Manpreet Malik, MD, a hospitalist at Emory University, takes care of patients with COVID-19 at Grady Memorial Hospital in downtown Atlanta. Born in India but living in the United States for more than 10 years, he is awaiting permanent resident status. At the current pace of U.S. Citizenship and Immigration Services, that may be decades away.

Dr. Malik lives and works in the United States on an H-1B visa, which is based on employment in a specialty occupation. Although he has a job that he loves, his immigrant status, social life, and geographic location in the United States is, technically, entirely dependent on doing that job.

“For single-income families with doctors on visas, the pandemic brings anxiety and uncertainty about legal status in the U.S. in case the breadwinner gets sick, disabled or unemployed,” he said.

In a presentation to be given at the HM20 Virtual, hosted by the Society of Hospital Medicine, Dr. Malik will offer perspective on the current challenges facing immigrant hospitalists and health care workers, especially in a U.S. health care system stretched thin and one in which many health professionals born outside the United States are working on the front lines. These challenges should be motivation to make legislative changes to give these health care workers more stability, flexibility, and peace of mind, he said.

The talk – to be given along with HM20 course director Benji Mathews, MD, SFHM, and called “The Immigrant Hospitalist: Navigating the Uncertain Terrain During COVID-19” – will describe a long-standing issue and outline a path forward, the two physicians said.

“The objective of this talk is to really highlight the contributions of these physicians and health care workers and also to provide a call for action for our hospitalist colleagues. This talk paints a picture of what my family and thousands of the other immigrant health care worker families are going through,” Dr. Malik said.

Dr. Mathews said that many physicians do not have benefits they can fall back on should they fall ill. And without the jobs their visas are based on, they could face deportation.

“That’s extreme – but the pathway towards that is very much there,” said Dr. Mathews, who was born in the Middle East and immigrated to the United States, received a green card, and later his citizenship. He now advocates for immigrant health and immigrant health care workers.

Dr. Malik and Dr. Mathews recently published a perspective piece in the Journal of Hospital Medicine. In it, they pointed out that 16.4% of health care workers are immigrants, and 29% of physicians are immigrants. Among practicing hospitalists, 32% are international medical graduates. They called for reform to visa regulations to allow physicians who are immigrants to travel to areas where they are most needed during the pandemic, for extensions of visa deadlines, and exemption from future immigration bans or limitations. These measures would only bolster the health care workforce that is under such strain during the pandemic, they write. (J Hosp Med. 2020 Aug;15[8]:505-506)

Dr. Malik said that, even while under added personal strain caused by the uncertainty of the past several months, he has never questioned his decision to be a physician in the United States.

“Now, more than ever, there is a sense of purpose and a passion to make a difference for our patients,” he said.

“I think most of us get into medicine and become hospitalists because we want to care for people, because we want to serve, because we want to be able to take care of sick, hospitalized patients, and that can be anywhere in the world, whether you’re in India serving a population that you grew up with or whether you’re in the U.S. serving the population that are your neighbors, your friends, your community, or people that are vulnerable. You’re serving humanity, and that is the ultimate goal.”
 

SHM advocacy on immigration issues

SHM has been advocating for more equitable skilled-immigration system, recognizing that from visa-backlogs to per-country caps, unfair visa restrictions have limited the United States’ ability to adequately expand its health care workforce.

The Society has consistently advocated on Capitol Hill for visa and skilled-immigration reform and has championed several significant immigration bills, including the following:

The Fairness for High Skilled Immigrants Act

• This legislation will eliminate per-country caps on green cards and convert the system into a “first-come, first-serve” system. This will help ensure certain nationalize are not disproportionally impacted by excessive green card backlogs.
• This legislation has passed the House of Representatives. Send a message to your Senator asking them to cosponsor this legislation.

The Conrad State 30 Physician Reauthorization Act

• This legislation will renew the Conrad State 30 program, which allows physicians on a J-1 visa to remain in the United States if they work in an underserved region for a minimum of three years. This legislation also included additional employment protection claims.
•  

The Healthcare Workforce Resilience Act

• This legislation will recapture 40,000 unused immigrant visas for foreign doctors (15,000) and nurses (25,000), as well as provide visas for their spouse and children.
• This legislation will only be in effect for the duration of the COVID-19 public health emergency.

To join SHM in supporting our immigrant clinicians, you can send a message to your representatives in support of these bills by visiting hospitalmedicine.org/takeaction.
 

Manpreet Malik, MD, a hospitalist at Emory University, takes care of patients with COVID-19 at Grady Memorial Hospital in downtown Atlanta. Born in India but living in the United States for more than 10 years, he is awaiting permanent resident status. At the current pace of U.S. Citizenship and Immigration Services, that may be decades away.

Dr. Malik lives and works in the United States on an H-1B visa, which is based on employment in a specialty occupation. Although he has a job that he loves, his immigrant status, social life, and geographic location in the United States is, technically, entirely dependent on doing that job.

“For single-income families with doctors on visas, the pandemic brings anxiety and uncertainty about legal status in the U.S. in case the breadwinner gets sick, disabled or unemployed,” he said.

In a presentation to be given at the HM20 Virtual, hosted by the Society of Hospital Medicine, Dr. Malik will offer perspective on the current challenges facing immigrant hospitalists and health care workers, especially in a U.S. health care system stretched thin and one in which many health professionals born outside the United States are working on the front lines. These challenges should be motivation to make legislative changes to give these health care workers more stability, flexibility, and peace of mind, he said.

The talk – to be given along with HM20 course director Benji Mathews, MD, SFHM, and called “The Immigrant Hospitalist: Navigating the Uncertain Terrain During COVID-19” – will describe a long-standing issue and outline a path forward, the two physicians said.

“The objective of this talk is to really highlight the contributions of these physicians and health care workers and also to provide a call for action for our hospitalist colleagues. This talk paints a picture of what my family and thousands of the other immigrant health care worker families are going through,” Dr. Malik said.

Dr. Mathews said that many physicians do not have benefits they can fall back on should they fall ill. And without the jobs their visas are based on, they could face deportation.

“That’s extreme – but the pathway towards that is very much there,” said Dr. Mathews, who was born in the Middle East and immigrated to the United States, received a green card, and later his citizenship. He now advocates for immigrant health and immigrant health care workers.

Dr. Malik and Dr. Mathews recently published a perspective piece in the Journal of Hospital Medicine. In it, they pointed out that 16.4% of health care workers are immigrants, and 29% of physicians are immigrants. Among practicing hospitalists, 32% are international medical graduates. They called for reform to visa regulations to allow physicians who are immigrants to travel to areas where they are most needed during the pandemic, for extensions of visa deadlines, and exemption from future immigration bans or limitations. These measures would only bolster the health care workforce that is under such strain during the pandemic, they write. (J Hosp Med. 2020 Aug;15[8]:505-506)

Dr. Malik said that, even while under added personal strain caused by the uncertainty of the past several months, he has never questioned his decision to be a physician in the United States.

“Now, more than ever, there is a sense of purpose and a passion to make a difference for our patients,” he said.

“I think most of us get into medicine and become hospitalists because we want to care for people, because we want to serve, because we want to be able to take care of sick, hospitalized patients, and that can be anywhere in the world, whether you’re in India serving a population that you grew up with or whether you’re in the U.S. serving the population that are your neighbors, your friends, your community, or people that are vulnerable. You’re serving humanity, and that is the ultimate goal.”
 

SHM advocacy on immigration issues

SHM has been advocating for more equitable skilled-immigration system, recognizing that from visa-backlogs to per-country caps, unfair visa restrictions have limited the United States’ ability to adequately expand its health care workforce.

The Society has consistently advocated on Capitol Hill for visa and skilled-immigration reform and has championed several significant immigration bills, including the following:

The Fairness for High Skilled Immigrants Act

• This legislation will eliminate per-country caps on green cards and convert the system into a “first-come, first-serve” system. This will help ensure certain nationalize are not disproportionally impacted by excessive green card backlogs.
• This legislation has passed the House of Representatives. Send a message to your Senator asking them to cosponsor this legislation.

The Conrad State 30 Physician Reauthorization Act

• This legislation will renew the Conrad State 30 program, which allows physicians on a J-1 visa to remain in the United States if they work in an underserved region for a minimum of three years. This legislation also included additional employment protection claims.
•  

The Healthcare Workforce Resilience Act

• This legislation will recapture 40,000 unused immigrant visas for foreign doctors (15,000) and nurses (25,000), as well as provide visas for their spouse and children.
• This legislation will only be in effect for the duration of the COVID-19 public health emergency.

To join SHM in supporting our immigrant clinicians, you can send a message to your representatives in support of these bills by visiting hospitalmedicine.org/takeaction.
 

Manpreet Malik, MD, a hospitalist at Emory University, takes care of patients with COVID-19 at Grady Memorial Hospital in downtown Atlanta. Born in India but living in the United States for more than 10 years, he is awaiting permanent resident status. At the current pace of U.S. Citizenship and Immigration Services, that may be decades away.

Dr. Malik lives and works in the United States on an H-1B visa, which is based on employment in a specialty occupation. Although he has a job that he loves, his immigrant status, social life, and geographic location in the United States is, technically, entirely dependent on doing that job.

“For single-income families with doctors on visas, the pandemic brings anxiety and uncertainty about legal status in the U.S. in case the breadwinner gets sick, disabled or unemployed,” he said.

In a presentation to be given at the HM20 Virtual, hosted by the Society of Hospital Medicine, Dr. Malik will offer perspective on the current challenges facing immigrant hospitalists and health care workers, especially in a U.S. health care system stretched thin and one in which many health professionals born outside the United States are working on the front lines. These challenges should be motivation to make legislative changes to give these health care workers more stability, flexibility, and peace of mind, he said.

The talk – to be given along with HM20 course director Benji Mathews, MD, SFHM, and called “The Immigrant Hospitalist: Navigating the Uncertain Terrain During COVID-19” – will describe a long-standing issue and outline a path forward, the two physicians said.

“The objective of this talk is to really highlight the contributions of these physicians and health care workers and also to provide a call for action for our hospitalist colleagues. This talk paints a picture of what my family and thousands of the other immigrant health care worker families are going through,” Dr. Malik said.

Dr. Mathews said that many physicians do not have benefits they can fall back on should they fall ill. And without the jobs their visas are based on, they could face deportation.

“That’s extreme – but the pathway towards that is very much there,” said Dr. Mathews, who was born in the Middle East and immigrated to the United States, received a green card, and later his citizenship. He now advocates for immigrant health and immigrant health care workers.

Dr. Malik and Dr. Mathews recently published a perspective piece in the Journal of Hospital Medicine. In it, they pointed out that 16.4% of health care workers are immigrants, and 29% of physicians are immigrants. Among practicing hospitalists, 32% are international medical graduates. They called for reform to visa regulations to allow physicians who are immigrants to travel to areas where they are most needed during the pandemic, for extensions of visa deadlines, and exemption from future immigration bans or limitations. These measures would only bolster the health care workforce that is under such strain during the pandemic, they write. (J Hosp Med. 2020 Aug;15[8]:505-506)

Dr. Malik said that, even while under added personal strain caused by the uncertainty of the past several months, he has never questioned his decision to be a physician in the United States.

“Now, more than ever, there is a sense of purpose and a passion to make a difference for our patients,” he said.

“I think most of us get into medicine and become hospitalists because we want to care for people, because we want to serve, because we want to be able to take care of sick, hospitalized patients, and that can be anywhere in the world, whether you’re in India serving a population that you grew up with or whether you’re in the U.S. serving the population that are your neighbors, your friends, your community, or people that are vulnerable. You’re serving humanity, and that is the ultimate goal.”
 

SHM advocacy on immigration issues

SHM has been advocating for more equitable skilled-immigration system, recognizing that from visa-backlogs to per-country caps, unfair visa restrictions have limited the United States’ ability to adequately expand its health care workforce.

The Society has consistently advocated on Capitol Hill for visa and skilled-immigration reform and has championed several significant immigration bills, including the following:

The Fairness for High Skilled Immigrants Act

• This legislation will eliminate per-country caps on green cards and convert the system into a “first-come, first-serve” system. This will help ensure certain nationalize are not disproportionally impacted by excessive green card backlogs.
• This legislation has passed the House of Representatives. Send a message to your Senator asking them to cosponsor this legislation.

The Conrad State 30 Physician Reauthorization Act

• This legislation will renew the Conrad State 30 program, which allows physicians on a J-1 visa to remain in the United States if they work in an underserved region for a minimum of three years. This legislation also included additional employment protection claims.
•  

The Healthcare Workforce Resilience Act

• This legislation will recapture 40,000 unused immigrant visas for foreign doctors (15,000) and nurses (25,000), as well as provide visas for their spouse and children.
• This legislation will only be in effect for the duration of the COVID-19 public health emergency.

To join SHM in supporting our immigrant clinicians, you can send a message to your representatives in support of these bills by visiting hospitalmedicine.org/takeaction.
 

Nathan Chomilo, MD, the Medicaid medical director for the state of Minnesota and assistant adjunct professor of pediatrics at the University of Minnesota, Minneapolis, was prepared to deliver a talk on structural racism in the U.S. health care system at Hospital Medicine 2020 meeting (HM20) in April 2020. But that changed in the COVID-19 era.

When the pandemic hit, the problems Dr. Chomilo was going to point out began to play out dramatically around the country: Black, Indigenous, and Latinx people – many of them under-insured; in high-exposure, frontline jobs; and already burdened with health comorbidities – are at a higher risk of contracting COVID-19 and dying from it.

He will now be giving his talk at HM20 Virtual in a session called “Structural Racism and Bias in Hospital Medicine During Two Pandemics,” with the powerful narrative of COVID-19 to get his message to sink in: For centuries, the medical field and the health care system more broadly have enabled racism to play out in a structural way, and this is leading to sickness and death.

“It’s something that’s been going on since the start of our country,” said Dr. Chomilo, who is also a founding member of Minnesota Doctors for Health Equity. Physicians, he said, participated in upholding the institution of slavery by trying to describe the physical discrepancies between White people and non-White people.

Now, the way health care is provided in the United States fundamentally favors Whites over Black, Indigenous, and Latinx patients.

“We have a health care system here in the United States that is based on employer-sponsored insurance,” he said. “And who has had access to those jobs over the course of our country’s history has been mostly White people.” That impacts who is more at risk of contracting the virus, who is able to shelter in place, and who has the financial reserves to withstand furloughs and unemployment.

In a recent blog post in Health Affairs, Dr. Chomilo and his coauthors discussed articles from the New England Journal of Medicine and the Journal of the American Medical Association that try to offer an ethical framework for allocating scarce medical resources – such as intensive-care beds and ventilators – during the pandemic.

“Unfortunately, neither article acknowledged the structural racial inequities that inherently bias its proposals, nor did either piece adequately acknowledge how its care rationing plan might worsen already racially disparate health outcomes,” Dr. Chomilo and his coauthors wrote. For instance, the life expectancy of a White female in the United States is 81 years, compared with 72 years for Black males, and any allocation plan that prioritizes preserving years of life would automatically be tilted against black patients.

In his talk, Dr. Chomilo will also discuss how physicians can make a difference by looking at their own perceptions and habits and then start helping others and the systems in which they work.

“The first thing is, we have to look at ourselves,” he said.

In the same session, Benji Mathews, MD, SFHM – chief of hospital medicine at Regions Hospital in St. Paul, Minn., which is part of HealthPartners; associate professor of medicine at the University of Minnesota, Minneapolis; and the Annual Conference’s course director – said he will be discussing the way social inequities are “patterned by place” and how resources for staying healthy vary neighborhood to neighborhood. He will point to dense housing and multigenerational households as a chief driver of COVID-19 infection risk. People of color are often “first fired, last hired, and in the front lines of fire,” he said, and they are experiencing a more severe impact from the pandemic.

And he will get deeper into the other disparities that track along racial lines, such as insurance disparities. For instance, the percentage of African Americans on Medicaid is three times as high as the percentage of White, non-Hispanic patients, he said.

Dr. Mathews will also discuss race’s role in the biases that everyone has and how health care professionals might, with deliberate reflection, be able to reshape or mitigate their own biases and deliver care more equitably.

“The associations we have, and our biases, are not necessarily declared beliefs or even reflect our stances that we explicitly endorse – sometimes it comes through in our default stance, and generally favor our in-group,” he said. “These implicit biases are malleable, so that allows us some hope. There are some ways they can be unlearned or progressively acted upon with some coaching – some active, intentional development.”
 

