Key Take-Aways:

• Research is ongoing and NPs will continue to need to be updated and monitoring results. For example, primary care providers should be looking for the results from the ACTIV4 COVID-19 outpatient thrombosis prevention trial.
• In hospitalized patients, benefit was found from several types of steroid treatments, but particularly Dexamethasone.
• Hospitalization and the need for oxygen are factors in guidelines for determining medication intervention.

NPACE Virtual Conference attendees were treated to an additional benefit from their September conference, an update on COVID-19 in a live up-to-date Q&A session with Dr. Sohera Syeda on October 29. Dr. Syeda is an Assistant Professor at Boston University School of Medicine’s Section of Pulmonary, Critical Care and a Lecturer of Medicine at Harvard Medical School. She is also a practicing physician with the VA Boston in both West Roxbury and Bedford, MA. She provided the keynote conference address in September on COVID-19.

Dr. Syeda’s dedication to NPACE and educating healthcare providers on the latest COVID-19 evidence was on full display in the 1-hour session, where she continued to emphasize the importance of understanding the epidemiology, current public health advisories, and driving factors behind the current state of COVID-19 infection in the US.

Dr. Syeda provided the most up-to-date treatment research for primary care practice application and answered questions on illness numbers in the US and how systemic health determinants affect health outcomes, and she emphasized needed public health messaging. Highlights from the session include the important benefits of dexamethasone, and other steroid therapies, in hospitalized patients and a review of the anti-viral Remdesivir overall trials and outcomes.

The presentation highlighted timely key information needed by practicing nurse practitioners. Dr. Syeda’s dynamic and concise presentation skills made for a must-see presentation for any NP.

For those who attended the conference, the session is available via the conference app until Dec 31st. It’s a ‘do not miss’ presentation that will help rapidly update nurse practitioners. Anyone interested who did not attend the conference may still do so. Register for on demand.

Takeaways

• Advancement in oral diabetes pharmaceuticals – achieved within the past 30 years – has given providers and patients 11 classes of medications to use in achieving glycemic control.
• Metformin remains the first line treatment, if appropriate, then, if goals are not met, oral medications are recommended for combination therapy.
• SGLT2 inhibitors should be considered in the setting of cardiovascular disease (established or at risk for), kidney disease, or heart failure as they show significant cardiovascular benefits.
• GLP-1 receptor agonists show the greatest reduction of Hgb A1C when added to Metformin therapy, even preferable to insulin.

Type 2 Diabetes Mellitus, a metabolic condition characterized by hyperglycemia, is commonly due to a progressive loss of insulin secretion from the beta cells of the pancreas accompanied with simultaneous insulin resistance that results in relative insulin deficiency (Inzucchi & Lupsa, 2020). Before 1923, when insulin became commercialized in the United States after groundbreaking discoveries by Dr. Frederick Banting, there was no effective treatment for diabetes, and fatal outcomes were inevitable (White, 2014). While insulin revolutionized the treatment of diabetes mellitus, the next 70 years proved barren in the way of discovery for oral medications. It was not until the 1990’s that most of the currently available treatments were developed (White, 2014).

Goals of diabetes treatment include Hgb A1c of ≤7.0 percent, which necessitates a fasting glucose of 80 to 130 mg/dL and a postprandial glucose (90 to 120 minutes after a meal) less than 180 mg/dL (Wexler, 2020).

The following is a brief review of T2DM oral medications and initial treatments.

Quick Guide to T2DM Oral Medications

SULFONYLUREA – Glipizide, Glyburide – stimulate beta cells in the pancreas to release more insulin into the blood. Take orally daily or multiple times daily (Agency for Healthcare Research and Quality [AHRQ], 2008).

THIAZOLIDINE (TZDs) – Pioglitozone/Actos – improves the way insulin works in the body which allows more glucose to enter into muscle and fat. Also reduce the amount of glucose production from the liver. Oral medication taken daily (AHRQ, 2008).

ALPHA- GLUCOSIDASE INHIBITORS (AGIs) – Acarbose/Precose – delays the breakdown of carbohydrates and reduces glucose absorption in the small intestine. Also, blocks certain enzymes in order to slow down digestion of some starches. Taken orally before each meal (AHRQ, 2008).

MEGLITINIDES – Repaglinide (Prandin) – works on beta cells of the pancreas to release more insulin into the blood. Taken orally before each meal, 3x/day (AHRQ, 2008).

