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Clinical ShowCase™: Developing a Personalized Treatment Plan for a Patient with Sickle Cell Disease

Clinical Showcase Sickle Cell 

Katie Huffling, DNP, RN, CNM, FAAN, executive director at Alliance of Nurses for Healthy Environments, recently gave a presentation on how environmental exposures have impacted women’s health at the 25th Annual Premier Women's Healthcare Conference in Houston, Texas, held in-person from September 29 to October 2.

In her presentation, Huffling examined data from the World Health Organization, stating that up to 24% of global diseases are caused by environmental exposures, which could be avoided with proper protocols. This makes up a part of the 80% of major diseases significantly impacted by the environment. In children, environmental exposures are the source of 33% of diseases.

Over 280 industrial chemicals were found in newborns during a benchmark investigation, stated Huffling. These chemicals included 217 brain/nervous system toxicants, 180 carcinogens, and 208 birth defects or abnormal development. When exposed to these chemicals, individuals may develop asthma, lung disease, autism, attention-deficit/hyperactivity disorder, Parkinson’s, autoimmune disorders, cancer, obesity, and complications in reproductive health such as fertility and breast cancer.

These chemicals can also be found in some personal care products. Huffling provided data stating that only 11% of chemicals in cosmetics have been screened for safety. Flame retardants also contain chemicals which can increase the risk of cancer, endocrine disruptors, and neurological impacts.

To minimize risk, Huffling suggested methods of reducing exposure to these kinds of pollutants. These include keeping flame retardants from children, using a vacuum with a HEPA filter, mopping floors and dusting furniture regularly, washing hands frequently, thoroughly cleaning a car’s interior, and using naturally flame-resistant fabrics.

There are also risks of exposure to harmful chemicals in certain types of food. Huffling listed a “dirty dozen” food products with these risks, which consisted of strawberries, spinach, kale, nectarines, apples, grapes, peaches, cherries, pears, tomatoes, celery, potatoes, and hot pepper.

To counter risk, Huffling also listed a “clean 15.” These products are safe for consumption, and included: sweet corn, avocadoes, pineapples, papaya, onions, frozen sweet peas, eggplant, cauliflower, cantaloupe, broccoli, mushroom, cabbage, honeydew melon, kiwi, and asparagus.

Huffling also reminded attendees to avoid water contaminated with per- and polyfluoroalkyl substances. This can help reduce exposure, along with avoiding microwave popcorn, decreasing processed food consumption, and using cast-iron pans over Teflon nonstick pans.

Phthalates were also discussed, as they can lead to metabolic issues, elevated blood pressure, precocious puberty, fertility issues, pregnancy complications such as low birth weight and preterm birth, neurodevelopment, and respiratory impacts.

To reduce exposure, Huffling recommended avoiding plastic wrap and plastic food containers, keeping plastic out of the microwave, avoiding products with fragrance or phthalate on the label, reducing fast food consumption, and supporting policies for banning phthalates.

For increased safety in women preparing to have children, Huffling suggested the Safe Baby Products Guide. This allows women to research information on specific baby products and understand how the chemicals in certain products would affect their baby’s health. Huffling reminded women that baby products can be affordable when you separate what you need from what you don’t need.

Climate change was also a concern, as a rise in temperature and changes in natural events such as drought, flooding, and forest fire affect women’s health. Many of the health impacts mentioned previously are also brought about by the effects of climate change.

The health impacts of climate change include adverse pregnancy outcomes, increased risk of certain conditions in young children with greater biological sensitivity, and increased risk of exposure to heart-related illnesses in activities of older children.

Huffling stressed the impact advocacy can make, especially among health care providers’ voices. This can be at an association and institutional level, a community level, or a state and federal level. Huffling concluded the presentation by showcasing the fracking ban in Maryland, a case where health voices made a difference.

This article was published by our sister publication Contemporary OB/GYN.

