Terri Schmitt PhD, APRN, FNP-BC, FAANP, Director of Education – NPACE

Anxiety, while one of the most common mental health disorders, escalated not only in the last decade in the U.S., but accelerated within the shadow of SARS-CoV-2.^1-5 From 2008 to 2018 the rates of anxiety increased in all ages and socioeconomic groups.¹ A Cochrane systematic review on mental health during COVID revealed that while all groups had increased anxiety throughout the pandemic, women, minorities, and adolescents suffered the greatest increases.² Even when accounting was made for previous anxiety, population characteristics, previous to current unemployment levels, the general trend for everyone is increased anxiety.

Healthcare and essential workers have been particularly vulnerable, with significant increases in anxiety and other mental health issues.^{3, 4} One year after the outbreak health workers were over six times more likely than other groups to report experiencing mental illness. With those most closely exposed to COVID patients having reported symptoms such as significant emotional exhaustion.⁴

As anxiety and mental health issues have risen, so have unhealthy self-treatment strategies and symptoms. The American Psychological Association and the CDC, through survey research, note the following of U.S. adults:

• A majority of adults report undesired weight change
• Sleep changes including both increased and decreased levels
• 47% of adults report delaying or canceling health services
• Essential workers are more than twice as likely to seek mental health treatment
• Increases in substance use and suicidal ideation, particularly in the 18 to 24 age group^{4, 5}

With increasing anxiety accelerated by the pandemic, helping patients, peers, and ourselves cope has become a priority. Tips such as taking a time-out, eating nutritiously, limiting alcohol, daily exercise, adequate sleep, being outside, meditation, and limiting social media can help. However, some patients may need further intervention. For adults, adolescents, and older children, cognitive behavioral therapy is the best first step, but medications may also be warranted.⁶

Dr. Sally Miller, nurse practitioner and nationally recognized speaker and clinician on mental health issues advised those attending the NPACE March conference that assessment, correct diagnosis and appropriate medication intervention is critical for diagnosed anxiety disorders. Dr. Miller notes that in treating anxiety, proper diagnosis is key. Questions like, does the anxiety need to be treated or is it actually abnormal? For example, a person in a situation of abuse or harm, either verbal, physical, etc., would anxiety in that situation be abnormal? The answer would be no. Anxiety would be normal and the treatment would need to come to the underlying risk or situation mitigation. 

Learn More

Below are a few of Dr. Miller’s anxiety pharmacotherapeutics practice tips from her presentation or you can view her presentation at https://learn.npace.org/products/anxiety-pharmacotherapeutics-2.

Practice Pearls on Pharmacology Management for Anxiety from Sally Miller:

• The amygdala, several neurotransmitters, and genetics contribute to anxiety and development of anxiety disorders.
• Only manage anxiety with medications if it is abnormal or maladaptive and is truly an anxiety disorder.
• Core features of anxiety disorders are fear and worry. Both must be present.
• SSRIs are a good first line group of medications for most anxiety disorders.
• SNRIs have a benefit of norepinephrine effect.
• There is a role for proper benzodiazepine use in anxiety management.

To learn more on specific treatment of anxiety, visit the American Psychological Association professional practice guidelines at https://www.apa.org/practice/guidelines.

References

1. Goodwin RD, Weinberger AH, Kim JH, Wu M, Galea S. Trends in anxiety among adults in the United States, 2008-2018: Rapid increases among young adults. J Psychiatry Res. 2020;130:441-446. doi:10.1016/j.jpsychires.2020.08.014
2. Anaya L, Howley P, Waquas M, Yalonetzky, G. Locked down in distress: a casual estimation of the mental-health fallout from the COVID-19 pandemic in the UK. The University of York. June 2021. https://www.york.ac.uk/media/economics/documents/hedg/workingpapers/2021/2110.pdf
3. Berman, R. COVID-19 and mental health: The Impact. Medical News Today; Aug 14, 2021. https://www.medicalnewstoday.com/articles/covid-19-and-mental-health-the-impact
4. America Psychological Association. Stress in America 2021: Pandemic Stress One Year On. APA Press; March 2021. https://www.apa.org/news/press/releases/stress/2021/sia-pandemic-report.pdf
5. Czeisler ME, Lane RI, Petrosky E, et al. Mental Health, Substance Use, and Suicidal Ideation during the COVID-19 Pandemic – United States, June 24-30, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1049-1057. doi: http://dx.doi.org/10.15585/mmwr.mm6932a1
6. GAD Clinical Practice Review Task Force. Clinical Practice review for GAD. Anxiety and Depression Association of America. July 2, 2015. https://adaa.org/resources-professionals/practice-guidelines-gad

Katherine Alexander, MS, APRN-CNP, BBA

The Zangmeister Cancer Center, Columbus, Ohio

The use of cannabis has been well documented for both recreational and medicinal purposes since the late 20th century. In recent years, many states have enabled legislation to allow the use of cannabis for medicinal purposes to treat a variety of conditions. Providers in both the acute and community settings are encountering patients using cannabis in a variety of forms.

The endo cannabinoid system is a lipid signaling network which modulates neuronal functions in the inflammatory processes. The system down regulates stress related signals that lead to chronic inflammation and pain. The EC is composed of endocannabinoids, which are endogenous lipid based retrograde neurotransmitters that bind to cannabinoid receptors and proteins located in the CNS and PNS. Receptors for CBD-1 are found mostly in the brain with high concentrations in the hippocampus, associated cortical regions, cerebellum, and basal ganglia. They are sparse in the brainstem, medulla and thalamus thus limiting the life-threatening effects on vital physiological functions. CBD-1 receptors are also found in the testis, sympathetic nervous synapses, adrenal glands, heart, lungs, prostate, bone marrow, thymus, and tonsils. CBD-2 receptors are found mainly in the immune system, with the highest expression seen in B lymphocytes. They also serve an important role in immune function and inflammation (Fine, P and Rosenfeld, M.).

The two main chemical components of cannabis are THC and CBD. THC is known for its psychotropic effect while CBD is used more for pain control. A secondary main component of cannabis are the terpenes. Terpenes provide an “entourage effect” which can be described as enhancements derived from combining phyto-cannabinoids with other plant-based molecules. Terpenes are full of flavor and fragrances that are common to the human diet such as lemon, pine, lavender, mango, and vanilla (Pertwee, R.).

Cannabis is grown as sativa, indica, or hybrid plant. Sativa based products are known for their stimulation effect while Indica based products can be utilized for sedation and pain control. Hybrid products are utilized frequently for patients attempting to achieve both pain control as well as appetite stimulation. Many patients will utilize both types of products within a 24-hour period to achieve maximum control of symptoms (Wilkie, S., Sakr, B., Rizack, T).

Cannabis has a favorable safety profile when compared to other analgesic medications. THC can be more sedating than codeine, but unlike opiates, it is not associated with respiratory depression. Possible side effects within the CNS include euphoria, disorientation, drowsiness, dizziness, motor incoordination, and poor concentration. Patients may also report tachycardia, hypotension, bronchodilatation, muscle relaxation, and decreased GI motility (Fine, P., and Rosenfeld, M.).