GLUCAGON-LIKE PEPTIDE-1 RECEPTOR AGONISTS(GLP-1) -Exenatide/Lixsenatide – increases insulin secretion, slows gastric emptying, and reduces postprandial glucagon. Available as short acting and long acting subcutaneous injectables only (Dungan & DeSantis, 2020).

DDP-4 INHIBITORS – Sitagliptin (Januvia) – help pancreas release more insulin after meals and lower the amount of glucose released by the liver. Orally medication taken once daily or multiple times a day (Dungan & DeSantis, 2020).

SODIUM GLUCOSE CO-TRANSPORTER 2 INHIBITORS (SGLT-2) – empagliflozin/Jardiance, Canagliflozin/ Invokana – works on the kidneys to remove excess glucose from the body but excreting it through the urine. Orally taken, usually once daily (DeSantis, 2020).

First line treatment: Metformin

Assuming the patient is without contraindications, Metformin remains the first line oral pharmacological treatment for T2DM recommended by the ADA, multiple international expert panels, the European Diabetic Board recommendations, and Canada’s treatment guidelines (American Diabetes Association [ADA], 2020).  Metformin provides reliable glycemic efficacy by reducing the amount of glucose produced by the liver, with minimal risks for weight gain and hypoglycemia and with good tolerance (ADA, 2020). Recommended starting dose is 500mg daily with the evening meal, increasing as needed to achieve goals to a total dose of 2000mg per day (ADA, 2020). Titrate slowly to ensure tolerance or switch to other formulation (ie: XR) as needed to combat associated GI distress.

Further treatment: Latest updates in Oral T2DM Medications

If A1C goals are not met after 3 months of Metformin monotherapy combined with lifestyle modifications, combination therapy is recommended (ADA, 2020). Other medications and/or treatment methods should be added according to individual risk factors, tolerance to medications, and comorbidities (ADA, 2020).

 There is benefit to specific oral medications with certain T2DM comorbidities.  Specifically, guidelines recommend the addition of SGLT2 inhibitor or GLP-1 agonist in patients with T2DM and established or highly at risk for atherosclerotic CVD, established kidney disease, or heart failure (ADA, 2020). This combination shows significant cardiovascular benefit and reduction in adverse cardiovascular events or worsening of cardiovascular conditions (ADA, 2020).

Another notable finding, SGLT2 inhibitors have additional favorable effects on hospitalizations forheart failure and decreasing risk of renal disease (ADA, 2020). However, the greatest Hgb A1C reduction was seen with the addition of a GLP-1 receptor agonist, preferable even to the addition of insulin, when added to Metformin therapy (ADA, 2020).

Perhaps most important, when making treatment decisions: include the patient. National guidelines and organizational resources urge providers to utilize patient centered decision making throughout the process of choosing a combination therapy and monitoring.

To learn the very latest and earn CE credit, register for our June 9-11 Virtual Conference, which will have several sessions on Diabetes treatment and management.

Want to learn more? Visit..

References

Agency for Healthcare Research and Quality. (2008, January). Toolkit for Implementing the Chronic Care Model in an Academic Environment. Retrieved November 8, 2020, from https://www.ahrq.gov/prevention/curriculum/chroniccaremodel/chronic2a12c.html

American Diabetes Association. (2020, January 01). 9. Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes-2020. Retrieved November 08, 2020, from https://doi.org/10.2337/dc20-S009

DeSantis, A., MD. (2020, October 29). Sodium-glucose co-transporter 2 inhibitors for the treatment of hyperglycemia in type 2 diabetes mellitus. Retrieved November 09, 2020, from https://www.uptodate.com/contents/sodium-glucose-co-transporter-2-inhibitors-for-the-treatment-of-hyperglycemia-in-type-2-diabetes-mellitus?search=sglt2+inhibitors

Dungan, K., MD, & DeSantis, A., MD. (2020, February 14). Dipeptidyl peptidase 4 (DPP-4) inhibitors for the treatment of type 2 diabetes mellitus. Retrieved November 10, 2020, from https://www.uptodate.com/contents/dipeptidyl-peptidase-4-dpp-4-inhibitors-for-the-treatment-of-type-2-diabetes-mellitus?search=DDP-4+INHIBITORS

Dungan, K., MD, & DeSantis, A., MD. (2020, October 30). Glucagon-like peptide 1 receptor agonists for the treatment of type 2 diabetes mellitus. Retrieved November 09, 2020, from https://www.uptodate.com/contents/glucagon-like-peptide-1-receptor-agonists-for-the-treatment-of-type-2-diabetes-mellitus?search=GLUCAGON-LIKE+PEPTIDE-1+RECEPTOR+AGONISTS%28GLP-1%29