Huffling K. Impact of environmental exposures on women’s health. Presented at: 25th Annual Premier Women's Healthcare Conference. Houston, Texas. September 29 to October 2, 2022.

Articles

In a presentation at the Nurse Practitioners in Women’s Health (NPWH) 25th Annual Conference, Katie Huffling DNP, RN, CNM, FAAN, explained how different cases of environmental exposure are impacting women’s health.

How environmental exposures affect our health

Jenny Madrid, MPH, RD, CDCES, BC-ADM, diabetes care and education specialist, gave a presentation on nutrition therapy used to treat gestational diabetes at the Nurse Practitioners in Women’s Health (NPWH) 25th Annual Premier Women's Healthcare Conference in Houston, Texas, from September 29 to October 2.

In the presentation, Madrid discussed the key components of Medical Nutrition Therapy (MNT) for Gestational Diabetes Mellitus (GDM). In cases of diabetes in pregnancy, Madrid mentioned how women will have to change their lifestyle behavior for proper management, developing a plan with a health care provider for MNT.

Diets should be a minimum of 175 g of carbohydrates, 71 g of protein, and 28 g of fiber. Nutrient dense carbohydrates were the most vital part of the diet mentioned, as they control glucose, reduce free fatty acids and excess infant adiposity, improve insulin action, and can provide vascular benefits.

When designing an MNT plan, Madrid recommended focus on carbohydrate intake, quality of carbohydrates, nutrient dense carbohydrates, nutrition needed for pregnancy, and level of saturated fat consumed. Plans should suit the individual and be culturally appropriate.

As insulin resistance is part of pregnancy and increases over time, total insulin doses should as well. The increase should be linear and 5% a week for 36 weeks. Cases will vary between individual women, with some women modifying their diets while others rely on insulin, which is the primary way to treat diabetes during pregnancy.

Though GDM is common, Madrid noted how it can be confusing, scary, and anxiety producing, along with how changes in diets can be difficult with cases of nausea, vomiting, heartburn, and food cravings. There may also be challenges in food insecurity and ability to cook, along with cultural norms surrounding pregnancy. These are just some of the barriers which can prevent optimization of MNT.

To reach the appropriate level of carbs, Madrid recommended steps such as limiting consumption of sugar beverages, carb counting, analyzing food labels, and reviewing and addressing barriers. For nutrient dense carbs, Madrid suggested grains, oats, beans, vegetables, fruit, and dairy products.

Saturated fat increases insulin resistance, leading Madrid to push for healthy fats which are provided by seeds, nuts, avocados, olive oil, and sesame oil. When measuring grams, 30 grams for breakfast, 60 for lunch, and 60 for dinner is best.

Madrid encouraged attendees not to make nutrition harder than in needs to be, reminding them that no diet is perfect. Each MNT should be individualized, and even with a strong MNT, some women will still need insulin. Proper expectations should be set by both healthcare providers and patients.

In a diet, Madrid found that carbs should not be low, nor should fat be high saturated. According to Madrid, tools should be customized for target populations.

Madrid J. Nutrition therapy for the treatment of gestational diabetes. Presented at: 25th Annual Premier Women's Healthcare Conference. Houston, Texas. September 29 to October 2, 2022.

In a recent presentation the NPWH 25th Annual Premier Women's Healthcare Conference, Jenny Madrid, MPH, RD, CDCES, BC-ADM, discussed medical nutrition therapy, a type of treatment plan for managing gestational diabetes by adjusting to an appropriate diet.

How changes in diet can manage gestational diabetes

 and joined the MJH Life Sciences team in December 2019. She graduated from Youngstown State University in 2019 with a bachelor's degree in journalism and a minor in political science. Prior to graduating, Morgan worked as the editor-in-chief of her college newspaper. She went on to work as an assignment editor at a broadcast news station in Youngstown, Ohio before joining 

Videos

Gregg Sylvester, MD, MPH, chief health officer at CSL Seqirus, discusses an FDA-approved cell-based flu vaccine for children as young as 6 months, trends in childhood vaccination rates, and how to prepare for the upcoming flu season.