Structural Racism and Bias in Hospital Medicine During Two Pandemics

Nathan Chomilo, MD, the Medicaid medical director for the state of Minnesota and assistant adjunct professor of pediatrics at the University of Minnesota, Minneapolis, was prepared to deliver a talk on structural racism in the U.S. health care system at Hospital Medicine 2020 meeting (HM20) in April 2020. But that changed in the COVID-19 era.

When the pandemic hit, the problems Dr. Chomilo was going to point out began to play out dramatically around the country: Black, Indigenous, and Latinx people – many of them under-insured; in high-exposure, frontline jobs; and already burdened with health comorbidities – are at a higher risk of contracting COVID-19 and dying from it.

He will now be giving his talk at HM20 Virtual in a session called “Structural Racism and Bias in Hospital Medicine During Two Pandemics,” with the powerful narrative of COVID-19 to get his message to sink in: For centuries, the medical field and the health care system more broadly have enabled racism to play out in a structural way, and this is leading to sickness and death.

“It’s something that’s been going on since the start of our country,” said Dr. Chomilo, who is also a founding member of Minnesota Doctors for Health Equity. Physicians, he said, participated in upholding the institution of slavery by trying to describe the physical discrepancies between White people and non-White people.

Now, the way health care is provided in the United States fundamentally favors Whites over Black, Indigenous, and Latinx patients.

“We have a health care system here in the United States that is based on employer-sponsored insurance,” he said. “And who has had access to those jobs over the course of our country’s history has been mostly White people.” That impacts who is more at risk of contracting the virus, who is able to shelter in place, and who has the financial reserves to withstand furloughs and unemployment.

In a recent blog post in Health Affairs, Dr. Chomilo and his coauthors discussed articles from the New England Journal of Medicine and the Journal of the American Medical Association that try to offer an ethical framework for allocating scarce medical resources – such as intensive-care beds and ventilators – during the pandemic.

“Unfortunately, neither article acknowledged the structural racial inequities that inherently bias its proposals, nor did either piece adequately acknowledge how its care rationing plan might worsen already racially disparate health outcomes,” Dr. Chomilo and his coauthors wrote. For instance, the life expectancy of a White female in the United States is 81 years, compared with 72 years for Black males, and any allocation plan that prioritizes preserving years of life would automatically be tilted against black patients.

In his talk, Dr. Chomilo will also discuss how physicians can make a difference by looking at their own perceptions and habits and then start helping others and the systems in which they work.

“The first thing is, we have to look at ourselves,” he said.

In the same session, Benji Mathews, MD, SFHM – chief of hospital medicine at Regions Hospital in St. Paul, Minn., which is part of HealthPartners; associate professor of medicine at the University of Minnesota, Minneapolis; and the Annual Conference’s course director – said he will be discussing the way social inequities are “patterned by place” and how resources for staying healthy vary neighborhood to neighborhood. He will point to dense housing and multigenerational households as a chief driver of COVID-19 infection risk. People of color are often “first fired, last hired, and in the front lines of fire,” he said, and they are experiencing a more severe impact from the pandemic.

And he will get deeper into the other disparities that track along racial lines, such as insurance disparities. For instance, the percentage of African Americans on Medicaid is three times as high as the percentage of White, non-Hispanic patients, he said.

Dr. Mathews will also discuss race’s role in the biases that everyone has and how health care professionals might, with deliberate reflection, be able to reshape or mitigate their own biases and deliver care more equitably.

“The associations we have, and our biases, are not necessarily declared beliefs or even reflect our stances that we explicitly endorse – sometimes it comes through in our default stance, and generally favor our in-group,” he said. “These implicit biases are malleable, so that allows us some hope. There are some ways they can be unlearned or progressively acted upon with some coaching – some active, intentional development.”
 

Structural Racism and Bias in Hospital Medicine During Two Pandemics

Nathan Chomilo, MD, the Medicaid medical director for the state of Minnesota and assistant adjunct professor of pediatrics at the University of Minnesota, Minneapolis, was prepared to deliver a talk on structural racism in the U.S. health care system at Hospital Medicine 2020 meeting (HM20) in April 2020. But that changed in the COVID-19 era.

When the pandemic hit, the problems Dr. Chomilo was going to point out began to play out dramatically around the country: Black, Indigenous, and Latinx people – many of them under-insured; in high-exposure, frontline jobs; and already burdened with health comorbidities – are at a higher risk of contracting COVID-19 and dying from it.

He will now be giving his talk at HM20 Virtual in a session called “Structural Racism and Bias in Hospital Medicine During Two Pandemics,” with the powerful narrative of COVID-19 to get his message to sink in: For centuries, the medical field and the health care system more broadly have enabled racism to play out in a structural way, and this is leading to sickness and death.

“It’s something that’s been going on since the start of our country,” said Dr. Chomilo, who is also a founding member of Minnesota Doctors for Health Equity. Physicians, he said, participated in upholding the institution of slavery by trying to describe the physical discrepancies between White people and non-White people.

Now, the way health care is provided in the United States fundamentally favors Whites over Black, Indigenous, and Latinx patients.

“We have a health care system here in the United States that is based on employer-sponsored insurance,” he said. “And who has had access to those jobs over the course of our country’s history has been mostly White people.” That impacts who is more at risk of contracting the virus, who is able to shelter in place, and who has the financial reserves to withstand furloughs and unemployment.

In a recent blog post in Health Affairs, Dr. Chomilo and his coauthors discussed articles from the New England Journal of Medicine and the Journal of the American Medical Association that try to offer an ethical framework for allocating scarce medical resources – such as intensive-care beds and ventilators – during the pandemic.

“Unfortunately, neither article acknowledged the structural racial inequities that inherently bias its proposals, nor did either piece adequately acknowledge how its care rationing plan might worsen already racially disparate health outcomes,” Dr. Chomilo and his coauthors wrote. For instance, the life expectancy of a White female in the United States is 81 years, compared with 72 years for Black males, and any allocation plan that prioritizes preserving years of life would automatically be tilted against black patients.

In his talk, Dr. Chomilo will also discuss how physicians can make a difference by looking at their own perceptions and habits and then start helping others and the systems in which they work.

“The first thing is, we have to look at ourselves,” he said.

In the same session, Benji Mathews, MD, SFHM – chief of hospital medicine at Regions Hospital in St. Paul, Minn., which is part of HealthPartners; associate professor of medicine at the University of Minnesota, Minneapolis; and the Annual Conference’s course director – said he will be discussing the way social inequities are “patterned by place” and how resources for staying healthy vary neighborhood to neighborhood. He will point to dense housing and multigenerational households as a chief driver of COVID-19 infection risk. People of color are often “first fired, last hired, and in the front lines of fire,” he said, and they are experiencing a more severe impact from the pandemic.

And he will get deeper into the other disparities that track along racial lines, such as insurance disparities. For instance, the percentage of African Americans on Medicaid is three times as high as the percentage of White, non-Hispanic patients, he said.

Dr. Mathews will also discuss race’s role in the biases that everyone has and how health care professionals might, with deliberate reflection, be able to reshape or mitigate their own biases and deliver care more equitably.

“The associations we have, and our biases, are not necessarily declared beliefs or even reflect our stances that we explicitly endorse – sometimes it comes through in our default stance, and generally favor our in-group,” he said. “These implicit biases are malleable, so that allows us some hope. There are some ways they can be unlearned or progressively acted upon with some coaching – some active, intentional development.”
 

Structural Racism and Bias in Hospital Medicine During Two Pandemics

Lindsey Criswell, MD, MPH, DSc, has been selected as the next director of the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS).

Dr. Criswell, vice chancellor of research at the University of California, San Francisco, will replace acting director Robert H. Carter, MD, who has overseen NIAMS since December 2018, following the unexpected death of longtime director Stephen I. Katz, MD, PhD, who had directed the institute since 1995. She will start her new role in early 2021, according to the NIH.

“Dr. Criswell has rich experience as a clinician, researcher, and administrator. Her ability to oversee the research program of one of the country’s top research-intensive medical schools, and her expertise in autoimmune diseases, including rheumatoid arthritis and lupus, make her well-positioned to direct NIAMS,” said NIH director Francis S. Collins, MD, PhD, said in an announcement.

Dr. Criswell, who holds the Kenneth H. Fye, M.D., endowed chair in rheumatology and the Jean S. Engleman Distinguished Professorship in Rheumatology at UCSF, spent most of her career at the university, focusing her research on the genetics and epidemiology of human autoimmune disease, particularly rheumatoid arthritis and systemic lupus erythematosus. Using genome-wide association and other genetic studies, her research team contributed to the identification of more than 30 genes linked to these disorders, according to the NIH.

NIAMS has a budget of nearly $625 million and its extramural research program supports scientific studies and research training and career development throughout the country through grants and contracts to research organizations in fields that include rheumatology, muscle biology, orthopedics, bone and mineral metabolism, and dermatology.

[email protected]

Lindsey Criswell, MD, MPH, DSc, has been selected as the next director of the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS).

Dr. Criswell, vice chancellor of research at the University of California, San Francisco, will replace acting director Robert H. Carter, MD, who has overseen NIAMS since December 2018, following the unexpected death of longtime director Stephen I. Katz, MD, PhD, who had directed the institute since 1995. She will start her new role in early 2021, according to the NIH.

“Dr. Criswell has rich experience as a clinician, researcher, and administrator. Her ability to oversee the research program of one of the country’s top research-intensive medical schools, and her expertise in autoimmune diseases, including rheumatoid arthritis and lupus, make her well-positioned to direct NIAMS,” said NIH director Francis S. Collins, MD, PhD, said in an announcement.

Dr. Criswell, who holds the Kenneth H. Fye, M.D., endowed chair in rheumatology and the Jean S. Engleman Distinguished Professorship in Rheumatology at UCSF, spent most of her career at the university, focusing her research on the genetics and epidemiology of human autoimmune disease, particularly rheumatoid arthritis and systemic lupus erythematosus. Using genome-wide association and other genetic studies, her research team contributed to the identification of more than 30 genes linked to these disorders, according to the NIH.

NIAMS has a budget of nearly $625 million and its extramural research program supports scientific studies and research training and career development throughout the country through grants and contracts to research organizations in fields that include rheumatology, muscle biology, orthopedics, bone and mineral metabolism, and dermatology.

[email protected]

Lindsey Criswell, MD, MPH, DSc, has been selected as the next director of the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS).

Dr. Criswell, vice chancellor of research at the University of California, San Francisco, will replace acting director Robert H. Carter, MD, who has overseen NIAMS since December 2018, following the unexpected death of longtime director Stephen I. Katz, MD, PhD, who had directed the institute since 1995. She will start her new role in early 2021, according to the NIH.

“Dr. Criswell has rich experience as a clinician, researcher, and administrator. Her ability to oversee the research program of one of the country’s top research-intensive medical schools, and her expertise in autoimmune diseases, including rheumatoid arthritis and lupus, make her well-positioned to direct NIAMS,” said NIH director Francis S. Collins, MD, PhD, said in an announcement.

Dr. Criswell, who holds the Kenneth H. Fye, M.D., endowed chair in rheumatology and the Jean S. Engleman Distinguished Professorship in Rheumatology at UCSF, spent most of her career at the university, focusing her research on the genetics and epidemiology of human autoimmune disease, particularly rheumatoid arthritis and systemic lupus erythematosus. Using genome-wide association and other genetic studies, her research team contributed to the identification of more than 30 genes linked to these disorders, according to the NIH.

NIAMS has a budget of nearly $625 million and its extramural research program supports scientific studies and research training and career development throughout the country through grants and contracts to research organizations in fields that include rheumatology, muscle biology, orthopedics, bone and mineral metabolism, and dermatology.

[email protected]

Targeted prophylaxis with posaconazole was more effective than fluconazole in children with acute lymphoblastic leukemia who were undergoing induction chemotherapy in order to prevent invasive fungal infection, according to a study by Tian Zhang of Xidian University, Xi’an, China, and colleagues.

The researchers performed a single-center, retrospective cohort study of 155 patients with newly diagnosed acute lymphoblastic leukemia, comparing invasive fungal infections in those who received no prophylaxis (60 patients), posaconazole prophylaxis (70), or fluconazole prophylaxis (55) during induction therapy, according to a report published in the Journal of Microbiology, Immunology and Infection.

Proven and probable invasive fungal infections occurred during the induction phase in 45% in the no-prophylaxis group, in 18% of the posaconazole group and in 72% of the fluconazole group. Posaconazole prophylaxis reduced the odds of invasive fungal infections by greater than 60%, prolonged infection-free survival significantly, and did not increase the risk of hepatotoxicity.

In addition, the researchers found that the combination of age at diagnosis, clinically documented bacterial infection in the first 15 days of induction therapy, and absolute neutrophil count curve enabled significant prediction of the susceptibility to infections after receiving posaconazole prophylaxis.

“In general, these findings may serve as a basis for developing screening protocols to identify children who are at high risk for infection despite posaconazole prophylaxis so that early intervention can be initiated to mitigate fungal infections,” the researchers concluded.

The authors reported that they had no conflicts of interest.

[email protected]

SOURCE: Zhang T et al. J Microbiol Immunol Infect. 2020 Aug 1. doi: 10.1016/j.jmii.2020.07.008.

Targeted prophylaxis with posaconazole was more effective than fluconazole in children with acute lymphoblastic leukemia who were undergoing induction chemotherapy in order to prevent invasive fungal infection, according to a study by Tian Zhang of Xidian University, Xi’an, China, and colleagues.

The researchers performed a single-center, retrospective cohort study of 155 patients with newly diagnosed acute lymphoblastic leukemia, comparing invasive fungal infections in those who received no prophylaxis (60 patients), posaconazole prophylaxis (70), or fluconazole prophylaxis (55) during induction therapy, according to a report published in the Journal of Microbiology, Immunology and Infection.

Proven and probable invasive fungal infections occurred during the induction phase in 45% in the no-prophylaxis group, in 18% of the posaconazole group and in 72% of the fluconazole group. Posaconazole prophylaxis reduced the odds of invasive fungal infections by greater than 60%, prolonged infection-free survival significantly, and did not increase the risk of hepatotoxicity.

In addition, the researchers found that the combination of age at diagnosis, clinically documented bacterial infection in the first 15 days of induction therapy, and absolute neutrophil count curve enabled significant prediction of the susceptibility to infections after receiving posaconazole prophylaxis.

“In general, these findings may serve as a basis for developing screening protocols to identify children who are at high risk for infection despite posaconazole prophylaxis so that early intervention can be initiated to mitigate fungal infections,” the researchers concluded.

The authors reported that they had no conflicts of interest.

[email protected]

SOURCE: Zhang T et al. J Microbiol Immunol Infect. 2020 Aug 1. doi: 10.1016/j.jmii.2020.07.008.

Targeted prophylaxis with posaconazole was more effective than fluconazole in children with acute lymphoblastic leukemia who were undergoing induction chemotherapy in order to prevent invasive fungal infection, according to a study by Tian Zhang of Xidian University, Xi’an, China, and colleagues.

The researchers performed a single-center, retrospective cohort study of 155 patients with newly diagnosed acute lymphoblastic leukemia, comparing invasive fungal infections in those who received no prophylaxis (60 patients), posaconazole prophylaxis (70), or fluconazole prophylaxis (55) during induction therapy, according to a report published in the Journal of Microbiology, Immunology and Infection.

Proven and probable invasive fungal infections occurred during the induction phase in 45% in the no-prophylaxis group, in 18% of the posaconazole group and in 72% of the fluconazole group. Posaconazole prophylaxis reduced the odds of invasive fungal infections by greater than 60%, prolonged infection-free survival significantly, and did not increase the risk of hepatotoxicity.

In addition, the researchers found that the combination of age at diagnosis, clinically documented bacterial infection in the first 15 days of induction therapy, and absolute neutrophil count curve enabled significant prediction of the susceptibility to infections after receiving posaconazole prophylaxis.

“In general, these findings may serve as a basis for developing screening protocols to identify children who are at high risk for infection despite posaconazole prophylaxis so that early intervention can be initiated to mitigate fungal infections,” the researchers concluded.

The authors reported that they had no conflicts of interest.

[email protected]

SOURCE: Zhang T et al. J Microbiol Immunol Infect. 2020 Aug 1. doi: 10.1016/j.jmii.2020.07.008.

The rapid decline in pediatric hospital visits that came quickly after COVID-19 has emerged as a major public health threat, creating the need for adaptations among those offering hospital-based care, according to an objective look at patient numbers that was presented at the virtual Pediatric Hospital Medicine.

