Children in the United States 15 years of age or younger living in the Midwest have the highest body mass index (BMI) levels on average, whereas those in the Western United States have the lowest, according to a study published in 

. The investigators said the results of the study suggest regional differences may play a role in the development of childhood obesity.

"If we know the factors that affect children's body size, we can help prevent them from becoming overweight or obese," said the study's senior author Dana Dabelea, MD, PhD, professor of pediatrics and epidemiology at the Colorado School of Public Health and director of the LEAD Center, in a press release. "This study looked at factors related to children's body size, like where children live, how much they weighed at birth, and their ethnic background."

The study also found that a higher birthweight and lower levels of formal education among mothers was associated with a higher BMI in children. Further, Black and Hispanic children had a higher BMI than non-Hispanic white children in some parts of the United States, but not all.

To conduct the research, investigators drew their study population from the Environmental influences on Child Health Outcomes Program, which investigates the effects of environmental exposures on the health of children. More than 14,000 children were enrolled in the study, with the investigators studying their height and weight between the years 2000 and 2018, calculating BMI based on these data.

According to the investigators, children in the Midwest had the highest average BMI, followed by the Northeast, the South, and the West. This connection between geographical regions and BMI is not well understood, according to the study, especially when studying the BMI of children.

Although adult data show diet quality and time doing moderate-to-vigorous exercise are higher in the West and Northeast compared to the South and Midwest, other studies have shown no regional variation in physical activity, according to the authors of the current study. Further, environmental factors such as density of fast food restaurants, supermarkets, and recreation facilities have been linked to childhood BMI, according to the investigators, but there is currently little evidence of regional variation. The study authors hope that their findings will lead to additional research further investigating why BMI varies by region.

"For example, researchers could study whether children's eating habits and their physical activity levels also vary based on the area they live in," Bekelman said in the release. "Another next step is to find out why there are racial and ethnic differences in BMI in some areas but not others."

Study finds body mass index for children greatest in Midwest, least in West [news release]. Science Daily; September 1, 2021. Accessed September 7, 2021. 

https://www.sciencedaily.com/releases/2021/09/210901142710.htm

The study also found that a higher birthweight and lower levels of formal education among mothers was associated with a higher BMI in children.

Body Mass Index of Children Highest in Midwest, May Be Linked to Regional Factors

Skylar Kenney, Assistant Editor

Factors such as climate change, widening distributions of host populations, and better clinician awareness are some of the main reasons for the geographic spread of Lyme disease over the past few months, according to recent data from epocrates.

Acey Albert, MD, director of clinical content at epocrates, is board certified in internal medicine and pediatrics with 15 years of experience in outpatient primary care and medical group leadership. He was able to combine his interest of technology, medicine, and physician leadership as a part of the epocrates team.

Albert explained how there was an increased interest in Lyme disease incidence compared to 2020 among clinicians who use epocrates’ medical application this summer, which measured at a 90% increase YoY.

“This was surprising because, while we know Lyme disease is becoming more common, this was a much steeper increase than we expected,” Albert said in an interview with 

. “For comparison, CDC data showed a doubling of Lyme disease cases between 1991 and 2018, while cases over the last 3 years of data (most recently, 2019) remained relatively flat.”

The increase in Americans traveling again this year and predictions of a warmer, wetter weather pattern could have also played a major factor in the uptick of Lyme disease this past summer, according to Albert.

As for the main implications that both providers and patients should know about in the spread of Lyme disease, Albert said diagnosis of the disease is highly dependent on the patient’s location and travel history.

“By current CDC and IDSA guidelines, patients with the pathognomonic rash, erythema migrans (EM), and tick exposure in an area where Lyme disease is common can be diagnosed and treated without further testing,” Albert said in an interview with 

. “Those exposed in areas with Lyme who don’t have EM but have other symptoms require testing.”

These guidelines also focus on when to empirically treat asymptomatic patients with tick bites in areas where Lyme disease is endemic, according to Albert.

“For clinicians, the possible geographic expansion of Lyme means that more of us might need to include it in the differential diagnoses of patients experiencing a fever, headache, myalgia, and joint pain. For patients, it means that more of us should take vital protective measures when venturing outdoors,” Albert said in an interview with 

At epocrates, an issue that was addressed in the summary of Lyme guidelines was how clinicians are often confronted by patients with concerns about chronic Lyme disease at the point-of-care. This term is not usually acknowledged by gold-standard medical organizations, but clinicians are still being asked about it, according to Albert.

Symptoms such as fatigue, pain, and “brain fog” are usually seen in 10% to 15% of patients who are fully treated for the disease, according to the CDC, which is also known as post-treatment Lyme disease syndrome. However, Albert said there have been some controversies around this condition. The society that promotes “Lyme literate” clinicians who believe the condition represents chronic, persistent 

 infection, despite a scarcity of evidence supporting this assertion is an example of this issue.