How to prepare for this upcoming flu season

Physicians and their staff should beware a 

 that is targeting health care providers.

 was published Sept. 19 by the Health Sector Cybersecurity Coordination Center (HC3), within the U.S. Department of Health and Human Services. The campaign uses official-sounding language to convince recipients to click on a bogus download that is really a program that attempts to steal email credentials.

The sector alert stated: “The campaign has a subject of: “Data from (Victim Organization Abbreviation): "Important read about - Monkey Pox – (Victim Organization) (Reference Number) and utilizes an “Important read about Monkey Pox” theme.

“Inside of the email is a PDF with a malicious link which lures the recipient to a Lark Docs site. “The site is Adobe Doc cloud themed and offers a secure fax Monkey Pox PDF download.

"Clicking the download attempts to harvest Outlook, O365, or other mail credentials.”

HC3 recommends the following actions to help protect 

Protect each account with complex, unique passwords. Use a passphrase and/or a complex combination of letters, numbers, and symbols.

In general, avoid opening unsolicited emails from senders you do not know.

Do not open a link or an attachment in an email unless you’re confident it comes from a legitimate source.

Do not download or install programs if you do not have complete trust in the publisher.

Do not visit unsafe websites and do not click on pop-up windows that promise free programs that perform useful tasks.

This article was initially published by our sister publication Medical Economics®.

Don’t click on links or attachments unless you’re sure they are legitimate.

Feds warn of monkeypox-themed malicious email campaign targeting health care providers

Burnout is bad for career engagement of physicians and for patient safety, according to a new study that examined the effects together.

Workplace burnout among physicians is approaching crisis levels worldwide – possibly the highest levels seen in the history of health care systems, said 

, “Associations of physician burnout with career engagement and quality of patient care: systematic review and meta-analysis,” published this month in 

The researchers said it was the first review to link physician burnout, career engagement, and quality of patient care “because these aspects are complementary of the overall efficiency of healthcare organisations according to existing theoretical frameworks and research evidence.”

The results are grim, and the authors called for new interventions including the improvement of health care organizational culture.

“The pervasive nature of physician burnout indicates a defective work system caused by deep societal problems and structural problems across the sector,” Matthias Weigl, Professor of Patient Safety at Bonn University, said in a 

 about the latest findings. Weigl also penned an accompanying editorial about the results. “Urgent action is imperative for the safety of physicians, patients, and health systems, including interventions that are evidence based and system oriented, to design working environments that promote staff engagement and prevent burnout.

Researchers examined 170 observational studies of 239,246 physicians largely from the United States and Europe, but with studies from other parts of the world. There were variations in definitions and survey questions, along with complex and interchangeable factors that affect patient safety incidents, so the authors advised caution in interpreting the data.

Among the findings, the study said physicians with burnout:

Are up to four times more likely to be dissatisfied with their jobs

More than three times as likely to have thoughts or intentions to leave their jobs or regret their career choices

Twice as likely to be involved in patient safety incidents and show low professionalism

More than twice as likely to receive low satisfaction ratings from patients

Lower job satisfaction was more prevalent in physicians aged 31 to 50 years working in emergency medicine and intensive care, while patient safety incident were more likely to occur in physicians aged 20 to 30 years working in those specialties. Burnout was lowest among general practitioners, the study said.

“Healthcare organisations should invest more time and effort in implementing evidence-based strategies to mitigate physician burnout across specialties, and particularly in emergency medicine and for physicians in training or residency,” the authors said. The study recognized the financial and medical effects as health care systems “across the globe are encountering a workforce crisis.”

“Our findings affirm that physician burnout can be a catalyst for the career disengagement of physicians and that burnout is associated with unsafe patient care, which costs billions to healthcare systems annually,” the study said. “Physician burnout deepens the workforce crisis and undermines a fundamental need societal need to be in receipt of safe care.”