“Pre-COVID, operating margins had already taken a significant decline – and there are lots of different reasons for why this was happening – but a lot of hospitals in the United States were going from seeing about a 5% operating margin to closer to 2% to 3%,” said Magna Dias, MD, medical director, pediatric inpatient services, at Yale New Haven Children’s Hospital, Bridgeport, Conn.

This nearly 50% decline “was already putting pressure on us in the community hospital setting where pediatrics is not necessarily generating a ton of revenue to justify our programs, but post COVID, our operating revenue – and this is a report from May – was down 282%,” Dr. Dias reported.

Dr. Dias said that hundreds of hospitals have furloughed workers in the United States since the pandemic began. Although the job losses are not confined to pediatric care, statistics show that pediatrics is one of the hardest hit specialties.

“Looking specifically at ED [emergency department] visits under age 14, one study showed a 71% to 72% decrease post COVID,” Dr. Dias said. This included a 97% reduction in ED visits for flu and more than an 80% reduction in visits for asthma, otitis media, and nausea or vomiting.

It is not clear when children will return to the hospital in pre-COVID-19 numbers, but it might not be soon if the a second wave of infections follows the first, according to Dr. Dias. She suggested that pediatric hospitalists should be thinking about how to expand their services.

“One thing we are really good at in terms of working in the community hospital is diversification. We are used to working in more than one area and being flexible,” Dr. Dias said. Quoting Charles Darwin, who concluded that adaption to change predicts species survival, Dr. Dias advised pediatric hospitalists to look for new opportunities.

Taking on a broader range of responsibilities will not be a significant leap for many pediatric hospitalists. In a survey conducted several years ago by the American Academy of Pediatrics (AAP), hospital staff pediatricians were associated with activities ranging from work in the neonatal intensive care unit to primary ED coverage, according to Dr. Dias. Now with declining patient volumes on pediatric floors, she foresees an even greater expansion, including the care of young adults.

One organization formed in response to the COVID-19 pandemic, called the Pediatric Overflow Planning Contingency Response Network (POPCoRN) has been taking a lead in guiding the delivery of adult care in a pediatric environment. As a cochair of a community hospital special interest group within POPCoRN, Dr. Dias said she has participated in these discussions.

“At some centers, they have gone from age 18 to 21, some have gone up to age 25, some have gone up to 30 years,” she said.

Many centers are working to leverage telemedicine to reach pediatric patients no longer coming to the hospital, according to Dr. Dias.

“There are a lot of people being very creative in telemedicine,” she said. While it is considered as one way “to keep children at your institution,” Dr. Dias said others are considering how telemedicine might provide new opportunities. For one example, telemedicine might be an opportunity to deliver care in rural hospitals without pediatric services.

In an AAP survey of pediatric hospitalists conducted several years ago, justifying services was listed as the second most important concern right after access to subspecialty support. Due to COVID-19, Dr. Dias expects the order of these concerns to flip. Indeed, she predicted that many pediatric hospitalists are going to need to reassess their programs.

“We have started looking at what are our opportunities for building back revenue as well as how to recession-proof our practices should there be another surge and another decrease in pediatric volume,” Dr. Dias said.

The changes in pediatric care are not confined to the hospital setting. According to Amy H. Porter, MD, assistant professor of pediatrics at the Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, Calif., COVID-19 has “changed the way pediatric medicine is being practiced.”

Although she works in outpatient pediatric care, she said that routine care “is way down” in this setting as well. Like Dr. Dias, she has witnessed a major increase in the use of telemedicine to reach pediatric patients, but she is very concerned about the large proportion of children who are missing routine care, including vaccinations.

“We were already seeing outbreaks of whooping cough and measles pre COVID, so we are quite worried that we will see more,” Dr. Porter said.

A reduction in demand for care does not have the same immediate effect on revenue at a large health maintenance organization like Kaiser Permanente, but growing unemployment in the general population will mean fewer HMO members. In turn, this could have an impact on the entire system.

“When membership goes down, then it will have implications for how we can provide services,” Dr. Porter said.

In the meantime, social workers at Kaiser Permanente “are tirelessly working” to help parents losing benefits to obtain medicines for sick children with chronic diseases, according to Dr. Porter. She echoed the comments of Dr. Dias in predicting major changes in pediatric care if the COVID-19 pandemic and its economic consequences persist.

The conference was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

The rapid decline in pediatric hospital visits that came quickly after COVID-19 has emerged as a major public health threat, creating the need for adaptations among those offering hospital-based care, according to an objective look at patient numbers that was presented at the virtual Pediatric Hospital Medicine.

“Pre-COVID, operating margins had already taken a significant decline – and there are lots of different reasons for why this was happening – but a lot of hospitals in the United States were going from seeing about a 5% operating margin to closer to 2% to 3%,” said Magna Dias, MD, medical director, pediatric inpatient services, at Yale New Haven Children’s Hospital, Bridgeport, Conn.

This nearly 50% decline “was already putting pressure on us in the community hospital setting where pediatrics is not necessarily generating a ton of revenue to justify our programs, but post COVID, our operating revenue – and this is a report from May – was down 282%,” Dr. Dias reported.

Dr. Dias said that hundreds of hospitals have furloughed workers in the United States since the pandemic began. Although the job losses are not confined to pediatric care, statistics show that pediatrics is one of the hardest hit specialties.

“Looking specifically at ED [emergency department] visits under age 14, one study showed a 71% to 72% decrease post COVID,” Dr. Dias said. This included a 97% reduction in ED visits for flu and more than an 80% reduction in visits for asthma, otitis media, and nausea or vomiting.

It is not clear when children will return to the hospital in pre-COVID-19 numbers, but it might not be soon if the a second wave of infections follows the first, according to Dr. Dias. She suggested that pediatric hospitalists should be thinking about how to expand their services.

“One thing we are really good at in terms of working in the community hospital is diversification. We are used to working in more than one area and being flexible,” Dr. Dias said. Quoting Charles Darwin, who concluded that adaption to change predicts species survival, Dr. Dias advised pediatric hospitalists to look for new opportunities.

Taking on a broader range of responsibilities will not be a significant leap for many pediatric hospitalists. In a survey conducted several years ago by the American Academy of Pediatrics (AAP), hospital staff pediatricians were associated with activities ranging from work in the neonatal intensive care unit to primary ED coverage, according to Dr. Dias. Now with declining patient volumes on pediatric floors, she foresees an even greater expansion, including the care of young adults.

One organization formed in response to the COVID-19 pandemic, called the Pediatric Overflow Planning Contingency Response Network (POPCoRN) has been taking a lead in guiding the delivery of adult care in a pediatric environment. As a cochair of a community hospital special interest group within POPCoRN, Dr. Dias said she has participated in these discussions.

“At some centers, they have gone from age 18 to 21, some have gone up to age 25, some have gone up to 30 years,” she said.

Many centers are working to leverage telemedicine to reach pediatric patients no longer coming to the hospital, according to Dr. Dias.

“There are a lot of people being very creative in telemedicine,” she said. While it is considered as one way “to keep children at your institution,” Dr. Dias said others are considering how telemedicine might provide new opportunities. For one example, telemedicine might be an opportunity to deliver care in rural hospitals without pediatric services.

In an AAP survey of pediatric hospitalists conducted several years ago, justifying services was listed as the second most important concern right after access to subspecialty support. Due to COVID-19, Dr. Dias expects the order of these concerns to flip. Indeed, she predicted that many pediatric hospitalists are going to need to reassess their programs.

“We have started looking at what are our opportunities for building back revenue as well as how to recession-proof our practices should there be another surge and another decrease in pediatric volume,” Dr. Dias said.

The changes in pediatric care are not confined to the hospital setting. According to Amy H. Porter, MD, assistant professor of pediatrics at the Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, Calif., COVID-19 has “changed the way pediatric medicine is being practiced.”

Although she works in outpatient pediatric care, she said that routine care “is way down” in this setting as well. Like Dr. Dias, she has witnessed a major increase in the use of telemedicine to reach pediatric patients, but she is very concerned about the large proportion of children who are missing routine care, including vaccinations.

“We were already seeing outbreaks of whooping cough and measles pre COVID, so we are quite worried that we will see more,” Dr. Porter said.

A reduction in demand for care does not have the same immediate effect on revenue at a large health maintenance organization like Kaiser Permanente, but growing unemployment in the general population will mean fewer HMO members. In turn, this could have an impact on the entire system.

“When membership goes down, then it will have implications for how we can provide services,” Dr. Porter said.

In the meantime, social workers at Kaiser Permanente “are tirelessly working” to help parents losing benefits to obtain medicines for sick children with chronic diseases, according to Dr. Porter. She echoed the comments of Dr. Dias in predicting major changes in pediatric care if the COVID-19 pandemic and its economic consequences persist.

The conference was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

The rapid decline in pediatric hospital visits that came quickly after COVID-19 has emerged as a major public health threat, creating the need for adaptations among those offering hospital-based care, according to an objective look at patient numbers that was presented at the virtual Pediatric Hospital Medicine.

“Pre-COVID, operating margins had already taken a significant decline – and there are lots of different reasons for why this was happening – but a lot of hospitals in the United States were going from seeing about a 5% operating margin to closer to 2% to 3%,” said Magna Dias, MD, medical director, pediatric inpatient services, at Yale New Haven Children’s Hospital, Bridgeport, Conn.

This nearly 50% decline “was already putting pressure on us in the community hospital setting where pediatrics is not necessarily generating a ton of revenue to justify our programs, but post COVID, our operating revenue – and this is a report from May – was down 282%,” Dr. Dias reported.

Dr. Dias said that hundreds of hospitals have furloughed workers in the United States since the pandemic began. Although the job losses are not confined to pediatric care, statistics show that pediatrics is one of the hardest hit specialties.

“Looking specifically at ED [emergency department] visits under age 14, one study showed a 71% to 72% decrease post COVID,” Dr. Dias said. This included a 97% reduction in ED visits for flu and more than an 80% reduction in visits for asthma, otitis media, and nausea or vomiting.

It is not clear when children will return to the hospital in pre-COVID-19 numbers, but it might not be soon if the a second wave of infections follows the first, according to Dr. Dias. She suggested that pediatric hospitalists should be thinking about how to expand their services.

“One thing we are really good at in terms of working in the community hospital is diversification. We are used to working in more than one area and being flexible,” Dr. Dias said. Quoting Charles Darwin, who concluded that adaption to change predicts species survival, Dr. Dias advised pediatric hospitalists to look for new opportunities.

Taking on a broader range of responsibilities will not be a significant leap for many pediatric hospitalists. In a survey conducted several years ago by the American Academy of Pediatrics (AAP), hospital staff pediatricians were associated with activities ranging from work in the neonatal intensive care unit to primary ED coverage, according to Dr. Dias. Now with declining patient volumes on pediatric floors, she foresees an even greater expansion, including the care of young adults.

One organization formed in response to the COVID-19 pandemic, called the Pediatric Overflow Planning Contingency Response Network (POPCoRN) has been taking a lead in guiding the delivery of adult care in a pediatric environment. As a cochair of a community hospital special interest group within POPCoRN, Dr. Dias said she has participated in these discussions.

“At some centers, they have gone from age 18 to 21, some have gone up to age 25, some have gone up to 30 years,” she said.

Many centers are working to leverage telemedicine to reach pediatric patients no longer coming to the hospital, according to Dr. Dias.

“There are a lot of people being very creative in telemedicine,” she said. While it is considered as one way “to keep children at your institution,” Dr. Dias said others are considering how telemedicine might provide new opportunities. For one example, telemedicine might be an opportunity to deliver care in rural hospitals without pediatric services.

In an AAP survey of pediatric hospitalists conducted several years ago, justifying services was listed as the second most important concern right after access to subspecialty support. Due to COVID-19, Dr. Dias expects the order of these concerns to flip. Indeed, she predicted that many pediatric hospitalists are going to need to reassess their programs.

“We have started looking at what are our opportunities for building back revenue as well as how to recession-proof our practices should there be another surge and another decrease in pediatric volume,” Dr. Dias said.

The changes in pediatric care are not confined to the hospital setting. According to Amy H. Porter, MD, assistant professor of pediatrics at the Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, Calif., COVID-19 has “changed the way pediatric medicine is being practiced.”

Although she works in outpatient pediatric care, she said that routine care “is way down” in this setting as well. Like Dr. Dias, she has witnessed a major increase in the use of telemedicine to reach pediatric patients, but she is very concerned about the large proportion of children who are missing routine care, including vaccinations.

“We were already seeing outbreaks of whooping cough and measles pre COVID, so we are quite worried that we will see more,” Dr. Porter said.

A reduction in demand for care does not have the same immediate effect on revenue at a large health maintenance organization like Kaiser Permanente, but growing unemployment in the general population will mean fewer HMO members. In turn, this could have an impact on the entire system.

“When membership goes down, then it will have implications for how we can provide services,” Dr. Porter said.

In the meantime, social workers at Kaiser Permanente “are tirelessly working” to help parents losing benefits to obtain medicines for sick children with chronic diseases, according to Dr. Porter. She echoed the comments of Dr. Dias in predicting major changes in pediatric care if the COVID-19 pandemic and its economic consequences persist.

The conference was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

Immune checkpoint inhibition was not associated with an increased mortality risk from COVID-19 in patients with cancer in an international observational study.

The study included 113 cancer patients who had laboratory-confirmed COVID-19 within 12 months of receiving immune checkpoint inhibitor therapy. The patients did not receive chemotherapy within 3 months of testing positive for COVID-19.

In all, 33 patients were admitted to the hospital, including 6 who were admitted to the ICU, and 9 patients died.

“Nine out of 113 patients is a mortality rate of 8%, which is in the middle of the earlier reported rates for cancer patients in general [7.6%-12%],” said Aljosja Rogiers, MD, PhD, of the Melanoma Institute Australia in Sydney.

COVID-19 was the primary cause of death in seven of the patients, including three of those who were admitted to the ICU, Dr. Rogiers noted.

He reported these results during the AACR virtual meeting: COVID-19 and Cancer.
 

Study details

Patients in this study were treated at 19 hospitals in North America, Europe, and Australia, and the data cutoff was May 15, 2020. Most patients (64%) were treated in Europe, which was the epicenter for the COVID-19 pandemic at the time of data collection, Dr. Rogiers noted. A third of patients were in North America, and 3% were in Australia.

The patients’ median age was 63 years (range, 27-86 years). Most patients were men (65%), and most had Eastern Cooperative Oncology Group performance scores of 0-1 (90%).

The most common malignancies were melanoma (57%), non–small cell lung cancer (17%), and renal cell carcinoma (9%). Treatment was for early cancer in 26% of patients and for advanced cancer in 74%. Comorbidities included cardiovascular disease in 27% of patients, diabetes in 15%, pulmonary disease in 12%, and renal disease in 5%.

Immunosuppressive therapy equivalent to a prednisone dose of 10 mg or greater daily was given in 13% of patients, and other immunosuppressive therapies, such as infliximab, were given in 3%.

Among the 60% of patients with COVID-19 symptoms, 68% had fever, 59% had cough, 34% had dyspnea, and 15% had myalgia. Most of the 40% of asymptomatic patients were tested because they had COVID-19–positive contact, Dr. Rogiers noted.

Immune checkpoint inhibitor treatment included monotherapy with a programmed death–1/PD–ligand 1 inhibitor in 82% of patients, combination anti-PD-1 and anti-CTLA4 therapy in 13%, and other therapy – usually a checkpoint inhibitor combined with a different type of targeted agent – in 5%.

At the time of COVID-19 diagnosis, 30% of patients had achieved a partial response, complete response, or had no evidence of disease, 18% had stable disease, and 15% had progression. Response data were not available in 37% of cases, usually because treatment was only recently started prior to COVID-19 diagnosis, Dr. Rogiers said.

Treatments administered for COVID-19 included antibiotic therapy in 25% of patients, oxygen therapy in 20%, glucocorticoids in 10%, antiviral drugs in 6%, and intravenous immunoglobulin or anti–interleukin-6 in 2% each.

Among patients admitted to the ICU, 3% required mechanical ventilation, 2% had vasopressin, and 1% received renal replacement therapy.

At the data cutoff, 20 of 33 hospitalized patients (61%) had been discharged, and 4 (12%) were still in the hospital.
 

Mortality results

Nine patients died. The rate of death was 8% overall and 27% among hospitalized patients.

