCV.^1,9 As the disease progresses, vessels are diffusely hyalinized, and there is epidermal atrophy and dermal sclerosis. Treatment options include antiplatelet and fibrinolytic drugs with a multidisciplinary approach to resolve pain and scarring.⁹ 

Primary systemic amyloidosis is a rare condition, and cutaneous manifestations are seen in approximately one-third of affected individuals. Amyloid deposition results in waxy papules that predominantly affect the face and periorbital areas but also may occur on the neck, flexural areas, and genitalia.⁵ Because the amyloid deposits also can be found within vessel walls, hemorrhagic lesions may occur. Microscopically, amorphous eosinophilic material can be found within the vessel walls, similar to CCV (Figure 3A); however, when stained with Congo red, cutaneous amyloidosis shows waxy red-orange material involving the vessel walls and exhibits apple green birefringence under polarization (Figure 3B).¹⁰ Amyloid also will be negative for type IV collagen, fibronectin, and laminin, whereas CCV will be positive.⁵

The Diagnosis: Cutaneous Collagenous Vasculopathy 

Cutaneous collagenous vasculopathy (CCV) is an idiopathic microangiopathy of the small vessels in the superficial dermis. A condition first identified by Salama and Rosenthal¹ in 2000, CCV likely is underreported, as its clinical mimickers are not routinely biopsied.² It presents as asymptomatic telangiectatic macules, initially on the lower extremities and often spreading to the trunk. Cutaneous collagenous vasculopathy often is seen in middle-aged adults, and most patients have comorbidities such as hypertension, diabetes mellitus, or cardiovascular disease. The exact etiology of this disease is unknown.^3,4 

Histopathologically, CCV is characterized by dilated superficial vessels with thickened eosinophilic walls. The eosinophilic material is composed of hyalinized type IV collagen, which is periodic acid-Schiff positive and diastase resistant (Figure 1).^3,4 Stains for amyloid are negative.  

Generalized essential telangiectasia (GET) is a condition that presents with symmetric, blanchable, erythematous telangiectases.⁵ These lesions can occur alone or can accompany systemic diseases. Similar to CCV, the telangiectases tend to begin on the legs before gradually spreading to the trunk; however, this process more often is seen in females and occurs at an earlier age. Unlike CCV, GET can occur on mucosal surfaces, with cases of conjunctival and oral involvement reported.⁶ Generalized essential telangiectasia usually is a diagnosis of exclusion.^7,8 It is thought that many CCV lesions have been misclassified clinically as GET, which highlights the importance of biopsy. Microscopically, GET is distinct from CCV in that the superficial dermis lacks thick-walled vessels.^5,7 Although usually not associated with systemic diseases or progressive morbidity, treatment options are limited.⁸ 

Livedoid vasculopathy, also known as atrophie blanche, is caused by fibrin thrombi occlusion of dermal vessels. Clinically, patients have recurrent telangiectatic papules and painful ulcers on the lower extremities that gradually heal, leaving behind white stellate scars. It is caused by an underlying prothrombotic state with a superimposed inflammatory response.⁹ Livedoid vasculopathy primarily affects middle-aged women, and many patients have comorbidities such as scleroderma or systemic lupus erythematosus. Histologically, the epidermis often is ulcerated, and thrombi are visualized within small vessels. Eosinophilic fibrinoid material is deposited in vessel walls, including but not confined to vessels at the base of the epidermal ulcer (Figure 2). The fibrinoid material is periodic acid-Schiff positive and diastase resistant and can be highlighted with immunofluorescence, which may help to distinguish this entity from CCV.^1,9 As the disease progresses, vessels are diffusely hyalinized, and there is epidermal atrophy and dermal sclerosis. Treatment options include antiplatelet and fibrinolytic drugs with a multidisciplinary approach to resolve pain and scarring.⁹ 

Primary systemic amyloidosis is a rare condition, and cutaneous manifestations are seen in approximately one-third of affected individuals. Amyloid deposition results in waxy papules that predominantly affect the face and periorbital areas but also may occur on the neck, flexural areas, and genitalia.⁵ Because the amyloid deposits also can be found within vessel walls, hemorrhagic lesions may occur. Microscopically, amorphous eosinophilic material can be found within the vessel walls, similar to CCV (Figure 3A); however, when stained with Congo red, cutaneous amyloidosis shows waxy red-orange material involving the vessel walls and exhibits apple green birefringence under polarization (Figure 3B).¹⁰ Amyloid also will be negative for type IV collagen, fibronectin, and laminin, whereas CCV will be positive.⁵

Only about 30% or fewer of patients with psoriatic arthritis (PsA) on therapy achieve disease remission by any definition. One reason for this may be inadequate attention to common comorbid conditions, Alexis Ogdie, MD, MSCE, declared at the 2021 Rheumatology Winter Clinical Symposium.

Courtesy Dr. Alexis Ogdie

“I believe that addressing off-target aspects of disease is really important to improving the patient experience of their disease. We might need to target these directly in order to improve outcomes,” said Dr. Ogdie, a rheumatologist and epidemiologist at the University of Pennsylvania, Philadelphia, who coauthored the current American College of Rheumatology/National Psoriasis Foundation PsA guidelines.

Since rheumatologists are by now well informed about the increased cardiovascular risk associated with PsA, she focused on two common comorbidities that get less attention, both of which are associated with worse clinical outcomes in PsA: obesity and mental health issues.
 

Anxiety and depression

Dr. Ogdie was first author of a large, population-based, longitudinal cohort study of cause-specific mortality in 8,706 U.K. patients with PsA, 41,752 with RA, and more than 81,000 controls. Particularly striking was the finding of elevated mortality because of suicide in the rheumatic disease patients: a 203% increased risk in the PsA population, compared with the general population, and a 147% greater risk in patients with RA.

Overall, 30%-40% of PsA patients have comorbid depression and/or anxiety.

“That’s pretty striking. It’s also true for rheumatoid arthritis and axial spondyloarthritis. And if you’re depressed, you’re much less likely to respond to therapy in the way that we are measuring response to therapy,” Dr. Ogdie said.

Her approach to screening for depression and anxiety in her PsA patients, and indeed in all her other patients, is to begin by normalizing the topic, explaining to them that these affective disorders are common among patients with these disorders. She lets her patients know they can talk to her about it. And she informs them that, while effective treatment of their rheumatic disease may improve their depression or anxiety, managing those is also important for improving their disease. Additionally, understanding whether depression is present is important prior to prescribing certain medications. Apremilast (Otezla), for example, can worsen preexisting depression.

“Ask about signs and symptoms of depression,” Dr. Ogdie urged her colleagues. “I do this at every single visit in my review of symptoms. This is one I don’t skip. I ask: ‘Do you have any symptoms of depression or anxiety?’ ”

Structured evidence-based screening tools, many of which are well suited for completion during a patient’s preappointment check-in survey, include the Patient Health Questionnaire–2, the PHQ-9, the Patient-Reported Outcomes Measure Information System–10, PROMIS–Depression, and Routine Assessment of Patient Index Data 3.

“I also really like the PROMIS-29. It covers many domains of interest: depression and anxiety, sleep, fatigue, pain, physical function. It gives a lot of information about what’s going on in a patient’s life right now,” according to the rheumatologist.

The main thing is to regularly screen for anxiety and depression and then refer symptomatic patients for further assessment and treatment. This is not something that all rheumatologists have been trained to do.

Obesity

Dr. Ogdie was lead author of a national CORRONA Registry study which concluded that obese patients with PsA were only half as likely to achieve remission on a tumor necrosis factor (TNF) inhibitor, compared with nonobese patients. She believes the same holds true for all other types of therapy: Across the board, obesity is associated with a poor response. And obesity is much more common in PsA patients than the general population in every age group. Moreover, obesity is associated with risk factors for cardiovascular disease and is associated with fatty liver disease, two other major comorbid conditions in the PsA population.

The CORRONA Registry findings are supportive of an earlier Italian prospective, observational study of 135 obese and an equal number of normal-weight PsA patients, all of whom started on a TNF inhibitor and were followed for 24 months. In a multivariate-adjusted analysis, obesity was independently associated with a 390% higher risk of not achieving minimal disease activity.