The study was yet another this month to log effects of physician burnout, a 

International study examines intertwined effects as problem approaches global crisis.

 Patients, careers suffer when burnout builds up for physicians

A recent review illuminated the varying ways in which costs for 

 treatment can be reduced for populations in need.

The review was conducted by Elisha M. Myers, BS, and Patrick O. Perche, BS, with the Wake Forest School of Medicine Center for Dermatology Research. Their research team sought to explore the ways in which 

 costs for AD can be reduced given specific education and resources, especially with regard to underserved populations.

Myers and colleagues took advantage of available resources to examine the various ways in which AD patients can receive treatment and management with costs and limited means in mind. AD is known to disproportionately affect children as well as minority groups.

The investigators conducted their review using GoodRx and WebMD to ascertain drug prices. They also used the PubMed search engine for AD guidelines, using a set of keywords to attain the necessary data:

The research team also found that prophylactic therapy through moisturizer use may reduce later costs for AD patients. In studies on newborns with high-risk of AD, the investigators noted that full-body moisturizing for a 6 - 8 month duration starting within the first few weeks of life for this group reduced disease instances significantly.

The investigators added that intermittent prophylactic corticosteroids or a non-corticosteroid medication for maintenance therapy may be preferable if moisturizing is not enough.

The investigators noted that in patients “with mild to moderate disease experiencing an AD flare, topical corticosteroids are the first-line treatment and should be started as soon as possible.” They added that if reducing cost is a concern for patients, then they recommend beginning with safe and less expensive medications, seeing how AD responds to them, and then escalating treatment if required.

The researchers found that mild to moderate cases of AD in patients may be served best through greater information about AD flare up triggers, given that the costs of things like medication, provider visits, and work absences can add up. Knowledge about ways to avoid exacerbating factors may promote cost reduction for AD patients.

The research team noted that those with moderate-to-severe AD require treatment options like methotrexate, phototherapy, dupilumab, cyclosporine , and oral JAK inhibitors like abrocitinib and upadacitinib. These vary in cost widely. One way to reduce cost and increase adherence is home-based phototherapy, which the investigators cite as comparable with in-office phototherapy.

The investigators wrote that “cyclosporine may be better suited in the treatment of flares, but from a cost-conscious perspective, an oral prednisone taper may be as effective and cost much less…For long-term use, methotrexate may not be the most effective of all these options, but its low cost makes it a desirable medication from a cost-conscious perspective.”

The researchers also noted in their review that Dupilumab and JAK inhibitors, while highly-effective for AD patients, are exceptionally expensive. They add that policy changes may be needed in the healthcare industry to reduce these costs.

The investigators note in their review that educating AD patients on corticosteroid use, on managing exacerbations, on increasing moisturization, and on the lack of evidence for certain therapies over others, can contribute to reduced cost as well.

“When treating AD several treatment approaches are available, but when cost reduction is a primary objective, starting with less costly treatments initially and only escalating treatment as needed may be appropriate,” they wrote. “Alternatively, providers may find it more appropriate to start a patient with the most effective and safest treatment regimen first to reduce the duration of a flare and overall disease burden.”

This article was initially published by our sister publication HCP Live®.

A review examined the ways in which costs can be reduced for patients with varying types of atopic dermatitis.

Review examines different ways to reduce costs for atopic dermatitis treatment

COVID-19 infection increases risk of new-onset type 1 diabetes (T1D), according to a recent study.

Data from the US Centers for Disease Control and Prevention indicated an increase in T1D cases during the pandemic, with an even greater increase seen in children after COVID-19 infection. However, this data included infections of type 1 and type 2 diabetes without separation.

To analyze the association between T1D and COVID-19 infection, investigators gathered data from the TriNetX Analytics Platform. This web-based database contains data from over 90 million patients across 74 large health care organizations, 50 US states, and 14 countries.