“The mortality rate of COVID-19 in the general population without comorbidities is about 1.4%,” Dr. Rogiers said. “For cancer patients, this is reported to be in the range of 7.6%-12%. To what extent patients on immune checkpoint inhibition are at a higher risk of mortality is currently unknown.”

Theoretically, immune checkpoint inhibition could either mitigate or exacerbate COVID-19 infection. It has been hypothesized that immune checkpoint inhibitors could increase the risk of severe acute lung injury or other complications of COVID-19, Dr. Rogiers said, explaining the rationale for the study.

The study shows that the patients who died had a median age of 72 years (range, 49-81 years), which is slightly higher than the median overall age of 63 years. Six patients were from North America, and three were from Italy.

“Two melanoma patients and two non–small cell lung cancer patients died,” Dr. Rogiers said. He noted that two other deaths were in patients with renal cell carcinoma, and three deaths were in other cancer types. All patients had advanced or metastatic disease.

Given that 57% of patients in the study had melanoma and 17% had NSCLC, this finding may indicate that COVID-19 has a slightly higher mortality rate in NSCLC patients than in melanoma patients, but the numbers are small, Dr. Rogiers said.

Notably, six of the patients who died were not admitted to the ICU. In four cases, this was because of underlying malignancy; in the other two cases, it was because of a constrained health care system, Dr. Rogiers said.

Overall, the findings show that the mortality rate of patients with COVID-19 and cancer treated with immune checkpoint inhibitors is similar to the mortality rate reported in the general cancer population, Dr. Rogiers said.

“Treatment with immune checkpoint inhibition does not seem to pose an additional mortality risk for cancer patients with COVID-19,” he concluded.

Dr. Rogiers reported having no conflicts of interest. There was no funding disclosed for the study.

[email protected]

SOURCE: Rogiers A et al. AACR: COVID-19 and Cancer, Abstract S02-01.

Immune checkpoint inhibition was not associated with an increased mortality risk from COVID-19 in patients with cancer in an international observational study.

The study included 113 cancer patients who had laboratory-confirmed COVID-19 within 12 months of receiving immune checkpoint inhibitor therapy. The patients did not receive chemotherapy within 3 months of testing positive for COVID-19.

In all, 33 patients were admitted to the hospital, including 6 who were admitted to the ICU, and 9 patients died.

“Nine out of 113 patients is a mortality rate of 8%, which is in the middle of the earlier reported rates for cancer patients in general [7.6%-12%],” said Aljosja Rogiers, MD, PhD, of the Melanoma Institute Australia in Sydney.

COVID-19 was the primary cause of death in seven of the patients, including three of those who were admitted to the ICU, Dr. Rogiers noted.

He reported these results during the AACR virtual meeting: COVID-19 and Cancer.
 

Study details

Patients in this study were treated at 19 hospitals in North America, Europe, and Australia, and the data cutoff was May 15, 2020. Most patients (64%) were treated in Europe, which was the epicenter for the COVID-19 pandemic at the time of data collection, Dr. Rogiers noted. A third of patients were in North America, and 3% were in Australia.

The patients’ median age was 63 years (range, 27-86 years). Most patients were men (65%), and most had Eastern Cooperative Oncology Group performance scores of 0-1 (90%).

The most common malignancies were melanoma (57%), non–small cell lung cancer (17%), and renal cell carcinoma (9%). Treatment was for early cancer in 26% of patients and for advanced cancer in 74%. Comorbidities included cardiovascular disease in 27% of patients, diabetes in 15%, pulmonary disease in 12%, and renal disease in 5%.

Immunosuppressive therapy equivalent to a prednisone dose of 10 mg or greater daily was given in 13% of patients, and other immunosuppressive therapies, such as infliximab, were given in 3%.

Among the 60% of patients with COVID-19 symptoms, 68% had fever, 59% had cough, 34% had dyspnea, and 15% had myalgia. Most of the 40% of asymptomatic patients were tested because they had COVID-19–positive contact, Dr. Rogiers noted.

Immune checkpoint inhibitor treatment included monotherapy with a programmed death–1/PD–ligand 1 inhibitor in 82% of patients, combination anti-PD-1 and anti-CTLA4 therapy in 13%, and other therapy – usually a checkpoint inhibitor combined with a different type of targeted agent – in 5%.

At the time of COVID-19 diagnosis, 30% of patients had achieved a partial response, complete response, or had no evidence of disease, 18% had stable disease, and 15% had progression. Response data were not available in 37% of cases, usually because treatment was only recently started prior to COVID-19 diagnosis, Dr. Rogiers said.

Treatments administered for COVID-19 included antibiotic therapy in 25% of patients, oxygen therapy in 20%, glucocorticoids in 10%, antiviral drugs in 6%, and intravenous immunoglobulin or anti–interleukin-6 in 2% each.

Among patients admitted to the ICU, 3% required mechanical ventilation, 2% had vasopressin, and 1% received renal replacement therapy.

At the data cutoff, 20 of 33 hospitalized patients (61%) had been discharged, and 4 (12%) were still in the hospital.
 

Mortality results

Nine patients died. The rate of death was 8% overall and 27% among hospitalized patients.

“The mortality rate of COVID-19 in the general population without comorbidities is about 1.4%,” Dr. Rogiers said. “For cancer patients, this is reported to be in the range of 7.6%-12%. To what extent patients on immune checkpoint inhibition are at a higher risk of mortality is currently unknown.”

Theoretically, immune checkpoint inhibition could either mitigate or exacerbate COVID-19 infection. It has been hypothesized that immune checkpoint inhibitors could increase the risk of severe acute lung injury or other complications of COVID-19, Dr. Rogiers said, explaining the rationale for the study.

The study shows that the patients who died had a median age of 72 years (range, 49-81 years), which is slightly higher than the median overall age of 63 years. Six patients were from North America, and three were from Italy.

“Two melanoma patients and two non–small cell lung cancer patients died,” Dr. Rogiers said. He noted that two other deaths were in patients with renal cell carcinoma, and three deaths were in other cancer types. All patients had advanced or metastatic disease.

Given that 57% of patients in the study had melanoma and 17% had NSCLC, this finding may indicate that COVID-19 has a slightly higher mortality rate in NSCLC patients than in melanoma patients, but the numbers are small, Dr. Rogiers said.

Notably, six of the patients who died were not admitted to the ICU. In four cases, this was because of underlying malignancy; in the other two cases, it was because of a constrained health care system, Dr. Rogiers said.

Overall, the findings show that the mortality rate of patients with COVID-19 and cancer treated with immune checkpoint inhibitors is similar to the mortality rate reported in the general cancer population, Dr. Rogiers said.

“Treatment with immune checkpoint inhibition does not seem to pose an additional mortality risk for cancer patients with COVID-19,” he concluded.

Dr. Rogiers reported having no conflicts of interest. There was no funding disclosed for the study.

[email protected]

SOURCE: Rogiers A et al. AACR: COVID-19 and Cancer, Abstract S02-01.

Immune checkpoint inhibition was not associated with an increased mortality risk from COVID-19 in patients with cancer in an international observational study.

The study included 113 cancer patients who had laboratory-confirmed COVID-19 within 12 months of receiving immune checkpoint inhibitor therapy. The patients did not receive chemotherapy within 3 months of testing positive for COVID-19.

In all, 33 patients were admitted to the hospital, including 6 who were admitted to the ICU, and 9 patients died.

“Nine out of 113 patients is a mortality rate of 8%, which is in the middle of the earlier reported rates for cancer patients in general [7.6%-12%],” said Aljosja Rogiers, MD, PhD, of the Melanoma Institute Australia in Sydney.

COVID-19 was the primary cause of death in seven of the patients, including three of those who were admitted to the ICU, Dr. Rogiers noted.

He reported these results during the AACR virtual meeting: COVID-19 and Cancer.
 

Study details

Patients in this study were treated at 19 hospitals in North America, Europe, and Australia, and the data cutoff was May 15, 2020. Most patients (64%) were treated in Europe, which was the epicenter for the COVID-19 pandemic at the time of data collection, Dr. Rogiers noted. A third of patients were in North America, and 3% were in Australia.

The patients’ median age was 63 years (range, 27-86 years). Most patients were men (65%), and most had Eastern Cooperative Oncology Group performance scores of 0-1 (90%).

The most common malignancies were melanoma (57%), non–small cell lung cancer (17%), and renal cell carcinoma (9%). Treatment was for early cancer in 26% of patients and for advanced cancer in 74%. Comorbidities included cardiovascular disease in 27% of patients, diabetes in 15%, pulmonary disease in 12%, and renal disease in 5%.

Immunosuppressive therapy equivalent to a prednisone dose of 10 mg or greater daily was given in 13% of patients, and other immunosuppressive therapies, such as infliximab, were given in 3%.

Among the 60% of patients with COVID-19 symptoms, 68% had fever, 59% had cough, 34% had dyspnea, and 15% had myalgia. Most of the 40% of asymptomatic patients were tested because they had COVID-19–positive contact, Dr. Rogiers noted.

Immune checkpoint inhibitor treatment included monotherapy with a programmed death–1/PD–ligand 1 inhibitor in 82% of patients, combination anti-PD-1 and anti-CTLA4 therapy in 13%, and other therapy – usually a checkpoint inhibitor combined with a different type of targeted agent – in 5%.

At the time of COVID-19 diagnosis, 30% of patients had achieved a partial response, complete response, or had no evidence of disease, 18% had stable disease, and 15% had progression. Response data were not available in 37% of cases, usually because treatment was only recently started prior to COVID-19 diagnosis, Dr. Rogiers said.

Treatments administered for COVID-19 included antibiotic therapy in 25% of patients, oxygen therapy in 20%, glucocorticoids in 10%, antiviral drugs in 6%, and intravenous immunoglobulin or anti–interleukin-6 in 2% each.

Among patients admitted to the ICU, 3% required mechanical ventilation, 2% had vasopressin, and 1% received renal replacement therapy.

At the data cutoff, 20 of 33 hospitalized patients (61%) had been discharged, and 4 (12%) were still in the hospital.
 

Mortality results

Nine patients died. The rate of death was 8% overall and 27% among hospitalized patients.

“The mortality rate of COVID-19 in the general population without comorbidities is about 1.4%,” Dr. Rogiers said. “For cancer patients, this is reported to be in the range of 7.6%-12%. To what extent patients on immune checkpoint inhibition are at a higher risk of mortality is currently unknown.”

Theoretically, immune checkpoint inhibition could either mitigate or exacerbate COVID-19 infection. It has been hypothesized that immune checkpoint inhibitors could increase the risk of severe acute lung injury or other complications of COVID-19, Dr. Rogiers said, explaining the rationale for the study.

The study shows that the patients who died had a median age of 72 years (range, 49-81 years), which is slightly higher than the median overall age of 63 years. Six patients were from North America, and three were from Italy.

“Two melanoma patients and two non–small cell lung cancer patients died,” Dr. Rogiers said. He noted that two other deaths were in patients with renal cell carcinoma, and three deaths were in other cancer types. All patients had advanced or metastatic disease.

Given that 57% of patients in the study had melanoma and 17% had NSCLC, this finding may indicate that COVID-19 has a slightly higher mortality rate in NSCLC patients than in melanoma patients, but the numbers are small, Dr. Rogiers said.

Notably, six of the patients who died were not admitted to the ICU. In four cases, this was because of underlying malignancy; in the other two cases, it was because of a constrained health care system, Dr. Rogiers said.

Overall, the findings show that the mortality rate of patients with COVID-19 and cancer treated with immune checkpoint inhibitors is similar to the mortality rate reported in the general cancer population, Dr. Rogiers said.

“Treatment with immune checkpoint inhibition does not seem to pose an additional mortality risk for cancer patients with COVID-19,” he concluded.

Dr. Rogiers reported having no conflicts of interest. There was no funding disclosed for the study.

[email protected]

SOURCE: Rogiers A et al. AACR: COVID-19 and Cancer, Abstract S02-01.

An atlas that displays the unique nuances between different skin types across the spectrum of dermatologic disease is scheduled for release this coming winter.

Available as an e-book or physical text, “Dermatology: A Diverse and Inclusive Color Atlas,” will display side-by-side images of the most common dermatology conditions in multiple skin types, with experts providing commentary on unique morphologies and features. Dermatologists need to know what skin diseases look like on all types of skin, said Adam Friedman, MD, who is developing this e-book with Misty Eleryan, MD, MS.

From the SARS-CoV-2 pandemic, multiple nonviral pandemics have rapidly emerged, “most notably the persistent and well-masked racism that maintains disparities in all facets of life, from economics to health care,” Dr. Friedman, professor and interim chair of dermatology at George Washington University, Washington, said in an interview.

In dermatology, “clear disparities in workforce representation and trainee/practitioner education have become more apparent than ever before,” he added.

The project is a collaboration of George Washington University and education publishers Sanova Works and Educational Testing & Assessment Systems.

As a person of color who recently completed her residency in dermatology at George Washington University, Dr. Eleryan had noticed a lack of diversity in photos of common dermatoses. This can contribute to misdiagnoses and delays in treatment in patients of color, Dr. Eleryan, who is now a micrographic surgery and dermatologic oncology fellow at the University of California, Los Angeles, said in an interview.

“We recognized the gap, which is the lack of diversity/variation of skin tones in our dermatology textbooks and atlases,” she added.

The project was several years in the making, Dr. Friedman said. To do this right, “you need resources, funding, and a collaborative and galvanized team of experts.” That involved coordinating with several medical publishers and amassing a team of medical photographers and an expert panel that will assist in evaluating and securing difficult-to-access clinical images.

The atlas is one of several initiatives in the dermatology field to address racial disparities in patient care.

Noticing similar information gaps about clinical presentations in darker skin, a medical student in the United Kingdom, Malone Mukwende, created “Mind the Gap,” a handbook that presents side-by-side images of diseases and illnesses in light and dark skin. This project “highlights how far behind we are, that a medical student with minimal dermatology exposure and experience not only recognized the need but was ready to do something about it,” Dr. Friedman noted.

Others in the field have spotlighted disparities in the medical literature. The SARS-CoV-2 pandemic has especially brought this out, Graeme M. Lipper, MD wrote in a recent editorial for this news organization.

He referred to a literature review of 46 articles describing COVID-19–associated skin manifestations, which included mostly (92%) images in patients with skin types I-III (92%) and none in patients with skin types V or VI.

“These investigators have identified a damning lack of images of COVID-19–associated skin manifestations in patients with darker skin,” added Dr. Lipper, an assistant clinical professor at the University of Vermont, Burlington, and a staff physician in the department of dermatology at Danbury (Conn.) Hospital.

For now, Dr. Friedman said that the atlas won’t contain a specific section on COVID-19 skin manifestations, although viral-associated skin reactions like morbilliform eruptions, urticaria, and retiform purpura will be displayed. Overall, the atlas will address 60-70 skin conditions.

Physicians who fail to educate themselves on the variations of skin conditions in all skin types may potentially harm patients of color, Dr. Eleryan said. As Dr. Lipper noted in his editorial, nearly half of all dermatologists feel they haven’t had adequate exposure to diseases in skin of color.

“Our atlas will fill that void and hopefully assist in closing the gap in health disparities among patients of color, who are often misdiagnosed or rendered diagnoses very late in the disease process,” Dr. Eleryan said.

An atlas that displays the unique nuances between different skin types across the spectrum of dermatologic disease is scheduled for release this coming winter.

Available as an e-book or physical text, “Dermatology: A Diverse and Inclusive Color Atlas,” will display side-by-side images of the most common dermatology conditions in multiple skin types, with experts providing commentary on unique morphologies and features. Dermatologists need to know what skin diseases look like on all types of skin, said Adam Friedman, MD, who is developing this e-book with Misty Eleryan, MD, MS.

From the SARS-CoV-2 pandemic, multiple nonviral pandemics have rapidly emerged, “most notably the persistent and well-masked racism that maintains disparities in all facets of life, from economics to health care,” Dr. Friedman, professor and interim chair of dermatology at George Washington University, Washington, said in an interview.

In dermatology, “clear disparities in workforce representation and trainee/practitioner education have become more apparent than ever before,” he added.

The project is a collaboration of George Washington University and education publishers Sanova Works and Educational Testing & Assessment Systems.

As a person of color who recently completed her residency in dermatology at George Washington University, Dr. Eleryan had noticed a lack of diversity in photos of common dermatoses. This can contribute to misdiagnoses and delays in treatment in patients of color, Dr. Eleryan, who is now a micrographic surgery and dermatologic oncology fellow at the University of California, Los Angeles, said in an interview.