Currently, 29 States and the District of Columbia have medical cannabis programs in place. Many states also allow recreational cannabis. While currently no advanced practice providers in any of the 29 states can prescribe or recommend medical marijuana, APPs can take an active role in education of patients and evaluation of efficacy of symptom control.

As the use of cannabis becomes more widespread in the United States, providers must take an active role in understanding the pharmacokinetics of cannabis in its utilization in practice. Providing other advanced practice providers, patients, and their caregivers with additional information on the utilization of cannabis will help our patients become better informed and take a more active role in their care.

Learn More

To learn more about this topic and earn CE credit, register for our NPacers Aug 30th – Sept 1st Virtual Conference, which features a session on Medical Marijuana.

References:

Fine, P. and Rosenfeld, M. (2013). The Endocannabinoid System, Cannabinoids and Pain. Rambam Maimoines Medical Journal. 4 (4): e0022. DOI: 10.5041/RMMJ.10129

Pertwee, R. (2006). Cannabinoid Pharmacology: the first 66 years. British Journal of Pharmacology.  147 (S1). S163-S171. DOI:10.1038/sj.bjp.0706406

Wilkie, G., Sakr, B., Rizack, T. (2016). Medical Marijuana Use in Oncology A Review. JAMA. 2(5):670-675. DOI:10.1001/jamaoncol.2016.0155

Devin Pinaroc, FNP-C

TakeAways 

• Pfizer-BioNTech, Moderna, and Johnson & Johnson/Janssen are the three FDA approved COVID-19 vaccinations in circulation around the world. 
• All are effective in preventing hospitalization and death from the COVID-19 virus and are likely to decrease transmission risk during breakthrough infections. 
• The vaccinations are proving effective against the variant strains of COVID-19 but effectiveness differs between specific variants.
• Patients are fully vaccinated 2 weeks after their last dose. There is a 4 day grace period prior to the 2nd vaccination recommended date as well as patients must receive the second dose 6 weeks after the first dose to receive the proven benefits of immunization. 

Three different COVID-19 vaccines – Pfizer-BioNTech, Moderna, and Johnson & Johnson/Janssen – have been authorized for emergency FDA approval and are currently in circulation throughout the world. All are safe, effective, and reduce the risk of severe illness and death from COVID-19. The Centers for Disease Control (CDC) does not promote one over another. Clinical trials and real-world studies confirm these vaccinations are highly effective against COVID-19 asymptomatic and symptomatic cases, severe disease, and death from the COVID-19 virus. Vaccinated people who do become infected with the SARS-CoV-2 virus demonstrate a reduced viral load, suggesting associated transmission risk is substantially lower than unvaccinated people. Side effects can occur within 7 days after vaccine administration, but are mostly mild and temporary. There is still more to learn regarding vaccinations and high-risk individuals (such as those who are immunocompromised), as well as how long the protection from COVID-19 vaccination may last. As of February 2021, two other COVID vaccines, Astrazeneca and Novavax, were in Phase 3 clinical trials and on the way to FDA emergency approval (Centers for Disease Control and Prevention [CDC], 2021a)

Pfizer-BioNTech’s COVID-19 vaccine is an mRNA 2-shot immunization series, separated by 21 days, and approved for people 12 years and older. In people 16 years or older, the clinical trials demonstrated a 95% effectiveness in preventing laboratory confirmed COVID-19 after 2 doses (CDC, 2021b). 

Moderna’s COVID-19 vaccine is also an mRNA 2-shot immunization series, separated by 28 days, and approved for people 18 years or older. In clinical trials, this vaccine was 94.1% effective at preventing laboratory-confirmed COVID-19 infection after 2 doses (CDC, 22021c). 

Johnson & Johnson/Janssen’s COVID-19 vaccine is a viral vector immunization that is approved for individuals 18 years or older and was 66.3% effective at preventing laboratory-confirmed COVID-19 infections in clinical trials, but still very effective in preventing severe disease, hospitalization, and death. Unique to this vaccine, the CDC has found “plausible causal relationship” with thrombosis with thrombocytopenia syndrome (TTS). This is a very rare complication with a rate of 7 per 1 million vaccinated women between 18 and 49 and even less in men of all ages or women over 50 years (CDC, 2021d).

Variants

Investigations continue on the vaccines’ efficacy with emerging variants. As of May 27, 2021, the CDC’s research demonstrated a large degree of protection from the vaccines from known variants (CDC, 2021e). Of note, prevention effectiveness may vary between different variants, and at the time of the CDC’s publication, the “Delta” variant (or SARS-CoV-2 B.1.617.2) was less active and prevalent in the U.S (CDC, 2021e). Today, early studies suggest the Delta variant is responsible for over 50% of cases – highest in locations with low vaccination rates (CDC, 2021f). Nevertheless, the vaccines are still efficacious in preventing severe disease, hospitalization, and death from the Delta variant (CDC, 2021f). 

Clinical Considerations 

The vaccinations are not interchangeable and patients are advised to continue with the immunization manufacturer of their first dose. The 2nd dose may be administered up to 4 days earlier than the recommended date and as late as 6 weeks after the first dose with sustained effectiveness. Other vaccinations are safe to be administered the same day with any of the COVID-19 vaccines and may be administered without regard to timing. Persons with an active COVID-19 infection should complete the isolation criteria and be completely healed prior to receiving their first vaccination, but should still be encouraged to complete the immunization schedule as soon as possible. If monoclonal antibodies or convalescent plasma were given for treatment for the virus, patients should wait 90 days prior to getting the vaccine. Full vaccine benefits are acquired 2 weeks after the last vaccine of each series, and people are then considered “fully vaccinated” (CDC, 2021g).

Want to know more…

CDC’s COVID-19 Vaccine Effectiveness Research

Talking to Recipients about COVID-19 Vaccination

CDC COVID-19 Vaccine FAQs for Healthcare Professionals

Earn CE credits

To learn more about COVID-19 and earn CE credits, visit the NPACE Learning Center On-Demand catalog and search on Infectious Disease or COVID: https://learn.npace.org/on-demand 

References

Centers for Disease Control and Prevention. (2021a, May 27). Different COVID-19 Vaccines. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/different-vaccines.html. 

Centers for Disease Control and Prevention. (2021b, June 24). Pfizer-BioNTech COVID-19 Vaccine Overview and Safety. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/different-vaccines/Pfizer-BioNTech.html. 

Centers for Disease Control and Prevention. (2021c, June 11). Moderna COVID-19 Vaccine Overview and Safety. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/different-vaccines/Moderna.html

Centers for Disease Control and Prevention. (2021d, June 23). Johnson & Johnson’s Janssen COVID-19 Vaccine Overview and Safety. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/different-vaccines/janssen.html. 

Centers for Disease Control and Prevention. (2021e, May 27). Science Brief: Background Rationale and Evidence for Public Health Recommendations for Fully Vaccinated People. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/science/science-briefs/fully-vaccinated-people.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fmore%2Ffully-vaccinated-people.html. 

Centers for Disease Control and Prevention. (2021f, July). COVID Data Tracker Weekly Review. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/covid-data/covidview/index.html. Retrieved on July 14, 2021.

