interviewed Lea Davis, an associate professor of medicine in the Department of Medicine at Vanderbilt University Medical Center and an investigator in the Vanderbilt Genetics Institute, on a recent study she co-authored that was published in 

 on the epidemiology of functional seizures among adults treated at a university hospital.

During the discussion, Davis explains what functional seizures are and why better understanding them can help to address medical stigma for patients who experience them.

So, Dr. Davis, what are functional seizures, and why were you and your research team interested in investigating them further?

 So functional seizures are seizures that occur in the absence of aberrant electrical activity happening in the brain, which is typical of epileptic seizures. Functional seizures have been really understudied.

So, I actually became interested in understanding more about functional seizures and their etiology (so what causes them), what other kinds of conditions are they associated with, [and] what's the biology behind the development of functional seizures after hearing a story on NPR that was really the patient perspective. So, they interviewed several people who experienced functional seizures, and I think the thing that spoke to me the most in this patient population was the stigma that they experienced even within the medical system.

So, I think that actually speaks to me at a personal level. As a kid, my mom had Crohn disease and while Crohn disease is really well understood now, back in the early 90s it was not so well understood, and she actually had doctors telling her that it was all in her head, and that she needed to see a psychiatrist instead of an internal medicine doctor.

And so, hearing [that] patients [are] kind of still experiencing difficulty with medical stigma and the lack of knowledge on functional seizures, it occurred to me that this was something that a) we really needed a lot more research on, and b) we were actually in a really good position to be able to do this research at Vanderbilt because we have an incredible neurology department and a really active research relationship with them.

So, I basically contacted some colleagues in neurology and said, ‘Hey is this something that you guys would be willing to consult with us on and work with us in a collaboration,’ and they said yes, and so that's where we went.

Videos

Contemporary Clinic ® interviewed Lea Davis, of Vanderbilt University Medical Center and the Vanderbilt Genetics Institute, on what functional seizures are and why better understanding them can help to address medical stigma for patients who experience them.

Understanding Functional Seizures In Order to Better Treat Patients

interviewed Carrie Cuttler, PhD, an assistant professor in the Department of Psychology at Washington State University, on a recent study she co-authored that was published in the 

 on the use of cannabis in treating symptoms of obsessive-compulsive disorder (OCD).

What were the findings of this most recent study that you published?

 Yes, actually, I'm just going to briefly mention the methodology, and that's because we use kind of an unconventional methodology for this study as well. So, for this study, we were really looking at the acute effects of cannabis on intrusive thoughts, compulsive behaviors, and anxiety in people with OCD, and we were really able to accomplish this for the generous support of Strainprint, which is a Canadian company with a real-world technology platform and journaling application that allows medical cannabis patients to indicate their conditions and symptoms and rate the severity of those symptoms immediately before and then again shortly after cannabis use.

Further, patients can provide information about the strains of cannabis they're about to use, including THC and CBD concentrations method of administration and dose. The Strainprint app was really developed to help medical cannabis patients find the strains and doses of cannabis that reduce their symptoms the most, but they were generous enough to freely and openly provide us with some of the global back data from this application.

Specifically, they provided us with symptom ratings of intrusions, compulsions, and anxiety made by individuals self-identifying with OCD before and after over 1800 cannabis-use sessions. They also provided us with data on doses, methods of administration, and, again, THC and CBD content in the strains.

So, we use some advanced modeling methods to examine changes in the severity of these symptoms from before to after use, and we found on average that intrusions were reduced by about 49%, compulsions were reduced by 60%, and anxiety was reduced by 52%, indicating that acute cannabis use is associated with about a 50% reduction in the perceived severity of symptoms of OCD.

Contemporary Clinic ® interviewed Carrie Cuttler, PhD, an assistant professor in the Department of Psychology at Washington State University, on a recent study she co-authored on the use of cannabis in treating symptoms of OCD.

Acute Cannabis Use Associated With Reduction in OCD Symptoms

Based on earlier research showing that depression, stress, loneliness, and poor health behaviors can weaken the body’s immune system and lower the effectiveness of certain vaccines, a new report suggests that the same may be true for the coronavirus disease 2019 (COVID-19) vaccines.

Vaccines are among the safest and most effective advances in medical history, according to the report published in 

. Their success, however, depends on ensuring that a critical percentage of the population is effectively vaccinated to achieve herd immunity.

Despite rigorous testing showing that the COVID-19 vaccines approved for distribution in the United States are highly effective and safe, not all recipients will experience the full benefit. Environmental and genetic factors, as well as factors such as physical and mental health, can weaken the body’s immune system and slow the response to the vaccine.