The same Italian group subsequently conducted a prospective dietary intervention study in 138 overweight or obese patients with PsA starting anti-TNF therapy. A total of 59% of participants randomized to either of the two dietary interventions experienced at least a 5% weight loss at 6 months. The key study finding: Compared with the subjects with less than 5% weight loss, those with 5%-10% weight loss were 275% more likely to achieve minimal disease activity at 6 months, and in those with greater than 10% weight loss the likelihood of attaining minimal disease activity increased by 567%.

“We’re talking about a disease where treatments tested in clinical trials have odds ratios in the 1.2 range, compared with other therapies, so this is a really striking difference,” she observed.

Several studies have demonstrated that obesity in psoriasis patients is a risk factor for developing PsA. Recently, U.K. investigators took things a step further, reporting in a huge observational study that obese or overweight psoriasis patients who reduced their body mass index over a 10-year period had a corresponding reduction in the risk of developing PsA, compared with overweight or obese psoriasis patients whose BMI remained steady over the same period.

What’s needed now is access to programs to help patients with PsA lose weight. Health insurers are often unwilling to provide coverage. “We have a really tough time getting the patients in to see a nutritionist unless they’re willing to pay out of pocket,” Dr. Ogdie said.

Physical activity is an important element in successful weight loss. It also is recommended in practice guidelines for patients with inflammatory arthritis because of its salutary effects on disease activity scores, pain and stiffness, sleep, and quality of life. But a recent survey conducted by Dr. Ogdie and coworkers concluded that patients with PsA and other forms of inflammatory arthritis don’t receive much exercise guidance from their rheumatologists. About 60% of subjects were inactive. Those who were physically active typically engaged in aerobic exercise but were much less likely to do the other guideline-recommended forms of exercise, namely flexibility, balance, and resistance training. The patients’ report of low engagement of their physicians “suggests an opportunity for more prescriptive exercise discussions,” according to the investigators.

Diabetes, a critical risk factor for cardiovascular disease, occurs at an increased incidence in PsA. This was demonstrated in a U.K. cohort study coauthored by Dr. Ogdie. The study, which included nearly 4,200 individuals with PsA, concluded that they had a 43% greater incidence of diabetes than the general population in an analysis adjusted for body mass index, smoking, alcohol use, and demographics.

New-onset diabetes can be readily picked up by rheumatologists based upon the laboratory work they often order at patient office visits, or during their review of symptoms, she noted, and added that the U.S. Preventive Services Task Force recommends ordering a hemoglobin A1c test every 3 years.

Dr. Ogdie reported receiving research grants and/or consulting fees from numerous pharmaceutical companies. Her research is also funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases, the Rheumatology Research Foundation, and the National Psoriasis Foundation.

[email protected]

Only about 30% or fewer of patients with psoriatic arthritis (PsA) on therapy achieve disease remission by any definition. One reason for this may be inadequate attention to common comorbid conditions, Alexis Ogdie, MD, MSCE, declared at the 2021 Rheumatology Winter Clinical Symposium.

Courtesy Dr. Alexis Ogdie

“I believe that addressing off-target aspects of disease is really important to improving the patient experience of their disease. We might need to target these directly in order to improve outcomes,” said Dr. Ogdie, a rheumatologist and epidemiologist at the University of Pennsylvania, Philadelphia, who coauthored the current American College of Rheumatology/National Psoriasis Foundation PsA guidelines.

Since rheumatologists are by now well informed about the increased cardiovascular risk associated with PsA, she focused on two common comorbidities that get less attention, both of which are associated with worse clinical outcomes in PsA: obesity and mental health issues.
 

Anxiety and depression

Dr. Ogdie was first author of a large, population-based, longitudinal cohort study of cause-specific mortality in 8,706 U.K. patients with PsA, 41,752 with RA, and more than 81,000 controls. Particularly striking was the finding of elevated mortality because of suicide in the rheumatic disease patients: a 203% increased risk in the PsA population, compared with the general population, and a 147% greater risk in patients with RA.

Overall, 30%-40% of PsA patients have comorbid depression and/or anxiety.

“That’s pretty striking. It’s also true for rheumatoid arthritis and axial spondyloarthritis. And if you’re depressed, you’re much less likely to respond to therapy in the way that we are measuring response to therapy,” Dr. Ogdie said.

Her approach to screening for depression and anxiety in her PsA patients, and indeed in all her other patients, is to begin by normalizing the topic, explaining to them that these affective disorders are common among patients with these disorders. She lets her patients know they can talk to her about it. And she informs them that, while effective treatment of their rheumatic disease may improve their depression or anxiety, managing those is also important for improving their disease. Additionally, understanding whether depression is present is important prior to prescribing certain medications. Apremilast (Otezla), for example, can worsen preexisting depression.

“Ask about signs and symptoms of depression,” Dr. Ogdie urged her colleagues. “I do this at every single visit in my review of symptoms. This is one I don’t skip. I ask: ‘Do you have any symptoms of depression or anxiety?’ ”

Structured evidence-based screening tools, many of which are well suited for completion during a patient’s preappointment check-in survey, include the Patient Health Questionnaire–2, the PHQ-9, the Patient-Reported Outcomes Measure Information System–10, PROMIS–Depression, and Routine Assessment of Patient Index Data 3.

“I also really like the PROMIS-29. It covers many domains of interest: depression and anxiety, sleep, fatigue, pain, physical function. It gives a lot of information about what’s going on in a patient’s life right now,” according to the rheumatologist.

The main thing is to regularly screen for anxiety and depression and then refer symptomatic patients for further assessment and treatment. This is not something that all rheumatologists have been trained to do.

Obesity

Dr. Ogdie was lead author of a national CORRONA Registry study which concluded that obese patients with PsA were only half as likely to achieve remission on a tumor necrosis factor (TNF) inhibitor, compared with nonobese patients. She believes the same holds true for all other types of therapy: Across the board, obesity is associated with a poor response. And obesity is much more common in PsA patients than the general population in every age group. Moreover, obesity is associated with risk factors for cardiovascular disease and is associated with fatty liver disease, two other major comorbid conditions in the PsA population.

The CORRONA Registry findings are supportive of an earlier Italian prospective, observational study of 135 obese and an equal number of normal-weight PsA patients, all of whom started on a TNF inhibitor and were followed for 24 months. In a multivariate-adjusted analysis, obesity was independently associated with a 390% higher risk of not achieving minimal disease activity.

The same Italian group subsequently conducted a prospective dietary intervention study in 138 overweight or obese patients with PsA starting anti-TNF therapy. A total of 59% of participants randomized to either of the two dietary interventions experienced at least a 5% weight loss at 6 months. The key study finding: Compared with the subjects with less than 5% weight loss, those with 5%-10% weight loss were 275% more likely to achieve minimal disease activity at 6 months, and in those with greater than 10% weight loss the likelihood of attaining minimal disease activity increased by 567%.

“We’re talking about a disease where treatments tested in clinical trials have odds ratios in the 1.2 range, compared with other therapies, so this is a really striking difference,” she observed.

Several studies have demonstrated that obesity in psoriasis patients is a risk factor for developing PsA. Recently, U.K. investigators took things a step further, reporting in a huge observational study that obese or overweight psoriasis patients who reduced their body mass index over a 10-year period had a corresponding reduction in the risk of developing PsA, compared with overweight or obese psoriasis patients whose BMI remained steady over the same period.

What’s needed now is access to programs to help patients with PsA lose weight. Health insurers are often unwilling to provide coverage. “We have a really tough time getting the patients in to see a nutritionist unless they’re willing to pay out of pocket,” Dr. Ogdie said.

Physical activity is an important element in successful weight loss. It also is recommended in practice guidelines for patients with inflammatory arthritis because of its salutary effects on disease activity scores, pain and stiffness, sleep, and quality of life. But a recent survey conducted by Dr. Ogdie and coworkers concluded that patients with PsA and other forms of inflammatory arthritis don’t receive much exercise guidance from their rheumatologists. About 60% of subjects were inactive. Those who were physically active typically engaged in aerobic exercise but were much less likely to do the other guideline-recommended forms of exercise, namely flexibility, balance, and resistance training. The patients’ report of low engagement of their physicians “suggests an opportunity for more prescriptive exercise discussions,” according to the investigators.

