Students share their experience in the virtual classroom, navigating new requirements, and the lessons learned from their position in a global pandemic.

How COVID-19 Transformed Medical Education

Anne Dixon, MD, joins Lungcast to discuss obesity's effect on asthma, and the newest recommendations for managed care.

New Asthma Management Guidelines: A Podcast Primer

Expert David W. Goodman, MD, explains why adults with ADHD may face unknown challenges during the pandemic.

Adult ADHD Challenges During COVID-19

What you need to know about vaccinator and patient education, counseling, billing, and reimbursement.

ACP Policy Statement on COVID-19 Vaccine Distribution and Administration

New ADA guidelines list more than 40 recommendations related to blood pressure targets, screening and diagnosis, and overall management strategies.

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An American Red Cross discusses the importance of National Blood Donor Month and the challenges faced during the COVID-19 pandemic.

The National Blood Shortage: An Unprecedented Challenge

The increase in hospitalized patients has many worried about an additional increase in 

A team, led by Jessica R. Allegretti, Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, evaluated the prevalence, patient characteristics, and clinical outcomes of CDI among hospitalized patients with COVID‐19.

Gastrointestinal symptoms has been a hallmark of COVID-19 since the beginning of the pandemic, with about a third of patients suffering from diarrhea.

While the US Food and Drug Administration (FDA) has yet to approve a treatment for COVID-19, hospitalized patients often are treated with broad-spectrum antibiotics, which is escalated as the clinical status of the patients deteriorates.

However, this class of treatment has been associated with an increased risk of CDI, even as hospitals take measures to limit the person-to-person spread of the virus.

“Strict isolation and social‐distancing protocols adopted by hospitals since the start of the pandemic may help mitigate this risk,” the authors wrote.

In the retrospective cohort study, the investigators examined hospitalized COVID-19 patients from 9 hospitals in Massachusetts.

Each patient in the cohort underwent stool testing for C diff infections and were confirmed to be positive with COVID-19 from a nasopharyngeal swab polymerase chain reaction (PCR) test, and testing was performed via glutamate dehydrogenase (GDH) and enzyme‐linked immunosorbent assay (ELISA) immunoassay (EIA) for toxin and considered diagnostic if both tests were positive.

The researchers compared outcomes and mortality for hospitalized COVID-19 patients with and without CDI. All CDI patients were exposed to at least 2 (2-8) antibiotics prior to their CDI diagnosis.

‐test and Fisher's exact tests for continuous variables and categorical variables, respectively, on univariate analyses.

Overall, there were 97 (24.9%) patients who were tested for CDI, with a mean age of 62.4 years old. Of this group, 5 (5.2%) patients tested positive for CDI, which was lower than the overall inpatient CDI-positive rate in 2019 (n = 280; 9.8% of tests performed). However, this was not statistically significant (

GDH/EIA‐positive rates were similar between the COVID‐19 and historical cohort (5.2% 

In addition, the PCR positive rate among GDH/EIA‐indeterminant patients was significantly lower among COVID‐19 patients (n = 0; 0% 

“In comparison, rates of confirmed CDI were lower among patients hospitalized with COVID‐19,” the authors wrote. “This difference was entirely driven by patients who were PCR positive but GDH/EIA indeterminant as the rates of GDH/EIA positivity were similar between COVID‐19 and the historical cohorts. This may suggest lower rates of 

 colonization despite a similar risk of CDI.”

However, the findings do show that COVID-19 patients who receive at least 2 systemic antibiotics are at a significant risk of developing CDI.

On the other hand, some of the measures taken up because of COVID-19 do show the importance of hand hygiene, contact precautions, and appropriate isolation of patients in lowering hospital‐acquired CDI.

“In conclusion, the prevalence of CDI among hospitalized COVID‐19 patients was not higher despite widespread use of multiple antibiotics, likely due to aggressive contact precaution and isolation measures implemented for COVID‐19,” the authors wrote. “The development of CDI was associated with poor outcomes and a high mortality rate among hospitalized COVID‐19 patients. A low threshold for early CDI testing should be implemented among COVID‐19 patients to ensure prompt diagnosis and appropriate therapeutic intervention.”