These effects are concerning as COVID-19 continues to spread, triggering a concurrent mental health crisis caused by isolation, economic stress, and uncertainty about the future. These stressors are the same factors that have been shown in earlier research to weaken vaccine efficacy, particularly among elderly patients. Fortunately, the report authors said it is possible to reduce these negative effects with simple steps like exercise and sleep.

“In addition to the physical toll of COVID-19, the pandemic has an equally troubling mental health component, causing anxiety and depression, among many other related problems,” said lead author Annelise Madison, a PhD candidate at Ohio State University, in a press release. “Emotional stressors like these can affect a person’s immune system, impairing their ability to ward off infections. Our new study sheds light on vaccine efficacy and how health behaviors and emotional stressors can alter the body’s ability to develop an immune response. The trouble is that the pandemic in and of itself could be amplifying these risk factors.”

Vaccines work by creating an innate, general immune response on the cellular level as the body recognizes a potential biological threat. This response is eventually helped by the production of antibodies, which target specific pathogens. The continued production of antibodies helps determine how effective a vaccine is at conferring long-term protection.

“In our research, we focus most heavily on the antibody response, though it is just one facet of the adaptive immune system’s response,” said senior author Janice Kiecolt-Glaser, PhD, director of the Institute for Behavioral Medicine Research at Ohio State University, in a press release.

According to the researchers, the good news is that the COVID-19 vaccines already in circulation are approximately 95% effective. However, these psychological and behavioral factors can lengthen the amount of time it takes to develop immunity and can shorten the duration of effectiveness.

“The thing that excites me is that some of these factors are modifiable,” Kiecolt-Glaser said. “It’s possible to do some simple things to maximize the vaccine’s initial effectiveness.”

The researchers noted that one potential strategy could be to engage in vigorous exercise and get a good night’s sleep in the 24 hours before vaccination, to ensure the immune system is operating at peak performance. This may help encourage the best and strongest immune response.

“Prior research suggests that psychological and behavioral interventions can improve vaccine responsiveness,” Madison concluded. “Even shorter-term interventions can be effective. Therefore, now is the time to identify those at risk for a poor immune response and intervene on those risk factors.”

Depression and Stress Could Dampen Efficacy of COVID-19 Vaccines: Interventions and Health Behavior Changes Could Boost Immunity [news release]. Association for Psychological Science; January 13, 2021. Accessed January 19, 2021. 

https://www.psychologicalscience.org/news/releases/2021-jan-depression-covid-vaccines.html

Articles

Environmental and genetic factors, as well as factors such as physical and mental health, can weaken the body’s immune system and slow the response to the COVID-19 vaccine.

Experts Warn Depression, Stress Could Lessen Efficacy of COVID-19 Vaccines

New research from the University of Saskatchewan suggests that cleaning surfaces with commercially available hydrogen peroxide-based disinfectants raises the level of airborne hydrogen peroxide to dangerously high levels, potentially leading to respiratory, skin, and eye irritation.

, found that cleaning a floor with the bleach alternative disinfectant raised the level of airborne hydrogen peroxide to more than 600 parts per billion, or approximately 60% of the maximum level permitted for exposure over 8 hours, and 600 times the level naturally occurring in the air.

 The study authors noted that the coronavirus disease 2019 (COVID-19) pandemic has led to increased demand for cleaning products, including bleach alternatives containing hydrogen peroxide.

“When you’re washing surfaces, you are also changing the air you are breathing,” said senior author Tara Kahan, PhD, in a prepared statement. “Poor indoor air quality is associated with respiratory issues such as asthma.”

Kahan noted that the team could not research this topic at the beginning of the pandemic because hydrogen peroxide solutions were out of stock.1 According to the United States’ National Capital Poison Center (NCPC), hydrogen peroxide splashed onto the skin could cause the skin to whiten for a short time and it could feel tingly. If this occurs the area should be rinsed with running water, and the same should be done if hydrogen peroxide is splashed into the eyes.

Hydrogen peroxide used to be used to disinfect skin wounds, although this is no longer recommended. Researchers have found that hydrogen peroxide can irritate or damage the cells needed for wound healing, according to NCPC.

In the new study, investigators sprayed a vinyl floor in a simulated room environment with 0.88% hydrogen peroxide disinfectant and wiped it dry with paper towels either immediately or after letting it soak for an hour. The investigators then tested the air at human head height.

Kahan said there are several ways to reduce risks when cleaning, including using soap and water rather than a disinfectant. According to the Canadian university, soap and water are known to kill the virus that causes COVID-19. Kahan also said ventilation is important, whether through opening a window, turning on a range hood, or using a central air system. Proper ventilation can dramatically reduce the levels of pollutants circulating in the air and can remove particles carrying the virus.

Despite the concerns around hydrogen peroxide, Kahan said it is still safer than bleach-based products. The impact of hydrogen peroxide on children and pets is not yet known, although it should be noted that they are physically close to the disinfected surfaces.