Centers for Disease Control and Prevention. (2021g, July 2 ). Interim Clinical Considerations for Use of COVID-19 Vaccines Currently Authorized in the United States. Centers for Disease Control and Prevention. https://www.cdc.gov/vaccines/covid-19/clinical-considerations/covid-19-vaccines-us.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fvaccines%2Fcovid-19%2Finfo-by-product%2Fclinical-considerations.html#Administration

Devin Pinaroc, FNP-C

Takeaways

• A normal sinus rhythm will display a rate of 60-99 beats/minute; P waves followed by QRS complexes, and upright P waves in leads I and Il  (Meet & Morris, 2002).
• STEMI ECGs will display ST-segment elevation at the J-point in more than 2 contiguous leads. ECG displaying NSTEMIs horizontal or downsloping ST-depression and/or T wave changes. 
• There is not one single proven interpretation method that is most efficient and accurate, and physicians of all levels and specialties displayed deficiencies in interpretation ability. 
• A standardized ECG education approach and interpretation method may improve accuracy in all healthcare providers

An electrocardiogram (ECG) displays different waveforms that map the electrical impulses moving through different areas of the heart during the cardiac cycle (Prutkin, 2019). The P wave, PR interval, QRS complex, ST segment, T wave, and (sometimes) U make up these ECG waves (Prutkin, 2019). In a standard 12 lead ECG, the leads represent different areas of the heart. Leads II, III, and aVF are associated with the inferior surface; V1 to V4 with the anterior surface; I, aVL, V5, and V6 with the lateral surface, and V1 and aVR with the right atrium and cavity of the left ventricle (Meet & Morris, 2002)

Providers rely heavily on ECG interpretation of these leads for the detection of irregular cardiac rhythms, conduction abnormalities, and myocardial infarction as well as to explore and better understand several other cardiac diseases, like valvular heart disease and pericarditis (Prutkin, 2019).

ECG Interpretation Methods

Despite the weight clinicians give ECG results, there seems to be a surprisingly underwhelming amount of knowledge on the optimal – most accurate and time efficient – ECG interpretation method. UpToDate advises clinicians to follow a systematic approach while other methods, like the CRISP method that was designed for perioperative nurses to rapidly interpret ECGs, promote quick interpretation using only certain leads or waveforms (Prutkin, 2020/Atwood & Wadlund, 2015). Automatic diagnosis from ECG machines present likely interpretations, but may hold too much influence. When the automatic interpretation was incorrect, physician confidence and accuracy suffered, especially non-cardiologists (Bond et al., 2018).

Readings in a “Normal ECG”

To ensure a normal sinus rhythm, where the SA node conducts the electrical impulse from the atrium to the ventricles, lead II is most commonly prolonged for viewing of the P waves (Sauer, 2020). Every P wave should be followed with a QRS complex and will be upright in Leads I and II (Meet & Morris, 2002). The heart rate should be between 60-99 beats/minute (Meet & Morris, 2002). The normal cardiac axis, the mean direction of the ventricular depolarization, is between -30 and 90 degrees (Meet & Morris, 2002). This is interpreted with positive (upright) QRS complexes in Leads I, II (Prutkin, 2019). 

A Must Know: Myocardial Ischemia/Infarction ECG changes

A patient experiencing myocardial ischemia/infarct will produce an ECG that displays one of the following: a) findings consistent with ST-elevation myocardial infarction (STEMI) or b) findings consistent with non-ST elevation myocardial infarction or unstable angina (NSTEMI). STEMIs, the classic “heart attack” ECG, display ST-segment elevation at the J-point in more than 2 contiguous leads (Prutkin, 2019). NSTEMIs cause a new horizontal or downsloping ST-depression ≥0.5 mm in two contiguous leads and/or T inversion >1 mm in two contiguous leads with prominent R wave or R/S ratio >1  (Goldberger, & Prutkin, 2021). 

ECG Interpretation Deficiencies 

A 2020 JAMA systematic review found that physicians’ ECG interpretation ability varied widely, but ultimately revealed major interpretation deficiencies across all training levels and specialties (Cook & Pusic, 2020). Even after educational interventions, physicians still showed deficiencies in accurately interpreting ECGs and only improved to 67% accuracy. 

These studies suggest the need for a standardized ECG interpretation and education system, one with proven accuracy and conducive to a clinician’s busy schedule, that can be utilized by and taught to all health care professionals  (Cook & Pusic, 2020).

Want to learn more..

To learn more and earn CE credits on ECG-related topics, visit our new Learning Center:

https://learn.npace.org/products/important-cardiology-considerations-when-performing-sports-physicals

https://learn.npace.org/products/assessment-of-cardiac-murmurs

Other Resources:

ABC of clinical electrocardiography: Introduction. I—Leads, rate, rhythm, and cardiac axis

The Normal Electrocardiogram: Resting 12-Lead and Electrocardiogram Monitoring in the Hospital

Accuracy of Physicians’ Electrocardiogram Interpretations: A Systematic Review and Meta-analysis | Cardiology | JAMA Internal Medicine

The essential skill of ECG interpretation: How do we define and improve competency?

References:

Atwood, D., & Wadlund, D. L. (2015). ECG Interpretation Using the CRISP Method: A Guide for Nurses. AORN journal, 102(4), 396–408. https://doi.org/10.1016/j.aorn.2015.08.004

Bond, R. R., Novotny, T., Andrsova, I., Koc, L., Sisakova, M., Finlay, D., Guldenring, D., McLaughlin, J., Peace, A., McGilligan, V., Leslie, S. J., Wang, H., & Malik, M. (2018). Automation bias in medicine: The influence of automated diagnoses on interpreter accuracy and uncertainty when reading electrocardiograms. Journal of Electrocardiology, 51(6). https://doi.org/10.1016/j.jelectrocard.2018.08.007 

Cook DA, Oh S, & Pusic MV. Accuracy of Physicians’ Electrocardiogram Interpretations: A Systematic Review and Meta-analysis. JAMA Intern Med. 2020;180(11):1461–1471. doi:10.1001/jamainternmed.2020.3989

Goldberger, A., & Prutkin, J. (2021, February 14). Electrocardiogram in the diagnosis of myocardial ischemia and infarction. UpToDate. https://www.uptodate.com/contents/electrocardiogram-in-the-diagnosis-of-myocardial-ischemia-and-infarction?search=EKG&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2#H99426212. 

Meek, S., & Morris, F. (2002). ABC of clinical electrocardiography.Introduction. I-Leads, rate, rhythm, and cardiac axis. BMJ (Clinical research ed.), 324(7334), 415–418. https://doi.org/10.1136/bmj.324.7334.415

Prutkin, J. (2019, June 10). ECG tutorial: Basic principles of ECG analysis. UpToDate. https://www.uptodate.com/contents/ecg-tutorial-basic-principles-of-ecg-analysis?search=EKG%20reading%20&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H7491826.

Sauer, W. (2020, October 20). Normal sinus rhythm and sinus arrhythmia. UpToDate. https://www.uptodate.com/contents/normal-sinus-rhythm-and-sinus-arrhythmia?search=normal%20sinus%20rhythm&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H7014381.