“Unsurprisingly, these tests and treatment aren’t typically covered by insurance, and they’re administered in the offices of those ‘Lyme literate’ providers on a cash-pay basis. (National Institutes of Health)-funded studies show this approach is no better than placebo, and that fatal complications of long-term antibiotic treatment have been observed,” Albert said in an interview with 

. “Nonetheless, this group is surrounded by large patient advocacy groups with scientific-sounding websites, aggressive social media campaigns, legislative lobbyists, and celebrity spokespeople. As we’ve seen in COVID-19, anti-science disinformation abounds and shapes patient interactions with health care.”

As for suggestions to know about combatting Lyme disease, Albert recommends knowing the evidence-based guidelines for treatment or having a quick, point-of-care reference that summarizes this guidance. Further, keeping an eye out for newer evidence in areas that are more generalized to the rest of the country is also highly recommended. 

 in ticks around the San Francisco Bay area doesn’t necessarily mean that clinicians in Denver need to think about Lyme disease right now. That said, the study is likely to raise interest in broader investigations of the current geographic range of the disease, and clinicians should be ready to adapt,” Albert said in an interview with 

Lyme Disease Continues to Be Top-Of-Mind for Clinicians Based on Past Summer Data

Jill Murphy, Associate Editor

Starting that fateful week in March 2020 when everyone’s life changed, health care settings closed their doors en masse.

From primary care to ambulatory surgery, physical therapy to massage therapy, nearly every setting of care suspended operations, except for emergency departments connected to hospitals and pharmacies. Yes, pharmacies. More than 60,000 remained open to patients, and most pharmacists continued their role as a source for OTC products and the free-of-charge counseling that often goes with them.

Telemedicine grew at an unprecedented rate starting in April 2020, but it did not entirely fill the health care void. Individuals needing acute medications, dose adjustments, or treatment for chronic diseases lost direct access to practitioners, but pharmacies remaining open meant patients could still receive their lifesaving medications. Of course, foot traffic slowed, and the flu was practically nonexistent in 2020, but hundreds of millions of Americans had access to basic triage, care delivery, medications, and testing supplies.

More than 80% of adults use OTC products as first-line treatment for common ailments. With Americans making approximately 3 billion trips to purchase OTC products annually and 60 million Americans using them who would otherwise not seek treatment, patient access to these products is essential to a well-functioning health care system. It is inconceivable these days to schedule an office visit, procure a prescription, and have it adjudicated by insurance just to get ibuprofen for an ankle sprain. A prescription for loratadine? Laughable. Yet less than 2 decades ago, nonsedating antihistamines were deemed too unsafe to be sold over the counter.

Making products available without a prescription does not have to mean patients go without care. Pharmacists and other health care professionals can counsel patients on all types of accessible and affordable OTC products. Does an Apple Watch’s electrocardiograph or pulse oximetry app keep patients from seeing their cardiologists? Do pregnancy tests keep women from visiting their gynecologists? Do wetting drops prevent patients from going to their ophthalmologists?

Do niacin or omega oils keep patients from getting their cholesterol checked? The answer to all these questions is no. Pharmacists have multiple encounters with patients every day, and most are just as meaningful to a patient’s care as billable encounters.

Expanding Access Through OTCs and Testing

COVID-19 self-administered testing is approved and available. Health plans have picked up on the power of patient convenience. Waning resistance against self-empowerment, which the pandemic necessitated, has enlisted a host of home-based diagnostics providing accessible and affordable screening and rescreening directly to health plan members—without a prescription. Need to improve A1c testing and reporting? Why not look to pharmacies or even send the tests directly to patients’ residences?

Postpandemic Self-Care and OTC Product Use

We are only a summer away from what will likely be the first widely prevalent cough and cold season of asthma flare ups, influenza, middle-ear infections, and rhinovirus in nearly 2 years. As social distancing and masking disappear, we will again share microbes. Disease surveillance and patient care will still have a prime spot in the consciousness of the frontline pharmacist’s mind in all seasons. Education, triage, testing, and counseling have a greater meaning and purpose than ever before, and much of this purpose is enabled by access to OTC products.

Click here to view the OTC products that pharmacists recommend the most to their patients

is vice president of pharmacy provider partnerships for Community Care of North Carolina, which works collaboratively with more than 2000 medical practices to serve more than 1.6 million Medicaid, Medicare, commercially insured, and uninsured patients. He received his PharmD and MBA degrees from Drake University and a PhD in pharmaceutical outcomes and policy from the University of North Carolina. He also serves on the board of directors of the American Pharmacists Association Foundation and the Pharmacy Quality Alliance.