“The real risk is for people who get repeatedly exposed, such as janitors and house cleaners,” Kahan concluded. “We washed the floor and collected measurements at face height—the concentrations will be even stronger at the floor or at the level of a countertop.”

Bleach-alternative COVID-19 surface disinfectants may pollute indoor air: USask research [news release]. University of Saskatchewan; December 1, 2020. 

https://news.usask.ca/articles/research/2020/bleach-alternative-covid-19-surface-disinfectants-may-pollute-indoor-air-usask-research.php

National Capital Poison Center. Hydrogen Peroxide; updated October 27, 2020. 

https://www.poison.org/articles/2012-jun/hydrogen-peroxide

There are several ways to reduce risk of indoor air pollution when cleaning, including using soap and water rather than a disinfectant.

There are several ways to reduce risks when cleaning, including using soap and water rather than a disinfectant.

Hydrogen Peroxide-Based Disinfectants Could Pollute Indoor Air, Pose Health Risk

interviewed Carrie Cuttler, an assistant professor in the Department of Psychology at Washington State University, on a recent study she co-authored that was published in the 

So Dr. Cuttler, I understand that your prior research has examined the effects of cannabis on various mental health conditions. What led you to investigate the use of cannabis in treating OCD?

 Yes. thank you. Before I started studying cannabis, I was actually studying links between memory and OCD, as it's a condition that has always been of interest to me. Also, my PhD student, Dakota Mauzay, who is the first author on this manuscript, he also has strong interests in OCD and spends a lot of time treating OCD as a clinical psychology graduate student.

Also, while many studies have examined cannabis in relation to various mental health conditions like depression, anxiety, PTSD, and psychosis, we found that very little research had actually examined either links between cannabis use and OCD, or the effects of cannabis on OCD. And to us, that represented a significant gap in the research that we thought really needed to be filled. Also, we knew that cannabis has effects on anxiety and, given the role of anxiety in OCD, we figured there would be good reason to suspect that cannabis may have some effects on this condition.

The Potential Role of Cannabis in the Treatment of OCD Symptoms

Addiction is 1 of the most costly and tragic diseases in the United States, in both financial and human terms.

Our nation spends around $740 million annually in costs on addiction-related crime, health care, and lost work productivity.

 Tobacco product use alone is linked to an estimated 480,000 deaths a year.

The real tragedy is that addiction disorders and substance use disorders (SUDs) are preventable, and the key is preventing youth initiation of substance use. There is no safe amount of any substance for children and teens. None. Never. No exceptions.

Decades of research across substances has shown that pre-teens and teens become addicted more easily and with less exposure than adults. In fact, 90% of people with drug dependency and addiction issues started using substances prior to age 18, with a significant number initiating use between the ages of 12 to 15 years.

 The earlier that use starts, the higher the risk. Multiple studies have shown many magnitudes higher lifetime risk for SUD with earlier initiation of substance uses.

Why is early substance use so risky? There is an amazing period of brain development and “rewiring” that starts at age 10 years and is not complete until about age 25 years.

 During that period, the brain is particularly vulnerable, and serious and often long-lasting injuries can be caused by substance use.

The limbic region of the brain (behavior, emotion, long-term memory, and motivation) develops faster than the prefrontal cortex (complex cognitive behavior, decision-making, moderating social behavior, and personality expression). This helps explain why pre-teens and teens are very motivated to be easily influenced by peers, take risks, and try novel experiences. At the same the areas of the brain that help them weigh risks are not fully developed. First-time use often occurs in social settings with easily accessible substances, such as alcohol and tobacco products, including high-nicotine-content e-cigarettes.

The young brain’s immature risk and reward system is particularly vulnerable to substance use. All drugs of abuse act directly and quickly on the brain’s reward system, flooding the brain with 2 to 10 times the amount of dopamine (the brain’s “feel good” chemical) as natural rewards from other pleasurable activities.

 The brain creates a memory of this intense satisfaction and quickly forms a conditioned response that causes the individual to repeatedly seek the same pleasure, shortening the path from use to abuse to addiction. Besides the risk of addiction, early drug use can alter the development of brain structures. Brain areas affected by substance use include the basal ganglia, extended amygdala, hippocampus, and pre-frontal cortex. Difficulties with concentration, impulse control, learning, and memory are well documented, with some deficits persisting into adulthood even if use ceases. Early substance use has also been linked to an increased risk for developing mood disorders, such as anxiety and depression.

Families and pediatric health care providers play a vital role in efforts to prevent the onset of substance use. Recognizing and addressing risk factors for substance use and enhancing protective factors are the hallmarks of effective prevention.