Prevalence and impact of Clostridioides difficile infection among hospitalized patients with coronavirus disease 2019

Journal of Gastroenterology and Hepatology

Articles

COVID-19 patients receiving at least 2 antibiotics were at a higher CDI risk.

News

C Difficile Infection

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, IBS and IBD, Crohn's disease, and more.

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Hospital Medicine

COVID-19 Measures Reduce Risk of C Diff Infections

A recent study found that over 32% of patients diagnosed with 

 use disorder (OUD) between 2001 and 2018 were prescribed non-cancer opioid analgesics prior to OUD diagnosis.

The proportion of opioid analgesic prescription prior to OUD peaked at 40% in 2011, but the percentage stabilized afterward and then declined.

Investigators, led by Bohdan Nosyk, PhD, of the BC Centre for Excellence in HIV/AIDS at St. Paul’s Hospital in Vancouver, said a link has been found between levels of opioid analgesic prescribing and mortality particularly in British Columbia (BC), Canada, where overdose rates are nearly 3 times higher than the national average.

Most overdoses in British Columbia had a history of long-term prescription opioid use but did not have an active prescription at the time of overdose, marking a transition to illicit opioid use.

Canada health experts recommend against the use of opioids for individuals with substance use disorders and doses exceeding 90 morphine milligram equivalents (MME/Day).

The team in the study aimed to characterize non-cancer opioid analgesic prescribing in British Columbia prior to OUD identification, as well as examining the extent of initial prescriptions concordant to current guidelines.

Investigators led a retrospective cohort study of a population-level linkage to define a cohort of individuals with OUD in British Columbia from January 1996 – September 2018.

Data was gathered using health records of 6 databases: PharmaNet, Discharge Abstract Database, Medical Services Plan, BC Vital Statistics, National Ambulatory Care Reporting System, and BC Corrections.

Individuals in the study were chosen based on who had accessed health services for OUD, but individuals who were diagnosed with cancer or had received palliative care were excluded from study.

Patients who initiated opioid analgesic therapy or identified with OUD between January 2001 and September 2018 were included in the study for 5 years of OUD identification data capturing.

The primary outcome of the study was initial observed opioid analgesic prescriptions. The doses of initial prescriptions in MME/day combined the product of drug strength per dose unit, number of units per day, and an MME conversion for comparison against different drug types.

Investigators identified 3 measures of initial analgesic prescriptions: high dose (≥90 MME/day), long-term (≥7 days), and concomitant sedative prescription.

The key exposure in the study was the source of prescription, with classifications by type of health system contact prior to initial prescription. These included inpatient-post discharge, non-inpatient acute or non-acute visit.

Sociodemographic and clinical characteristics such as age, sex, and substance use disorders were gathered to include key factors that may influence prescriptions, as well as other comorbid conditions.
Results 

The cohort in the study included 66,372 individuals identified with OUD from 2001 – 2018, with 32.1% having an opioid analgesic prescription prior to OUD identification.

The proportion increased from 3% (n = 79) in 2001 to 41% (n = 1535) in 2011 and decreased to 32.2% (n = 1667) in 2018.

Individuals receiving prescriptions prior to OUD were older and had a higher prevalence of comorbid conditions. The proportion of males grew from 57.9% (n = 4847) to 64.5% (n = 2182).

Across all sources, the percentage of individuals receiving high dose (≥90

MME/day) initial prescriptions decreased from 15.7% (n = 1314) to 14.5% (n = 490).

Long-term (≥7 day) prescriptions decreased from 52.8% (n = 4419) to 43.8% (n = 1484), and concomitant sedative prescriptions decreased from 16.5% (n = 1378) to 10.8% (n = 365).

Over half of initial opioid prescriptions originated from non-acute care visits, with a peak of 56.8% in 2001. The proportion of prescriptions from inpatient visits increased from 19.7% in 2001 to over 28% at the end of the study in 2018.

The probability of receiving non-guideline prescriptions decreased for all 3 measures for inpatient and non-inpatient acute care, but remained stable for non-acute care.