OTC use statistics. Consumer Healthcare Products Association. Accessed May 24, 2021. https://www.chpa.org/about-consumer-healthcare/research-data/otc-use-statistics.

COVID-19 permanently changed how pharmacists recommend and sell nonprescription options.

OTC Products Are Accessible When Traditional Health Care Delivery Is Not

Troy Trygstad, PharmD, PhD, MBA

Mary Koslap-Petraco, DNP, PPCNP-BC, CPNP, FAANP, is a clinical assistant professor at Stony Brook University School of Nursing in New York.

The pandemic has changed life as we knew it, but COVID-19 vaccines are changing lives again, this time for the better.

Grandparents are once again able to hug their grandchildren, but those same grandchildren are still at risk for COVID-19 until we can get all of them who are medically able vaccinated. At press time, children accounted for the largest number of new cases of COVID-19, because most are still not vaccinated (AAP, 2021, April).1 Hospitalization rates for children with COVID-19 have also risen, and serious cases are being seen (AAP, 2021, June).2 From March 1, 2020, through April 30, 2021, approximately 1.5 million COVID-19 cases in individuals aged 11 to 17 years had been reported to the CDC (USFDA, 2021, May 10).3

Most children will return to classrooms for school in the fall, if they have not done so already (Parents, 2021, March).4 Although handwashing, masks, and social distancing are essential public health measures and have slowed the pandemic, the best and most long-lasting way to protect children is to vaccinate them. The number of COVID-19 cases among individuals aged 50 years and older has dropped dramatically. A large segment of this population is fully vaccinated (CDC, 2021, June 13).5 There is also a serious public health threat from other vaccine-preventable diseases, such as measles and pertussis, as the rates of routine immunizations took a precipitous drop during the pandemic (Santoli, et al. 2020).6 The CDC is recommending that children receive all regularly scheduled vaccines, along with the COVID-19 vaccine (CDC, 2021 April 6).7

The Pfizer-BioNTech COVID-19 vaccine, which is an mRNA vaccine, recently received FDA approval for adolescents aged 12 through 15 years (USFDA, 2021, May 10).3 This vaccine is administered intramuscularly as a series of 2 doses (0.3 mL each) 3 weeks apart. The most common adverse effects are chills, fever, headache, joint and muscle pain, pain and redness at the injection site, and tiredness. Aside from pain at the injection site, more adolescents reported these adverse effects after the second dose than after the first dose, so it is important to advise adolescents and parents to expect that there may be some adverse effects after either dose but even more so after the second. The adverse effects in adolescents were consistent with those reported in clinical trial participants aged 16 years and older (USFDA, 2021, May 10).3

Pfizer also said that it plans to request authorization for BioNTech COVID vaccine use in children aged 2 through 11 years in September 2021 and for children younger than aged 2 years later in 2021 (Jenco, 2021, May 6).8

Recently, there have been reports of myocarditis and pericarditis following mRNA vaccines. These events occurred mostly in male adolescents and young adults aged 16 years and older. Myocarditis and pericarditis are seen more often after getting the second dose of either Moderna or Pfizer COVID-19 vaccines than after the first dose. The symptoms typically occur within 4 days after COVID-19 vaccination. As of press time, there have been 275 cases of either myocarditis or pericarditis of more than 600,000 doses administered to adolescents and children in the United States since Pfizer received its emergency use authorization on May 10, 2021 (CDC, 2021, May 18).9 Most patients who received care responded well to rest and treatment and quickly recovered. Patients can usually return to normal daily activities after their symptoms improve, and they should speak with health care providers about returning to exercise or sports. The CDC continues to monitor the situation and recommends COVID-19 vaccinations for everyone aged 12 years and older, given the greater risk of COVID-19 illness and related, possibly severe complications (CDC, 2021, May 27).10 Getting vaccinated is the best way to help protect individuals aged 12 years and older from COVID-19 illness and potential complications.

Another COVID-19 vaccine for adolescents is also moving toward approval. Moderna reported that its COVID-19 vaccine is 96% effective for adolescents aged 12 through 17 years after at least 1 dose and has no serious safety concerns (Jenco, 2021, May 6).8 The report did not provide additional details on a projected timeline for requesting FDA approval. Moderna is also continuing to study its vaccine in children aged 6 months to 11 years (Jenco, 2021, May 6).8