“We recognized the gap, which is the lack of diversity/variation of skin tones in our dermatology textbooks and atlases,” she added.

The project was several years in the making, Dr. Friedman said. To do this right, “you need resources, funding, and a collaborative and galvanized team of experts.” That involved coordinating with several medical publishers and amassing a team of medical photographers and an expert panel that will assist in evaluating and securing difficult-to-access clinical images.

The atlas is one of several initiatives in the dermatology field to address racial disparities in patient care.

Noticing similar information gaps about clinical presentations in darker skin, a medical student in the United Kingdom, Malone Mukwende, created “Mind the Gap,” a handbook that presents side-by-side images of diseases and illnesses in light and dark skin. This project “highlights how far behind we are, that a medical student with minimal dermatology exposure and experience not only recognized the need but was ready to do something about it,” Dr. Friedman noted.

Others in the field have spotlighted disparities in the medical literature. The SARS-CoV-2 pandemic has especially brought this out, Graeme M. Lipper, MD wrote in a recent editorial for this news organization.

He referred to a literature review of 46 articles describing COVID-19–associated skin manifestations, which included mostly (92%) images in patients with skin types I-III (92%) and none in patients with skin types V or VI.

“These investigators have identified a damning lack of images of COVID-19–associated skin manifestations in patients with darker skin,” added Dr. Lipper, an assistant clinical professor at the University of Vermont, Burlington, and a staff physician in the department of dermatology at Danbury (Conn.) Hospital.

For now, Dr. Friedman said that the atlas won’t contain a specific section on COVID-19 skin manifestations, although viral-associated skin reactions like morbilliform eruptions, urticaria, and retiform purpura will be displayed. Overall, the atlas will address 60-70 skin conditions.

Physicians who fail to educate themselves on the variations of skin conditions in all skin types may potentially harm patients of color, Dr. Eleryan said. As Dr. Lipper noted in his editorial, nearly half of all dermatologists feel they haven’t had adequate exposure to diseases in skin of color.

“Our atlas will fill that void and hopefully assist in closing the gap in health disparities among patients of color, who are often misdiagnosed or rendered diagnoses very late in the disease process,” Dr. Eleryan said.

An atlas that displays the unique nuances between different skin types across the spectrum of dermatologic disease is scheduled for release this coming winter.

Available as an e-book or physical text, “Dermatology: A Diverse and Inclusive Color Atlas,” will display side-by-side images of the most common dermatology conditions in multiple skin types, with experts providing commentary on unique morphologies and features. Dermatologists need to know what skin diseases look like on all types of skin, said Adam Friedman, MD, who is developing this e-book with Misty Eleryan, MD, MS.

From the SARS-CoV-2 pandemic, multiple nonviral pandemics have rapidly emerged, “most notably the persistent and well-masked racism that maintains disparities in all facets of life, from economics to health care,” Dr. Friedman, professor and interim chair of dermatology at George Washington University, Washington, said in an interview.

In dermatology, “clear disparities in workforce representation and trainee/practitioner education have become more apparent than ever before,” he added.

The project is a collaboration of George Washington University and education publishers Sanova Works and Educational Testing & Assessment Systems.

As a person of color who recently completed her residency in dermatology at George Washington University, Dr. Eleryan had noticed a lack of diversity in photos of common dermatoses. This can contribute to misdiagnoses and delays in treatment in patients of color, Dr. Eleryan, who is now a micrographic surgery and dermatologic oncology fellow at the University of California, Los Angeles, said in an interview.

“We recognized the gap, which is the lack of diversity/variation of skin tones in our dermatology textbooks and atlases,” she added.

The project was several years in the making, Dr. Friedman said. To do this right, “you need resources, funding, and a collaborative and galvanized team of experts.” That involved coordinating with several medical publishers and amassing a team of medical photographers and an expert panel that will assist in evaluating and securing difficult-to-access clinical images.

The atlas is one of several initiatives in the dermatology field to address racial disparities in patient care.

Noticing similar information gaps about clinical presentations in darker skin, a medical student in the United Kingdom, Malone Mukwende, created “Mind the Gap,” a handbook that presents side-by-side images of diseases and illnesses in light and dark skin. This project “highlights how far behind we are, that a medical student with minimal dermatology exposure and experience not only recognized the need but was ready to do something about it,” Dr. Friedman noted.

Others in the field have spotlighted disparities in the medical literature. The SARS-CoV-2 pandemic has especially brought this out, Graeme M. Lipper, MD wrote in a recent editorial for this news organization.

He referred to a literature review of 46 articles describing COVID-19–associated skin manifestations, which included mostly (92%) images in patients with skin types I-III (92%) and none in patients with skin types V or VI.

“These investigators have identified a damning lack of images of COVID-19–associated skin manifestations in patients with darker skin,” added Dr. Lipper, an assistant clinical professor at the University of Vermont, Burlington, and a staff physician in the department of dermatology at Danbury (Conn.) Hospital.

For now, Dr. Friedman said that the atlas won’t contain a specific section on COVID-19 skin manifestations, although viral-associated skin reactions like morbilliform eruptions, urticaria, and retiform purpura will be displayed. Overall, the atlas will address 60-70 skin conditions.

Physicians who fail to educate themselves on the variations of skin conditions in all skin types may potentially harm patients of color, Dr. Eleryan said. As Dr. Lipper noted in his editorial, nearly half of all dermatologists feel they haven’t had adequate exposure to diseases in skin of color.

“Our atlas will fill that void and hopefully assist in closing the gap in health disparities among patients of color, who are often misdiagnosed or rendered diagnoses very late in the disease process,” Dr. Eleryan said.

Summary

Evidence on emerging therapeutics and the treatment of COVID-19 and its complications has been incomplete, often contradictory, and rapidly changing. The brisk development of effective strategies aimed at identifying, isolating, and treating this disease requires an equally fluid response. At Dell Seton Medical Center, a safety-net hospital that serves Austin in central Texas, our hospitalists have led the formation of numerous collaborative work groups to address the appropriate triage, management, and operational processes during the COVID-19 evolving pandemic.

We created a hospitalist-led COVID Therapeutics and Informatics Committee composed of specialists (infectious disease, pulmonary and critical care, hematology/oncology, neurology), pharmacy, nursing leadership, and the hospital chief medical officer). This committee was formed to evaluate and reach consensus regarding therapeutic interventions in order to ensure appropriate and timely evidence-based treatment. The goal was to limit practice variation and create a shared mental model to deliver consistent value-based care without increasing complexity. We discuss how evidence was evaluated in an interprofessional setting, focusing on not just the quality of data, but its application in an environment of uncertainty and resource scarcity.

We review the use of electronic communication platforms to facilitate direct and rapid communication among interprofessional providers and hospital leadership. We also discuss the development of creative workarounds to build protocols into the electronic medical record to implement new therapeutic interventions in real time.

This session will address the barriers to the constructive discussion required to build consensus, disseminate protocols around controversial evidence, and share strategies to work through them. This approach allows the rapid establishment and adoption of therapeutic protocols based on expert and consensus opinion in the absence of comprehensive national guidelines. This model may also be adopted for other complex disease states that require coordinated interprofessional interventions and frequent revisions to the standard of care.
 

Key takeaways

1. Protocols improve care by creating a shared framework for approaching complex diseases and open communication within teams to personalize care.

2. Rapidly appraising evidence requires equipoise, thoughtful interpretation of retrospective data, and applying that specifically to a hospital’s local context.

3. Guidelines are best utilized when they are built into clinical care through Standardized Order Sets and disseminated in multiple modalities that reach their audience just in time.

4. The perfect can’t be the enemy of the good.
 

Protocolized care in progress: Rapid appraisal of evidence and standardization of practice in a pandemic

Live Q&A: Tuesday, Aug. 11, 1:00-2:00 p.m.

Dr. Brode and Dr. Busch are assistant professors in the department of internal medicine at Dell Medical School, University of Texas, Austin.

Summary

Evidence on emerging therapeutics and the treatment of COVID-19 and its complications has been incomplete, often contradictory, and rapidly changing. The brisk development of effective strategies aimed at identifying, isolating, and treating this disease requires an equally fluid response. At Dell Seton Medical Center, a safety-net hospital that serves Austin in central Texas, our hospitalists have led the formation of numerous collaborative work groups to address the appropriate triage, management, and operational processes during the COVID-19 evolving pandemic.

We created a hospitalist-led COVID Therapeutics and Informatics Committee composed of specialists (infectious disease, pulmonary and critical care, hematology/oncology, neurology), pharmacy, nursing leadership, and the hospital chief medical officer). This committee was formed to evaluate and reach consensus regarding therapeutic interventions in order to ensure appropriate and timely evidence-based treatment. The goal was to limit practice variation and create a shared mental model to deliver consistent value-based care without increasing complexity. We discuss how evidence was evaluated in an interprofessional setting, focusing on not just the quality of data, but its application in an environment of uncertainty and resource scarcity.

We review the use of electronic communication platforms to facilitate direct and rapid communication among interprofessional providers and hospital leadership. We also discuss the development of creative workarounds to build protocols into the electronic medical record to implement new therapeutic interventions in real time.

This session will address the barriers to the constructive discussion required to build consensus, disseminate protocols around controversial evidence, and share strategies to work through them. This approach allows the rapid establishment and adoption of therapeutic protocols based on expert and consensus opinion in the absence of comprehensive national guidelines. This model may also be adopted for other complex disease states that require coordinated interprofessional interventions and frequent revisions to the standard of care.
 

Key takeaways

1. Protocols improve care by creating a shared framework for approaching complex diseases and open communication within teams to personalize care.

2. Rapidly appraising evidence requires equipoise, thoughtful interpretation of retrospective data, and applying that specifically to a hospital’s local context.

3. Guidelines are best utilized when they are built into clinical care through Standardized Order Sets and disseminated in multiple modalities that reach their audience just in time.

4. The perfect can’t be the enemy of the good.
 

Protocolized care in progress: Rapid appraisal of evidence and standardization of practice in a pandemic

Live Q&A: Tuesday, Aug. 11, 1:00-2:00 p.m.

Dr. Brode and Dr. Busch are assistant professors in the department of internal medicine at Dell Medical School, University of Texas, Austin.

Summary

Evidence on emerging therapeutics and the treatment of COVID-19 and its complications has been incomplete, often contradictory, and rapidly changing. The brisk development of effective strategies aimed at identifying, isolating, and treating this disease requires an equally fluid response. At Dell Seton Medical Center, a safety-net hospital that serves Austin in central Texas, our hospitalists have led the formation of numerous collaborative work groups to address the appropriate triage, management, and operational processes during the COVID-19 evolving pandemic.

We created a hospitalist-led COVID Therapeutics and Informatics Committee composed of specialists (infectious disease, pulmonary and critical care, hematology/oncology, neurology), pharmacy, nursing leadership, and the hospital chief medical officer). This committee was formed to evaluate and reach consensus regarding therapeutic interventions in order to ensure appropriate and timely evidence-based treatment. The goal was to limit practice variation and create a shared mental model to deliver consistent value-based care without increasing complexity. We discuss how evidence was evaluated in an interprofessional setting, focusing on not just the quality of data, but its application in an environment of uncertainty and resource scarcity.

We review the use of electronic communication platforms to facilitate direct and rapid communication among interprofessional providers and hospital leadership. We also discuss the development of creative workarounds to build protocols into the electronic medical record to implement new therapeutic interventions in real time.

This session will address the barriers to the constructive discussion required to build consensus, disseminate protocols around controversial evidence, and share strategies to work through them. This approach allows the rapid establishment and adoption of therapeutic protocols based on expert and consensus opinion in the absence of comprehensive national guidelines. This model may also be adopted for other complex disease states that require coordinated interprofessional interventions and frequent revisions to the standard of care.
 

Key takeaways

1. Protocols improve care by creating a shared framework for approaching complex diseases and open communication within teams to personalize care.

2. Rapidly appraising evidence requires equipoise, thoughtful interpretation of retrospective data, and applying that specifically to a hospital’s local context.

3. Guidelines are best utilized when they are built into clinical care through Standardized Order Sets and disseminated in multiple modalities that reach their audience just in time.

4. The perfect can’t be the enemy of the good.
 

Protocolized care in progress: Rapid appraisal of evidence and standardization of practice in a pandemic

Live Q&A: Tuesday, Aug. 11, 1:00-2:00 p.m.

Dr. Brode and Dr. Busch are assistant professors in the department of internal medicine at Dell Medical School, University of Texas, Austin.

Aug. 12, 2020. 12:00 p.m. to 1:00 p.m. ET

Clinical Insights in VTE: Treatment and Risk Reduction Through Prophylaxis

Speaker: Michael S. Oleksyk, MD, FACP, CPE, CMPE

Clinical assistant professor, Florida State University, Pensacola

Hospitalist & palliative care physician, Baptist Hospital, Pensacola.

Program description:

This lecture will discuss venous thromboembolism prophylaxis, as well as treatment options for patients with deep vein thrombosis and/or pulmonary embolism, and how these treatment options may reduce the risk of recurrent thrombotic events.

Sponsored by Janssen Pharmaceuticals Inc.

Aug. 12, 2020. 12:00 p.m. to 1:00 p.m. ET

Clinical Insights in VTE: Treatment and Risk Reduction Through Prophylaxis

Speaker: Michael S. Oleksyk, MD, FACP, CPE, CMPE

Clinical assistant professor, Florida State University, Pensacola

Hospitalist & palliative care physician, Baptist Hospital, Pensacola.

Program description:

This lecture will discuss venous thromboembolism prophylaxis, as well as treatment options for patients with deep vein thrombosis and/or pulmonary embolism, and how these treatment options may reduce the risk of recurrent thrombotic events.

Sponsored by Janssen Pharmaceuticals Inc.

Aug. 12, 2020. 12:00 p.m. to 1:00 p.m. ET

Clinical Insights in VTE: Treatment and Risk Reduction Through Prophylaxis

Speaker: Michael S. Oleksyk, MD, FACP, CPE, CMPE

Clinical assistant professor, Florida State University, Pensacola

Hospitalist & palliative care physician, Baptist Hospital, Pensacola.

Program description:

This lecture will discuss venous thromboembolism prophylaxis, as well as treatment options for patients with deep vein thrombosis and/or pulmonary embolism, and how these treatment options may reduce the risk of recurrent thrombotic events.

Sponsored by Janssen Pharmaceuticals Inc.

Melanoma Risk for Servicemembers

Dr. Dunn: Active-duty jobs are quite diverse. We have had almost every civilian occupation category—everything from clerical to food service to outdoor construction workers. Federal service and active-duty military service could lead to assignments that involve high sunlight exposure and subsequently higher risk for melanoma and nonmelanoma skin cancer.

Dr. Miller: I found 2 articles on the topic. The first published in June 2018 reviewed melanoma and nonmelanoma skin cancers in the military.¹ Riemenschneider and colleagues¹ looked at 9 studies. Statistically, there was increased risk of melanoma associated with service and/or prisoner-of-war status. In World War II, they found tropical environments had the highest risk. And the highest rates were in the US Air Force.

The other article provided US Department of Defense data on skin cancer incidence rates, incidence rates of malignant melanoma in relation to years of military service overall, and the rates for differing military occupational groups.² The researchers demonstrated that fixed-wing pilots and crew members had the highest rates of developing melanoma. The general trend was that the incidence rate was exponentially higher with more missions flown in relation to years of active service, which I thought was rather interesting.

For other occupational categories, the rate increase was not as great as those involved in aviation. Yes, it’s probably related to exposure. Flying at 40,000 feet on a transcontinental airplane trip is equivalent to the radiation dosage of a chest X-ray. Given all the training time and operational flying for the Air Force, it is anticipated that that mutagenic radiation would increase rates. An aircraft does not offer a lot of protection, especially in the cockpit.

We just had the anniversary of the Apollo 11 mission. Those astronauts received the equivalent of about 40 chest X-rays going to the moon and back. Exposure to UV and at higher altitudes cosmic radiation explains why we would see that more in Air Force personnel.

Dr. Bandino: At high altitude there is less ozone protecting you, although the shielding in a cockpit is better in modern aircraft. As an Air Force member, that was one of the first things I thought about was that an aviator has increased skin cancer risk. But it’s apt to think of military service in general as an occupational risk because there are so many contingency operations and deployments. Regarding sun exposure, sunscreen is provided nowadays and there is more sun awareness, but there is still a stigma and reluctance to apply the sunscreen. It leaves people’s skin feeling greasy, which is not ideal when one has to handle a firearm. It can also get in someone’s eyes and affect vision and performance during combat operations. In other words, there are many reasons that would reduce the desire to wear sunscreen and therefore increase exposure to the elements.