Patients were divided into 2 groups. The first consisted of individuals aged less than 18 years who had been infected with COVID-19 between March 2020 and December 2021, while the second consisted of individuals in the same age group and time range who had been infected with a respiratory illness besides COVID-19. 

The 2 groups were divided further into subgroups aged 0 to 9 years and 10 to 18 years. Subgroups were matched based on family history of diabetes. 

Of the 1,091,494 participants, 314,917 had been diagnosed with COVID-19 while 776,577 had been diagnosed with another respiratory illness. In those with T1D, 0.043% had been diagnosed within 6 months after COVID-19 infection, while 0.025% were diagnosed within 6 months after non-COVID-19 respiratory infection.

Risk rose further in the COVID-19 infected group than the other respiratory illness group after 6 months, with an additional increased risk in patients aged 0 to 9 years. While prior studies had associated respiratory infection with T1D, the increased risk from COVID-19 has led to concerns over long-term autoimmune complications in pediatric patients after COVID-19.

Kendall EK, Olaker VR, Kaelber DC, Xu R, Davis PB. Association of SARS-CoV-2 infection with new-onset type 1 diabetes among pediatric patients from 2020 to 2021. 

. 2022;5(9):e2233014. doi:10.1001/jamanetworkopen.2022.33014

In a recent study, pediatric patients infected with COVID-19 were more likely to develop type 1 diabetes than those infected with other respiratory illnesses.

COVID-19 associated with increased type 1 diabetes risk

In this video interview, Ian McGovern, epidemiologist, senior manager at CSL Seqirus, discussed the results of a recent study: "A Retrospective Database Analysis to Estimate the Epidemiology and Burden of Influenza in Children 0-14 Years Over 10 Consecutive Seasons."

McGovern noted how hospitals' resources are strained during the influenza season, even prior to the COVID-19 pandemic. Over 700,000 hospitalizations occur in the United States because of influenza annually, infection control measures draining hospital resources to prevent further spread.

COVID-19 has magnified the stress, according to McGovern, with fears of a "twindemic" occuring this season. This would be a case where influenza and COVID-19 both spread in the population, the number of infections pushing hospitals past their limits. Without proper resources in hospitals, mortality rates may rise.

For the past 2 years, COVID-19 precautions have led to drastically reduced cases of influenza. McGovern noted this reduces the possibility of people having a natural immunization, making them more susceptible to the flu. Young children are especially at risk, based on the study's results. 

Currently, influenza vaccines are the primary mode of prevention against severe cases of influenza, making them crucial among children. However, certain populations experience barriers to receiving vaccines. McGovern stated that these issues should be recognized and addressed so that more children may be vaccinated.

As a final note, McGovern recommended that parents speak with their child's health care provider and schedule an appointment to get vaccinated.

Ian McGovern, Epidemiologist, Senior Manager at CSL Seqirus, discusses new data on influenza gathered in a recent study, and how influenza rates are expecting to rise in the 2022 to 2023 flu season.

What to expect this influenza season

Respiratory illnesses commonly seen in pediatric patients decreased during the 2020 to 2021 influenza season, when precautions against COVID-19 were being made, according to a recent study.

Social distancing, mask wearing, and other precautions were taken during the COVID-19 pandemic. Along with preventing COVID-19 cases, these measures lowered the incidence of other illnesses, especially respiratory illnesses. 

As precautions were removed, cases of COVID-19 began to increase. Investigators conducted a study to observe if other respiratory illnesses increased with the reversal of COVID-19 precautions.

Data was gathered from a pediatric primary care network with about 375,000 pediatric patients. Information on the incidence of 9 common respiratory illnesses in children aged 0 to 17 years was then analyzed, with diagnoses from both in-person and telemedicine encounters analyzed.