Devin Pinaroc, FNP-C

Splashing in the pool, hiking favorite trails, and sipping iced tea at cookouts, summer is upon us. People enjoy outdoor activities during the summer months, and solar radiation exposure becomes a concern with the sun shining higher, hotter, and lingering longer into the evenings. 

Not only does sun exposure increase the risk of developing skin cancer, but it can also stimulate premature aging and creates several undesired skin changes, like fine and coarse wrinkles, mottled pigmentation, and loss of elasticity (Chien & Kang, 2021). Clinicians have a responsibility to educate patients about the harmful effects of solar radiation and how to protect themselves. 

Prevention Techniques

All patients should engage in prevention and protection from the sun, even those with highly pigmented skin. Sunscreen, sunglasses, hats, and other protective clothing should be utilized to aid in shade. Staying indoors or seeking shade during peak hours (10am-2pm) will help in avoiding the strongest UV irradiation (ADD, 2019). Sun protection should be practiced daily even during cloudy and rainy days. Water, snow, and concrete can reflect up to 90% of UV rays and should be especially observed during pool/lake days (Chien & Kang, 2021). 

Sunscreen Application  

While no sunscreen blocks 100% of UV rays, the American Academy of Dermatology (ADD) advises use of broad spectrum, water resistant sunscreen of at least SPF 30 or higher for effective protection from solar rays (2019). SPF efficacy studies used 2 mg/cm^2 and should be the goal dose of application (Narla & Lim, 2020). Reapplication should ultimately be directed by the bottle, but sunscreen will likely need to be reapplied every 2 hours or after sweating/swimming (Chien & Kang, 2021). While sunscreen spray preparation may be more convenient and quicker, caution patients about inability to measure the amount of sunscreen used and inconsistency of protection. Ensure patients apply an adequate amount by creating a thick layer on the skin surface and then lightly rub into the skin with any preparation. 

Vitamin  D Concerns

Many patients are concerned about sunscreen causing vitamin D deficiency. Clinicians should reassure patients that the usual amounts applied have not shown in research to affect Vitamin D levels (Chien & Kang, 2021). Vitamin D can easily be obtained from common fortified foods, and oral supplementation is cost-effective, easy, and well tolerated without an increased risk for skin cancer (ADD, 2019). 

Sunscreen Safety Questions

Within the last 5 years the FDA questioned the safety of several UVR filters used in sunscreens after reviewing percutaneous absorption safety data and found inadequate information to determine effect on health (Young & Rossi, 2017). Animal trials revealed high concentrations of some UVR filters from percutaneous absorption, resulting in endocrinological changes and deformities (Young & Rossi, 2017). While concerning, other research found reaching comparable levels in humans was highly unlikely and “unattainable” (Young & Rossi, 2017). Stll, the FDA is pushing manufacturers for more answers on how much is absorbed and effects of absorption to regulate safety (ADD, 2019).

The FDA continues to promote the use of sunscreen despite the lacking data and has proposed a 3 tiered safety grouping to classify sunscreen ingredients that specifies ingredients as safe, unsafe, and unknown.  (ADD, 2019). The FDA considers Titanium dioxide and Zinc oxide as “generally recognized as safe and effective” (GRASE), and para-aminobenzoic acid (PABA) and trolamine salicylate as not GRASE (Young & Rossi, 2017). There are 12 other UVR filters with insufficient safety data whose safety determination is yet to be known (Young & Rossi, 2017). 

Despite the unknowns regarding sunscreen safety and lack of uniformity among brands, any UV radiation has known damaging, potentially fatal, effects. Clinicians should encourage daily adequate sunscreen use coupled with other forms of sun protection. 

Want To Know More…

Ultraviolet radiation and the skin: Photobiology and sunscreen photoprotection

Sunscreen Application, Safety, and Sun Protection: The Evidence

Review of environmental effects of oxybenzone and other sunscreen active ingredients

References 

American Academy of Dermatology. (2019). Sunscreen FAQs. American Academy of Dermatology Association. https://www.aad.org/public/everyday-care/sun-protection/sunscreen-patients/sunscreen-faqs#:~:text=Is%20a%20high%2Dnumber%20SPF,of%20the%20sun’s%20UVB%20rays 

Chien, A. L., & Kang, S. (2021, April 1). Photoaging. UpToDate. https://www.uptodate.com/contents/photoaging?search=sun+daamage&source=search_result&selectedTitle=1~54&usage_type=default&display_rank=1#H16665025 

Narla, S., & Lim, H. W. (2020). Sunscreen: FDA regulation, and environmental and health impact. Photochemical & photobiological sciences : Official journal of the European Photochemistry Association and the European Society for Photobiology, 19(1), 66–70. https://doi.org/10.1039/c9pp00366e

Young, A. R., Claveau, J., & Rossi, A. B. (2017). Ultraviolet radiation and the skin: Photobiology and sunscreen photoprotection. Journal of the American Academy of Dermatology, 76(3S1), S100–S109. https://doi.org/10.1016/j.jaad.2016.09.038 https://www.jaad.org/article/S0190-9622(16)30880-5/fulltext#secsectitle0035

Devin Pinaroc, FNP-C

Takeaways

• Treatment of migraine episodes is addressed in a stratified or “step” approach, choosing an initial medication based on intensity or starting with the simplest treatment and moving up, respectively. 
• Abortive therapies should not be used more than 10 days per month (or less than 15 days per month for aspirin, acetaminophen, and NSAIDS) 
• First line treatment is NSAIDs and/or acetaminophen for mild to moderate episodes. Triptans are first line treatment for moderate to severe episodes. 
• Adjunct medications and therapies are often given to address symptoms associated with migraines, like providing antibiotics for migraine – associated nausea or steroids to prevent recurrence. 

Migraine is a primary headache disorder characterized by recurrent debilitating, severe headaches associated with nausea, photophobia, and/or phonophobia (Smith, 2021). The POUND mnemonic summarizes the clinical features (Mayans & Walling, 2018).  

(P)ulsatile quality of headache

(O)ne-day duration of headache

(U)nilateral headache

N)ausa/vomitting

(D)isabilty intensity of headache 

Treatments are categorized between acute “abortive” therapy – addressing an active migraine – and preventative therapy –  stopping migraines before they happen. Although prevention is the goal, taking a preventative medication every day may not be feasible or unneeded for those with infrequent migraines. 

Treatment Principles 

Overall, abortive medications work best when given early in the course of the headache and in large initial doses rather than in small repetitive doses (Smith, 2021). The variety of abortive medications allow individualized treatment plans that often consist of multiple medications, so follow up and treatment adjustment are key in managing acute migraines (Mayans & Walling, 2018).  In addition to medications, guidelines advise avoidance of triggers and maintaining a healthy lifestyle to prevent migraine recurrence (Mayans & Walling, 2018).  

There are two therapeutic treatment approaches when addressing an active migraine: stratified and “step” (Peters,2019). The stratified approach primarily considers headache intensity for initial medication choice, whereas the stepwise approach starts with simple analgesics and moves to more potent medications after treatment failure (Mayans & Walling, 2018).  Generally, the stratified approach is recommended given it yields quicker response time, faster headache resolution, and reduced treatment cost, particularly when patients are able to classify their headache intensity and provide a thorough history of effective treatment plans (Peters, 2019). The stepwise approach should be considered during a prolonged headache episode or in cases involving inconsistent symptom patterns (Mayans & Walling, 2018). 