COVID-19 vaccines are becoming a reality for children. With the vaccines comes the return to birthday parties, in-classroom school, play dates, and sleepovers. But the COVID vaccine is not the only one children need. Routine vaccination is an essential preventive care service for adolescents, children, and adults, including pregnant women, that should not be delayed because of the COVID-19 pandemic. Parents have not been bringing their children into the offices of health care providers for well-child visits and vaccines. It is essential to assess the vaccination status of all adolescents and children at each patient visit to avoid missed opportunities for vaccination and ensure timely vaccine catch-up. All vaccines due or overdue should be administered according to the recommended CDC immunization schedules during each visit unless there is a specific contraindication. This will provide protection as soon as possible and minimize the number of health care visits needed to complete vaccination. Health care providers should identify children who have missed recommended vaccinations and/or well-child visits. Contact parents to schedule in-person appointments, starting with newborns, infants, and children up to aged 2 years, young children, and extending through adolescence. COVID-19 is still circulating, and cases among children can often be asymptomatic. Consequently, the importance of evidence-based infection prevention practices cannot be overemphasized for all patient encounters. These measures include hand and respiratory hygiene, physical distancing, source control, and surface decontamination (CDC, 2021, April 6).7

Because vaccine administration has decreased during the COVID-19 pandemic, under vaccinated or unvaccinated children are susceptible to preventable illness, such as measles, and communities are at risk for outbreaks. Strategies should be implemented to promote vaccination schedule adherence and ensure catch-up vaccination. Reminder and recall systems should be implemented to identify children who are due for or who have missed vaccine doses. Electronic health records and immunization information systems can be essential to tracking delinquent vaccine doses. In addition, the vaccination status of all children should be assessed at every health care visit to reduce missed opportunities for vaccination, including COVID-19 vaccination, and standing orders should be implemented (CDC, 2021, April 6).7

Health care providers who care for children must ensure that children receive not just COVID-19 vaccines but all age-appropriate vaccines that are due and catch up on any missed doses. It would be a travesty if children headed back to school without the vaccine-induced protection they need to stay healthy. Without all Advisory Committee on Immunization Practices (ACIP)-indicated vaccines, children could be headed back to school and out of the COVID-19 pandemic into a measles or pertussis epidemic.

1. Children and COVID-19: state data report. American Academy of Pediatrics. April 29, 2021. Accessed June 17, 2021. 

https://downloads.aap.org/AAP/PDF/AAP%20and%20CHA%20-%20Children%20and%20COVID-19%20State%20Data%20Report%204.29.21%20FINAL.pdf

2. Children and COVID-19: state data report. American Academy of Pediatrics. June 3, 2021. Accessed June 17, 2021. 

https://downloads.aap.org/AAP/PDF/AAP%20and%20CHA%20-%20Children%20and%20COVID-19%20State%20Data%20Report%206.3.21%20FINAL.pdf

3. United Stated Food and Drug Administration. (2021, May 10). Coronavirus (COVID-19) Update: FDA Authorizes Pfizer-BioNTech COVID-19 Vaccine for Emergency Use in Adolescents in Another Important Action in Fight Against Pandemic. Retrieved from 

https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-pfizer-biontech-covid-19-vaccine-emergency-use

4. Harris N. Will kids go back to school in the fall? Here’s what experts think and what it may look like. 

https://www.parents.com/kids/education/back-to-school/will-kids-go-back-to-school-in-the-fall-heres-what-experts-think-and-what-it-may-look-like/

5. Demographic characteristics of people receiving COVID-19 vaccinations in the United States. CDC. June 16, 2021. Accessed June 17, 2021. 

https://covid.cdc.gov/covid-data-tracker/#vaccination-demographic

6. Santoli JM, Lindley MC, DeSilva MB, et al. Effects of the COVID-19 pandemic on routine pediatric vaccine ordering and administration — United States, 2020. 

 2020;69(19):591-593. doi:10.15585/mmwr.mm6919e2

7. Interim guidance for routine and influenza immunization services during the COVID-19 pandemic. CDC. April 6, 2021. Accessed June 17, 2021. 

https://www.cdc.gov/vaccines/pandemic-guidance/index.html

8. Jenco M. Moderna reports COVID-19 vaccine for teens safe, effective. 

https://www.aappublications.org/news/2021/05/06/moderna-covid-vaccine-teens-050621

9. Mendez R. CDC says 600,000 kids ages 12 to 15 have received Covid vaccine shots in last week. CDC. May 18, 2021. Accessed June 17, 2021. 

https://www.cnbc.com/2021/05/18/cdc-says-600000-kids-aged-12-to-15-have-received-covid-shots-in-last-week-.html

10. Myocarditis and pericarditis following mRNA COVID-19 vaccination. CDC. May 27, 2021. Accessed June 17, 2021. 

https://www.cdc.gov/coronavirus/2019-ncov/vaccines/safety/myocarditis.html

Practitioners can help ensure that kids get these and all age-appropriate vaccinations before school starts in the fall.

COVID Vaccines for Children Are Becoming a Reality

Mary Koslap-Petraco, DNP, PPCNP-BC, CPNP, FAANP

Individuals with anemia, which is blood with low oxygen levels, can be treated with transfusions of blood substitutes, a new mathematical model of the body's physiological and biochemical processes shows.