Long-term prescriptions had the highest decrease measures, as inpatient visits decreased from 53.3% (95% CI, 50.9 - 55.8) in 2001 to 37.2% (95% CI, 33.9 - 40.5) in 2018.

Investigators concluded that although opioid analgesic prescription rates prior to OUD identification has declined since a peak in 2011, individuals identified with OUD in 2018 had previously received prescription opioid analgesics.

The team noted that current guidelines in opioid prescription may still need to adapt to reduce opioid use harms for patients and educate prescribers on the dangers.

“While understanding the causal contribution of opioid prescriptions to the rise in OUD prevalence in BC remains critical to evaluating current guidelines, evidence on the implications of opioid prescribing before and after OUD identification may be equally important in shaping policies to reduce opioid-related harms,” investigators wrote.

Opioid analgesic prescribing for opioid-naïve individuals prior to identification of opioid use disorder in British Columbia, Canada

New research over 2 decades shows patients with opioid use disorder are often prescribed opioid analgesic prior to OUD diagnosis, although rates have decreased in recent years.

Opioid-induced Constipation

Addiction

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Chronic Pain

Opioid Analgesic Prescription Contributes to One-Third of OUDs in British Columbia

A systematic literature review has reported on outcomes in pregnant women with 

. The review primarily explored disease activity during pregnancy course and adverse pregnancy outcomes, thus finding a general worsening of disease following delivery.

The study was conducted by investigators from the German Rheumatism Research Centre Berlin. Led by Yvette Meissner, MSc, the investigative team searched within the Pubmed and Embase databases for relevant literature on psoriatic arthritis pregnancy outcomes through November 2020.

“Recommendations for the use of disease-modifying anti-rheumatic drugs (DMARDs) in pregnant and lactating women with rheumatic diseases have been published, but information on disease activity during pregnancy and adverse pregnancy outcomes in women with PsA are still scarce,” they noted.

In addition to maternal outcomes, the team evaluated neonatal outcomes during gestation.

Meissner’s team evaluated 13 relevant publications, which consisted of 2332 pregnancies in women affected by PsA. All studies reported on disease activity and/or pregnancy outcomes.

Furthermore, 5 studies prospectively followed patients, and 8 were retrospective. A majority (n = 7) reported on data based on single center hospital records or cohorts. The analysis also included data from Scandinavian national registries and a United States birth registry.

All studies were published between 2017-2020, save for one that was published in 1988.

The mean or median age range across studies was from 29 – 34 years.

Thus, 9 studies reported disease activity during pregnancy—representing a total of 536 pregnancies.

Additionally, a majority of PsA patients in each study was classified with mild/low disease activity. Up to 1/3 of patients reported a moderate to severe/high disease activity. 

However, one such study reported moderate or severe PsA in 8 of 14 pregnant patient.

“Throughout the studies, disease activity deteriorated postpartum compared to the pregnancy period,” the investigators wrote. “In addition, 3 studies reported worsening of arthritis and psoriatic skin involvement after birth in a considerable proportion of patients.”

Adverse pregnancy outcomes were reported in 9 studies representing 2135 pregnancies in women with PsA.

Outcomes, although of various rates for each study, included pre-eclampsia, preterm birth, gestational diabetes, small for gestational age, and low birth weight. However, none of the studies found an increased risk for the latter 4 outcomes.

The investigators noted the considerable inconsistencies in risk for adverse pregnancy outcomes, particularly for caesarean section and low birth weight.

And finally, there were no reported increased risks for adverse neonatal outcomes in this maternal patient population.

Some of the limitations acknowledged by the investigators were the heterogeneity of study designs and differences in PsA activity assessments, such as use of Disease Activity Score based on 28 tender and swollen joints and C-reactive protein (DAS28-CRP3), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Routine Assessment of Patient Index Data (RAPID3), and Health Assessment Questionnaire (HAQ), for example.

Additionally, not all studies were entirely forthcoming and clear about methodologies (i.e. time point of patient enrollment).