Diabetes, a critical risk factor for cardiovascular disease, occurs at an increased incidence in PsA. This was demonstrated in a U.K. cohort study coauthored by Dr. Ogdie. The study, which included nearly 4,200 individuals with PsA, concluded that they had a 43% greater incidence of diabetes than the general population in an analysis adjusted for body mass index, smoking, alcohol use, and demographics.

New-onset diabetes can be readily picked up by rheumatologists based upon the laboratory work they often order at patient office visits, or during their review of symptoms, she noted, and added that the U.S. Preventive Services Task Force recommends ordering a hemoglobin A1c test every 3 years.

Dr. Ogdie reported receiving research grants and/or consulting fees from numerous pharmaceutical companies. Her research is also funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases, the Rheumatology Research Foundation, and the National Psoriasis Foundation.

[email protected]

Only about 30% or fewer of patients with psoriatic arthritis (PsA) on therapy achieve disease remission by any definition. One reason for this may be inadequate attention to common comorbid conditions, Alexis Ogdie, MD, MSCE, declared at the 2021 Rheumatology Winter Clinical Symposium.

Courtesy Dr. Alexis Ogdie

“I believe that addressing off-target aspects of disease is really important to improving the patient experience of their disease. We might need to target these directly in order to improve outcomes,” said Dr. Ogdie, a rheumatologist and epidemiologist at the University of Pennsylvania, Philadelphia, who coauthored the current American College of Rheumatology/National Psoriasis Foundation PsA guidelines.

Since rheumatologists are by now well informed about the increased cardiovascular risk associated with PsA, she focused on two common comorbidities that get less attention, both of which are associated with worse clinical outcomes in PsA: obesity and mental health issues.
 

Anxiety and depression

Dr. Ogdie was first author of a large, population-based, longitudinal cohort study of cause-specific mortality in 8,706 U.K. patients with PsA, 41,752 with RA, and more than 81,000 controls. Particularly striking was the finding of elevated mortality because of suicide in the rheumatic disease patients: a 203% increased risk in the PsA population, compared with the general population, and a 147% greater risk in patients with RA.

Overall, 30%-40% of PsA patients have comorbid depression and/or anxiety.

“That’s pretty striking. It’s also true for rheumatoid arthritis and axial spondyloarthritis. And if you’re depressed, you’re much less likely to respond to therapy in the way that we are measuring response to therapy,” Dr. Ogdie said.

Her approach to screening for depression and anxiety in her PsA patients, and indeed in all her other patients, is to begin by normalizing the topic, explaining to them that these affective disorders are common among patients with these disorders. She lets her patients know they can talk to her about it. And she informs them that, while effective treatment of their rheumatic disease may improve their depression or anxiety, managing those is also important for improving their disease. Additionally, understanding whether depression is present is important prior to prescribing certain medications. Apremilast (Otezla), for example, can worsen preexisting depression.

“Ask about signs and symptoms of depression,” Dr. Ogdie urged her colleagues. “I do this at every single visit in my review of symptoms. This is one I don’t skip. I ask: ‘Do you have any symptoms of depression or anxiety?’ ”

Structured evidence-based screening tools, many of which are well suited for completion during a patient’s preappointment check-in survey, include the Patient Health Questionnaire–2, the PHQ-9, the Patient-Reported Outcomes Measure Information System–10, PROMIS–Depression, and Routine Assessment of Patient Index Data 3.

“I also really like the PROMIS-29. It covers many domains of interest: depression and anxiety, sleep, fatigue, pain, physical function. It gives a lot of information about what’s going on in a patient’s life right now,” according to the rheumatologist.

The main thing is to regularly screen for anxiety and depression and then refer symptomatic patients for further assessment and treatment. This is not something that all rheumatologists have been trained to do.

Obesity

Dr. Ogdie was lead author of a national CORRONA Registry study which concluded that obese patients with PsA were only half as likely to achieve remission on a tumor necrosis factor (TNF) inhibitor, compared with nonobese patients. She believes the same holds true for all other types of therapy: Across the board, obesity is associated with a poor response. And obesity is much more common in PsA patients than the general population in every age group. Moreover, obesity is associated with risk factors for cardiovascular disease and is associated with fatty liver disease, two other major comorbid conditions in the PsA population.

The CORRONA Registry findings are supportive of an earlier Italian prospective, observational study of 135 obese and an equal number of normal-weight PsA patients, all of whom started on a TNF inhibitor and were followed for 24 months. In a multivariate-adjusted analysis, obesity was independently associated with a 390% higher risk of not achieving minimal disease activity.

The same Italian group subsequently conducted a prospective dietary intervention study in 138 overweight or obese patients with PsA starting anti-TNF therapy. A total of 59% of participants randomized to either of the two dietary interventions experienced at least a 5% weight loss at 6 months. The key study finding: Compared with the subjects with less than 5% weight loss, those with 5%-10% weight loss were 275% more likely to achieve minimal disease activity at 6 months, and in those with greater than 10% weight loss the likelihood of attaining minimal disease activity increased by 567%.

“We’re talking about a disease where treatments tested in clinical trials have odds ratios in the 1.2 range, compared with other therapies, so this is a really striking difference,” she observed.

Several studies have demonstrated that obesity in psoriasis patients is a risk factor for developing PsA. Recently, U.K. investigators took things a step further, reporting in a huge observational study that obese or overweight psoriasis patients who reduced their body mass index over a 10-year period had a corresponding reduction in the risk of developing PsA, compared with overweight or obese psoriasis patients whose BMI remained steady over the same period.

What’s needed now is access to programs to help patients with PsA lose weight. Health insurers are often unwilling to provide coverage. “We have a really tough time getting the patients in to see a nutritionist unless they’re willing to pay out of pocket,” Dr. Ogdie said.

Physical activity is an important element in successful weight loss. It also is recommended in practice guidelines for patients with inflammatory arthritis because of its salutary effects on disease activity scores, pain and stiffness, sleep, and quality of life. But a recent survey conducted by Dr. Ogdie and coworkers concluded that patients with PsA and other forms of inflammatory arthritis don’t receive much exercise guidance from their rheumatologists. About 60% of subjects were inactive. Those who were physically active typically engaged in aerobic exercise but were much less likely to do the other guideline-recommended forms of exercise, namely flexibility, balance, and resistance training. The patients’ report of low engagement of their physicians “suggests an opportunity for more prescriptive exercise discussions,” according to the investigators.

Diabetes, a critical risk factor for cardiovascular disease, occurs at an increased incidence in PsA. This was demonstrated in a U.K. cohort study coauthored by Dr. Ogdie. The study, which included nearly 4,200 individuals with PsA, concluded that they had a 43% greater incidence of diabetes than the general population in an analysis adjusted for body mass index, smoking, alcohol use, and demographics.

New-onset diabetes can be readily picked up by rheumatologists based upon the laboratory work they often order at patient office visits, or during their review of symptoms, she noted, and added that the U.S. Preventive Services Task Force recommends ordering a hemoglobin A1c test every 3 years.

Dr. Ogdie reported receiving research grants and/or consulting fees from numerous pharmaceutical companies. Her research is also funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases, the Rheumatology Research Foundation, and the National Psoriasis Foundation.

[email protected]

Novel therapies have transformed the treatment of hemophilia in recent decades, but these new approaches also raise new challenges for clinicians who monitor joint health in persons with hemophilia, a specialist said.

“Patient-reported outcomes should be combined with other, more objective outcome measures for joint health monitoring, and joint ultrasound is a promising tool for objective joint health monitoring, although, due to its relatively recent introduction in clinical practice, we lack objective data and standardization,” said Roberta Gualtierotti, MD, PhD, from the Università Degli Studi of Milan.

She reviewed the challenges and approaches to monitoring joint health in persons with hemophilia during the annual congress of the European Association for Haemophilia and Allied Disorders.

Over the last decades the target of hemophilia treatment has shifted from prolonging survival to improving joint health and quality of life, and care has improved with the introduction of novel therapies such as extended half-life replacement products, nonreplacement therapies, and gene therapy, she noted.

However, “due to different pharmacodynamics and pharmacokinetics profiles, the currently available therapies cannot be compared to each other on several levels,” Dr. Gualtierotti said.