“Instead of real blood, we can use a substitute that can lower the costs and eliminate blood transfusion's negative effects,” Weiyu Li, a PhD student in energy resources engineering at Stanford's School of Earth, Energy & Environmental Sciences, said in a statement.

Results show that low-cost and safe blood substitutes can decrease the overall cost of blood transfusions by 10 times, while lowering the negative aspects of the process as well, investigators said.

The new model shows that during transfusion, some of the individuals’ blood vessels did not dilate and thickens the blood. Therefore, it was not as easy to deliver oxygen in the blood.

“Our mathematical model identifies natural physiological processes that explain the conclusion of multiple observational studies: People can get the benefit of blood transfusion without using blood,” Daniel Tartakovsky, PhD, a professor of energy resources engineering at Stanford Earth, said in the statement.

“But nothing really comes out of modeling alone; it has to be grounded in observations, investigational studies and experience,” he said.

The model also shows that abstaining from transfusion or transfusing alternative fluids, or plasma expanders, promotes blood vessels dilating more, increasing oxygen delivery.

Plasma expanders consist of high-molecular-weight starch dissolved in normal saline, which has been used in transfusion medication and is proven to be effective.

Transfusions are common procedures for transferring blood to the circulation of individuals with anemia, which helps the red blood cells carry more oxygen. However, the process is costly and intensive, because it must be obtained, stored, delivered, and sanitized.

New model points to solution to global blood shortage. ScienceDaily. News release. October 19, 2021. Accessed on October 19, 2021. 

https://www.sciencedaily.com/releases/2021/10/211019110513.htm

A new mathematical model shows that low-cost and safe plasma expanders for transfusion can decrease the overall cost by 10 times, while also lowering the negative aspects of the process.

Blood Transfusions With Substitutes Prove Beneficial for Individuals With Anemia

Ashley Gallagher, Assistant Editor

Health care professionals regularly have to judge whether they can cure patients of a medical condition or manage the condition to enable them to live the best life they can. Many pharmaceutical interventions and treatment options are designed to manage people’s illnesses, however, they are not necessarily a cure.

There are many medical conditions that have been difficult to cure from a historical perspective, from diabetes to high blood pressure, for which a maintenance approach to treatment has been the only option. However, this is expensive and challenging, both in terms of medicine and clinical resources.

Curing a condition is better than management, because managing these conditions can result in an increased burden on the health care system. This is particularly applicable as people live longer and the proportion of illnesses that are manageable increase versus those that are curable.

New interdisciplinary approaches to treatment include rebalancing the scales and exploring non-pharmaceutical interventions, such as dietary changes, exercise, and medical devices, to work alongside or instead of traditional care management techniques.

An example of this would be in the treatment process for leg ulcers. According to the Wound Healing Society, 15% of older adults in the United States suffer from chronic wounds, including predominantly venous stasis ulcers, pressure ulcers, and diabetic foot ulcers.

Every year, up to 3 million more Americans are diagnosed with various types of chronic wounds, with the annual cost of treating venous ulcers alone to the US health care system estimated to be $2.5 to $3.5 billion, which highlights the sheer scale of the growing problem.

These wounds often take months of traditional treatment to heal, and for health care professionals, managing the condition and its symptoms is a huge therapeutic challenge. It may require regular visits from health care professionals, which is expensive and time consuming. As the incidence of ulceration rises due to the aging population, and increased risk factors such as smoking and diabetes, so does the cost of intervention.

New medical technology devices offer an alternative because many of these devices can not only maintain people’s wellbeing, but provide a permanent treatment to chronic medical conditions. This new breed of technology has the potential to deliver better patient outcomes at a lower cost.

Technology has been one of the most significant disruptors to society. From Amazon in retail to new competitors banks in financial services, technology-first businesses are aiming to achieve both cost reduction and improved efficiencies.

In health care systems, technology is increasingly being seen as the key to reducing financial pressure while enhancing patient outcomes simultaneously. Implementing new medical devices into health care systems is challenging, because it requires time, money, clinical data, regulatory approval, and support from clinicians within the system.

Using the example of leg ulcers, clinical data now demonstrates that by increasing blood circulation to wound surfaces to enhance oxygen and nutrient delivery,

 ulcers can be cured rather than simply managed, with wounds closing in a matter of weeks as opposed to months or not at all.

Managing the care of patients with these types of conditions is always complex, but after receiving regulatory approval from the FDA, bioelectronic medical devices that increase blood flow in the lower limbs are now being deployed by forward-thinking clinicians to treat patients with the condition.

 This has dramatically reduced the financial and staffing impact on the health care system while achieving improved results for the patients.