Adverse childhood experiences (ACEs), especially living with someone who has an alcohol or drug problem, are strongly linked to an increased risk of and increase risk for ACEs in the subsequent generations. Below are some risk factors.

Academic failure and difficulties concentrating in school

Prenatal exposure to alcohol, marijuana, or tobacco

ACEs, especially living with anyone with a problem with alcohol or drugs

Behavioral health concerns in children or family members, such as anxiety or depression

Lack of attachment to and nurturing by caregivers and parents

Families also provide strong protections that offset risk including:

Accepting and open communication with children

Expressing disapproval of substance use and setting a good example

Forming strong loving and supportive bonds between children and parents

Increasing parental involvement in children’s activities and lives

Setting clear limits and consistently enforcing discipline

Health care providers play a vitally important role in identifying risk factors for substance use and helping families address them. Identifying family history of SUD and more widespread screening for ACEs is needed. The American Academy of Pediatrics recommends that health care providers routinely screen patients for substance use, provide brief interventions, and refer to addiction or behavioral specialists, as needed.

 The National Association of Pediatric Nurse Practitioners also has a position statement on exposure to tobacco products.

 is a widely used substance screening tool that was recently modified to include nicotine.

 Anticipatory guidance should include providing prevention information and supporting effective parenting. It is especially important to address common parental misperceptions of youth substance use that are not supported by data, such as all kids experiment; at least it isn’t heroin; if I let them drink here and collect the keys, they will be safe; and they only listen to their friends. National surveys show that some children are already experiencing difficulties with substance use at age 12 or 13, so prevention and screening activities should start earlier at about age 10.

Substance Abuse and Mental Health Services Administration

 (SAMHSA) are rich in information and resources, including tools to help build parents confidence and skills in discussing substance use with their children. In particular, the SAMHSA’s 

. prevention campaign helps caregivers and parent start talking to their kids early about the dangers of alcohol and other drugs.

The horrible price of addiction in both financial and human terms can be greatly reduced by delaying or stopping youth initiation of substance use. It is important to emphasize that increasing numbers and young people are making healthy choices to abstain from alcohol and drugs. Prevention works. Providers in partnership with families and parents are in a powerful position to identify those at most risk and intervene early.

, is a pediatric nurse practitioner at Marietta Neonatology in Georgia and the program coordinator of the Georgia Tobacco-Free Youth Project, and a member of the National Association of Pediatric Nurse Practitioners.

National Institutes of Health. Costs of substance abuse. National Institute on Drug Abuse. April 6, 2020. Accessed December 8, 2020. 

https://www.drugabuse.gov/drug-topics/trends-statistics/costs-substance-abuse

CDC. Smoking & tobacco use. Updated May 21, 2020. Accessed December 8, 2020. 

https://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/index.htm

Key substance use and mental health indicators in the United States: results from the 2018 National Survey on Drug Use and Health. Substance Abuse and Mental Health Services Administration. August 2019. Accessed December 8, 2020. 

https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHNationalFindingsReport2018/NSDUHNationalFindingsReport2018.pdf

Arain M, Hague M, Johal L, et al. Maturation of the adolescent brain. 

National Institutes of Health. Drugs, brains, and behavior. National Institute on Drug Abuse. Updated July 2014. Accessed December 8, 2020. drugabuse.gov/sites/default/files/soa_2014.pdf

Levy SJL, Williams JF, Committee on Substance Use and Prevention. Substance use screening, brief intervention, and referral to treatment. Pediatrics. 2016;138(1):e20161211. doi:https://doi.org/10.1542/peds.2016-1211

National Association of Pediatric Nurse Practitioners, Daley AM, Searcy L, et al. NAPNAP position statement regarding the use and exposure to tobacco products in children, adolescents, and young adults. 

 2020;34;630-634. doi:10.1016/j.pedhc.2020.07.007

Get the CRAFTT. CRAFTT. Accessed December 8, 2020. 

Talk. They Hear You. Substance Abuse and Mental Health Services Administration. Updated June 11, 2020. Accessed December 8, 2020.

Providers Can Help Identify Young People at Risk for Addiction

During the coronavirus disease 2019 (COVID-19) pandemic, many patients in the United States reduced the number of in-person preventive and elective health care visits and increased the number of telemedicine appointments. However, an analysis of the data from March and April 2020, which were the first 2 months of the COVID-19 pandemic lockdown, found that the switch to telemedicine was not sufficient enough to offset the overall reduction in visits.

The analysis of the data was pulled from the medical records of approximately 5 million Americans with private health insurance and demonstrated that the number of mammograms and colonoscopies decreased by approximately 65%, as these types of elective medical care were not easily transferable to a telemedicine format. Overall, use of preventive and elective health care by patients declined by 23% in March and by 52% in April.