Categories for respiratory illnesses included common cold, bronchiolitis, acute otitis media, croup, pneumonia, influenza, nonstreptococcal pharyngitis, sinusitis, and streptococcal pharyngitis. There were 1,573,838 encounters overall throughout 4 fall to winter seasons, 375,216 of which had one or more diagnoses for a respiratory illness.

All 9 common respiratory illnesses saw a reduction in the 2020 to 2021 season when compared to seasons prior to the pandemic, with influenza, bronchiolitis, and pneumonia seeing reduction rates of 95%. These reductions were not as great in the 2021 to 2022 season but were still significant when compared to prior seasons.

Common cold and nonstreptococcal pharyngitis were the only 2 illnesses without a significant reduction in the 2021 to 2022 season. As certain illnesses saw reductions when others did not, researchers speculated that multiple factors could have decreased incidence rates, such as infection control measure, changes in care-seeking behaviors, or an increase in circulation of specific viruses.

In many cases, diagnoses for respiratory illnesses were given to children who received a negative COVID-19 test after experiencing symptoms such as sore throat, fever, and cough. Researchers stated they are unsure if these diagnoses were given to avoid a COVID-19 diagnosis which would prevent return to school.

While January and February of 2022 were not included in the analysis, respiratory infections had decreased during that time, correlating with the SARS-CoV-2 Omicron variant and the return of pandemic precautions.

Hatoun J, Correa ET, Vernacchio L. COVID-19 pandemic-related changes in pediatric seasonal respiratory infections. 

In a recent study, researchers found that respiratory illness rates fell when precautions against COVID-19 were in place.

How COVID-19 trends affected respiratory illness rates

The American Academy of Pediatrics conference, the “Super Bowl” of medical conferences for all things related to children and adolescent health, is going live again, for the first time since 2019 (when it was held in New Orleans, Louisiana). The agenda is chockful of a dazzling array of sessions, product theaters, workshops, and an exhibit hall on virtually every pediatric topic under the sun. Topics range, but are not limited to, sessions and lectures on LGBT health and wellness; oral health; obesity and nutrition; neurology; pediatric trainees; osteopathic pediatricians, and so much more. 

Some of the most engaging topics include:

“Building Pediatric Capacity to Address Food Insecurity”

“Common Problems in the Newborn Nursery”

“Essential Advice for Food Introduction and Allergy Prevention”

“Let’s Talk: Practical Approach to Delivering Difficult News”

“Birthmarks: Red, White, Blue, and Brown”

“ Untold Stories: American Indians and Tobacco in the US”

“Feeling the Burn: Physician Burnout and Resiliency”

“Published Stories That Could Change the Way You Practice”

“Up in Smoke: Unintended Consequences of Marijuana Legalization”

An AAP Resource Center exhibition allows attendees to meet with authors of AAP-published books, share ideas with members of the AAP publishing staff, visit a board-certified internist from the Section on Med-Peds for a personal preventive service consultation and see the hottest products and gadgets from Global Child Health and Life Support. Additionally, AAP leaders and staff will be on hand to answer questions about AAP products, services, and programs and discuss how you can become more involved at the Academy.

There will be more on hand as well, including, on Friday, the AAP President’s Welcome Reception and AAP Block Party, and on Sunday, a Lunchtime Laughs and Learning with the Pediatrics On Call Podcast as well as a Trivia Night.

In this brief interview, the editor-in-chief of Contemporary Pediatrics, Tina Q, Tan, MD,FAAP, FIDSA, FPIDS, shares her enthusiasm about this important conference going live once again and what she is most looking forward to.

The editor-in-chief of Contemporary Pediatrics® shares her enthusiasm about heading out to Anaheim, California, for the first live American Academy of Pediatrics Conference since 2019.

Review examines different ways to reduce costs for atopic dermatitis treatment

COVID-19 associated with increased type 1 diabetes risk

What to expect this influenza season

How COVID-19 trends affected respiratory illness rates

Let's get excited about the AAP Conference!