Instead of requiring nurses to attend people’s homes 3 times a week to assess and redress ulcers, connected devices have the potential to monitor patients remotely and provide feedback data to health care providers enabling them to manage treatment plans and focus resource where it is most needed.

The current challenge is reshaping how health care systems reward positive outcomes to allow new solutions to continue to be adopted effectively, which rewards innovation and risk without reducing the impact of what already exists.

The US health care system presents a unique landscape because the process of paying for health care products or services is managed by either private commercial health insurers or public government payers. Traditionally, health care providers operate a fee-for-service model, which means they are paid separately for each service they provide regardless of whether that service leads to a positive and lasting outcome. For patients suffering with chronic conditions that require long-term care, specifically in wound care, this can result in expensive medical bills over a long period of time.

The US government has already legislated for change, which has led to the Centers for Medicare and Medicaid Services starting an episode-based approach to treatment and payment. With episode-based payments, the cost for a patient’s care related to any single medical issue is predetermined versus having to pay separately for each service and provider.

Based on the projected costs, a single amount is issued to all health care providers and institutions working on the same case. This will include physicians, hospitals, nurses, medical equipment providers, and post-acute care operators. The more effectively health care providers control expenses and stay within the budgeted amount, the better they share in the savings generated.

This approach means it is in the interests of both the patient and the provider to adopt the best possible treatment plan using the most effective medical technologies in the attempt to cure the patient’s condition.

Medical technology is uniquely placed to help facilitate positive change in health care, especially in the United States. Instead of trying to ensure the adoption of new innovations within the confines of the previous system, the health care system is actively fostering adoption of new, innovative solutions.

The hope is that this important shift will not only enable more investment in the development of new medical technologies, but will help decrease the pressure on the entire health care operation, creating a brighter, more effective, and affordable system for all.

Jones NJ & Harding KG et al, Neuromuscular electrostimulation on lower limb wounds. British Journal of Nursing VOL. 27, No. 20. Published Online: 12 Nov 2018. 

https://doi.org/10.12968/bjon.2018.27.Sup20.S16

https://www.accessdata.fda.gov/cdrh_docs/pdf13/K133638.pdf

. August 21, 2014. Accessed August 3, 2021.

NICE Guidance (MTG19) costing statement Implementing the NICE guidance on the geko™ device for reducing the risk of venous thromboembolism (MTG19). Published June 25, 2014. Accessed August 3, 2021. 

How Technology Can Improve Patient Outcomes While Reducing Financial Burdens

Sky Medical Technology

Osteoporosis is a systemic skeletal disease involving low bone mass and microarchitectural deterioration of bone tissue, resulting in increased bone fragility and fracture risk.

Bone density corresponds to the amount of mineral within a volume, and bone quality depends on architecture, bone matrix composition, bone turnover, damage accumulation, and mineralization.

 Osteoporosis develops silently over years before it becomes apparent through bone mineral density (BMD) screening or fractures. Fragility fractures are the main physical manifestation and occur at diverse sites, such as the distal radius, proximal femur, and vertebral bodies.

Recommend a dual-energy x-ray absorptiometry (DXA) to check BMD and screen for osteoporosis in the following patients at high risk

Adults on chronic glucocorticoid therapy, such as oral prednisone ≥5 mg/day for 3 or more months or an equivalent

Individuals aged 50 years and older with a recent low-trauma fracture

Other patients may also be good candidates for a DXA to check BMD, especially those with multiple risk factors. Assess risk factors to see if BMD testing is warranted with a thorough history in men aged 50 to 69 years or postmenopausal women younger than age 65 years with the following medical concerns

Excessive alcohol intake of 3 or more drinks per day

Radiographic osteopenia (DXA T-score between -1 and -2.5)

Taking medications that decrease BMD, such as aromatase inhibitors, glucocorticoids, GnRH agonists, phenobarbital, or phenytoin

There are 3 different categories of bone health for classification purposes:

: BMD 1 standard deviation or less below that of young white women reference mean (ie, T-score of −1 or greater)

: BMD between 1 and 2.5 standard deviations below that of young white women reference mean (ie, T-score between −1 and −2.5)

: BMD more than 2.5 standard deviations below that of young white women reference mean (ie, 

There are specific indications for pharmacotherapy:

T-score of −2.5 or less (ie, or worse) in distal third of radius, femoral neck, spine, or total hip

T-score from −1 down to −2.5 in distal third of radius, femoral neck, spine, or total hip, and fragility fracture of hip or spine

T-score from −1 down to −2.5 in distal third of radius, femoral neck, spine, or total hip, and FRAX score shows that that 10-year probability of hip fracture is 3% or greater or the 10-year probability of a major osteoporotic fracture is 20% or more

There are different approaches to screening. Some think that it is not necessary to check a DXA in patients who are receiving osteoporosis treatment because women receiving osteoporosis treatment may have reduced fractures, regardless of the impact on BMD. Others recommend continuing to check a DXA during treatment until BMD has stabilized or after 3 to 5 years of bisphosphonate therapy.