However, in lower-income or predominately non-white zip codes, there was a lower reduction in in-person care in addition to lower rates of telemedicine use. The authors who published these findings in 

 noted that this is another example of how the COVID-19 pandemic intensified existing disparities related to health care.

"This adds detailed evidence to the anecdotal reports that Americans quit going to see the doctor when the pandemic shutdown started," said lead author Christopher Whaley, PhD, a policy researcher at the nonprofit research organization RAND Corporation, in a press release. "If important visits are only delayed for a few months, there will likely be no harm. But if patients do not get important screenings, there could be long-term negative health consequences."

Although other studies have analyzed data from this same period, most have assessed data from a single health system or geographic market in order to observe the impact of COVID-19 on the utilization of medical services. In this study conducted by Whaley and his colleagues, the researchers used insurance claims data from 2018 to 2020 from approximately 200 employers across the country.

The results of the study demonstrated that when compared to the rates in March and April 2019, colonoscopies decreased by approximately 70% during March and April 2020. When conducting the same comparison for mammograms, the researchers observed a 67% decrease among women aged 46 to 64 years.

Additionally, utilization of blood sugar tests decreased by approximately 50%, vaccinations among children under age 2 decreased by 22%, and angioplasty procedures decreased by approximately 17%. Surgeries such as musculoskeletal surgery and cataract surgery, as well as MRIs, all decreased by 45% or more. However, only a small decreased was observed in utilization of chemotherapy treatments.

In April 2020, use of telemedicine appointments increased by over 4000% when compared to April 2019. Yet, this significant increase in telemedicine visits replaced only approximately 40% of the decline in in-person visits during this period.

Notably, the authors observed that patients living in lower-income or predominately non-white zip codes had approximately a third lower increase in telehealth visits than those who lived in the wealthiest neighborhoods.

"The extent to which access barriers to telemedicine contribute to lower rates of in-person care deferral, and thus increases in potential exposure to COVID-19, should be examined in future work," Whaley said in the press release.

Health care use drops during pandemic; switch to telemedicine creates disparities. Rand Corporation; November 5, 2020. 

https://www.eurekalert.org/pub_releases/2020-11/rc-hcu110320.php

During the first 2 months of the COVID-19 pandemic, many Americans reduced their in-person preventive and elective health care visits and increased telemedicine appointments. 

Telemedicine Use During the First 2 Months of the Pandemic Did Not Offset the Drop in In-Person Visits

New research suggests that statins, which are commonly prescribed to lower cholesterol and reduce the risk of heart disease and stroke, may also protect patients from heart damage caused by early breast cancer treatment.

The observational study found that women who were already taking statins and were treated with either anthracyclines or trastuzumab were half as likely to be hospitalized or visit an emergency department for heart failure within 5 years following chemotherapy. The researchers focused on women in Ontario, Canada, and included markers of heart failure severe enough for women to be hospitalized, rather than markers just indicating a weaker heart.

“Our job is to protect the heart and ensure it has the greatest fighting chance to get through chemotherapy,” said lead author of the paper Husam Abdel-Qadir, MD, PhD, FRCPC, DABIM, in a press release.

He added that prior observational studies have reported measures of heart strength in statin-treated women after chemotherapy, but only focused on a single center.

Anthracyclines and trastuzumab are used in many women with breast cancer, although increased risk of toxicity has limited use of these drugs and damage can be severe enough to lead to heart failure. The investigators used several health databases in Ontario to review the occurrence of heart failure in women aged 66 years and older who received trastuzumab or anthracyclines for newly diagnosed early-stage breast cancer between 2007 and 2017.

In the 666 pairs of women treated with anthracyclines, those taking statins were 55% less likely to be treated at the hospital for heart failure, according to a press release. In the 390 pairs of women treated with trastuzumab, those taking statins were 54% less likely, suggesting a protecting trend although it did not meet statistical significance.

One of the ways that the treatments are believed to damage heart muscles is through oxidative stress, defined as the imbalance of free radicals, compounds which can harm the body if levels are too high, and antioxidants, which fight free radicals. In addition to lowering cholesterol, statins may also protect the body against the effects of oxidative stress, which may decrease the likelihood of the heart sustaining damage due to cancer treatment.

“In order to know whether it’s a true cause and effect relationship, we need to do a proper randomized controlled trial,” Abdel-Qadir said. “For the time being, if a woman is supposed to be starting treatment for breast cancer and already has an established indication to be on a statin, there’s now additional motivation to start it or stay on it.”

Common drug may protect hearts from damage caused by breast cancer chemotherapy [news release]. EurekAlert; January 6, 2020. Accessed January 7, 2020. 

https://www.eurekalert.org/pub_releases/2021-01/uhn-cdm010521.php

Anthracyclines and trastuzumab are used in many women with breast cancer, although increased risk of toxicity has limited use of these drugs and damage can be severe enough to lead to heart failure.