“To enable informed counselling of patients with PsA before, during and after pregnancy, future research should address the development of standardised instruments for assessing disease activity in PsA during pregnancy, the investigation of the interplay between pregnancy in PsA and effect of DMARD treatment on the course of PsA, pregnancy and the development of the foetus,” Meissner and colleagues concluded.

Pregnancy in women with psoriatic arthritis: A systematic literature review of disease activity and adverse pregnancy outcomes

A majority of studies reported a worsening of disease activity post-delivery.


Psoriatic Arthritis

Women's Health

Internal Medicine

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Literature Review Explores Pregnancy Outcomes in Women with Psoriatic Arthritis

 Biggest Issue Before and After COVID-19


While much of the focus since the beginning on 2020 was to learn about and mitigate the effects of 

 issues that may have been pushed aside are now at the forefront of another public health crisis.

Mitigation measures like shelter-in-place orders, social distancing requirements, and mask mandates had some success in curtailing the spread of the virus, they also likely increased what was already a growing mental health problem in the US.

And a year where nothing was normal, screenings for new patients, checkups on existing patients, and warning signs for troubled patients may all have been missed.

But with the pandemic comes an opportunity to improve psychiatry care in the US.

Coping After COVID: Navigating Psychiatry After a Pandemic

, each month an expert in psychiatry will discuss a specific condition and how patients with that disorder may have been impacted by the events of the last 13 months and what the best way to proceed in the future will be.

The expert-led discussion will focus both on a review of how patients may have been impacted by the ongoing pandemic and what needs to change in mental health care to mitigate some of the damage.

For the inaugural episode, Jennifer Payne, MD, Director of the Women’s Mood Disorder Center at Johns Hopkins University, discussed how difficult the pandemic has been for patients with mood disorders who often suffer from symptoms of impulsivity.

Payne explained how common it has been for her patients to request psychiatric assistances because they are either decompensating or overly stressed to the point where they need additional help.

There is also a number of patients who feared contracted COVID-19 and neglected psychiatric help.

And the best advice for both patients and doctors is to develop a self-care plan that includes regular exercise, a good diet, and placing strict boundaries between work and home life.

However, Payne said the ending of the pandemic might offer psychiatrists an opportunity to really improve how mental health disorders are treated in the US and some of the thoughts about how mental illnesses manifest may have changed.

Videos

Dr. Jennifer Payne discusses how the events of the last year has impacted her patients and what needs to happen to improve mental health care in the future.

Psychiatry

Psychiatry condition center page is a comprehensive resource for clinical news and insights on mental illnesses. This page consists of interviews, articles, podcasts, and videos on the research, treatment and development of therapies for depression, schizophrenia, bipolar disorder, anxiety, and more.

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The 2021 State of the Air Report from the American Lung Association (ALA) found that more than 40% of people in the United States live in an area with an unhealthy level of air pollution, while people of color are 3 times more likely to breathe polluted air compared to White people.

The annual State of the Air reports on the most widespread air pollutants, including ozone and fine particulate matter. Data is collected from monitoring sites across the United States and then calculated by the ALA, to rank cities and counties with the most pollution.

The ALA stated that while the data show some progress in cleaning up air pollution, the 3 assessed years (2017, 2018, and 2019) in their 2021 report rank among the 6 hottest years on record.

Polluted air can trigger serious effects, with new data showing it may even worsen outcomes of COVID-19 among infected persons.

Particle pollution is linked to triggers of asthma and cardiovascular (CV) events including heart attacks, as well as dementia. Ozone pollution effects have been linked to asthma attacks, shortened life and an increased risk of metabolic disorders.

The data on air quality in the study was obtained from the US Environmental Protection Agency (EPA) Air Quality System (AQS).

Investigators used AQS data from 2017 – 2019 to calculate daily eight-hour maximum concentration for each ozone monitoring area and the highest maximum in each county was identified. The national ambient air quality standard for ozone was reflected by a 70 parts per billion (ppb) measure over an eight-hour period.

The daily maximum data of an eight-hour average is obtained from 17 consecutive eight-hour averages, beginning with a 7:00 A.M. to 3:00 P.M. period and ending with the 8-hour period from 11:00 P.M. to 7:00 A.M.