There are several pharmacotherapeutic options for osteoporosis treatment. Medications are classified mechanistically as antiresorptive agents that slow bone breakdown or anabolic “bone building” agents.

Antiresorptive medications include intravenous (IV) and oral bisphosphonates; selective estrogen receptor modulators (SERMs), specifically raloxifene and calcitonin nasal spray; and subcutaneous denosumab. Romosozumab-aqqg is a subcutaneously administered monoclonal antibody with anabolic/antiresorptive properties.

Anabolic agents are the subcutaneous parathyroid hormone analogs abaloparatide and teriparatide. Oral bisphosphonates, such as alendronate or risendronate, are generally preferred first-line agents for osteoporosis prevention and treatment in most patients. The choice of osteoporosis medication depends on multiple factors, including cost, osteoporosis fracture risk and severity, route of administration, and tolerability. The 

details the adverse effects (AEs), contraindications, and dosing of osteoporosis medications.

There are specific circumstances for which other osteoporosis medications may be considered.Raloxifene may be an option for women at high risk for breast cancer and in women who cannot tolerate bisphosphonates or denosumab.

 Calcitonin may be an option to reduce acute bone pain associated with vertebral fractures as well.

Patients with severe osteoporosis and very high fracture risk who cannot tolerate or respond poorly to IV and oral bisphosphonates may be candidates for anabolic agents abaloparatide or teriparatide or alternatively romosomuzab.

 Denosumab is an alternative to anabolic agents for high-risk older patients who cannot take or tolerate or respond poorly to bisphosphonates.

AE indicates adverse effect; BMD, bone mineral density; IV, intravenous; PTH, parathyroid hormone; PTHrP, parathyroid hormone-related protein; and SERM, selective estrogen receptor modulator.

Osteoporosis is a common medical condition that increases fracture risk and requires individualized screening and management. Lifestyle management includes adequate vitamin D and calcium intake, increased physical activity, and smoking cessation. Oral bisphosphonates are first line for most patients with osteoporosis. Other agents may be reserved for high-risk patients who are intolerant or poorly responsive to bisphosphonates. Follow-up BMD testing is recommended to monitor response to therapy.

-------------------------------------------------------------------------------------

 is a clinical associate professor at Pace University’s College of Health Professions in New York, New York.

 is a clinical professor at a department chairperson at Pace University’s College of Health Professions.

-----------------------------------------------------------------------------------

Black DM, Rosen CJ. Postmenopausal osteoporosis. 

. 2016;374(3):254-262. doi:10.1056/NEJMcp1513724

 7th ed. Jameson JL, De Groot L, eds. Saunders; Philadelphia, PA: 2016;1184-213.e6.

Allen S, Forney-Gorman A, Homan M, Kearns A, Kramlinger A, Sauer M. Diagnosis and treatment of osteoporosis. Institute for Clinical Systems Improvement. Updated July 2017. Accessed February 11, 2021. 

https://www.icsi.org/wp-content/uploads/2019/01/Osteo.pdf

Eastell R, Rosen CJ, Black DM, Cheung AM, Murad MH, Shoback D. Pharmacological management of osteoporosis in postmenopausal women: an Endocrine Society clinical practice guideline. 

. 2019;104(5):1595-1622. doi:10.1210/jc.2019-00221

Qaseem A, Forciea MA, McLean RM, Denberg TD, Clinical Guidelines Committee of the American College of Physicians. Treatment of low bone density or osteoporosis to prevent fractures in men and women: a clinical practice guideline update from the American College of Physicians. 

 2017;166(11):818-839. doi:10.7326/M15-1361

Adler RA, El-Hajj Fuleihan G, Bauer DC, et al. Managing Osteoporosis in Patients on Long-Term Bisphosphonate Treatment: Report of a Task Force of the American Society for Bone and Mineral Research. 

Silverman S, Christiansen C. Individualizing osteoporosis therapy. 

. 2012;23(3):797-809. doi:10.1007/s00198-011-1775-y

Cranney A, Papaioannou A, Zytaruk N, et al. Parathyroid hormone for the treatment of osteoporosis: a systematic review. 

. 2006;175(1):52-59. doi:10.1503/cmaj.050929

Cosman F, Crittenden DB, Adachi JD, et al. Romosozumab treatment in postmenopausal women with osteoporosis. 

 2016;375:1532-1543. doi:10.1056/NEJMoa1607948

Forteo [prescribing information]. Indianapolis, IN; Lilly USA: 2020. Accessed February 18, 2021. https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/021318s053lbl.pdf

Ringe JD, Doherty JG. Absolute risk reduction in osteoporosis: assessing treatment efficacy by number needed to treat. 