Statins May Protect Heart from Adverse Effects of Early Breast Cancer Treatment

New research suggests that shared decision-making interventions can help address asthma disparities among Black adults in urban settings, with study participants showing significantly better asthma control at every checkpoint during the 3-month trial.

Asthma is one of the most common chronic illnesses, affecting approximately 339 million individuals globally with an estimated 15 million disability-adjusted life-years lost due to the disease.1 According to the study authors, asthma affects approximately 19 million adults in the United States, with those living below the poverty level having a higher asthma prevalence than those above it.

Compared to whites and Hispanics, Black Americans have a higher prevalence of asthma and are about 3 times as likely to die of the disease, according to researchers at the Columbia University School of Nursing. To help address these disparities, investigators conducted a group-randomized longitudinal trial designed to assess the effects of a novel shared decision-making intervention.

, evaluated an intervention called BREATHE (Brief Intervention to Evaluate Asthma Therapy) to determine its efficacy, feasibility, and acceptance. Relative to a comparator group of 40 adults, the 40 individuals who participated in BREATHE showed significantly better asthma control and higher perceived shared decision-making immediately after the intervention visit with their health care provider.

The participants were all Black or multiracial, and 83% were female, with a mean age of 45 years. They were followed monthly for 3 months post-intervention and data were collected from December 2017 to May 2019, including surveys, lung function tests, and interviews.

According to the authors, BREATHE is a brief, tailored intervention that can be integrated into office visits using clinicians as the interventionists. The authors said using the patient’s own clinician as the interventionist helps keep the patient appraised of the challenges in asthma management, and the intervention could serve as a template for other patient populations with similar challenges.

“Based on this study, BREATHE has shown to be a promising, brief, and tailored intervention that can be integrated into office visits, with clinicians as interventionists,” said lead author Maureen George, PhD, an associate professor at Columbia University School of Nursing, in a prepared statement. “We believe BREATHE is particularly useful because it’s a pragmatic, shared decision-making approach to improving asthma outcomes in a population that experiences marked health disparities.”

George M, Bruzzese J, Sommers M, Pantalon M, et al. Group-randomized trial of tailored brief shared decision-making to improve asthma control in urban black adults. 

https://pubmed.ncbi.nlm.nih.gov/33249632/

Group-randomized Trial Showed Significant Improvement in Asthma Control Among Urban Black Adults [news release]. Columbia University School of Nursing; December 8, 2020. 

https://www.nursing.columbia.edu/news/group-randomized-trial-showed-significant-improvement-asthma-control-among-urban-black-adults

Intervention with shared decision-making in asthma treatment could serve as a template for other patient populations with similar challenges.


Study: Shared Decision-Making in Asthma Treatment Improves Disease Control in Urban Black Adults

Contemporary Clinic spoke with Thomas So, manager of the Meducation Group at First Databank, about insomnia during the COVID-19 pandemic, also known as "coronasomnia."

After a recent study found that high rates of insomnia have been recorded following the COVID-19 pandemic, So described how this came to be a reality for many people around the world. So also discussed sleep medications and underlying issues revolved around insomnia.

Dealing with the Public Surge in Coronasomnia

A University of California, Irvine (UCI) study identified communities where the nearest pharmacy was at least 1 mile away to provide the first record of “pharmacy deserts” in Los Angeles County, California.

Unlike previous studies, the current study describes pharmacy deserts in terms of social determinants of health, such as owning a vehicle, crime rates, and poverty, to determine which communities have the greatest need for pharmacy access, according to a press release.

“My goal is to bring these concepts together at the intersection of pharmacy practice, public health and social justice to reduce health disparities,” said study author Cheryl Wisseh, a health sciences assistant clinical professor of clinical pharmacy practice at UCI, in a press release.

The study found that some Los Angeles County areas lacking pharmacy access are characterized by denser populations, larger numbers of Latino and Black residents, fewer vehicles and home ownership, higher crime rates, and greater poverty.

“These social determinants of health compound the negative effects of pharmacy shortage through competing needs,” Wisseh said in a press release. “For example, some residents living below the poverty line may choose to forgo picking up their medications so that they can pay for food, rent and other necessities.”

According to Wisseh, pharmacy storage likely equates to fewer clinical pharmacy services, such as health screenings, vaccines, and medication management.

Additionally, the coronavirus disease 2019 (COVID-19) pandemic makes access to pharmacists even more pressing.