Given many abortive treatments (ie: simple analgesics) are easily accessible and cost effective, they are also frequently overused, causing a self perpetuating rebound headache. These medication overuse headaches are ranked among the top-20 disability conditions globally and create serious morbidity (Peters, 2019). To avoid overuse headaches, most acute medications should be limited to less than 10 days per month (or less than 15 days per month for aspirin, acetaminophen, and NSAIDS) (Smith, 2021).

First line therapies

In multiple randomized trials, acetaminophen and NSAIDs showed significant efficacy in controlling mild to moderate migraines, and use should be considered in all patients (Smith, 2021). Details to consider when choosing from the multitude of simple analgesics include preparation, side effects, and time of onset. For example, Ketorolac is usually given IM, avoiding a potentially ineffective oral route in nauseous patients; naproxen has a slower onset of action but longer half life which may reduce refractory migraines; and acetaminophen is associated with less gastric upset than NSAIDs (Mayans & Walling, 2018).  

Triptans are first line treatment for moderate to severe episodes, proving effective and associated with minimal side effects (Smith, 2021). However, if treatment failure occurs with one triptan, trial of a different triptan is recommended (Peters,2019). Patients can respond better to certain triptans over others due to underlying genetic factors(Mayans & Walling, 2018). Triptans are available in a plethora of preparations and have few side effects, but expense is often a deterrent (Mayans & Walling, 2018). Sumatriptan is perhaps the most well known and cost effective triptan, available in nasal spray, pills, or subQ injections. 

The addition of 500mg of naproxen, available in combination pills with some triptans, is likely more effective than each drug alone (Smith, 2021). Use as an initial treatment for moderate/severe episodes and as a step-up therapy is appropriate.

Second line/Adjunct therapies

The following therapies should be considered after above medications fail or are not tolerated. Either adding or replacing medications can be advised and will be specific to the individual case. 

Dihydroergotamine, especially the intranasal preparation, shows great efficacy in managing moderate to severe episodes, but usually causes more side effects than the first line therapies (Mayans & Walling, 2018).  Nausea is the most common side effect, and providing an antiemetic in conjunction should be considered. This has the added benefit of reducing nausea associated with the migraine. Studies have proven metoclopramide IV and IM/IV prochlorperazine can be used as monotherapy for acute migraine headaches as their mechanism of action reduces migraine pain as well as controls nausea/vomiting (Smith, 2021). However, this preparation must be given in office and cannot be prescribed for at home use. Oral ondansetron is a low cost option that is commonly used, although this may only address the migraine-associated nausea and not the primary migraine (Smith, 2021). Diphenhydramine can help prevent akathisia and dystonic reaction when given IV antiemetics, but is not recommended by the American Family Physicians for the specific treatment of migraines (Mayans & Walling, 2018 ; Smith, 2021).  Dexamethasone (10 to 24 mg) IV or IM can be given after a standard abortive treatment has been given to decrease recurrence of headache (Smith, 2021).

Emerging Therapies

As migraine etiology is better understood, new therapies are emerging. The “biologic” class has found some success in treating episodes, using the new understanding of the migraine pathway. Hopefully, these emerging medications will help overcome the current barriers to care, like contraindications, adverse effects, and tolerability issues (Peters, 2019). 

Want to know more…

Update: Pharmacologic Treatment for Episodic Migraine Prevention in Adults

Emerging Treatment Options for Migraine

References

Mayans, L., & Walling, A. (2018). Acute Migraine Headache: Treatment Strategies. American family physician, 97(4), 243–251.

Peters G. L. (2019). Migraine overview and summary of current and emerging treatment options. The American journal of managed care, 25(2 Suppl), S23–S34.

Smith, J. h. (2021, March 29). Acute treatment of migraine in adults. UpToDate. https://www.uptodate.com/contents/acute-treatment-of-migraine-in-adults?search=migraine&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H68879808. 

Devin Pinaroc, FNP-C

Takeaways

• Conservative measures can be very effective when used in combination and strict adherence is practiced.
• Artificial tears are the mainstay treatment in Dry Eye Disease (DED), available in many different preparations, and should be initially tried 4-6 times a day. 
• Prescription medications, procedures, and devices treat severe disease when conservative therapies fail, but should be managed by an ophthalmologist/optometrist. 

Dry eye disease (DED) is a condition of the ocular surface characterized by tear film instability due to reduction of tear production and/or increased evaporative loss from any dysfunction of the lacrimal functional unit (Shtein, 2021). Symptoms include conjunctival injection, ocular burning, photophobia, visual disturbances and tend to eb and flow depending on associated factors (ie: seasonal allergies, increased screen time, contact lens) (Shtein, 2021). Even mild disease can affect vision and make daily tasks, like driving or reading, more difficult, affecting quality of life. Treatments target evaporation of the tear film on the surface of the eye and optimization of meibomian gland production to promote underlying ocular moisture (Messmer, 2015). 

Conservative Therapies 

There are many simple interventions that relieve symptoms, but efficacy relies heavily on patient adherence (O’Neil et al., 2019). Re-evaluation of treatment/care should follow 2-4 months of compliance to a combination of supportive therapies. 

Artificial tears are the mainstay treatment in any severity of DED, and several preparations are available over the counter. Although no RCT data compares efficacy, avoiding preservatives, especially benzalkonium chloride, is recommended to avoid ocular inflammatory response (Messmer, 2015). Initial dosing of artificial tears is 4-6 times a day for 1-2 months.  If treatment failure occurs, adding or switching to higher viscosity gel/ointment preparation can be more effective, but do cause temporary blurry vision (Shtein, 2021). 

Warm compresses over the eyes maintain secretions and patency of the meibomian glands. Eye compresses able to be microwaved are sold over the counter. Ten to fifteen minutes of warm compress therapy before bed, in combination with application of an artificial tear gel, can be very soothing. 

Environmental strategies such as avoidance of heating and air conditioning or room humidification reduce evaporation from the ocular surface. Frequent blinking is helpful in upkeeping the tear film (Shtein, 2021). Blinking decreases with attentive tasks like in computer use, so setting reminders to take frequent breaks can reduce evaporation of tears.  

Moisture Chambers create physical barriers around the eye to decrease exposure from the environment and maintain humidity around the eye (Shtein, 2021). These can be worn daily or only during times of exacerbation. 

Severe Disease Treatments

During the last decade, research into DED has increased as well as dry eye treatments available after conservative measures fail or for severe dry eye. An emerging, but not (yet) FDA approved, eye drop showed efficacy in using eye-platelet rich plasma and growth factors to address surface evaporation and promote ocular surface health. In-office procedures like meibomian gland probing, address meibomian gland health and output through mechanical energy or heat. A range of devices have been developed to offer alternative therapies to people with dry eyes. For example, the intranasal tear neurostimulator is a relatively new device that targets natural tear production through the nasolacrimal reflex pathway (O’Neil et al., 2019).