Laboratory monitoring of replacement therapies with standard coagulation assays may be unreliable, and depending on the mechanism of action and type of administration of nonreplacement agents, patients may experience breakthrough bleeding, especially after traumatic injury, she said.

Until the specific noncoagulatory effects of factor VIII on bone and joint health is better understood, close monitoring of patients will be required, she added.
 

Outcome measures

Subjective measures of joint health include patient-reported bleeding rates and health-related quality of life. These are practical for home management, but patients may not be able to distinguish symptoms of acute joint bleeding from chronic arthritis pain, with the potential for either under- or overtreatment, and subjective reporting is likely to miss subclinical bleeding that can occur even when patients are on prophylaxis.

Health-related quality of life tools, whether generic or specific for hemophilia, are not sensitive to small improvements, and they are not always used in routine clinical practice.

Objective measures include physical examination with scoring according to the World Federation of Hemophilia (Gilbert Scale) score or Hemophilia Joint Health Score, but these measures have limited ability to identify early or subclinical joint abnormalities.

“Therefore, joint physical examination on its own is not a sufficient measure of treatment efficacy, and it should be used in combination with other tools more objective, such as imaging,” Dr. Gualtierotti said.
 

Get the picture?

Imaging with x-rays, MRI, and, recently in some centers, point-of-care ultrasound can provide clinicians with important real-time information about the joint stability and health.

Point-of-care ultrasound in particular offers promise as a practical tool, with no ionizing radiation and high sensitivity for synovial hyperplasia subclinical joint effusion. It’s relatively inexpensive, can be used to image multiple joints, and allows for ease of follow-up, she said. The technique requires specialized training, however, and there is a lack of prospective data about its utility in hemophilia.

Various ultrasound scoring systems have been proposed, and home-based ultrasound is currently being explored in several clinical trials, Dr. Gualtierotti noted.

Other avenues for remote joint health monitoring under consideration are serum or synovial biomarkers for joint bleeding and arthropathy that could be employed at bedside or at home, smartphone apps for breakthrough bleeding and patient-reported outcomes, and sensors for detecting abnormalities in gait that may signal joint dysfunction, she said.
 

Best practice

In the question-and-answer session following the talk, Fernando Zikan, MD, from the Federal University of Rio de Janeiro noted that, “in underdeveloped countries, we still find it very difficult to guide good practices for joint health control by the patient and family members. Which strategy do you think is fundamental for the patient to feel safe to notice changes in his body?”

“It would be useful to educate patients to come to the center whenever the patient has trauma and whenever an increase in his physical activity occurs. If this is far, a bedside ultrasound evaluation by the general practitioner could help avoid joint damage. Finally, a correct rehabilitation is fundamental,” Dr. Gualtierotti replied.

Asked by several others whether she used ultrasound in her daily practice, Dr. Gualtierotti said that “we use joint ultrasound in our clinical practice in the regular annual check-up examination and whenever the patient suspects and reports hemarthrosis.”

Dr. Gualtierotti reported participation in advisory boards for Biomarin, Pfizer, Bayer, and Takeda, and in educational seminars sponsored by Pfizer, Sobi, and Roche. She has received support for congress travel and/or attendance by Bayer and Pfizer. Dr. Zikan reported no relevant disclosures.

Novel therapies have transformed the treatment of hemophilia in recent decades, but these new approaches also raise new challenges for clinicians who monitor joint health in persons with hemophilia, a specialist said.

“Patient-reported outcomes should be combined with other, more objective outcome measures for joint health monitoring, and joint ultrasound is a promising tool for objective joint health monitoring, although, due to its relatively recent introduction in clinical practice, we lack objective data and standardization,” said Roberta Gualtierotti, MD, PhD, from the Università Degli Studi of Milan.

She reviewed the challenges and approaches to monitoring joint health in persons with hemophilia during the annual congress of the European Association for Haemophilia and Allied Disorders.

Over the last decades the target of hemophilia treatment has shifted from prolonging survival to improving joint health and quality of life, and care has improved with the introduction of novel therapies such as extended half-life replacement products, nonreplacement therapies, and gene therapy, she noted.

However, “due to different pharmacodynamics and pharmacokinetics profiles, the currently available therapies cannot be compared to each other on several levels,” Dr. Gualtierotti said.

Laboratory monitoring of replacement therapies with standard coagulation assays may be unreliable, and depending on the mechanism of action and type of administration of nonreplacement agents, patients may experience breakthrough bleeding, especially after traumatic injury, she said.

Until the specific noncoagulatory effects of factor VIII on bone and joint health is better understood, close monitoring of patients will be required, she added.
 

Outcome measures

Subjective measures of joint health include patient-reported bleeding rates and health-related quality of life. These are practical for home management, but patients may not be able to distinguish symptoms of acute joint bleeding from chronic arthritis pain, with the potential for either under- or overtreatment, and subjective reporting is likely to miss subclinical bleeding that can occur even when patients are on prophylaxis.

Health-related quality of life tools, whether generic or specific for hemophilia, are not sensitive to small improvements, and they are not always used in routine clinical practice.

Objective measures include physical examination with scoring according to the World Federation of Hemophilia (Gilbert Scale) score or Hemophilia Joint Health Score, but these measures have limited ability to identify early or subclinical joint abnormalities.

“Therefore, joint physical examination on its own is not a sufficient measure of treatment efficacy, and it should be used in combination with other tools more objective, such as imaging,” Dr. Gualtierotti said.
 

Get the picture?

Imaging with x-rays, MRI, and, recently in some centers, point-of-care ultrasound can provide clinicians with important real-time information about the joint stability and health.

Point-of-care ultrasound in particular offers promise as a practical tool, with no ionizing radiation and high sensitivity for synovial hyperplasia subclinical joint effusion. It’s relatively inexpensive, can be used to image multiple joints, and allows for ease of follow-up, she said. The technique requires specialized training, however, and there is a lack of prospective data about its utility in hemophilia.

Various ultrasound scoring systems have been proposed, and home-based ultrasound is currently being explored in several clinical trials, Dr. Gualtierotti noted.

Other avenues for remote joint health monitoring under consideration are serum or synovial biomarkers for joint bleeding and arthropathy that could be employed at bedside or at home, smartphone apps for breakthrough bleeding and patient-reported outcomes, and sensors for detecting abnormalities in gait that may signal joint dysfunction, she said.
 

Best practice

In the question-and-answer session following the talk, Fernando Zikan, MD, from the Federal University of Rio de Janeiro noted that, “in underdeveloped countries, we still find it very difficult to guide good practices for joint health control by the patient and family members. Which strategy do you think is fundamental for the patient to feel safe to notice changes in his body?”

“It would be useful to educate patients to come to the center whenever the patient has trauma and whenever an increase in his physical activity occurs. If this is far, a bedside ultrasound evaluation by the general practitioner could help avoid joint damage. Finally, a correct rehabilitation is fundamental,” Dr. Gualtierotti replied.

Asked by several others whether she used ultrasound in her daily practice, Dr. Gualtierotti said that “we use joint ultrasound in our clinical practice in the regular annual check-up examination and whenever the patient suspects and reports hemarthrosis.”

Dr. Gualtierotti reported participation in advisory boards for Biomarin, Pfizer, Bayer, and Takeda, and in educational seminars sponsored by Pfizer, Sobi, and Roche. She has received support for congress travel and/or attendance by Bayer and Pfizer. Dr. Zikan reported no relevant disclosures.

Novel therapies have transformed the treatment of hemophilia in recent decades, but these new approaches also raise new challenges for clinicians who monitor joint health in persons with hemophilia, a specialist said.

“Patient-reported outcomes should be combined with other, more objective outcome measures for joint health monitoring, and joint ultrasound is a promising tool for objective joint health monitoring, although, due to its relatively recent introduction in clinical practice, we lack objective data and standardization,” said Roberta Gualtierotti, MD, PhD, from the Università Degli Studi of Milan.

She reviewed the challenges and approaches to monitoring joint health in persons with hemophilia during the annual congress of the European Association for Haemophilia and Allied Disorders.

Over the last decades the target of hemophilia treatment has shifted from prolonging survival to improving joint health and quality of life, and care has improved with the introduction of novel therapies such as extended half-life replacement products, nonreplacement therapies, and gene therapy, she noted.