. 2010;30(7):863-869. doi:10.1007/s00296-009-1311-y

Cummings SR, San Martin J, McClung MR, et al. Denosumab for prevention of fractures in postmenopausal women with osteoporosis. 

 2009;361(8):756-765. doi:10.1056/NEJMoa0809493

Osteoporosis is a common medical condition that increases fracture risk and may require patients to make lifestyle changes.


Osteoporosis Requires Individualized Screening and Management

Jennifer Hofmann, DMSc, MS, PA-C, and Jean Covino, DHSc, MPA, PA-C

The Advisory Committee on Immunization Practices (ACIP) recommends that all Americans 6 months and older who do not have contraindications receive the flu vaccine.

Health care providers should recommend the high-dose or adjuvanted flu vaccine for patients 65 and older. These 2 types of the vaccine are designed to spur a stronger immune response. The difference between adjuvanted and high-dose vaccines is that the adjuvanted vaccine is made with MF59 adjuvant, which is designed to enhance the immune response. The high-dose vaccine is designed for patients 65 and older and contains 4 times the amount of antigen as the regular flu vaccine. As such, it is associated with a stronger immune response, and patients who received the high-dose vaccine had 24% fewer influenza infections compared with those who received the standard-dose flu vaccine.

Children aged 6 months to 8 years who have never received the vaccine should receive 2 doses, the first as soon as it is available and the second about a month later.

showed that the vaccine significantly reduces a child’s risk of dying from the influenza virus. The study looked at data from 2010 to 2014 and found that the vaccine reduced the risk of flu-associated death by 51% among children with underlying high-risk medical conditions. Just 1 in 4 children who reportedly died from influenza had received the vaccine. As of March, 61 pediatric flu-related deaths had been reported in 2017.

From 1982-2016, peak influenza activity did not occur until January or later, but it can start as early as October.

Considering inconclusive evidence that delaying immunization may increase immunity in the latter half of the flu season, the ACIP recommends that patients get vaccinated early. The deferral of vaccination could result in a missed opportunity to vaccinate a patient or the patient becoming infected with the influenza virus prior to obtaining the vaccine.

A potential safety signal associated with the flu vaccination of pregnant women has been raised. A case control study has reported that women early in pregnancy who have been vaccinated with vaccine containing the H1N1 component had a higher rate of spontaneous abortion within 28 days of vaccination. However, the ACIP has not changed its re

commendation on not vaccinating pregnant women in any trimester. There is an ongoing study involving pregnant patients and the flu vaccine that should produce results by 2018 or 2019.

According to the CDC, the flu vaccine is associated with decreased hospitalizations among patients with diabetes (79%) and chronic lung disease (52%).

Additionally, a meta-analysis suggests that the influenza vaccine is associated with a lower risk of major cardiovascular events in patients with active coronary disease.

With these statistics in mind, health care providers should be the most prominent advocates of the flu vaccine, especially concerning these special patient populations.

Another concern when considering the flu vaccine in certain patient populations is an egg allergy. The ACIP recommends that patients who have experienced urticaria after exposure to eggs should be vaccinated. Patients who have experienced severe reactions to eggs, such as angioedema or respiratory distress, or who require epinephrine, may receive any licensed and recommended flu vaccine. However, vaccine administration should be supervised by a health care provider who is trained to manage severe allergic reactions. As always, patients who have suffered an allergic reaction to the flu vaccine previously should not receive the vaccine.

One option for patients with severe egg allergies is Flublok, a vaccine that is not produced using chicken eggs. If a patient asks for the Flublok vaccine, it should be noted that the vaccine has a slightly shorter shelf life of 9 months from the production date.

Always remember the CDC’s SHARE method: Share the reasons that the influenza vaccine is right for patients, highlight positive experiences with the vaccine, address all patient questions, remind patients that influenza vaccines protect them and their loved ones, and explain the potential costs of getting the flu. It is important that patients understand the vaccine and the reasoning behind its recommendation so that they can make informed decisions about the flu and other vaccines.

Pharmacists, nurse practitioners, physician assistants, and physicians are vital to increasing influenza immunization rates. Patients trust health care providers to provide the latest evidence involving the vaccine and data surrounding special patient populations.

is a community pharmacy resident at the University of Georgia and Kroger Pharmacy.

1. CDC. Prevention and control of influenza with vaccines. Recommendations of the Advisory Committee on Immunization Practices—United States, 2013-2014.

2. What you should know and do this flu season if you are 65 years and older. CDC website.

. Updated October 13, 2017. Accessed November 2, 2017.

The deferral of vaccination could result in a missed opportunity to vaccinate a patient or the patient becoming infected with the influenza virus prior to obtaining the vaccine.

Authors