These medications and alternative therapies should be managed by an eye specialist (Messmer, 2015). The time to refer is patient dependent and should involve a discussion regarding cost, goals versus expectations of care, worsening or severity of symptoms, and continued compliance to conservative measures.  

Want to know more…

AAO – What Is Dry Eye?

Dry Eye Disease: Prevalence, Assessment, and Management

Update on the association between dry eye disease and meibomian gland dysfunction

References

Messmer E. M. (2015). The pathophysiology, diagnosis, and treatment of dry eye disease. Deutsches Arzteblatt international, 112(5), 71–82. https://doi.org/10.3238/arztebl.2015.0071

O’Neil, E. C., Henderson, M., Massaro-Giordano, M., & Bunya, V. Y. (2019). Advances in dry eye disease treatment. Current opinion in ophthalmology, 30(3), 166–178. https://doi.org/10.1097/ICU.0000000000000569

Shtein, R. M. (2021, April). Dry eye disease. UpToDate. https://www.uptodate.com/contents/dry-eye-disease?search=dry+eyes&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H6 

Robin Gosdin Farrell, DNP, CRNP

Auburn University

rgf0001@auburn.edu

          Mycoplasma Genitalium (MG), first identified in the 1980s, is one of six mycoplasma species that inhabit the urogenital and reproductive tracts of males and females with equal prevalence. MG is classified as a simple self-replicating prokaryote belonging to the bacteria class known as mollicutes. Over the past decade, MG has emerged as a sexually transmitted infection (STI) to be reckoned with due to the increase in prevalence, complications, morbidity, diagnostic difficulties, and antibiotic resistance. The prevalence of MG is greater than gonorrhea in sexually active young adults in the United States. MG is commonly seen in adolescents and young adults. Of individuals diagnosed with MG, 50% of partners test positive. Significant risk factors for MG infections include African American race, younger age, non-Hispanic ethnicity, and female symptomatic status.

        Studies have shown an association of MG to increased risk of urethritis, prostatitis, mucopurulent cervicitis, pelvic inflammatory disease, adverse pregnancy outcomes, infertility, and neonatal infection. A high co-infection rate exists between MG and other STIs including Chlamydia trachomatis, trichomonas vaginitis, and a co-factor in HIV transmission. Prior bacterial vaginosis infections were associated with a 3.5-fold increase in odds of incident MG. This strong association suggests that BV may enhance susceptibility to MG infection. Testing for M. genitalium in asymptomatic populations is not currently recommended; improved diagnosis and management of BV may be a useful approach to mitigating these risks. Studies have shown suboptimal eradication rates of MG, thus indicating the bacteria has the primary link to recurrent and persistent STIs. Shedding of MG in untreated individuals can persist longer than 8-12 weeks.  

        Symptomology ranges from complaints of dysuria, penile or vaginal discharge, vaginal itching, vulvar erythema, and dyspareunia to being asymptomatic. Risks associated with MG infections were found to be those with greater numbers of partners in the past three months and those who have been diagnosed with Chlamydia. Detection of MG is difficult due to the fact the organism lacks a cell wall and is a small genome which creates a poor and slow growth in culture medium. There is no reliable gold standard diagnostic tool available as a commercial culture or assay, nor do present guidelines recommend testing of asymptomatic individuals. MG is most accurately diagnosed by nucleic acid amplification tests, including polymerase chain reaction and transcription-mediated amplified tests. These currently are available for research purposes in a limited number of medical facilities and labs. However, microscopic evidence of infection can be detected by increased white blood cells and bacteria on slides from urethral, vaginal, endocervical, and urine secretions.

       MG should be suspected and treated presumptively in cases of recurrent urogenital infections or STIs and if microscopic findings and examination support treatment. Treatment options include a single dose of azithromycin or a 5-day dosing schedule. However, up to 40% of MG infections are resistant to azithromycin. Moxifloxin is recommended in its place for 7-10 days. However, quinolone resistance is beginning to trend. Healthcare providers need to be aware of the existence, prevalence, recurrence, treatment, complications, and antibiotic resistance of MG.

References

Association of Public Health Laboratories. (2019). Mycoplasma genitalium: An emerging issue in the world of sexually transmitted infections.   https://www.ncsddc.org/wp-content/uploads/2019/04/ID-2019Feb-M-genitalium-fact-sheet.pdf

Baum, S. (2011). Mycoplasma hominis and ureaplasma urealyticum infections. Journal of  Clinical Microbiology, 42(4), 425-438.

Baum, S., Waites, K. & Robinson, D. (2016). Clinical microbiology (9^th ed.). Washington, D.C.: Associated Medical Press.

Baum, S. (2010). Principles and practice of infectious diseases (7^th ed.). Philadelphia, Pennsylvania: Churchill Livingstone.

Bhattacharya, A. (2018). Emerging pathogens and antibiotic resistance in STIs an urgent challenge. Medical Laboratory Observer. 50(2), 18-29.

Cunningham, S., Mandrekar, J., Rosenblatt, J., & Patel, R. (2013). Rapid PCR detection of mycoplasma hominis, ureaplasma urealyticum, and ureaplasma parvum. International  Journal of Bacteriology, 20(13), 1-7.

Dabrazhynetskaya, A., Volokhov, D., David, S., Ikonomi, P., Brewer, A., Chang, A. & Chizhikov, V. (2011). Preparation of reference strains for validation and comparison of mycoplasma testing methods. Journal of Applied Microbiology, 112(2), 904-914. doi:10.1111/j.1365-2672.2011.05108x

Davies, N. (2015). Mycoplasma genitalium: The need for testing and emerging diagnostic options. Medical Laboratory Observer, 47(12), 8-12.

Getman, D., Jiang, A., O’Donnell, M., & Cohen, S. (2016). Mycoplasma genitalium: Prevalence, coinfection, and macrolide antibiotic resistance frequency in a multi-center clinical study cohort in the United States. Journal of Clinical Microbiology, 54(9), 2278-2283. Doi:10.1128/JCM.01053-16

Heavey, E. (2017). Mycoplasma genitalium. Nursing, 47(7) 61-62. doi:10.1097/01.NURSE.0000520524.30192.07

Jones, L., Felblinger, D., & Cooper, L. (2009). Mycoplasma genitalium: More prevalent than you think. Nurse Practitioner, 34(8), 50-52. doi:10.1097/01.NPR.0000358664.73596.4c

Kent, B. Emerging sexually transmitted diseases. Clinical Laboratory Science, 30(2), 124-130.

Manhart, L.E., & Trent, M. (2017). Mycoplasma genitalium: A review of current issues and challenges. Contemporary Obstetrics & Gynecology, 62(7) 1-6.

Manhart, L.E. (2013). Mycoplasma genitalium: An emergent sexually transmitted disease? Journal of Infectious Disease Clinics, 27(4), 779-792. doi:10.1016/j.idc.2013.08.003

McGowin, C.L., & Totten, P.A. (2017). The unique microbiology and molecular pathogenesis of mycoplasma genitalium. Journal of Infectious Diseases, 2, 382-388. doi.org.spot.lib.auburn.edu/10.1093/infdis/jix172

McGowin, C. L., Rohde, E. E., & Redwine, G. (2014). Epidemiological and clinical rationale for screening and diagnosis of mycoplasma genitalium infections. Clinical Laboratory Sciences, 27(1), 47-52.