However, “due to different pharmacodynamics and pharmacokinetics profiles, the currently available therapies cannot be compared to each other on several levels,” Dr. Gualtierotti said.

Laboratory monitoring of replacement therapies with standard coagulation assays may be unreliable, and depending on the mechanism of action and type of administration of nonreplacement agents, patients may experience breakthrough bleeding, especially after traumatic injury, she said.

Until the specific noncoagulatory effects of factor VIII on bone and joint health is better understood, close monitoring of patients will be required, she added.
 

Outcome measures

Subjective measures of joint health include patient-reported bleeding rates and health-related quality of life. These are practical for home management, but patients may not be able to distinguish symptoms of acute joint bleeding from chronic arthritis pain, with the potential for either under- or overtreatment, and subjective reporting is likely to miss subclinical bleeding that can occur even when patients are on prophylaxis.

Health-related quality of life tools, whether generic or specific for hemophilia, are not sensitive to small improvements, and they are not always used in routine clinical practice.

Objective measures include physical examination with scoring according to the World Federation of Hemophilia (Gilbert Scale) score or Hemophilia Joint Health Score, but these measures have limited ability to identify early or subclinical joint abnormalities.

“Therefore, joint physical examination on its own is not a sufficient measure of treatment efficacy, and it should be used in combination with other tools more objective, such as imaging,” Dr. Gualtierotti said.
 

Get the picture?

Imaging with x-rays, MRI, and, recently in some centers, point-of-care ultrasound can provide clinicians with important real-time information about the joint stability and health.

Point-of-care ultrasound in particular offers promise as a practical tool, with no ionizing radiation and high sensitivity for synovial hyperplasia subclinical joint effusion. It’s relatively inexpensive, can be used to image multiple joints, and allows for ease of follow-up, she said. The technique requires specialized training, however, and there is a lack of prospective data about its utility in hemophilia.

Various ultrasound scoring systems have been proposed, and home-based ultrasound is currently being explored in several clinical trials, Dr. Gualtierotti noted.

Other avenues for remote joint health monitoring under consideration are serum or synovial biomarkers for joint bleeding and arthropathy that could be employed at bedside or at home, smartphone apps for breakthrough bleeding and patient-reported outcomes, and sensors for detecting abnormalities in gait that may signal joint dysfunction, she said.
 

Best practice

In the question-and-answer session following the talk, Fernando Zikan, MD, from the Federal University of Rio de Janeiro noted that, “in underdeveloped countries, we still find it very difficult to guide good practices for joint health control by the patient and family members. Which strategy do you think is fundamental for the patient to feel safe to notice changes in his body?”

“It would be useful to educate patients to come to the center whenever the patient has trauma and whenever an increase in his physical activity occurs. If this is far, a bedside ultrasound evaluation by the general practitioner could help avoid joint damage. Finally, a correct rehabilitation is fundamental,” Dr. Gualtierotti replied.

Asked by several others whether she used ultrasound in her daily practice, Dr. Gualtierotti said that “we use joint ultrasound in our clinical practice in the regular annual check-up examination and whenever the patient suspects and reports hemarthrosis.”

Dr. Gualtierotti reported participation in advisory boards for Biomarin, Pfizer, Bayer, and Takeda, and in educational seminars sponsored by Pfizer, Sobi, and Roche. She has received support for congress travel and/or attendance by Bayer and Pfizer. Dr. Zikan reported no relevant disclosures.

The Society of Hospital Medicine has announced its 2021 class of Master Fellows, Senior Fellows, and Fellows in Hospital Medicine.

All Fellowship classes are listed in alphabetical order.
 