Inzucchi, S. E., MD, & Lupsa, B., MD. (2020, August 07). Clinical presentation, diagnosis, and initial evaluation of diabetes mellitus in adults. Retrieved November 07, 2020, from https://www.uptodate.com/contents/clinical-presentation-diagnosis-and-initial-evaluation-of-diabetes-mellitus-in-adults?search=type+2+diabetes+mellitus+diagonsis

Wexler, D. J., MD, MSc. (2020, June 25). Overview of general medical care in nonpregnant adults with diabetes mellitus. Retrieved November 10, 2020, from https://www.uptodate.com/contents/overview-of-general-medical-care-in-nonpregnant-adults-with-diabetes-mellitus?search=Diabetes+mellitus++goals

White J. R., Jr (2014). A Brief History of the Development of Diabetes Medications. Diabetes Spectrum: a publication of the American Diabetes Association, 27(2), 82–86. https://doi.org/10.2337/diaspect.27.2.82

Takeaways

• While there is still lacking research, the adverse effects of using e-cigarettes include more than just the risks of nicotine. Some of the additional risks include re-normalizing smoking behavior in youths, causing injury from device malfunction, and unknowingly inhaling potentially toxic chemicals.
• The E‐cigarette or vaping product use‐associated lung injury (EVALI) health crisis in the Fall 2019 was likely due to an additive (Vitamin E acetate) in e-cigarettes involving THC. 
• Healthcare providers should recommend that patients who use e-cigs avoid THC containing products due to the potential association with EVALI.
• The USPSTF does not recommend the use of e-cigarettes as a smoking cessation tool due to a lack of evidence. 

Known in colloquial terms as “ vapes”, “vape pens”, or  “e-cigs”, electronic cigarettes refer to electronic, handheld devices that heat a liquid, usually containing nicotine, to produce an aerosol which the user may inhale (Rigotti & Kalkhoran, 2020). These electronic nicotine delivery devices were first commercialized by a Chinese inventor in 2003 and did not find their way to the US market until 2006, where they have made quite an impact in the last 14 years (Historical Timeline of Electronic Cigarette, 2019). 

Potential Adverse Effects of E-cigs

Nicotine, most often vaporized in e-cigs, is a highly addictive substance and has multiple known health risks to people of all ages (CDC, September 2020). Using nicotine can be toxic to developing fetuses, interfere with brain development in adolescents, and may contribute to acute coronary events in adults (CDC, September 2020 ; Giardina, 2020).  The health risks attributed to e-cigarettes were considered to be mostly those of the inhaled nicotine, but, while still applicable, there are other additional potential adverse effects to consider. The physical use of the device can cause potential burns/injuries from malfunctioning or exploding (Uptodate, 2020). The CDC found that in 2020, 3.6 million U.S. middle and high school students used e-cigarettes in the past 30 days (CDC, September 2020). Youths are especially at risk for nicotine dependence given their developing brains.  

Other concerns are not so apparent though. Some speculate there may be a “gateway effect”, where e-cigarettes could lead to smoking conventional cigarettes (Rigotti & Kalkhoran, 2020). The popularity of vaping products among the youths may be renormalizing smoking behavior and reverse the negative associations attributed to conventional smoking (Rigotti & Kalkhoran, 2020). What’s more,vaping products do not deliver a uniform amount of nicotine with each inhalation which creates more unknown potential health risks. The level of nicotine inhaled is dependent on individual puffing intensity, device characteristics, and nicotine concentration of the liquid, so blood nicotine levels can vary greatly (Rigotti & Kalkhoran, 2020). To add to this variability, many manufactured e-cigarettes contain a number of chemical substances that can be potentially toxic (CDC, September 2020). This danger was made apparent in the fall of 2019 when there was a sharp, sudden rise of emergency department visits related to e-cigarette or vaping products (CDC, 2020).

EVALI 

E‐cigarette or vaping product use‐associated lung injury (EVALI) is a serious respiratory condition that, as of February 2020, has claimed a total of 68 lives across the U.S. and is responsible for 2,807 hospitalizations in all US territories (CDC, February 2020). 