Mobley, V., Senna, A. & Hobbs, M. (2012). Mycoplasma genitalium infection in women and men attending a sexually   transmitted infection clinic: Diagnostic specimen type, coinfections, and predictors. Sexually Transmitted Disease, 39(706), 47-54.

Nye, M.B., Harris, A.B., Pherson, A.J., & Cartwright, C.P. (2020). Prevalence of mycoplasma genitalium infection in women with bacterial vaginosis. BMC Women’s Health, 20(62), doi.org/10.1186/s12905-020-00926-6

Ona, S., Molina, R., & Diouf, K. (2016). Mycoplasma genitalium: An overlooked sexually transmitted pathogen in women. Infectious Diseases in Obstetrics & Gynecology, 16, doi.org/10.1155/2016/4513089.

Ronda, J. Gaydos, C. Perin, J., Tobacco, L. Coleman, J., & Trent,M. (2018). Does mycoplasma genitalium infection predict future sexually transmitted infections in female urban adolescents and young adults? Journal of Adolescent Health, 62, 82-85. doi:10.1016/j.jadohealth.2017.11.165

Seña, A., Lee, J., Schwebke, J., Philip, S., Wiesenfeld, W., Rompalo, A., Cook, R., & Hobbs, M.

(2018) A silent epidemic: The prevalence, incidence and persistence of mycoplasma genitalium among young, asymptomatic high-risk women in the United States. Clinical Infectious Diseases, 67(1), 73–79, doi.org/10.1093/cid/ciy025.

Tan, L. (2017). Clinical and diagnostic challenges of antimicrobial resistance in mycoplasma genitalium. Medical Laboratory Observer, 49(5), 8-14.

Tosh, A. K., Van derPol, B., Fortenberry, J.D., Williams, J.A., Katz, B.P., Batteiger, B.E., & Orr, P. (2006). Mycoplasma genitalium among adolescent women and their partners. Journal of Adolescent Health, 40, 412-417. doi:10.1016/j.jadohealth.2006.12.00595

Wiesenfeld, H.C. & Manhart, L.E. (2017). Mycoplasma Genitalium in women: Current knowledge and research priorities for this recently emerged pathogen. Journal of Infectious Diseases, 2(216), 389-395. doi:10.1093/infdis/jix198

By: Devin Pinaroc, MSN, FNP-C

Elevated cholesterol is associated with increased risk of atherosclerotic cardiovascular disease (ASCVD), acute cardiovascular events, and premature death (Pignone, 2021). Achieving cholesterol targets is paramount in preventing cardiovascular conditions and events. Backed by expert groups like the ACC and AHA and recommended specifically by the USPSTF, statin therapy has emerged as the mainstay treatment of ASCVD showing great efficacy in preventing acute cardiovascular events and reducing overall cardiovascular mortality (Pignone, 2021). Despite this, questions continue to surround statin prescribing. This uncertainty is perpetuated by biased risk versus benefit considerations and a misinterpretation of research.  

The Lower, The Better

Hyperlipidemia is diagnosed at a serum total cholesterol level greater than 200mg/dL and an LDL-C level greater than 100mg/dL. While a serum total cholesterol of ~150 mg/dL may optimize a low ASCVD risk level, a specific LDL-C cholesterol target is more elusive after the achievement of sub-100mg/dL levels (Grundy et al., 2018). The landmark study, “JUPITER”, supports the understanding that there is no specific low threshold that conveys negative effects as the study was halted early given LDL-C level as low as 55 mg/dL demonstrated great cardiovascular benefit (Pignone, 2021). In short, “the lower, the better” (Grundy et al., 2018).

Statin Therapy

The 2018 ACC/AHA Blood Cholesterol Guidelines outline screening for lipid disorders, how to calculate ASCVD risk scores, and score utilization in statin initiation and selection.  Focus, in treatment decisions, is placed on intensity of response rather than specific lipid value (Karr, 2017). 

 Statins are the first line pharmaceuticals given their superior ability to reduce cholesterol more than any other lipid lowering drugs, proven to lower LDL-C by more than 50% depending on dosage (Grundy et al., 2018). There is an overwhelming amount of evidence regarding statin efficacy in reducing risk of ASCVD, acute cardiovascular and thrombotic events, and even all cause mortality (Pignone, 2021). 

Statin Use: Hesitations     

Statin muscle-related injury and myalgias are perhaps the most common worries among patients and can create significant barriers to care. Karr (2017) reported approximately 1 out of 10 people document some muscle-related symptoms, like myalgias, weakness, or inflammation, with statin use (Karr, 2017). However, the USPSTF found no statistical difference in control versus interventional cohorts when specifically assessing muscle pain related to statin use (USPSTF, 2016). Clinicians should reassure patients that myalgias are often temporary and mild, do not cause long term exercise intolerance, and can be addressed with certain interventions if they do occur.  

Gastrointestinal distress, weakness, and headache are other common side effects that contribute to patient noncompliance and treatment plan failure (Karr, 2017). Other more concerning adverse events include elevated LFTs and rhabdomyolysis, but are very rare and easily managed with proper monitoring and patient education. Decreased cognitive function was documented in a few case reports but disproven in 3 large RCTs, so clear association seems very limited and unlikely. (Grundy et al., 2018). Further, increased cancer prevalence, renal dysfunction, low testosterone, and hemorrhagic stroke lack the research to support correlation claims (Rosenson, 2021). 

Statins and Diabetes Mellitus 

Some research suggests statins influence glucose metabolism in a way that causes an increase in blood glucose levels (Rosenson, 2021). Logically, this could confer an increased risk for developing diabetes, but the details of this are not fully understood. Several observational and meta-analysis studies produce no clear answer, but many RCT’s did not show a statistical significance in diabetes prevalence with and without statin use (USPSTF, 2016). The JUPITER study did report a statistically significant increase in diabetes mellitus with statin use, but this study uniquely involved high intensity statins (Karr, 2017). Consistent duplication of these results has not been achieved, potentially pulling weight from its significance. The ACC/AHA do acknowledge a possible increased risk of diabetes mellitus with statin use, but the increase is small and is likely affected by other factors rather than pure statin use, like using a high intensity dose and other diabetes risk factors (ie: obesity, metabolic syndrome, etc) (Grundy et al., 2018). 

Ultimately, the research is unclear with different expert groups drawing different conclusions. 

Decision Time 

Overall, clinicians must weigh risk versus benefit for each patient, engaging in shared decision-making regarding statin use. Clinicians should consider and explain a statin’s known ability to make a concrete impact in the risk of heart attacks and strokes with the possible, unclear risks of diabetes mellitus and potential side effects. This discussion should include education about potential side effects and the “red flag” signs for rhabdomyolysis and other serious adverse events. Slow dose titration and careful statin selection – as some statins may produce more muscle pain and weakness –  can help reduce side effects and improve tolerance. As all pharmaceuticals can produce side effects, clinicians and patients must decide if a statin is more dangerous than other lipid lowering drugs.