Master Fellows Class of 2021

Nasim Afsar, MD, MBA, MHM

Shaun D. Frost, MD, MHM

Jeffrey L. Schnipper, MD, MPH, MHM

Senior Fellows Class of 2021

Akindele Adaramola, MD, MPH, SFHM

Ramesh Adhikari, MD, SFHM

Pankaj Agrawal, MD, SFHM

Robert L. Anderson, MD, SFHM

Glenda B. Atilano, MD, SFHM

Bi A. Awosika, MD, FACP, SFHM

David N. Aymond, MD, SFHM

Paula Bailey, MD, SFHM

Amit B. Bansal, MD, MBA, SFHM

Jamie K. Bartley, DO, FACP, SFHM

Stephen J. Behnke, MD, SFHM

Christina A. Beyer, MD, SFHM

Vinil K. Bhuma, MD, SFHM

John P. Biebelhausen, MD, MBA, SFHM

Matthew T. Calestino, MD, FACP, SFHM

Domingo Caparas Jr., MD, FAAFP, SFHM

Darren Caudill, DO, FACP, SFHM

Julie M. Cernanec, MD, FAAP, SFHM

Will Cushing, PA-C, SFHM

Douglas A. Dodds II, MD, FAAP, SFHM

Coley B. Duncan, MD, CPE, MMM, SFHM

Noah Finkel, MD, SFHM

Justin Glasgow, MD, PhD, SFHM

Taylor Goot, MD, SFHM

Craig G. Gunderson, MD, SFHM

Alan Hall, MD, SFHM

Vivian Hamlett, MD, SFHM

Kathrin Harrington, MD, SFHM

Hossan Hassan, MD, SFHM

Anand D. Hongalgi, MD, FACP, SFHM

Akshata Hopkins, MD, FAAP, SFHM

Neelima Kamineni, MD, SFHM

Sudheer R. Kantharajpur, MBBS, MD, MHA, SFHM

Prakash Karki, MD, SFHM

Susrutha Kotwal, MD, SFHM

Ethan Kuperman, MD, SFHM

Rumman A. Langah, MD, FACP, SFHM

Sean LaVine, MD, FACP, SFHM

Don S. Lee, MD, FACP, SFHM

Charmaine A. Lewis, MD, MPH, CLHM, SFHM

Rishi Likhi, MD, SFHM

Lenny Lopez, MD, MPH, SFHM

Anthony Macchiavelli, MD, SFHM

Brian McGillen, MD, FACP, SFHM

Parth H. Mehta, MBBS, MD, MPH, SFHM

Anuj Mehta, MBBS, MD, MBA, SFHM

Prem Nair, MD, FACP, SFHM

Don J. Neer, MD, FACP, SFHM

Shyam Odeti, MD, FAAFP, SFHM

Amy T. O’Linn, DO, SFHM

Mihir Patel, MD, FACP, MBA, MPH, SFHM

Kimberly S. Pedram, MD, FACP, SFHM

Thomas Pineo, DO, SFHM

Mauricio Pinto, MD, SFHM

Lakmali C. Ranathunga, MBBS, SFHM

Matthew Reuter, MD, SFHM

Erik P. Rufa, MD, SFHM

Dipali Ruby Sahoo, DO, MBA, SFHM

Chady Sarraf, MD, SFHM

Suchita S. Sata, MD, SFHM

Klint Schwenk, MD, FAAP, MBA, SFHM

Aaron M. Sebach, CRNP, DNP, MBA, PhD, SFHM

Kevin Sowti, MD, MBA, SFHM

Joseph G. Surber, DO, FAAFP, SFHM

Bright Thilagar, MD, SFHM

Thomas S. Trawick Jr., MD, SFHM

Rehman Usmani, MD, SFHM

Arash Velayati, MD, SFHM

Jose A. Ventura, MD, FAAFP, SFHM

Andre Wajner, MD, PhD, SFHM

Phillip D. Warr, MD, SFHM

Virginia E. Watson, MD, SFHM

Kristin R. Wise, MD, SFHM

Elham A. Yousef, MD, FACP, MBA, MSc, SFHM

Fellows Class of 2021

Elizabeth M. Aarons, MD, FHM

Suhail A. Abbasi, MD, FACP, FHM

Waqas Adeel, MD, FHM

Rajender K. Agarwal, MD, MBA, MPH, FHM

Khaalisha Ajala, MD, MBA, FHM

Faraz S. Alam, MD, FHM

Amee Amin, MD, FHM

Muhammad W. Amir, MD, FACP, FHM

Saba Asad, MD, FHM

Logan Atkins, MD, FHM

Navneet Attri, MD, FHM

Jennifer Barnett, PA, FHM

Karyn Baum, MD, FHM

Prabhjot Bedi, MD, FHM

Nicolle R. Benz, DO, FHM

Ricky Bhimani, MD, FHM

Elizabeth Blankenship, PA-C, FHM

Rahul Borsadia, MD, FHM

Kalpana Chalasani, MD, FHM

Rani Chikkanna, MD, FHM

Venu Chippa, MBBS, MD, FHM

Lisa M. Coontz, FNP, FHM

Christie Crawford, MD, FHM

Rene Daniel, MD, PhD, FHM

Elda Dede, FHM

Radha Denmark, CNP, FHM

Alvine N. Nwehla Desamours, PA-C, FHM

Satyendra Dhar, MD, FHM

Manuel Jose Diaz, MD, FHM

Tiffany Egbe, MD, FHM

Chinwe Egbo, MD, FHM

Mohammad A. Farkhondehpour, MD, FACP, FHM

Shaheen Faruque, MBBS, FHM

Chris W. Fellin, MD, FACP, FHM

Juan Carlos Fuentes-Rosales, MD, FACP, MPH, FHM

Evelyn W. Gathecha, MD, FHM

Benjamin P. Geisler, MD, FACP, MPH, FHM

Matthew George, MD, FHM

Sonia George, DO, FHM

Mirna Giordano, MD, FHM

Rebecca Gomez, MD, FHM

David Gonzales, MD, FHM

Maria A. Guevara Hernandez, MD, FACP, FHM

Shubhra Gupta, MBBS, FHM

Rohini Harvey, MD, FHM

Allison Heinen, DO, FHM

Hollie L. Hurner, PA-C, FHM

Doug Hutcheon, MD, FHM

Varalakshmi Janamanchi, MD, FHM

Brian Keegan, MD, FACP, FHM

Qasim Khalil, MD, FHM

Irfana Khan, MD, FHM

Muhammad O. Khan, MD, FAAFP, MBA, FHM

Smita Kohli, MD, FHM

Julie Kolinski, MD, FAAP, FHM

Ewa Kontny, MD, FHM

Sungmi Lian, MD, FHM

Brian Lichtenstein, MD, FHM

Fernando Madero Gorostieta, MD, FHM

Vipul Mahajan, MD, FACP, FHM

Neetu Mahendraker, MD, FHM

Victoria McCurry, MD, FHM

Bridget McGrath, PA-C, FHM

Evan Meadors, MD, FHM

Kapil Mehta, MD, FACP, MBA, FHM

Waseem Mohamed, MD, FHM

Ernest Murray, MD, FHM

Murali K. Nagubandi, MD, FHM

Jessica Nave Allen, MD, FHM

Peter Nwafor, MD, FACP, FHM

Ike Anthony Nwaobi, MBBS, MBA, FHM

Olugbenga B. Ojo, MD, FACP, MBA, FHM

Jacqueline Okere, MD, FHM

Ifedolapo S. Olanrewaju, MD, MBchB, FHM

Mobolaji Olulade, MD, FHM

Elizabeth H. Papetti, MBA, FHM

Love Patel, MBBS, FHM

Kamakshya P. Patra, MD, MMM, FHM

Charles Pizanis, MD, FHM

Rajat Prakash, MD, FHM

Chris Pribula, MD, FHM

Michael Puchaev, MD, FHM

Ryan Punsalan, MD, FHM

Bhavya Rajanna, MD, FHM

Miguel A. Ramirez, MD, FHM

Raymund Ramirez, MD, FHM

Sandeep Randhawa, MBBS, FHM

Rohit Rattan, MD, FHM

Denisha Powell Rawlings, MD, FHM

Praveen K. Reddy, MD, MPH, FHM

Michael Ree, DO, MPH, FHM

Patrick Rendon, MD, FHM

David J. Rizk, MD, FAAFP, MBA, FHM

Michael Roberts, MD, FHM

Edwin Rosas, MD, FHM

Devjit Roy, MD, FHM

Sabyasachi Roy, MD, FHM

Paul Sandroni, CMPE, MSM, FHM

Vijairam Selvaraj, MD, MPH, FHM

Megha Shah, MD, MMM, FHM

Edie Shen, MD, FHM

Gurpinder Singh, MD, FACP, FHM

Vishwas A. Singh, MD, FHM

Karen Slatkovsky, MD, FHM

Sean M. Snyder, MD, FHM

Jaclyn Spiegel, MD, FHM

Dale Stapler Jr., MD, FHM

Christina E. Stovall, MD, FHM

Daniel Suders, DO, FHM

Clayton Swalstad, CMPE, MSM, FHM

Harshil Swaminarayan, MD, FHM

Keniesha Thompson, MD, FHM

Tet Toe, MD, FACP, FHM

Christine Tsai, MD, FHM

Ajay Vaikuntam, MD, FHM

Valerie Vaughn, MD, FHM

Jane N. Wainaina, FACP, MBchB, FHM

Neshahthari Wijeyakuhan, MD, FACP, FHM

Chia-Shing Yang, MD, FHM

Jennifer Zagursky, MD, FHM

The Society of Hospital Medicine has announced its 2021 class of Master Fellows, Senior Fellows, and Fellows in Hospital Medicine.

All Fellowship classes are listed in alphabetical order.
 