A great current example is coronavirus disease 2019 (COVID-19) operations. Although I’m a dermatologist and typically work inside, I’ve been tasked to run a COVID-19 screening tent in the middle of a field in San Antonio, and thus I’ve got to make sure I take my sunscreen out there every day. The general population may not have that variability in their work cycle and sudden change in occupational UV exposure.

Dr. Miller: I was deployed in a combat zone for operations Desert Shield and Desert Storm. I was with the 2nd Armored Division of the US Army deployed to the desert. There really wasn’t an emphasis on photoprotection. It’s just the logistics. The commanders have a lot more important things to think about, and that’s something, usually, that doesn’t get a high priority. The US military is deploying to more places near the equator, so from an operational sense, there’s probably something to brief the commanders about in terms of the long-term consequences of radiation exposure for military servicemembers.

Dr. Dunn: If you look at deployments over the past 2 decades, we have been putting tens of thousands of individuals in high UV exposure regions. Then you have to look at the long-term consequence of the increased incidence of skin cancer in those individuals. What is the cost of that when it comes to treatment of precancerous lesions and skin cancer throughout a life expectancy of 80-plus years?

Dr. Bandino: With most skin cancers there is such long lag time between exposures and development. I wish there were some better data and research out there that really showed whether military service truly is an independent risk factor or if it’s just specific occupation types within the military. I have family members who both work in contracting services and had served in the military. Would their skin cancer risk be the same as others who are doing similar jobs without the military service?

Dr. Dunn: I have had county employees present for skin cancer surgery and with them comes a form that relates to disability. For groundskeepers or police, we assumed that skin cancer is occupation related due to the patient’s increased sun exposure. Their cancers may be unrelated to their actual years of service, but it seems that many light-skinned individuals in the military are going to develop basal cell and squamous cell skin cancer in the coming decades, which likely is going to be attributed to their years of federal service, even though they may have had other significant recreational exposure outside of work. So, my gut feeling is that we are going to see skin cancer as a disability tied to federal service, which is going to cost us.

Dr. Logemann: Yes, I think there are always going to be confounders—what if the servicemembers used tanning beds, or they were avid surfers? It’s going to be difficult to always parse that out.

Dr. Miller: In talking about melanoma, you really have to parse out the subsets. Is it melanoma in situ, is it superficial, is it acral, is it nodular? They all have different initiation events.

Nodular melanomas probably don’t need UV light to initiate a tumor. Another risk factor is having more than 100 moles or many atypical moles, which puts that person in a higher risk category. Perhaps when soldiers, airmen, and navy personnel get inducted, they should be screened for their mole population because that is a risk factor for developing melanoma, and then we can intervene a little bit and have them watch their UV exposure.

Dr. Jarell: You can’t overstate the importance of how heterogeneous melanoma is as a disease. While there are clearly some types of melanoma that are caused by UV radiation, there are also many types that aren’t. We don’t understand why someone gets melanoma on the inner thigh, bottom of the foot, top of the sole, inside the mouth, or in the genital region—these aren’t places of high sun exposure.

Lentigo maligna, as an example, is clearly caused by UV radiation in most cases. But there are so many other different types of melanoma that you can’t just attribute to UV radiation, and so you get into this whole other discussion as to why people are getting melanoma—military or not.

Dr. Bandino: When volunteering for military service, there’s the DoDMERB (Department of Defense Medical Examination Review Board) system that screens individuals for medical issues incompatible with military service such as severe psoriasis or atopic dermatitis. But to my knowledge, the DoDMERB process focuses more on current or past issues and does little to investigate for future risk of disease. A cutaneous example would be assessing quantity of dysplastic nevi, Fitzpatrick scale 1 phenotype, and family history of melanoma to determine risk of developing melanoma in someone who may have more UV exposure during their military service than a civilian. This dermatological future risk assessment was certainly not something I was trained to do as a flight surgeon when performing basic trainee flight physicals prior to becoming a dermatologist.

Dr. Jarell: I am a little bit hard-pressed to generalize the military as high occupational risk for melanoma. There are clearly other professions—landscapers, fishermen—that are probably at much higher risk than, say, your general military all-comers. Us physicians in the military were probably not at increased risk compared to other physicians in the United States. We have to be careful not to go down a slippery slope and designate all MOSs (military occupational specialties) as at increased risk for skin cancer, in particular melanoma. Nonmelanoma skin cancer, such as basal cell and squamous cell carcinoma, is clearly related to the proportional amount of UV exposure. But melanoma is quite a diverse cancer that has many, many disparate etiologies.

Dr. Dunn: The entry physical into the military is an opportunity to make an impact on the number of nonmelanoma skin cancers that would arise in that population. There is an educational opportunity to tell inductees that nonmelanoma skin cancer is going to occur on convex surfaces of the sun-exposed skin—nose, ears, forehead, chin, tops of the shoulders. If offered sun protection for those areas and you stretch the potential impact of that information over tens of thousands of military members over decades, you might actually come up with a big number of people that not only decreases their morbidity but also dramatically decreased the cost to the system as a whole.

Dr. Jarell: You also have to factor in ethnicity and the role it plays in someone’s likelihood to get skin cancer—melanoma or nonmelanoma skin cancer. Darker-skinned people are at certainly decreased risk for different types of skin cancers.

Dr. Dunn: Yes, that would have to be part of the education and should be. If you have light skin and freckles, then you’re at much higher risk for nonmelanoma skin cancer and need to know the high-risk areas that can be protected by sunblock and clothing.

Dr. Logemann: One thing that might be a little bit unique in the military is that you’re living in San Antonio one minute, and then the next minute you’re over in Afghanistan with a different climate and different environment. When you’re deployed overseas, you might have a little bit less control over your situation; you might not have a lot of sunscreen in a field hospital in Afghanistan. Whereas if you were just living in San Antonio, you could go down to the store and buy it.

Dr. Miller: Is sunblock now encouraged or available to individuals in deployment situations or training situations where they’re going to have prolonged sun exposure every day? Is it part of the regimen, just like carrying extra water because of the risk for dehydration?

Dr. Logemann: To the best of my knowledge, it is not always included in your normal rations or uniform and it may be up to the servicemember to procure sunscreen.

Dr. Bandino: There have been improvements, and usually you at least have access to sunscreen. In many deployed locations, for example, you have the equivalent of a small PX (post exchange) or BX (base exchange), where they have a variety of products for sale from toothbrushes to flip-flops, and now also sunscreen. Of course, the type and quality of the sunscreen may not be that great. It’s likely going to be basic SPF (sun protection factor) 15 or 30 in small tubes. As a recent example, I participated in a humanitarian medical exercise in South America last summer and was actually issued sunscreen combined with DEET, which is great but it was only SPF 30. The combination product is a good idea for tropical locations, but in addition to people just not wanting to wear it, the DEET combination tends to burn and sting a little bit more; you can get a heat sensation from the DEET; and the DEET can damage plastic surfaces, which may not be ideal for deployed equipment.

The other problem is quantity. We all learned in residency the appropriate sunscreen quantity of at least 1 fl oz for the average adult body, and that’s what we counsel our patients on, but what they issued me was 1 small 2- to 3-fl oz tube. It fit in the palm of my hand, and that was my sunscreen for the trip.

So, I do think, even though there have been some improvements, much of sun protection will still fall on the individual servicemember. And, as mentioned, depending on your ethnicity, some people may need it more than others. But it is an area where there probably could be continued improvements.

Dr. Logemann: In addition to sunscreen, I think that maybe we should be taking into consideration some simple measures. For example, is it necessary for people to stand out in formation at 2 pm on a blistering hot day, or could that function be performed at an earlier or later time? If people are needing to be out in formation in bright sunlight, could they maybe wear their boonie covers and not the caps that don’t provide any circumferential protection to the sun? Do they have sleeves down? Do they have sleeves up? I think commanders do take these things into consideration, but potentially there might be some additional measures that could be taken besides sunscreen in terms of just culture and practices.

Dr. Dunn: I think we all kind of agree that the military service is diverse and that many of the subcategories of occupations within the military lead to increased sun exposure by mandate. We advise sun protection by physical barriers and sunblock.

Diagnosis of Skin Cancer Via Telemedicine

Dr. Dunn: I have friends who remain in the VA (US Department of Veterans Affairs) system, and they are involved with telemedicine in dermatology, which can reduce waiting time and increase the number of patients seen by the dermatologist. In-person and teledermatology visits now are available to servicemembers on active duty and retirees.

Dr. Bandino: At our residency program (San Antonio Uniformed Services Health Education Consortium), we’ve had asynchronous teledermatology for over a decade, even before I was a resident. We provide it primarily as a service for patients at small bases without access to dermatology. Some bases also use it as part of their prescreening process prior to authorizing an in-person dermatology consultation.

Certainly, with the coronavirus pandemic, civilian dermatology is seeing a boom in the teledermatology world that had been slowly increasing in popularity for the last few years. In our residency program, teledermatology has traditionally been just for active-duty servicemembers or their dependents, but now due to the coronavirus pandemic, our teledermatology services have significantly expanded to include adding synchronous capability. We have patients take pictures before their virtual appointment and/or FaceTime during the appointment. Even after the pandemic, there will likely be more integration of synchronous teledermatology going forward as we’re seeing some of the value. Of course, I’m sure we would all agree that accurate diagnosis of pigmented lesions can be very challenging with teledermatology, not to mention other diagnostic limitations. But I think there is still utility and it should only get better with time as technology improves. So, I’m hopeful that we can incorporate more of it in the military.

Dr. Logemann: I’m definitely aware that we have different telehealth opportunities available, even using some newer modalities that are command approved in recent weeks. My experience has been for more complicated dermatology, so people are in remote locations, and they’re being seen by a nondermatologist, and they have questions about how to approach management. But I’m not aware of telemedicine as a screening tool for skin cancer in the military or among my civilian colleagues. I would hope that it could be someday because we’re developing these total-body photography machines as well. It could be a way for a nondermatologist who identifies a lesion to have it triaged by a dermatologist. To say, “Oh yeah, that looks like a melanoma. They need to get in sooner vs later,” but not on a large-scale sort of screening modality.

Dr. Bandino: In my recent experience, it has definitely been a helpful triage tool. In the military, this form of triage can be particularly helpful if someone is overseas to determine whether he/she needs to evacuated and evaluated in-person right away.

Dr. Jarell: It’s been useful in looking at benign things. People have shown me in the past few weeks a lot of seborrheic keratoses and a lot of benign dermal nevus-type things, and I say, “Don’t worry about that.” And you can tell if the resolution is good enough. But a lot of people have shown me things in the past few weeks that have clearly been basal cell carcinoma, which we can probably let that ride out for a few more weeks, but I’m not sure if maybe somebody has an amelanotic melanoma. Maybe you need to come in and get that biopsied ASAP. Or something that looks like a melanoma. The patient should probably come in and get that biopsied.

Dr. Miller: I think we can rely on teledermatology. It’s all predicated on the resolution because we’re all trained in pattern recognition. I think it’s very useful to screen for things that look clinically benign. We have to understand that most dermatology is practiced by nondermatologists in the United States, and many studies show that their diagnostic accuracy is 20%, at best maybe 50%. So, they do need to reach out to a dermatologist and perhaps get some guidance on what to do. I think it could be a very useful tool if used appropriately.

Dr. Dunn: If used appropriately, teledermatology could function in a couple of ways. One, it could allow us to declare lesions to be wholly benign, and only should a lesion change would it need attention. The second is that it would allow us to accelerate the process of getting a patient to us—physically in front of us—for a biopsy if a suspicious lesion is seen. A by-product of that process would be that if patients who have wholly benign, nonworrisome lesions could be screened by telemedicine, then physical appointments where a patient is in front of the doctor would be more open. In other words, let’s say if 25% of all lesional visits could be declared benign via telemedicine that would allow dermatology to preserve its face-to-face appointments for patients who are more likely to have cancer and require procedures like skin biopsy.

Love it or hate it, I think we’re getting it no matter what now. Telemedicine creeped along forever and within 6 weeks it’s become ubiquitous. It’s phenomenal how fast we had to adapt to a system or perish in private practice. Sometimes these episodes that we go through have good consequences as well as bad consequences. Telemedicine probably has been needed for a long time and the insurers were not covering it very well, but suddenly a stay-at-home mandate has unveiled valuable technology—something that we probably should have been able to use more and be adequately reimbursed.

Surgical Treatment of Skin Cancer

Dr. Dunn: Treatment historically has been surgical for nonmelanoma and melanoma skin cancers. Some radiation devices have gained popularity again in the past decade or so, but excisional surgery remains the standard treatment for skin cancer. Nonmelanoma skin cancers almost all are probably treated surgically still, with a small percentage treated with superficial radiation.

Access to care is important to discuss. Are Mohs surgeons readily available, or are plastic surgeons, general surgeons, or vascular surgeons in the federal system contributing to the care of skin cancer? Are they doing excisional surgery after biopsies are done? Are they doing excisional biopsies with the intent of cure?

Dr. Logemann: For active duty, I don’t see any issues getting access to the medical center for Mohs micrographic surgery. Sometimes, if we have a lot of volume, some patients may get deferred to the network, but in my experience, it would not typically be an active-duty servicemember. An active-duty servicemember would get care rendered at one of the medical centers for Mohs surgery. Typically the active-duty–aged population isn’t getting much skin cancer. It certainly does happen, but most of the skin cancers frequently that are treated at medical centers are not infrequently retirees.

Dr. Bandino: Because of our residency program, we are required to have Mohs surgery capability to be ACGME (Accreditation Council for Graduate Medical Education) accredited. We typically have 3 Mohs surgeons, so we never have a problem with access.

In the military, I just refer cases to our Mohs surgeons and everything is taken care of in-house. In fact, this is an area where we may even have better access than the civilian world because there are no insurance hurdles or significant delay in care since our Mohs surgeons aren’t typically booked up for 3 to 4 months like many civilian Mohs surgeons. This is especially true for complex cases since we provide hospital-based care with all specialty services under the same umbrella. So, for example, if the Mohs surgeons have an extensive and complex case requiring multidisciplinary care such as ENT (ear, nose, and throat), facial plastics, or radiation-oncology, they’re all in-house with no insurance issues to navigate. This of course is not usual for most military bases and is only capable at bases attached to a large medical center. There are some similar scenarios in the civilian world with university medical centers and managed care organizations, but we may still have a slight advantage in accessibility and cost.

Dr. Dunn: There are guidelines from the National Comprehensive Cancer Network as to how to treat nonmelanoma and melanoma skin cancer. Almost all of them are surgical and almost all of them are safe, outpatient, local anesthetic procedures with a high cure rate. The vast majority of melanoma and nonmelanoma skin cancers can be handled safely and effectively with minimal morbidity and almost no known mortalities from the treatments themselves. Some of the cancers have been identified as high risk for metastasis and mortality, but they’re relatively uncommon still. The good news about skin cancer is that the risk of death remains very small.

Melanoma Risk for Servicemembers

Dr. Dunn: Active-duty jobs are quite diverse. We have had almost every civilian occupation category—everything from clerical to food service to outdoor construction workers. Federal service and active-duty military service could lead to assignments that involve high sunlight exposure and subsequently higher risk for melanoma and nonmelanoma skin cancer.

Dr. Miller: I found 2 articles on the topic. The first published in June 2018 reviewed melanoma and nonmelanoma skin cancers in the military.¹ Riemenschneider and colleagues¹ looked at 9 studies. Statistically, there was increased risk of melanoma associated with service and/or prisoner-of-war status. In World War II, they found tropical environments had the highest risk. And the highest rates were in the US Air Force.

The other article provided US Department of Defense data on skin cancer incidence rates, incidence rates of malignant melanoma in relation to years of military service overall, and the rates for differing military occupational groups.² The researchers demonstrated that fixed-wing pilots and crew members had the highest rates of developing melanoma. The general trend was that the incidence rate was exponentially higher with more missions flown in relation to years of active service, which I thought was rather interesting.

For other occupational categories, the rate increase was not as great as those involved in aviation. Yes, it’s probably related to exposure. Flying at 40,000 feet on a transcontinental airplane trip is equivalent to the radiation dosage of a chest X-ray. Given all the training time and operational flying for the Air Force, it is anticipated that that mutagenic radiation would increase rates. An aircraft does not offer a lot of protection, especially in the cockpit.