Presentation consists most often of respiratory symptoms, including shortness of breath and cough, and can be accompanied by common GI symptoms, like nausea, vomiting, and diarrhea (Hollingsworth, 2020). There will also be a positive history of vaping in the last 90 days, lung opacities on chest imaging, and negative testing for other common causes (Hollingsworth, 2020). Progression to respiratory distress/failure is common, and about 95% of patients of EVALI cases needed hospitalization (Hollingsworth, 2020). 

Since September 2019, the incidence of EVALI is steadily declining but should still be considered if consistent symptoms are noted upon exam.

Vitamin E Acetate – The Cause?

The declining rate is likely in part due to the investigations headed by the FDA and CDC. They have both found laboratory data suggesting an additive in tetrahydrocannabinol (THC)-containing e-cigarette products is correlated to the development of this respiratory illness (CDC, February 2020; U.S Food and Drug Association, 2020). In a recent study, Vitamin E acetate was speculated to be this specific additive as it was found in the lungs of 48 out of the 51 EVALI cases (Blount et al., 2020). It was also found in 81% of the e-cigarette samples that were confirmed to be connected with specific CDC cases, further supporting its involvement (Blount et al., 2020; U.S Food and Drug Association, 2020). 

Recommendations for Healthcare Providers

Overall, no confirmed causation or specific correlation has been identified but the CDC still recommends avoidance of using Vitamin E acetate as an additive (February 2020). Based on the current studies, the CDC recommends avoiding use of THC-containing electronic cigarette products as well (February 2020). 

Healthcare providers should urge patients to refrain from smoking altogether, but should especially stress avoidance of “dual use”- using both e-cigs and cigarettes/other tobacco products together (CDC, February 2020).  A Cochrane Review did provide some evidence that showed e-cigarettes with nicotine can play a positive role in long term smoking cessation (Hartmann-Boyce et al., 2020). However, the limited sample size of the studies and small number of trials limit the evidence. Ultimately, the US Preventive Services Task Force deemed the evidence to be insufficient, and more information is needed prior to recommending e-cigarettes for smoking cessation (Rigotti & KalKhoran, 2020). 

Want to Learn More?

For Healthcare Providers | Electronic Cigarettes | Smoking & Tobacco Use

Quick Facts on the Risks of E-cigarettes for Young People

Vaporizers, E-Cigarettes, and other Electronic Nicotine Delivery Systems (ENDS)

References

Blount, B. C., Karwowski, M. P., Shields, P. G., Morel-Espinosa, M., Valentin-Blasini, L., Gardner, M., . . . Pirkle, J. L. (2020). Vitamin E Acetate in Bronchoalveolar-Lavage Fluid Associated with EVALI. New England Journal of Medicine, 382(8), 697-705. doi:10.1056/nejmoa1916433

CDC. (2020, September 09). About Electronic Cigarettes (E-Cigarettes). Retrieved October 25, 2020, from https://www.cdc.gov/tobacco/basic_information/e-cigarettes/about-e-cigarettes.html

CDC. (2020, February 25). Outbreak of Lung Injury Associated with the Use of E-Cigarette, or Vaping, Products. Retrieved October 25, 2020, from https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html

Giardina, E. (2020, May 06). Cardiovascular effects of nicotine. Retrieved October 26, 2020, from https://www.uptodate.com/contents/cardiovascular-effects-of-nicotine?sectionName=SMOKING+AND+CARDIOVASCULAR+RISK

Hartmann-Boyce, J., Mcrobbie, H., Lindson, N., Bullen, C., Begh, R., Theodoulou, A., . . . Hajek, P. (2020). Electronic cigarettes for smoking cessation. Cochrane Database of Systematic Reviews. doi:10.1002/14651858.cd010216.pub4

Historical Timeline of Electronic Cigarettes. (2019, November 18). Retrieved October 28, 2020, from http://www.casaa.org/historical-timeline-of-electronic-cigarettes/

Hollingsworth, H. (2020, August 31). E-cigarette or vaping product use associated lung injury (EVALI). Retrieved October 25, 2020, from https://www.uptodate.com/contents/e-cigarette-or-vaping-product-use-associated-lung-injury-evali?search=vaping

Rigotti, N., & KalKhoran, S. (2020, October 6). Vaping and e-cigarettes. Retrieved October 24, 2020, from https://www.uptodate.com/contents/vaping-and-e-cigarettes?search=vaping

U.S Food and Drug Association. (2020, April 13). Respiratory Illnesses Associated with Use of Vaping Products. Retrieved October 28, 2020, from https://www.fda.gov/news-events/public-health-focus/lung-injuries-associated-use-vaping-products

Takeaways 

• Heart failure has variable symptoms without a uniform presentation, which can make diagnosis difficult.
• Symptoms include dyspnea, fatigue, exercise intolerance, weakness, peripheral edema.
• There is no single diagnostic test, and diagnosis is clinical based.
• Biomarkers, like BNP and NT-proBNP, are more helpful in gauging the severity of an already diagnosed patient as elevations can be the result of other causes.
• All patients with reduced ejection fraction (Stage B) should be placed on ACE inhibitor and beta blocker.