The ALA investigators then identified the air quality of each day in the observed counties, as orange (Unhealthy for Sensitive Groups), red (Unhealthy), or purple ( Very Unhealthy).

The team identified the maximum daily 24-hour AQS coarse particle (PM) concentration for the years 2017 – 2019 and data was compiled into 24-hour average PM values.

The standard concentration for moderate air quality index levels is 12.1 µg/m3 to 35.4 µg/m3 n.

Investigators identified the number of days when the maximum of daily PM in each county occurred. 

The ALA identified the number of days each county, with at ≥1 PM monitor, experienced air quality designated as orange (Unhealthy for Sensitive Groups), red (Unhealthy), purple (Very Unhealthy) or maroon (Hazardous).

For year-round particle pollution calculations, the EPA listed counties at 12 µg/m3 and were given grades of “pass.” Counties listed at or above 12.1 µg/m3 were given grades of “fail.” If data was insufficient, counties were given a grade of “incomplete.”

The report found more than 135 million Americans live in the 217 counties with monitors that capture unhealthy pollution levels.

The rate is nearly 15 million fewer people compared to last year’s report, but there was an increase of over 1 million people in areas with unhealthy levels of short-term particle pollution compared to last year.

Over 20 million people live in the 13 counties that fail all 3 measures, and 14 million (~70%) people in this group were people of color. People of color were also 61% more likely to live in a county with a failing grade for 1 pollutant and more than 3 times as likely to live in a county with a failing grade for 3 pollutants.

Los Angeles is the city with the worst pollution in the nation, remaining in this spot for all but 1 of the 22 years observed in the annual report.

The data shows 3 out of every 8 Americans, or 123.2 million people, live in the 163 counties that received an “F” for ozone.

Investigators said the 135 million Americans who live in places with unhealthy levels of pollution are at risk of harm to their health, but some groups are more vulnerable to death and illness from exposure.

These groups included people experiencing poverty, with more 15.8 million people meeting the federal poverty definition living in a county with an “F” in at least 1 pollutant metric. Nearly 3 million people in poverty live in counties that failed all 3 measures.

Investigators additionally reported that 4.9 million children and 2.9 million seniors live in counties that failed all 3 pollutant measures.

Groups with underlying health conditions, including asthma, chronic obstructive pulmonary disease (COPD), lung cancer and CV disease, also experience high rates of exposure to pollutants.

Rates included 2.3 million children and 9.2 million adults with asthma, nearly 5.9 million people with COPD, more than 67,000 people with lung cancer, and nearly 10 million people with CV disease who live in a county that received a “F” for at least 1 measured pollutant.

More than 14.6 million Americans with a history of smoking live in counties that received an “F,” a group with a greater risk of premature death and lung cancer when subjected to long-term pollution exposure.

Ground-level ozone is formed in the lower atmosphere when a combination of pollutants such as nitrogen oxides (NOx) and volatile organic compounds (VOCs), “cook” in sunlight. The chemical reaction can often spread miles from where it originated.

Data show ozone has a harmful effect on the respiratory system, both in short- and long-term exposure to the pollutant. Symptoms that present because of high ozone levels include chest tightness, coughing and shortness of breath, even in healthy adults.

More exposure to ozone can cause lasting damage to the respiratory system, such as new cases of asthma in children and the development of COPD.

Investigators also noted that inflammation and systemic stress caused by exposure to ozone can cause or worsen other diseases, such as metabolic disorders, brain inflammation, reproductive harm, and possible CV events, although evidence is mixed, according to the EPA.

Particle pollution is a mixture of tiny particles of solids and liquids in the air, that originate from sources including factories, motor vehicles and equipment, as well as wildfires, woodburning, and NOx that forms into fine particles in the atmosphere.

In high pollution levels, particles are grouped by size as coarse, fine, and ultrafine, which can penetrate the air sacs of the lungs and the smallest are dispersed to other organs of the body. It is estimated that 48,000 premature deaths in the United States can be attributed to PM.