We just had the anniversary of the Apollo 11 mission. Those astronauts received the equivalent of about 40 chest X-rays going to the moon and back. Exposure to UV and at higher altitudes cosmic radiation explains why we would see that more in Air Force personnel.

Dr. Bandino: At high altitude there is less ozone protecting you, although the shielding in a cockpit is better in modern aircraft. As an Air Force member, that was one of the first things I thought about was that an aviator has increased skin cancer risk. But it’s apt to think of military service in general as an occupational risk because there are so many contingency operations and deployments. Regarding sun exposure, sunscreen is provided nowadays and there is more sun awareness, but there is still a stigma and reluctance to apply the sunscreen. It leaves people’s skin feeling greasy, which is not ideal when one has to handle a firearm. It can also get in someone’s eyes and affect vision and performance during combat operations. In other words, there are many reasons that would reduce the desire to wear sunscreen and therefore increase exposure to the elements.

A great current example is coronavirus disease 2019 (COVID-19) operations. Although I’m a dermatologist and typically work inside, I’ve been tasked to run a COVID-19 screening tent in the middle of a field in San Antonio, and thus I’ve got to make sure I take my sunscreen out there every day. The general population may not have that variability in their work cycle and sudden change in occupational UV exposure.

Dr. Miller: I was deployed in a combat zone for operations Desert Shield and Desert Storm. I was with the 2nd Armored Division of the US Army deployed to the desert. There really wasn’t an emphasis on photoprotection. It’s just the logistics. The commanders have a lot more important things to think about, and that’s something, usually, that doesn’t get a high priority. The US military is deploying to more places near the equator, so from an operational sense, there’s probably something to brief the commanders about in terms of the long-term consequences of radiation exposure for military servicemembers.

Dr. Dunn: If you look at deployments over the past 2 decades, we have been putting tens of thousands of individuals in high UV exposure regions. Then you have to look at the long-term consequence of the increased incidence of skin cancer in those individuals. What is the cost of that when it comes to treatment of precancerous lesions and skin cancer throughout a life expectancy of 80-plus years?

Dr. Bandino: With most skin cancers there is such long lag time between exposures and development. I wish there were some better data and research out there that really showed whether military service truly is an independent risk factor or if it’s just specific occupation types within the military. I have family members who both work in contracting services and had served in the military. Would their skin cancer risk be the same as others who are doing similar jobs without the military service?

Dr. Dunn: I have had county employees present for skin cancer surgery and with them comes a form that relates to disability. For groundskeepers or police, we assumed that skin cancer is occupation related due to the patient’s increased sun exposure. Their cancers may be unrelated to their actual years of service, but it seems that many light-skinned individuals in the military are going to develop basal cell and squamous cell skin cancer in the coming decades, which likely is going to be attributed to their years of federal service, even though they may have had other significant recreational exposure outside of work. So, my gut feeling is that we are going to see skin cancer as a disability tied to federal service, which is going to cost us.

Dr. Logemann: Yes, I think there are always going to be confounders—what if the servicemembers used tanning beds, or they were avid surfers? It’s going to be difficult to always parse that out.

Dr. Miller: In talking about melanoma, you really have to parse out the subsets. Is it melanoma in situ, is it superficial, is it acral, is it nodular? They all have different initiation events.

Nodular melanomas probably don’t need UV light to initiate a tumor. Another risk factor is having more than 100 moles or many atypical moles, which puts that person in a higher risk category. Perhaps when soldiers, airmen, and navy personnel get inducted, they should be screened for their mole population because that is a risk factor for developing melanoma, and then we can intervene a little bit and have them watch their UV exposure.

Dr. Jarell: You can’t overstate the importance of how heterogeneous melanoma is as a disease. While there are clearly some types of melanoma that are caused by UV radiation, there are also many types that aren’t. We don’t understand why someone gets melanoma on the inner thigh, bottom of the foot, top of the sole, inside the mouth, or in the genital region—these aren’t places of high sun exposure.

Lentigo maligna, as an example, is clearly caused by UV radiation in most cases. But there are so many other different types of melanoma that you can’t just attribute to UV radiation, and so you get into this whole other discussion as to why people are getting melanoma—military or not.

Dr. Bandino: When volunteering for military service, there’s the DoDMERB (Department of Defense Medical Examination Review Board) system that screens individuals for medical issues incompatible with military service such as severe psoriasis or atopic dermatitis. But to my knowledge, the DoDMERB process focuses more on current or past issues and does little to investigate for future risk of disease. A cutaneous example would be assessing quantity of dysplastic nevi, Fitzpatrick scale 1 phenotype, and family history of melanoma to determine risk of developing melanoma in someone who may have more UV exposure during their military service than a civilian. This dermatological future risk assessment was certainly not something I was trained to do as a flight surgeon when performing basic trainee flight physicals prior to becoming a dermatologist.

Dr. Jarell: I am a little bit hard-pressed to generalize the military as high occupational risk for melanoma. There are clearly other professions—landscapers, fishermen—that are probably at much higher risk than, say, your general military all-comers. Us physicians in the military were probably not at increased risk compared to other physicians in the United States. We have to be careful not to go down a slippery slope and designate all MOSs (military occupational specialties) as at increased risk for skin cancer, in particular melanoma. Nonmelanoma skin cancer, such as basal cell and squamous cell carcinoma, is clearly related to the proportional amount of UV exposure. But melanoma is quite a diverse cancer that has many, many disparate etiologies.

Dr. Dunn: The entry physical into the military is an opportunity to make an impact on the number of nonmelanoma skin cancers that would arise in that population. There is an educational opportunity to tell inductees that nonmelanoma skin cancer is going to occur on convex surfaces of the sun-exposed skin—nose, ears, forehead, chin, tops of the shoulders. If offered sun protection for those areas and you stretch the potential impact of that information over tens of thousands of military members over decades, you might actually come up with a big number of people that not only decreases their morbidity but also dramatically decreased the cost to the system as a whole.

Dr. Jarell: You also have to factor in ethnicity and the role it plays in someone’s likelihood to get skin cancer—melanoma or nonmelanoma skin cancer. Darker-skinned people are at certainly decreased risk for different types of skin cancers.

Dr. Dunn: Yes, that would have to be part of the education and should be. If you have light skin and freckles, then you’re at much higher risk for nonmelanoma skin cancer and need to know the high-risk areas that can be protected by sunblock and clothing.

Dr. Logemann: One thing that might be a little bit unique in the military is that you’re living in San Antonio one minute, and then the next minute you’re over in Afghanistan with a different climate and different environment. When you’re deployed overseas, you might have a little bit less control over your situation; you might not have a lot of sunscreen in a field hospital in Afghanistan. Whereas if you were just living in San Antonio, you could go down to the store and buy it.

Dr. Miller: Is sunblock now encouraged or available to individuals in deployment situations or training situations where they’re going to have prolonged sun exposure every day? Is it part of the regimen, just like carrying extra water because of the risk for dehydration?

Dr. Logemann: To the best of my knowledge, it is not always included in your normal rations or uniform and it may be up to the servicemember to procure sunscreen.

Dr. Bandino: There have been improvements, and usually you at least have access to sunscreen. In many deployed locations, for example, you have the equivalent of a small PX (post exchange) or BX (base exchange), where they have a variety of products for sale from toothbrushes to flip-flops, and now also sunscreen. Of course, the type and quality of the sunscreen may not be that great. It’s likely going to be basic SPF (sun protection factor) 15 or 30 in small tubes. As a recent example, I participated in a humanitarian medical exercise in South America last summer and was actually issued sunscreen combined with DEET, which is great but it was only SPF 30. The combination product is a good idea for tropical locations, but in addition to people just not wanting to wear it, the DEET combination tends to burn and sting a little bit more; you can get a heat sensation from the DEET; and the DEET can damage plastic surfaces, which may not be ideal for deployed equipment.

The other problem is quantity. We all learned in residency the appropriate sunscreen quantity of at least 1 fl oz for the average adult body, and that’s what we counsel our patients on, but what they issued me was 1 small 2- to 3-fl oz tube. It fit in the palm of my hand, and that was my sunscreen for the trip.

So, I do think, even though there have been some improvements, much of sun protection will still fall on the individual servicemember. And, as mentioned, depending on your ethnicity, some people may need it more than others. But it is an area where there probably could be continued improvements.

Dr. Logemann: In addition to sunscreen, I think that maybe we should be taking into consideration some simple measures. For example, is it necessary for people to stand out in formation at 2 pm on a blistering hot day, or could that function be performed at an earlier or later time? If people are needing to be out in formation in bright sunlight, could they maybe wear their boonie covers and not the caps that don’t provide any circumferential protection to the sun? Do they have sleeves down? Do they have sleeves up? I think commanders do take these things into consideration, but potentially there might be some additional measures that could be taken besides sunscreen in terms of just culture and practices.

Dr. Dunn: I think we all kind of agree that the military service is diverse and that many of the subcategories of occupations within the military lead to increased sun exposure by mandate. We advise sun protection by physical barriers and sunblock.

Diagnosis of Skin Cancer Via Telemedicine

Dr. Dunn: I have friends who remain in the VA (US Department of Veterans Affairs) system, and they are involved with telemedicine in dermatology, which can reduce waiting time and increase the number of patients seen by the dermatologist. In-person and teledermatology visits now are available to servicemembers on active duty and retirees.

Dr. Bandino: At our residency program (San Antonio Uniformed Services Health Education Consortium), we’ve had asynchronous teledermatology for over a decade, even before I was a resident. We provide it primarily as a service for patients at small bases without access to dermatology. Some bases also use it as part of their prescreening process prior to authorizing an in-person dermatology consultation.

Certainly, with the coronavirus pandemic, civilian dermatology is seeing a boom in the teledermatology world that had been slowly increasing in popularity for the last few years. In our residency program, teledermatology has traditionally been just for active-duty servicemembers or their dependents, but now due to the coronavirus pandemic, our teledermatology services have significantly expanded to include adding synchronous capability. We have patients take pictures before their virtual appointment and/or FaceTime during the appointment. Even after the pandemic, there will likely be more integration of synchronous teledermatology going forward as we’re seeing some of the value. Of course, I’m sure we would all agree that accurate diagnosis of pigmented lesions can be very challenging with teledermatology, not to mention other diagnostic limitations. But I think there is still utility and it should only get better with time as technology improves. So, I’m hopeful that we can incorporate more of it in the military.

Dr. Logemann: I’m definitely aware that we have different telehealth opportunities available, even using some newer modalities that are command approved in recent weeks. My experience has been for more complicated dermatology, so people are in remote locations, and they’re being seen by a nondermatologist, and they have questions about how to approach management. But I’m not aware of telemedicine as a screening tool for skin cancer in the military or among my civilian colleagues. I would hope that it could be someday because we’re developing these total-body photography machines as well. It could be a way for a nondermatologist who identifies a lesion to have it triaged by a dermatologist. To say, “Oh yeah, that looks like a melanoma. They need to get in sooner vs later,” but not on a large-scale sort of screening modality.

Dr. Bandino: In my recent experience, it has definitely been a helpful triage tool. In the military, this form of triage can be particularly helpful if someone is overseas to determine whether he/she needs to evacuated and evaluated in-person right away.

Dr. Jarell: It’s been useful in looking at benign things. People have shown me in the past few weeks a lot of seborrheic keratoses and a lot of benign dermal nevus-type things, and I say, “Don’t worry about that.” And you can tell if the resolution is good enough. But a lot of people have shown me things in the past few weeks that have clearly been basal cell carcinoma, which we can probably let that ride out for a few more weeks, but I’m not sure if maybe somebody has an amelanotic melanoma. Maybe you need to come in and get that biopsied ASAP. Or something that looks like a melanoma. The patient should probably come in and get that biopsied.

Dr. Miller: I think we can rely on teledermatology. It’s all predicated on the resolution because we’re all trained in pattern recognition. I think it’s very useful to screen for things that look clinically benign. We have to understand that most dermatology is practiced by nondermatologists in the United States, and many studies show that their diagnostic accuracy is 20%, at best maybe 50%. So, they do need to reach out to a dermatologist and perhaps get some guidance on what to do. I think it could be a very useful tool if used appropriately.

Dr. Dunn: If used appropriately, teledermatology could function in a couple of ways. One, it could allow us to declare lesions to be wholly benign, and only should a lesion change would it need attention. The second is that it would allow us to accelerate the process of getting a patient to us—physically in front of us—for a biopsy if a suspicious lesion is seen. A by-product of that process would be that if patients who have wholly benign, nonworrisome lesions could be screened by telemedicine, then physical appointments where a patient is in front of the doctor would be more open. In other words, let’s say if 25% of all lesional visits could be declared benign via telemedicine that would allow dermatology to preserve its face-to-face appointments for patients who are more likely to have cancer and require procedures like skin biopsy.

Love it or hate it, I think we’re getting it no matter what now. Telemedicine creeped along forever and within 6 weeks it’s become ubiquitous. It’s phenomenal how fast we had to adapt to a system or perish in private practice. Sometimes these episodes that we go through have good consequences as well as bad consequences. Telemedicine probably has been needed for a long time and the insurers were not covering it very well, but suddenly a stay-at-home mandate has unveiled valuable technology—something that we probably should have been able to use more and be adequately reimbursed.

Surgical Treatment of Skin Cancer

Dr. Dunn: Treatment historically has been surgical for nonmelanoma and melanoma skin cancers. Some radiation devices have gained popularity again in the past decade or so, but excisional surgery remains the standard treatment for skin cancer. Nonmelanoma skin cancers almost all are probably treated surgically still, with a small percentage treated with superficial radiation.

Access to care is important to discuss. Are Mohs surgeons readily available, or are plastic surgeons, general surgeons, or vascular surgeons in the federal system contributing to the care of skin cancer? Are they doing excisional surgery after biopsies are done? Are they doing excisional biopsies with the intent of cure?

Dr. Logemann: For active duty, I don’t see any issues getting access to the medical center for Mohs micrographic surgery. Sometimes, if we have a lot of volume, some patients may get deferred to the network, but in my experience, it would not typically be an active-duty servicemember. An active-duty servicemember would get care rendered at one of the medical centers for Mohs surgery. Typically the active-duty–aged population isn’t getting much skin cancer. It certainly does happen, but most of the skin cancers frequently that are treated at medical centers are not infrequently retirees.

Dr. Bandino: Because of our residency program, we are required to have Mohs surgery capability to be ACGME (Accreditation Council for Graduate Medical Education) accredited. We typically have 3 Mohs surgeons, so we never have a problem with access.

In the military, I just refer cases to our Mohs surgeons and everything is taken care of in-house. In fact, this is an area where we may even have better access than the civilian world because there are no insurance hurdles or significant delay in care since our Mohs surgeons aren’t typically booked up for 3 to 4 months like many civilian Mohs surgeons. This is especially true for complex cases since we provide hospital-based care with all specialty services under the same umbrella. So, for example, if the Mohs surgeons have an extensive and complex case requiring multidisciplinary care such as ENT (ear, nose, and throat), facial plastics, or radiation-oncology, they’re all in-house with no insurance issues to navigate. This of course is not usual for most military bases and is only capable at bases attached to a large medical center. There are some similar scenarios in the civilian world with university medical centers and managed care organizations, but we may still have a slight advantage in accessibility and cost.

Dr. Dunn: There are guidelines from the National Comprehensive Cancer Network as to how to treat nonmelanoma and melanoma skin cancer. Almost all of them are surgical and almost all of them are safe, outpatient, local anesthetic procedures with a high cure rate. The vast majority of melanoma and nonmelanoma skin cancers can be handled safely and effectively with minimal morbidity and almost no known mortalities from the treatments themselves. Some of the cancers have been identified as high risk for metastasis and mortality, but they’re relatively uncommon still. The good news about skin cancer is that the risk of death remains very small.

Melanoma Risk for Servicemembers

Dr. Dunn: Active-duty jobs are quite diverse. We have had almost every civilian occupation category—everything from clerical to food service to outdoor construction workers. Federal service and active-duty military service could lead to assignments that involve high sunlight exposure and subsequently higher risk for melanoma and nonmelanoma skin cancer.

Dr. Miller: I found 2 articles on the topic. The first published in June 2018 reviewed melanoma and nonmelanoma skin cancers in the military.¹ Riemenschneider and colleagues¹ looked at 9 studies. Statistically, there was increased risk of melanoma associated with service and/or prisoner-of-war status. In World War II, they found tropical environments had the highest risk. And the highest rates were in the US Air Force.