Definition/Clinical Presentation

Heart failure is defined as “a complex clinical syndrome that results from any structural or functional impairment of ventricular filling or ejection of blood” (Colucci, 2019). In other words, the heart is unable to sufficiently pump blood throughout its chambers and/or out of the heart to the entire body. Any condition that weakens or injures the integrity of the cardiovascular system – the heart, the valves, or the vessels – can contribute to the heart’s lacking performance and the body’s subsequent clinical manifestations. This pump failure inadequately supplies the body with necessary oxygen and nutrients, which creates a symptom cascade characterized by fluid overload and reduction of cardiac output (Colucci, 2019). Dyspnea and fatigue are the defining symptoms of the condition but clinical presentations are often variable (Yancy et al., 2013). Other common symptoms include shortness of breath, exercise intolerance, weakness, and peripheral edema (Colucci, 2019). Predisposing factors that may complete the clinical picture include Coronary Artery Disease, Hypertension, cigarette smoking, obesity, and Diabetes Mellitus (Vasan & Wilson, 2020).

Heart failure, without a single, specific diagnostic test, remains a clinical diagnosis, ultimately decided in the exam room (Colucci, 2019). Due to the variability of the presentation, many providers struggle to diagnose and treat this condition.

Classification

In 2013, the American College of Cardiology and American Heart Association (ACCF/AHA) Task Force on Practice Guidelines reviewed the literature to create a set of recommendations (revised in 2016 and 2017) for the diagnosis and treatment of heart failure (Yancy et al., 2013). This task force organized heart failure into 4 progressive stages, starting from at-risk patients without symptoms and without structural injury (Stage A); to patients with structural heart disease without symptoms (Stage B); to patients with structural heart disease with symptoms or history of symptoms (Stage C); and finally to refractory heart failure (stage D) (Armstrong, 2014). Overall, the goal is to decrease risk factors before the disease and then reduce morbidity and mortality after diagnosis (Yancy et al., 2017). In 2016 the Europe Society of Cardiology also released guidelines that complemented these as well.

Initial vs Serial Diagnostic Testing

A detailed history and physical evaluation should be obtained, understanding the patient’s comorbidities and risk factors for heart disease (Yancy et al., 2013). A set of vital signs should be monitored at each visit (Yancy et al., 2013).

Initial laboratory orders should include complete blood count, urinalysis, fasting lipid panel, liver function testing, measurement of serum electrolytes, blood urea nitrogen, measurement of serum creatine, glucose, and TSH (Armstrong, 2014). These should be repeated as clinically indicated throughout treatment.

Biomarker testing, including B-type natriuretic peptide (BNP) or N-terminal pro-B-type natriuretic peptide (NT-proBNP), should be used with limitations and are more useful during the later stages of heart failure when patients are symptomatic (Yancy et al., 2017). These biomarkers can be elevated due to other reasons other than heart failure. Ultimately the 2017 ACCF/AHA revisions found insufficient data to inform population specific screening guidelines related to NT-proBNP and BNP guided therapy (Yancy et al., 2017).

An electrocardiogram, a comprehensive 2-D echocardiogram coupled with Doppler flow studies and transthoracic echocardiogram, and a chest radiography are needed initially (Yancy et al., 2013). The echocardiogram should be repeated as needed to evaluate the ejection fraction and structural remodeling of the heart – usually when there is a change in clinical status or recovery from exacerbation, assessing effect of therapy, or evaluating candidates for new devices (Armstrong, 2014). 

Treatment

STAGE A: The focus should be on preventing heart failure by reducing modifiable risk factors. Clinicians should work to control chronic conditions according to their individual guidelines, especially hypertension, hyperlipidemia, diabetes mellitus, and sleep disorders (Armstrong, 2014/Borlaug, 2019). Lifestyle attributes like tobacco use, obesity, alcohol consumption, and drug use, should be addressed in detail and serially to reduce the risk of heart failure.  (Armstrong, 2014/Borlaug, 2019).