“As the COVID-19 vaccines start rolling out, pharmacists will be key to the rapid and equitable distribution and administration of doses, just as they have been with COVID-19 testing,” said Jan D. Hirsch, BS Pharm, PhD, founding dean of the UCI’s School of Pharmacy & Pharmaceutical Sciences, in a press release.

Wisseh added that the communities within pharmacy deserts are particularly vulnerable to COVID-19.

“The same forces of structural inequity and systemic racism that contribute to the formation of Los Angeles pharmacy deserts contribute to the disproportionate test positivity, incidence and mortality rates of COVID-19 in racial and ethnic minorities,” Wisseh said in a press release.

The study authors noted that residents in Los Angeles County pharmacy deserts might benefit greatly from equitable, innovative, community-based interventions that increase access to medications, pharmacy services, and pharmacists. For example, the county could add pharmacists to local clinics and other primary care settings to provide clinical services.

Wisseh plans to conduct a similar study on a larger scale to examine how pharmacy deserts contribute to whether minority communities take medications as prescribed and investigate disparities in available medications within pharmacies, according to the press release.

UCI study first to link disparities and ‘pharmacy deserts’ in California. 

https://pharmsci.uci.edu/uci-study-first-to-link-disparities-and-pharmacy-deserts-in-california/

. Published January 6, 2021. Accessed January 7, 2021.

The study describes pharmacy deserts in terms of social determinants of health, such as owning a vehicle, crime rates, and poverty, to determine which communities have the greatest need for pharmacy access

UCI Study First to Link Health Disparities, ‘Pharmacy Deserts’ in California

In a recent study conducted in Sweden, researchers found that women who were diagnosed with invasive cervical cancer had an increased risk of iatrogenic injuries, which are injuries that occur as a result of medical intervention, and noniatrogenic injuries, which occur due to accidents and self-harm.

The correlation was observed through the analysis of data from approximately 3 million women who had participated in cervical cancer screenings during the period of 2001 to 2012. By cross referencing multiple Swedish registries, the researchers were able to identify women within this cohort who received a diagnosis of invasive cervical cancer or cervical cancer precursor lesions, as well as women who had a normal smear during follow-up examination.

"Cervical cancer screening is one of the most successful cancer prevention programs, [and] has greatly reduced cervical cancer incidence and mortality," said Qing Shen, PhD, researcher in the Department of Medical Epidemiology and Biostatistics at the Karolinska Institutet in Stockholm, in a prepared statement. "Despite these substantial benefits, our research indicates that women with invasive cervical cancer experienced medical complications and psychological stress during their diagnostic workup, although at a very low level."

In prior research, Shen and her colleagues had found the potential for increased risk of injuries to be demonstrated during the time period before and after a diagnosis of any cancer.

"These injuries were likely a result of invasive procedures and the severe psychological distress experienced during the clinical evaluation of a potential cancer," Shen said in the press release. She additionally noted that what remains unknown is whether there would be a similar increase in risk among patients screened for cervical cancer if an organized cancer screening program was largely accessible.

After analysis of the initial 3 million women who had participated in cervical cancer screenings, the final cohort of women included in the study were approximately 1.85 million women with a normal smear, approximately 22,000 women with cervical intraepithelial neoplasia (CIN) grade 1, approximately 21,000 women with CIN grade 2 (CIN2), approximately 37,000 with CIN grade 3 (CIN3)/adenocarcinoma in situ (AIS), and approximately 5000 women with invasive cervical cancer.

The researchers then investigated the incidence rates of both iatrogenic injuries and noniatrogenic injuries that had occurred during the diagnostic workup. They found that the Iatrogenic injuries were frequently related to receipt of a punch biopsy, while noniatrogenic injuries were most frequently the result of unintentional falls.

For those injuries that occurred during the diagnostic workup, incidence rate ratios were found through comparing women with a diagnosis of cervical cancer or its precursor lesions to women who had a normal smear, with adjustments made for age, calendar period, screening adherence, education, income, and marital status.

The results of the research showed that women with a diagnosis of invasive cervical cancer, when compared with women with a normal smear, had 8 times the likelihood of iatrogenic injuries, while women with CIN3/AIS had a 3 times increased likelihood of iatrogenic injuries. However, women with CIN1-2 did not have a significantly increased rate of iatrogenic injuries when compared with women with a normal smear.

"Women with invasive cancer can have greater vascularity due to tumor growth, which can lead to hemorrhage and hematoma following a biopsy," Shen said.

Additionally, the results showed that women with a diagnosis of invasive cervical cancer had about twice the likelihood of noniatrogenic injuries than women with a normal smear. However, women with CIN1-2, CIN3, or AIS did not have a significantly increased rate of noniatrogenic injuries when compared with women with a normal smear.