The other article provided US Department of Defense data on skin cancer incidence rates, incidence rates of malignant melanoma in relation to years of military service overall, and the rates for differing military occupational groups.² The researchers demonstrated that fixed-wing pilots and crew members had the highest rates of developing melanoma. The general trend was that the incidence rate was exponentially higher with more missions flown in relation to years of active service, which I thought was rather interesting.

For other occupational categories, the rate increase was not as great as those involved in aviation. Yes, it’s probably related to exposure. Flying at 40,000 feet on a transcontinental airplane trip is equivalent to the radiation dosage of a chest X-ray. Given all the training time and operational flying for the Air Force, it is anticipated that that mutagenic radiation would increase rates. An aircraft does not offer a lot of protection, especially in the cockpit.

We just had the anniversary of the Apollo 11 mission. Those astronauts received the equivalent of about 40 chest X-rays going to the moon and back. Exposure to UV and at higher altitudes cosmic radiation explains why we would see that more in Air Force personnel.

Dr. Bandino: At high altitude there is less ozone protecting you, although the shielding in a cockpit is better in modern aircraft. As an Air Force member, that was one of the first things I thought about was that an aviator has increased skin cancer risk. But it’s apt to think of military service in general as an occupational risk because there are so many contingency operations and deployments. Regarding sun exposure, sunscreen is provided nowadays and there is more sun awareness, but there is still a stigma and reluctance to apply the sunscreen. It leaves people’s skin feeling greasy, which is not ideal when one has to handle a firearm. It can also get in someone’s eyes and affect vision and performance during combat operations. In other words, there are many reasons that would reduce the desire to wear sunscreen and therefore increase exposure to the elements.

A great current example is coronavirus disease 2019 (COVID-19) operations. Although I’m a dermatologist and typically work inside, I’ve been tasked to run a COVID-19 screening tent in the middle of a field in San Antonio, and thus I’ve got to make sure I take my sunscreen out there every day. The general population may not have that variability in their work cycle and sudden change in occupational UV exposure.

Dr. Miller: I was deployed in a combat zone for operations Desert Shield and Desert Storm. I was with the 2nd Armored Division of the US Army deployed to the desert. There really wasn’t an emphasis on photoprotection. It’s just the logistics. The commanders have a lot more important things to think about, and that’s something, usually, that doesn’t get a high priority. The US military is deploying to more places near the equator, so from an operational sense, there’s probably something to brief the commanders about in terms of the long-term consequences of radiation exposure for military servicemembers.

Dr. Dunn: If you look at deployments over the past 2 decades, we have been putting tens of thousands of individuals in high UV exposure regions. Then you have to look at the long-term consequence of the increased incidence of skin cancer in those individuals. What is the cost of that when it comes to treatment of precancerous lesions and skin cancer throughout a life expectancy of 80-plus years?

Dr. Bandino: With most skin cancers there is such long lag time between exposures and development. I wish there were some better data and research out there that really showed whether military service truly is an independent risk factor or if it’s just specific occupation types within the military. I have family members who both work in contracting services and had served in the military. Would their skin cancer risk be the same as others who are doing similar jobs without the military service?

Dr. Dunn: I have had county employees present for skin cancer surgery and with them comes a form that relates to disability. For groundskeepers or police, we assumed that skin cancer is occupation related due to the patient’s increased sun exposure. Their cancers may be unrelated to their actual years of service, but it seems that many light-skinned individuals in the military are going to develop basal cell and squamous cell skin cancer in the coming decades, which likely is going to be attributed to their years of federal service, even though they may have had other significant recreational exposure outside of work. So, my gut feeling is that we are going to see skin cancer as a disability tied to federal service, which is going to cost us.

Dr. Logemann: Yes, I think there are always going to be confounders—what if the servicemembers used tanning beds, or they were avid surfers? It’s going to be difficult to always parse that out.

Dr. Miller: In talking about melanoma, you really have to parse out the subsets. Is it melanoma in situ, is it superficial, is it acral, is it nodular? They all have different initiation events.

Nodular melanomas probably don’t need UV light to initiate a tumor. Another risk factor is having more than 100 moles or many atypical moles, which puts that person in a higher risk category. Perhaps when soldiers, airmen, and navy personnel get inducted, they should be screened for their mole population because that is a risk factor for developing melanoma, and then we can intervene a little bit and have them watch their UV exposure.

Dr. Jarell: You can’t overstate the importance of how heterogeneous melanoma is as a disease. While there are clearly some types of melanoma that are caused by UV radiation, there are also many types that aren’t. We don’t understand why someone gets melanoma on the inner thigh, bottom of the foot, top of the sole, inside the mouth, or in the genital region—these aren’t places of high sun exposure.

Lentigo maligna, as an example, is clearly caused by UV radiation in most cases. But there are so many other different types of melanoma that you can’t just attribute to UV radiation, and so you get into this whole other discussion as to why people are getting melanoma—military or not.

Dr. Bandino: When volunteering for military service, there’s the DoDMERB (Department of Defense Medical Examination Review Board) system that screens individuals for medical issues incompatible with military service such as severe psoriasis or atopic dermatitis. But to my knowledge, the DoDMERB process focuses more on current or past issues and does little to investigate for future risk of disease. A cutaneous example would be assessing quantity of dysplastic nevi, Fitzpatrick scale 1 phenotype, and family history of melanoma to determine risk of developing melanoma in someone who may have more UV exposure during their military service than a civilian. This dermatological future risk assessment was certainly not something I was trained to do as a flight surgeon when performing basic trainee flight physicals prior to becoming a dermatologist.

Dr. Jarell: I am a little bit hard-pressed to generalize the military as high occupational risk for melanoma. There are clearly other professions—landscapers, fishermen—that are probably at much higher risk than, say, your general military all-comers. Us physicians in the military were probably not at increased risk compared to other physicians in the United States. We have to be careful not to go down a slippery slope and designate all MOSs (military occupational specialties) as at increased risk for skin cancer, in particular melanoma. Nonmelanoma skin cancer, such as basal cell and squamous cell carcinoma, is clearly related to the proportional amount of UV exposure. But melanoma is quite a diverse cancer that has many, many disparate etiologies.

Dr. Dunn: The entry physical into the military is an opportunity to make an impact on the number of nonmelanoma skin cancers that would arise in that population. There is an educational opportunity to tell inductees that nonmelanoma skin cancer is going to occur on convex surfaces of the sun-exposed skin—nose, ears, forehead, chin, tops of the shoulders. If offered sun protection for those areas and you stretch the potential impact of that information over tens of thousands of military members over decades, you might actually come up with a big number of people that not only decreases their morbidity but also dramatically decreased the cost to the system as a whole.

Dr. Jarell: You also have to factor in ethnicity and the role it plays in someone’s likelihood to get skin cancer—melanoma or nonmelanoma skin cancer. Darker-skinned people are at certainly decreased risk for different types of skin cancers.

Dr. Dunn: Yes, that would have to be part of the education and should be. If you have light skin and freckles, then you’re at much higher risk for nonmelanoma skin cancer and need to know the high-risk areas that can be protected by sunblock and clothing.

Dr. Logemann: One thing that might be a little bit unique in the military is that you’re living in San Antonio one minute, and then the next minute you’re over in Afghanistan with a different climate and different environment. When you’re deployed overseas, you might have a little bit less control over your situation; you might not have a lot of sunscreen in a field hospital in Afghanistan. Whereas if you were just living in San Antonio, you could go down to the store and buy it.

Dr. Miller: Is sunblock now encouraged or available to individuals in deployment situations or training situations where they’re going to have prolonged sun exposure every day? Is it part of the regimen, just like carrying extra water because of the risk for dehydration?

Dr. Logemann: To the best of my knowledge, it is not always included in your normal rations or uniform and it may be up to the servicemember to procure sunscreen.

Dr. Bandino: There have been improvements, and usually you at least have access to sunscreen. In many deployed locations, for example, you have the equivalent of a small PX (post exchange) or BX (base exchange), where they have a variety of products for sale from toothbrushes to flip-flops, and now also sunscreen. Of course, the type and quality of the sunscreen may not be that great. It’s likely going to be basic SPF (sun protection factor) 15 or 30 in small tubes. As a recent example, I participated in a humanitarian medical exercise in South America last summer and was actually issued sunscreen combined with DEET, which is great but it was only SPF 30. The combination product is a good idea for tropical locations, but in addition to people just not wanting to wear it, the DEET combination tends to burn and sting a little bit more; you can get a heat sensation from the DEET; and the DEET can damage plastic surfaces, which may not be ideal for deployed equipment.

The other problem is quantity. We all learned in residency the appropriate sunscreen quantity of at least 1 fl oz for the average adult body, and that’s what we counsel our patients on, but what they issued me was 1 small 2- to 3-fl oz tube. It fit in the palm of my hand, and that was my sunscreen for the trip.

So, I do think, even though there have been some improvements, much of sun protection will still fall on the individual servicemember. And, as mentioned, depending on your ethnicity, some people may need it more than others. But it is an area where there probably could be continued improvements.

Dr. Logemann: In addition to sunscreen, I think that maybe we should be taking into consideration some simple measures. For example, is it necessary for people to stand out in formation at 2 pm on a blistering hot day, or could that function be performed at an earlier or later time? If people are needing to be out in formation in bright sunlight, could they maybe wear their boonie covers and not the caps that don’t provide any circumferential protection to the sun? Do they have sleeves down? Do they have sleeves up? I think commanders do take these things into consideration, but potentially there might be some additional measures that could be taken besides sunscreen in terms of just culture and practices.

Dr. Dunn: I think we all kind of agree that the military service is diverse and that many of the subcategories of occupations within the military lead to increased sun exposure by mandate. We advise sun protection by physical barriers and sunblock.

Diagnosis of Skin Cancer Via Telemedicine

Dr. Dunn: I have friends who remain in the VA (US Department of Veterans Affairs) system, and they are involved with telemedicine in dermatology, which can reduce waiting time and increase the number of patients seen by the dermatologist. In-person and teledermatology visits now are available to servicemembers on active duty and retirees.

Dr. Bandino: At our residency program (San Antonio Uniformed Services Health Education Consortium), we’ve had asynchronous teledermatology for over a decade, even before I was a resident. We provide it primarily as a service for patients at small bases without access to dermatology. Some bases also use it as part of their prescreening process prior to authorizing an in-person dermatology consultation.

Certainly, with the coronavirus pandemic, civilian dermatology is seeing a boom in the teledermatology world that had been slowly increasing in popularity for the last few years. In our residency program, teledermatology has traditionally been just for active-duty servicemembers or their dependents, but now due to the coronavirus pandemic, our teledermatology services have significantly expanded to include adding synchronous capability. We have patients take pictures before their virtual appointment and/or FaceTime during the appointment. Even after the pandemic, there will likely be more integration of synchronous teledermatology going forward as we’re seeing some of the value. Of course, I’m sure we would all agree that accurate diagnosis of pigmented lesions can be very challenging with teledermatology, not to mention other diagnostic limitations. But I think there is still utility and it should only get better with time as technology improves. So, I’m hopeful that we can incorporate more of it in the military.

Dr. Logemann: I’m definitely aware that we have different telehealth opportunities available, even using some newer modalities that are command approved in recent weeks. My experience has been for more complicated dermatology, so people are in remote locations, and they’re being seen by a nondermatologist, and they have questions about how to approach management. But I’m not aware of telemedicine as a screening tool for skin cancer in the military or among my civilian colleagues. I would hope that it could be someday because we’re developing these total-body photography machines as well. It could be a way for a nondermatologist who identifies a lesion to have it triaged by a dermatologist. To say, “Oh yeah, that looks like a melanoma. They need to get in sooner vs later,” but not on a large-scale sort of screening modality.

Dr. Bandino: In my recent experience, it has definitely been a helpful triage tool. In the military, this form of triage can be particularly helpful if someone is overseas to determine whether he/she needs to evacuated and evaluated in-person right away.

Dr. Jarell: It’s been useful in looking at benign things. People have shown me in the past few weeks a lot of seborrheic keratoses and a lot of benign dermal nevus-type things, and I say, “Don’t worry about that.” And you can tell if the resolution is good enough. But a lot of people have shown me things in the past few weeks that have clearly been basal cell carcinoma, which we can probably let that ride out for a few more weeks, but I’m not sure if maybe somebody has an amelanotic melanoma. Maybe you need to come in and get that biopsied ASAP. Or something that looks like a melanoma. The patient should probably come in and get that biopsied.

Dr. Miller: I think we can rely on teledermatology. It’s all predicated on the resolution because we’re all trained in pattern recognition. I think it’s very useful to screen for things that look clinically benign. We have to understand that most dermatology is practiced by nondermatologists in the United States, and many studies show that their diagnostic accuracy is 20%, at best maybe 50%. So, they do need to reach out to a dermatologist and perhaps get some guidance on what to do. I think it could be a very useful tool if used appropriately.

Dr. Dunn: If used appropriately, teledermatology could function in a couple of ways. One, it could allow us to declare lesions to be wholly benign, and only should a lesion change would it need attention. The second is that it would allow us to accelerate the process of getting a patient to us—physically in front of us—for a biopsy if a suspicious lesion is seen. A by-product of that process would be that if patients who have wholly benign, nonworrisome lesions could be screened by telemedicine, then physical appointments where a patient is in front of the doctor would be more open. In other words, let’s say if 25% of all lesional visits could be declared benign via telemedicine that would allow dermatology to preserve its face-to-face appointments for patients who are more likely to have cancer and require procedures like skin biopsy.

Love it or hate it, I think we’re getting it no matter what now. Telemedicine creeped along forever and within 6 weeks it’s become ubiquitous. It’s phenomenal how fast we had to adapt to a system or perish in private practice. Sometimes these episodes that we go through have good consequences as well as bad consequences. Telemedicine probably has been needed for a long time and the insurers were not covering it very well, but suddenly a stay-at-home mandate has unveiled valuable technology—something that we probably should have been able to use more and be adequately reimbursed.

Surgical Treatment of Skin Cancer

Dr. Dunn: Treatment historically has been surgical for nonmelanoma and melanoma skin cancers. Some radiation devices have gained popularity again in the past decade or so, but excisional surgery remains the standard treatment for skin cancer. Nonmelanoma skin cancers almost all are probably treated surgically still, with a small percentage treated with superficial radiation.

Access to care is important to discuss. Are Mohs surgeons readily available, or are plastic surgeons, general surgeons, or vascular surgeons in the federal system contributing to the care of skin cancer? Are they doing excisional surgery after biopsies are done? Are they doing excisional biopsies with the intent of cure?

Dr. Logemann: For active duty, I don’t see any issues getting access to the medical center for Mohs micrographic surgery. Sometimes, if we have a lot of volume, some patients may get deferred to the network, but in my experience, it would not typically be an active-duty servicemember. An active-duty servicemember would get care rendered at one of the medical centers for Mohs surgery. Typically the active-duty–aged population isn’t getting much skin cancer. It certainly does happen, but most of the skin cancers frequently that are treated at medical centers are not infrequently retirees.

Dr. Bandino: Because of our residency program, we are required to have Mohs surgery capability to be ACGME (Accreditation Council for Graduate Medical Education) accredited. We typically have 3 Mohs surgeons, so we never have a problem with access.

In the military, I just refer cases to our Mohs surgeons and everything is taken care of in-house. In fact, this is an area where we may even have better access than the civilian world because there are no insurance hurdles or significant delay in care since our Mohs surgeons aren’t typically booked up for 3 to 4 months like many civilian Mohs surgeons. This is especially true for complex cases since we provide hospital-based care with all specialty services under the same umbrella. So, for example, if the Mohs surgeons have an extensive and complex case requiring multidisciplinary care such as ENT (ear, nose, and throat), facial plastics, or radiation-oncology, they’re all in-house with no insurance issues to navigate. This of course is not usual for most military bases and is only capable at bases attached to a large medical center. There are some similar scenarios in the civilian world with university medical centers and managed care organizations, but we may still have a slight advantage in accessibility and cost.

Dr. Dunn: There are guidelines from the National Comprehensive Cancer Network as to how to treat nonmelanoma and melanoma skin cancer. Almost all of them are surgical and almost all of them are safe, outpatient, local anesthetic procedures with a high cure rate. The vast majority of melanoma and nonmelanoma skin cancers can be handled safely and effectively with minimal morbidity and almost no known mortalities from the treatments themselves. Some of the cancers have been identified as high risk for metastasis and mortality, but they’re relatively uncommon still. The good news about skin cancer is that the risk of death remains very small.