Master Fellows Class of 2021

Nasim Afsar, MD, MBA, MHM

Shaun D. Frost, MD, MHM

Jeffrey L. Schnipper, MD, MPH, MHM

Senior Fellows Class of 2021

Akindele Adaramola, MD, MPH, SFHM

Ramesh Adhikari, MD, SFHM

Pankaj Agrawal, MD, SFHM

Robert L. Anderson, MD, SFHM

Glenda B. Atilano, MD, SFHM

Bi A. Awosika, MD, FACP, SFHM

David N. Aymond, MD, SFHM

Paula Bailey, MD, SFHM

Amit B. Bansal, MD, MBA, SFHM

Jamie K. Bartley, DO, FACP, SFHM

Stephen J. Behnke, MD, SFHM

Christina A. Beyer, MD, SFHM

Vinil K. Bhuma, MD, SFHM

John P. Biebelhausen, MD, MBA, SFHM

Matthew T. Calestino, MD, FACP, SFHM

Domingo Caparas Jr., MD, FAAFP, SFHM

Darren Caudill, DO, FACP, SFHM

Julie M. Cernanec, MD, FAAP, SFHM

Will Cushing, PA-C, SFHM

Douglas A. Dodds II, MD, FAAP, SFHM

Coley B. Duncan, MD, CPE, MMM, SFHM

Noah Finkel, MD, SFHM

Justin Glasgow, MD, PhD, SFHM

Taylor Goot, MD, SFHM

Craig G. Gunderson, MD, SFHM

Alan Hall, MD, SFHM

Vivian Hamlett, MD, SFHM

Kathrin Harrington, MD, SFHM

Hossan Hassan, MD, SFHM

Anand D. Hongalgi, MD, FACP, SFHM

Akshata Hopkins, MD, FAAP, SFHM

Neelima Kamineni, MD, SFHM

Sudheer R. Kantharajpur, MBBS, MD, MHA, SFHM

Prakash Karki, MD, SFHM

Susrutha Kotwal, MD, SFHM

Ethan Kuperman, MD, SFHM

Rumman A. Langah, MD, FACP, SFHM

Sean LaVine, MD, FACP, SFHM

Don S. Lee, MD, FACP, SFHM

Charmaine A. Lewis, MD, MPH, CLHM, SFHM

Rishi Likhi, MD, SFHM

Lenny Lopez, MD, MPH, SFHM

Anthony Macchiavelli, MD, SFHM

Brian McGillen, MD, FACP, SFHM

Parth H. Mehta, MBBS, MD, MPH, SFHM

Anuj Mehta, MBBS, MD, MBA, SFHM

Prem Nair, MD, FACP, SFHM

Don J. Neer, MD, FACP, SFHM

Shyam Odeti, MD, FAAFP, SFHM

Amy T. O’Linn, DO, SFHM

Mihir Patel, MD, FACP, MBA, MPH, SFHM

Kimberly S. Pedram, MD, FACP, SFHM

Thomas Pineo, DO, SFHM

Mauricio Pinto, MD, SFHM

Lakmali C. Ranathunga, MBBS, SFHM

Matthew Reuter, MD, SFHM

Erik P. Rufa, MD, SFHM

Dipali Ruby Sahoo, DO, MBA, SFHM

Chady Sarraf, MD, SFHM

Suchita S. Sata, MD, SFHM

Klint Schwenk, MD, FAAP, MBA, SFHM

Aaron M. Sebach, CRNP, DNP, MBA, PhD, SFHM

Kevin Sowti, MD, MBA, SFHM

Joseph G. Surber, DO, FAAFP, SFHM

Bright Thilagar, MD, SFHM

Thomas S. Trawick Jr., MD, SFHM

Rehman Usmani, MD, SFHM

Arash Velayati, MD, SFHM

Jose A. Ventura, MD, FAAFP, SFHM

Andre Wajner, MD, PhD, SFHM

Phillip D. Warr, MD, SFHM

Virginia E. Watson, MD, SFHM

Kristin R. Wise, MD, SFHM

Elham A. Yousef, MD, FACP, MBA, MSc, SFHM

Fellows Class of 2021

Elizabeth M. Aarons, MD, FHM

Suhail A. Abbasi, MD, FACP, FHM

Waqas Adeel, MD, FHM

Rajender K. Agarwal, MD, MBA, MPH, FHM

Khaalisha Ajala, MD, MBA, FHM

Faraz S. Alam, MD, FHM

Amee Amin, MD, FHM

Muhammad W. Amir, MD, FACP, FHM

Saba Asad, MD, FHM

Logan Atkins, MD, FHM

Navneet Attri, MD, FHM

Jennifer Barnett, PA, FHM

Karyn Baum, MD, FHM

Prabhjot Bedi, MD, FHM

Nicolle R. Benz, DO, FHM

Ricky Bhimani, MD, FHM

Elizabeth Blankenship, PA-C, FHM

Rahul Borsadia, MD, FHM

Kalpana Chalasani, MD, FHM

Rani Chikkanna, MD, FHM

Venu Chippa, MBBS, MD, FHM

Lisa M. Coontz, FNP, FHM

Christie Crawford, MD, FHM

Rene Daniel, MD, PhD, FHM

Elda Dede, FHM

Radha Denmark, CNP, FHM

Alvine N. Nwehla Desamours, PA-C, FHM

Satyendra Dhar, MD, FHM

Manuel Jose Diaz, MD, FHM

Tiffany Egbe, MD, FHM

Chinwe Egbo, MD, FHM

Mohammad A. Farkhondehpour, MD, FACP, FHM

Shaheen Faruque, MBBS, FHM

Chris W. Fellin, MD, FACP, FHM

Juan Carlos Fuentes-Rosales, MD, FACP, MPH, FHM

Evelyn W. Gathecha, MD, FHM

Benjamin P. Geisler, MD, FACP, MPH, FHM

Matthew George, MD, FHM

Sonia George, DO, FHM

Mirna Giordano, MD, FHM

Rebecca Gomez, MD, FHM

David Gonzales, MD, FHM

Maria A. Guevara Hernandez, MD, FACP, FHM

Shubhra Gupta, MBBS, FHM

Rohini Harvey, MD, FHM

Allison Heinen, DO, FHM

Hollie L. Hurner, PA-C, FHM

Doug Hutcheon, MD, FHM

Varalakshmi Janamanchi, MD, FHM

Brian Keegan, MD, FACP, FHM

Qasim Khalil, MD, FHM

Irfana Khan, MD, FHM

Muhammad O. Khan, MD, FAAFP, MBA, FHM

Smita Kohli, MD, FHM

Julie Kolinski, MD, FAAP, FHM

Ewa Kontny, MD, FHM

Sungmi Lian, MD, FHM

Brian Lichtenstein, MD, FHM

Fernando Madero Gorostieta, MD, FHM

Vipul Mahajan, MD, FACP, FHM

Neetu Mahendraker, MD, FHM

Victoria McCurry, MD, FHM

Bridget McGrath, PA-C, FHM

Evan Meadors, MD, FHM

Kapil Mehta, MD, FACP, MBA, FHM

Waseem Mohamed, MD, FHM

Ernest Murray, MD, FHM

Murali K. Nagubandi, MD, FHM

Jessica Nave Allen, MD, FHM

Peter Nwafor, MD, FACP, FHM

Ike Anthony Nwaobi, MBBS, MBA, FHM

Olugbenga B. Ojo, MD, FACP, MBA, FHM

Jacqueline Okere, MD, FHM

Ifedolapo S. Olanrewaju, MD, MBchB, FHM

Mobolaji Olulade, MD, FHM

Elizabeth H. Papetti, MBA, FHM

Love Patel, MBBS, FHM

Kamakshya P. Patra, MD, MMM, FHM

Charles Pizanis, MD, FHM

Rajat Prakash, MD, FHM

Chris Pribula, MD, FHM

Michael Puchaev, MD, FHM

Ryan Punsalan, MD, FHM

Bhavya Rajanna, MD, FHM

Miguel A. Ramirez, MD, FHM

Raymund Ramirez, MD, FHM

Sandeep Randhawa, MBBS, FHM

Rohit Rattan, MD, FHM

Denisha Powell Rawlings, MD, FHM

Praveen K. Reddy, MD, MPH, FHM

Michael Ree, DO, MPH, FHM

Patrick Rendon, MD, FHM

David J. Rizk, MD, FAAFP, MBA, FHM

Michael Roberts, MD, FHM

Edwin Rosas, MD, FHM

Devjit Roy, MD, FHM

Sabyasachi Roy, MD, FHM

Paul Sandroni, CMPE, MSM, FHM

Vijairam Selvaraj, MD, MPH, FHM

Megha Shah, MD, MMM, FHM

Edie Shen, MD, FHM

Gurpinder Singh, MD, FACP, FHM

Vishwas A. Singh, MD, FHM

Karen Slatkovsky, MD, FHM

Sean M. Snyder, MD, FHM

Jaclyn Spiegel, MD, FHM

Dale Stapler Jr., MD, FHM

Christina E. Stovall, MD, FHM

Daniel Suders, DO, FHM

Clayton Swalstad, CMPE, MSM, FHM

Harshil Swaminarayan, MD, FHM

Keniesha Thompson, MD, FHM

Tet Toe, MD, FACP, FHM

Christine Tsai, MD, FHM

Ajay Vaikuntam, MD, FHM

Valerie Vaughn, MD, FHM

Jane N. Wainaina, FACP, MBchB, FHM

Neshahthari Wijeyakuhan, MD, FACP, FHM

Chia-Shing Yang, MD, FHM

Jennifer Zagursky, MD, FHM

The Society of Hospital Medicine has announced its 2021 class of Master Fellows, Senior Fellows, and Fellows in Hospital Medicine.

All Fellowship classes are listed in alphabetical order.
 