"This study, for the first time, systematically examined the risks of injuries during the cervical diagnostic workup,” Shen said. “Although the chance of having such injuries was rare, we found an increased risk of inpatient care for iatrogenic and noniatrogenic injuries for women with invasive cervical cancer. It is important to emphasize, however, that cervical cancer screening is greatly beneficial for the early detection of cancer and is largely safe."

Women with cervical cancer may have increased risk of injury during diagnostic workup. Philadelphia, PA: American Association for Cancer Research; October 21, 2020. eurekalert.org/pub_releases/2020-10/aafc-wwc101920.php. Accessed January 8, 2020.

Researchers found that women who were diagnosed with invasive cervical cancer had an increased risk of injuries during diagnostic workups.

Women With Cervical Cancer May Have Increased Risk of Injury During Diagnostic Workup

Telehealth is severally underused in nursing homes, however the current coronavirus disease 2019 (COVID-19) pandemic can open doors for its proliferation, according to a study published in the 

Journal of the American Medical Informatics Association.

The COVID-19 pandemic has caused more than 1.84 million deaths and there have been more than 84.4 million confirmed cases worldwide, according to the World Health Organization.

 In the United States, nursing homes account for 27% of deaths from COVID-19. The virus has left many nursing home residents isolated from family and health care providers. According to the study, in response to the pandemic, Medicare relaxed its rules and regulations surrounding telehealth services in order broaden access, allowing residences to receive care without having to risk travel to a health care facility.

“Before the COVID-19 pandemic, before March 6th and the telehealth waiver, nursing homes were not reimbursed unless they were in rural areas. They were not reimbursed for their use of telehealth. So, they weren’t really reimbursed for telehealth visits. So, many homes did not use telehealth until COVID-19 happened. Then, all of the sudden, there was not only this waiver, the 1135 waiver which allows them to use telehealth but there was also a relaxation of regulations around HIPPA,” said lead study author Gregory Alexander, PhD of the Columbia School of Nursing.

The study sample was made up of 664 nursing homes randomly selected from Nursing Home Compare. In total, 13,858 residents were included. According to the study, the sample was representative of location but not bed size or ownership. The sample had a greater proportion of smaller (fewer than 60 beds) and medium (between 60 and 120 beds) sized nursing homes than large (more than 120 beds) sized nursing homes compared with the national sample. Nursing homes were given score between 0 and 42 to rate telehealth use. Higher scores correlated with a higher use of telehealth technology.

Only 5% of the nursing homes samples achieved the maximum telehealth use score while 16% had a score of 0. Investigators found that as bed size increased, so did mean telehealth use scores. Additionally, while the sample size was made up of mostly not-for-profit nursing homes, mean telehealth scores did not vary much between ownership types. However, mean telehealth scores were lower for nursing homes in rural locations compared to those in areas with a larger population size.

According to the study, the COVID-19 has further isolated nursing home patients. The study, which was published prior to the FDA’s authorization of vaccines for emergency use and subsequent rollout, says that nursing home residents who do not have an electronic connection could go months or even years without communication outside the facility’s staff and residents. In the long run, lack of outside communication may worsen patient outcomes, including higher rates of depression and mobility. Study authors suggest that the Medicare regulation relaxation on telehealth services should continue in order to reduce isolation and preserve limited resources.

“The concern, I think, going forward is what will happen to these regulations now once we get the vaccine out there and people get vaccinated…Will we go backwards?” Alexander said. “Will there be more restrictions placed on telehealth or will they continue to be expanded? And I think it will be hard for facilities who have implemented and taken on new forms of communicating and connectivity to go back to where they were before.”

Alexander, G. Powell, K. Deroche, C. An evaluation of telehealth expansion in U.S. nursing homes [Journal Article] September 2020; 

Journal of the American Medical Informatics Association

. Accessed January 6, 2021. doi: 10.1093/jamia/ocaa253

WHO Coronavirus Disease (COVID-19) Dashboard

. The World Health Organization website. Accessed January 6, 2021. 

In response to the crisis, Medicare relaxed its rules and regulations surrounding telehealth services in order broaden access, allowing residences to receive care without having to risk travel to a health care facility.

Telehealth Technology is Underused in Nursing Homes Despite Pandemic

In March 2020 the United States was in the early stages of the coronavirus disease 2019 (COVID-19) pandemic. We shut down the entire country and ground the economy to a halt to slow the spread of the virus. Think back to March and how much uncertainty we were living under.

Nine months later, the FDA approved 2 COVID-19 vaccines under emergency authorization. Before New Year’s Day, millions of Americans had received the vaccine, including health care providers and nursing home patients, our most vulnerable citizens.

Nine months. Take a moment to let that sink in.

The US and the world must appreciate the role of the pharmaceutical industry—the investigators, health care workers, and business leaders—who are rescuing the world from COVID-19. 

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