Other Therapies

Adjunct to pharmaceutical therapies, lifestyle interventions create a holistic approach that addresses both inherent factors, like age and family history, as well as modifiable risk factors, like physical inactivity, a diet high in saturated and trans fats, obesity, and smoking (USPSTF, 2016).

Other medications that lower LDL-C levels include ezetimibe, bile acid sequestrants, and PCSK9 inhibitors (Karr, 2017). Niacin and fibric acid derivatives target the reduction of triglycerides with only a small LDL-C lowering effect, but can be helpful in some cases (Grundy et al., 2018). These medications are used in conjunction with statins when the LDL continues to stay elevated or ASCVD risk is high. Solo use has not been proven to provide the adequate reduction of risk or improve outcomes. 

Want to learn more.. 

Learn more about dyslipidemia at our June 9-11 Virtual Conference from expert Gary Graf, MSN, ARPN-C!

2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

Cardiovascular benefits and diabetes risks of statin therapy in primary prevention: an analysis from the JUPITER trial

Optimizing Dyslipidemia Management for the Prevention of Cardiovascular Disease: a Focus on Risk Assessment and Therapeutic Options

References

Grundy, S. M.,, Stone, N. J., Bailey, A. L.,, … Al., E. (2018, November 10). 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. https://www.ahajournals.org/doi/10.1161/CIR.0000000000000625. 

Karr, S. (2017). Epidemiology and management of hyperlipidemia. The American journal of managed care, 23 (9 Suppl), S139–S148. https://www.ajmc.com/view/epidemiology-and-management-of-hyperlipidemia-article

Pignone, M. (2021, January 15). Management of elevated low density lipoprotein-cholesterol (LDL-C) in primary prevention of cardiovascular disease. UpToDate. https://www.uptodate.com/contents/management-of-elevated-low-density-lipoprotein-cholesterol-ldl-c-in-primary-prevention-of-cardiovascular-disease?search=Dislipidemia&topicRef=7573&source=see_link#H3715821088. 

Rosenson, R. (2021, February 21). Statins: Actions, side effects, and administration UpToDate. https://www.uptodate.com/contents/statins-actions-side-effects-and-administration?search=statin&source=search_result&selectedTitle=2~133&usage_type=default&display_rank=1#H17

US Preventive Services Task Force. Statin Use for the Primary Prevention of Cardiovascular Disease in Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2016;316(19):1997–2007. doi:10.1001/jama.2016.15450

By: Devin Pinaroc, MSN, FNP-C

Biologic, socioeconomic and environmental factors, like race, ethnicity, sex, age, income, and geographical location, create “determinants of health”. Each plays a role in how patients receive and respond to health interventions. For example, food deserts make fresh produce and healthy foods difficult to access and areas with high crime rates create barriers to exercise. Each of these socioeconomic barriers ultimately affects a person’s health, creating the health disparities that dictate adverse health outcomes for some ethnic groups. 

A Problem Across All Healthcare

Minority groups consistently bear worse health outcomes for a variety of conditions and diseases and are generally more negatively affected in health disparities. In 2007, the maternal death rate for African American, non-Hispanic or Latino, women was almost 3 times higher than white women, non-Hispanic or Latino (Office of Disease Prevention and Health Promotion [ODPHP]). Hispanics have a higher prevalence of lung disease, like asthma and chronic obstructive pulmonary disease, and higher rates of obesity than non Hispanic Whites. (Chartbook for Hispanic Health Care, 2015). While improvements in outcomes continue, they are not equally experienced across all groups. For example, while non-Hispanic whites saw a marked decrease in infant death rate, American Indian or Alaskan Natives saw a steady infant death rate of 8.3 infant deaths per 1000 live births from 2006 to 2017 (ODPHP, 2017c). Racial and ethnic minorities are more likely to be poor or near poor and are less likely to have a highschool education than non-Hispanic Whites, perpetuating health inequalities (Chartbook for Hispanic Health Care, 2015). 

Given that in the 2010 Census, 36% of the US population, or more than 100 million people, identified themselves in a racial or ethnic minority, improving the health of the nation lies in correcting these discrepancies (CDC).

Barriers to Care

Health disparities are perpetuated along all of healthcare. Obtaining insurance and navigating insurance policies confuses even the most educated native English speaker. Inherent systematic biases and racism create obstacles that disporportionately affect minority groups. Furthermore, the needs of marginalized groups are not well understood from an organizational level. This is apparent in the Healthy People 2020’s goals for the LGBTQ population, where initiatives aimed simply to improve data collection and monitoring systems to better understand healthcare obstacles (ODPHP, 2014). 

On an individual level, lack of access to quality care, unique provider biases, language barriers, and health literacy further disenfranchise those that are more likely to lack access to healthy foods and safe streets. 

Often in minority and marginalized groups, health disparities complicate even simple conditions and treatment. Clinicians must be aware, knowledgeable of their community, and able to adapt care.  By resisting to modify medical advice based on individual circumstances, patients are further ostracized and outcomes are affected. Identification of personal bias is imperative in effectively treating patients of all backgrounds. In understanding our own individual preconceived notions, patients will not be subjected to a biased diagnosis or treatment plan (Braveman & Gottieb, 2014).

Want to Learn More… 

Minority Health and Health Equity

Reducing disparities in health care

Disparities in Healthcare Quality Among Racial and Ethnic Minority Groups: Fact Sheet

National Healthcare Quality and Disparities Reports

References:

Braveman, P., & Gottlieb, L. (2014). The social determinants of health: it’s time to consider the causes of the causes. Public health reports (Washington, D.C. : 1974), 129Suppl 2(Suppl 2), 19–31. https://doi.org/10.1177/00333549141291S206

Chartbook for Hispanic health care. (2015, October). Agency for Healthcare Research and Quality. Retrieved April 06, 2021, from https://www.ahrq.gov/research/findings/nhqrdr/2014chartbooks/hispanichealth/part1.html#QDR. 

Center for Disease Control and Prevention:  Office of Minority Health and Health Equity. (2021). Minority Health. Health Equity. Retrieved April 06, 2021 https://www.cdc.gov/minorityhealth/index.html

Office of Disease Prevention and Health Promotion. (2007). Maternal deaths (per 100,000 live births) By Race/Ethnicity. Healthy People 2030. Retrieved April 06, 2021, from https://www.healthypeople.gov/2020/data/Chart/4897?category=3&by=Race/Ethnicity&fips=-1

Office of Disease Prevention and Health Promotion. (2014). LGBTQ 1-1. Healthy People 2030. Retrieved April 06, 2021, from https://www.healthypeople.gov/node/4802/data_details

Office of Disease Prevention and Health Promotion. (2017a). C-1. Reduce the Overall Cancer Death Rate. Healthy People 2030. Retrieved April 06, 2021, from https://www.healthypeople.gov/2020/data-search/Search-the-Data#objid=4047;

Office of Disease Prevention and Health Promotion. (2017b). Disparities Overview by Health Insurance Status. Healthy People 2030. Retrieved April 06, 2021, from https://www.healthypeople.gov/2020/data/disparities/summary/Chart/4121/11