Master Fellows Class of 2021

Nasim Afsar, MD, MBA, MHM

Shaun D. Frost, MD, MHM

Jeffrey L. Schnipper, MD, MPH, MHM

Senior Fellows Class of 2021

Akindele Adaramola, MD, MPH, SFHM

Ramesh Adhikari, MD, SFHM

Pankaj Agrawal, MD, SFHM

Robert L. Anderson, MD, SFHM

Glenda B. Atilano, MD, SFHM

Bi A. Awosika, MD, FACP, SFHM

David N. Aymond, MD, SFHM

Paula Bailey, MD, SFHM

Amit B. Bansal, MD, MBA, SFHM

Jamie K. Bartley, DO, FACP, SFHM

Stephen J. Behnke, MD, SFHM

Christina A. Beyer, MD, SFHM

Vinil K. Bhuma, MD, SFHM

John P. Biebelhausen, MD, MBA, SFHM

Matthew T. Calestino, MD, FACP, SFHM

Domingo Caparas Jr., MD, FAAFP, SFHM

Darren Caudill, DO, FACP, SFHM

Julie M. Cernanec, MD, FAAP, SFHM

Will Cushing, PA-C, SFHM

Douglas A. Dodds II, MD, FAAP, SFHM

Coley B. Duncan, MD, CPE, MMM, SFHM

Noah Finkel, MD, SFHM

Justin Glasgow, MD, PhD, SFHM

Taylor Goot, MD, SFHM

Craig G. Gunderson, MD, SFHM

Alan Hall, MD, SFHM

Vivian Hamlett, MD, SFHM

Kathrin Harrington, MD, SFHM

Hossan Hassan, MD, SFHM

Anand D. Hongalgi, MD, FACP, SFHM

Akshata Hopkins, MD, FAAP, SFHM

Neelima Kamineni, MD, SFHM

Sudheer R. Kantharajpur, MBBS, MD, MHA, SFHM

Prakash Karki, MD, SFHM

Susrutha Kotwal, MD, SFHM

Ethan Kuperman, MD, SFHM

Rumman A. Langah, MD, FACP, SFHM

Sean LaVine, MD, FACP, SFHM

Don S. Lee, MD, FACP, SFHM

Charmaine A. Lewis, MD, MPH, CLHM, SFHM

Rishi Likhi, MD, SFHM

Lenny Lopez, MD, MPH, SFHM

Anthony Macchiavelli, MD, SFHM

Brian McGillen, MD, FACP, SFHM

Parth H. Mehta, MBBS, MD, MPH, SFHM

Anuj Mehta, MBBS, MD, MBA, SFHM

Prem Nair, MD, FACP, SFHM

Don J. Neer, MD, FACP, SFHM

Shyam Odeti, MD, FAAFP, SFHM

Amy T. O’Linn, DO, SFHM

Mihir Patel, MD, FACP, MBA, MPH, SFHM

Kimberly S. Pedram, MD, FACP, SFHM

Thomas Pineo, DO, SFHM

Mauricio Pinto, MD, SFHM

Lakmali C. Ranathunga, MBBS, SFHM

Matthew Reuter, MD, SFHM

Erik P. Rufa, MD, SFHM

Dipali Ruby Sahoo, DO, MBA, SFHM

Chady Sarraf, MD, SFHM

Suchita S. Sata, MD, SFHM

Klint Schwenk, MD, FAAP, MBA, SFHM

Aaron M. Sebach, CRNP, DNP, MBA, PhD, SFHM

Kevin Sowti, MD, MBA, SFHM

Joseph G. Surber, DO, FAAFP, SFHM

Bright Thilagar, MD, SFHM

Thomas S. Trawick Jr., MD, SFHM

Rehman Usmani, MD, SFHM

Arash Velayati, MD, SFHM

Jose A. Ventura, MD, FAAFP, SFHM

Andre Wajner, MD, PhD, SFHM

Phillip D. Warr, MD, SFHM

Virginia E. Watson, MD, SFHM

Kristin R. Wise, MD, SFHM

Elham A. Yousef, MD, FACP, MBA, MSc, SFHM

Fellows Class of 2021

Elizabeth M. Aarons, MD, FHM

Suhail A. Abbasi, MD, FACP, FHM

Waqas Adeel, MD, FHM

Rajender K. Agarwal, MD, MBA, MPH, FHM

Khaalisha Ajala, MD, MBA, FHM

Faraz S. Alam, MD, FHM

Amee Amin, MD, FHM

Muhammad W. Amir, MD, FACP, FHM

Saba Asad, MD, FHM

Logan Atkins, MD, FHM

Navneet Attri, MD, FHM

Jennifer Barnett, PA, FHM

Karyn Baum, MD, FHM

Prabhjot Bedi, MD, FHM

Nicolle R. Benz, DO, FHM

Ricky Bhimani, MD, FHM

Elizabeth Blankenship, PA-C, FHM

Rahul Borsadia, MD, FHM

Kalpana Chalasani, MD, FHM

Rani Chikkanna, MD, FHM

Venu Chippa, MBBS, MD, FHM

Lisa M. Coontz, FNP, FHM

Christie Crawford, MD, FHM

Rene Daniel, MD, PhD, FHM

Elda Dede, FHM

Radha Denmark, CNP, FHM

Alvine N. Nwehla Desamours, PA-C, FHM

Satyendra Dhar, MD, FHM

Manuel Jose Diaz, MD, FHM

Tiffany Egbe, MD, FHM

Chinwe Egbo, MD, FHM

Mohammad A. Farkhondehpour, MD, FACP, FHM

Shaheen Faruque, MBBS, FHM

Chris W. Fellin, MD, FACP, FHM

Juan Carlos Fuentes-Rosales, MD, FACP, MPH, FHM

Evelyn W. Gathecha, MD, FHM

Benjamin P. Geisler, MD, FACP, MPH, FHM

Matthew George, MD, FHM

Sonia George, DO, FHM

Mirna Giordano, MD, FHM

Rebecca Gomez, MD, FHM

David Gonzales, MD, FHM

Maria A. Guevara Hernandez, MD, FACP, FHM

Shubhra Gupta, MBBS, FHM

Rohini Harvey, MD, FHM

Allison Heinen, DO, FHM

Hollie L. Hurner, PA-C, FHM

Doug Hutcheon, MD, FHM

Varalakshmi Janamanchi, MD, FHM

Brian Keegan, MD, FACP, FHM

Qasim Khalil, MD, FHM

Irfana Khan, MD, FHM

Muhammad O. Khan, MD, FAAFP, MBA, FHM

Smita Kohli, MD, FHM

Julie Kolinski, MD, FAAP, FHM

Ewa Kontny, MD, FHM

Sungmi Lian, MD, FHM

Brian Lichtenstein, MD, FHM

Fernando Madero Gorostieta, MD, FHM

Vipul Mahajan, MD, FACP, FHM

Neetu Mahendraker, MD, FHM

Victoria McCurry, MD, FHM

Bridget McGrath, PA-C, FHM

Evan Meadors, MD, FHM

Kapil Mehta, MD, FACP, MBA, FHM

Waseem Mohamed, MD, FHM

Ernest Murray, MD, FHM

Murali K. Nagubandi, MD, FHM

Jessica Nave Allen, MD, FHM

Peter Nwafor, MD, FACP, FHM

Ike Anthony Nwaobi, MBBS, MBA, FHM

Olugbenga B. Ojo, MD, FACP, MBA, FHM

Jacqueline Okere, MD, FHM

Ifedolapo S. Olanrewaju, MD, MBchB, FHM

Mobolaji Olulade, MD, FHM

Elizabeth H. Papetti, MBA, FHM

Love Patel, MBBS, FHM

Kamakshya P. Patra, MD, MMM, FHM

Charles Pizanis, MD, FHM

Rajat Prakash, MD, FHM

Chris Pribula, MD, FHM

Michael Puchaev, MD, FHM

Ryan Punsalan, MD, FHM

Bhavya Rajanna, MD, FHM

Miguel A. Ramirez, MD, FHM

Raymund Ramirez, MD, FHM

Sandeep Randhawa, MBBS, FHM

Rohit Rattan, MD, FHM

Denisha Powell Rawlings, MD, FHM

Praveen K. Reddy, MD, MPH, FHM

Michael Ree, DO, MPH, FHM

Patrick Rendon, MD, FHM

David J. Rizk, MD, FAAFP, MBA, FHM

Michael Roberts, MD, FHM

Edwin Rosas, MD, FHM

Devjit Roy, MD, FHM

Sabyasachi Roy, MD, FHM

Paul Sandroni, CMPE, MSM, FHM

Vijairam Selvaraj, MD, MPH, FHM

Megha Shah, MD, MMM, FHM

Edie Shen, MD, FHM

Gurpinder Singh, MD, FACP, FHM

Vishwas A. Singh, MD, FHM

Karen Slatkovsky, MD, FHM

Sean M. Snyder, MD, FHM

Jaclyn Spiegel, MD, FHM

Dale Stapler Jr., MD, FHM

Christina E. Stovall, MD, FHM

Daniel Suders, DO, FHM

Clayton Swalstad, CMPE, MSM, FHM

Harshil Swaminarayan, MD, FHM

Keniesha Thompson, MD, FHM

Tet Toe, MD, FACP, FHM

Christine Tsai, MD, FHM

Ajay Vaikuntam, MD, FHM

Valerie Vaughn, MD, FHM

Jane N. Wainaina, FACP, MBchB, FHM

Neshahthari Wijeyakuhan, MD, FACP, FHM

Chia-Shing Yang, MD, FHM

Jennifer Zagursky, MD, FHM