Short-term exposure to particle pollution that lasts from a few hours to days can result in death, even on the day the particle levels are high. Investigators said in many cases these deaths would not have occurred if the air was cleaner.

Other harmful effects include increased mortality rates in infants, increased hospitalization for CV disease and COPD, and increased severity of asthma attacks.

Year-round exposure to particle pollution can have serious negative effects in both infants and adults. Infants were found to have increased fetal mortality, reduced lung development and a higher likelihood of developing asthma.

Adults were linked to increased risk of CV and respiratory disease, higher likelihood of diabetes and lung cancer, and impaired cognitive functioning. 

Investigators found communities that reduce their year-round particle pollution had a direct improvement in respiratory health.

The team also looked at other studies linking particle pollution and COVID-19, finding other data that a small increase in long-term average exposure to fine particle pollution was associated with an 11% increase in COVID-19 mortality.

In their list of 25 cities most polluted by ozone, the ALA found that the cities mostly remained the same as last year, with a cluster of cities in the west and southwest continuing to be the most polluted. California has 10, while the southwest takes up 8; the remaining 7 are east of the Mississippi River.

The top 5 cities most polluted by ozone are:

In the list of 25 worst cities for short-term particle pollution, there were minor changes, with 13 cities improving since last year’s report with fewer unhealthy days. However, investigators said all the areas remain seriously polluted. These are the 5 worst cities for short-term particle pollution:

San Jose – San Francisco – Oakland, CA

In the list of the 25 cities with the unhealthiest year-round particle pollution levels, 13 worsened since from last year’s report. The 5 worst were:

Investigators also compiled a list of the nation’s cleanest cities, where the city must experience no high ozone or particle pollution days, as well as rank in the 25 cities with the lowest year-round particle pollution levels. The top 5 were:

Burlington-South Burlington-Barre, Vermont

Investigators concluded that climate change remains one of the worst culprits in worsening air pollution. Western cities are experiencing record-breaking particle pollution due to wildfires caused by changing climate patterns, and as temperatures increase, so does ozone pollution.

As more affected groups are the hardest hit by an exposure to poor air quality, including increasing COVID-19 rates, the ALA looks to reduce air pollution to benefit respiratory health for the nation and years to come.

“This report shines a spotlight on the urgent need to curb climate change, clean up air pollution and advance environmental justice,” said ALA President and chief executive officer Harold Wimmer. “The nation has a real opportunity to address all three at once—and to do that, we must center on health and health equity as we move away from combustion and fossil fuels to clean, renewable energy.”

The 2021 State of the Air Report was published online by the American Lung Association.

The 2021 annual report finds that Los Angeles remains the most polluted US city, while negative impacts of climate change and COVID-19 are both linked to increased pollution rates.

COPD

COPD condition center page, resources on the topics of medical news and expert insight into chronic obstructive pulmonary disease can be found. Content includes articles, interviews, videos, podcasts, and breaking news on COPD research, treatment, and drug development.

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Asthma

ALA State of the Air: 4 in 10 Americans Suffer from Unhealthy Air Pollution Levels

The odds of suicidal behavior was 49% lower for OUD patients receiving substance use disorder treatment.

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Family Medicine

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Behavioral Therapy Could Reduce Suicidal Behavior for Patients with Opioid Use Disorder

New data show female veterans receive poorer secondary prevention care in treating premature and extremely premature atherosclerotic cardiovascular disease, compared to male veterans. 

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Female Veterans Experience Poorer CV Care, Worse Mortality Rates Than Males

An expert writes on the value of shared knowledge into the intricacies of allergic risks.

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Food Allergy and Anaphylaxis: Promoting Awareness and Understanding

Direct-acting antivirals have been a major milestone in the treatment of hepatitis C virus, new data show they also work in nearly all children, without serious adverse events.

Hepatitis C

DAA Safe, Effective in Children with HCV Infection, Study Finds

Data also suggests the nonionic block polymer surfactant may be harmful for children <16 years of age. 


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ALA State of the Air: 4 in 10 Americans Suffer from Unhealthy Air Pollution Levels