STAGE B: The focus should be continuing to reduce risk factors and maintaining the already damaged structure of the heart. All patients with reduced ejection fraction should be placed on ACE inhibitor and beta blocker to reduce their risk of cardiovascular events (Yancy et al., 2013). ARBs are appropriate substitutes (Armstrong, 2014). Strict control of hypertension according to guidelines and optimizing of lipids with statins is especially important to reduce future risk (Yancy et al, 2017).

Further evaluation by a specialist may be considered at this stage, and especially if the patient has a recent history of cardiovascular event. However, it should be noted by all clinicians that nondihydropyridine calcium channel blockers with negative inotropic effects may be harmful in asymptomatic patients with low left ventricular ejection fraction after an MI (Armstrong, 2014).

STAGE C: The interventions are focused on symptom management through pharmacologic and nonpharmacologic interventions. Patients will likely need to be followed by a specialist. However, diuretics should be used for fluid overload symptoms and the appropriate monitoring will need to be coordinated (Yancy et al., 2017). Other medications, like aldosterone receptor antagonist, digoxin, anticoagulants, etc. are discussed in this stage. Implantable cardiac devices become an option as well.

Most importantly, patients should understand their symptoms and how to monitor their status. It should be stressed to observe their weight fluctuations, restrict their sodium intake (<3g/day), medical adherence, and stay physically active (Yancy et al., 2013).

STAGE D:  This stage incorporates patients who experience persistently severe symptoms and often called “end stage HF” or “advanced HF”. The focus is on improving the patient’s quality of life (Yancy et al., 2013). Treatment strategies are very specialized and complex, even experimental at times. (Yancy et al., 2013). These advanced therapies include mechanical circulatory support, cardiac transplantation, etc. 

More Information

What is Heart Failure?

Heart Failure | cdc.gov

Heart Failure | NHLBI, NIH

Heart Failure: Understanding Heart Failure Management and Treatment

References

Armstrong, C. (2014, August 01). ACCF and AHA Release Guidelines on the Management of Heart Failure. Retrieved October 10, 2020, from https://www.aafp.org/afp/2014/0801/p186.html

Borlaug, B. A. (2019, March 05). Clinical manifestations and diagnosis of heart failure with preserved ejection fraction. Retrieved October 10, 2020, from https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-heart-failure-with-preserved-ejection-fraction?search=heart+failure+diagnosis

Colucci, W. S. (2019, July 17). Evaluation of the patient with suspected heart failure (986750469 763432333 S. S. Gottlieb, Ed.). Retrieved October 10, 2020, from https://www.uptodate.com/contents/evaluation-of-the-patient-with-suspected-heart-failure?search=heart+failure+symptoms

Vasan, R. S., & Wilson, P. W. (2020, May 05). Epidemiology and causes of heart failure. Retrieved October 10, 2020, from https://www.uptodate.com/contents/epidemiology-and-causes-of-heart-failure?search=heart+failure

Yancy, C. W., Jessup, M., Bozkurt, B., Butler, J., Casey, D. E., Drazner, M. H., . . . Wilkoff, B. L. (2013). 2013 ACCF/AHA Guideline for the Management of Heart Failure. Journal of the American College of Cardiology, 62(16), 147-239. doi:10.1016/j.jacc.2013.05.019

Yancy, C. W., Jessup, M., Bozkurt, B., Butler, J., Casey, D. E., Colvin, M. M., . . . Westlake, C. (2017). 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure. Journal of Cardiac Failure, 23(8), 628-651. doi:10.1016/j.cardfail.2017.04.014

Takeaways

• Many teens are taking advantage of today’s newfound technological availability by being online at a near constant basis, connecting with friends on social media, utilizing search engines for information, and pursuing various forms of entertainment.
• This frequent use of the internet and social media may actually have very deleterious effects on a youth’s mental health.
• By utilizing remote video conferencing, online communication, and other technologies to aid in the treatment of mental illnesses, healthcare providers can use a teenager’s already overwhelming online presence to reduce barriers and improve health outcomes.

Adolescence: Growing Up One Tap At A Time

Today’s social climate – that in which adolescents must grow from their cherubic naïveté into a healthy minded young adult – has drastically changed due to the recent technology boom of the 21st century. Social media platforms like Snapchat, Youtube, and Instagram allow adolescents to interact with one another instantaneously and constantly. In a 2018 survey by the Pew Research Institute, 44% of teenagers reported going online several times a day and 45% of respondents admitted to being online “almost constantly” (Anderson & Jiang, 2018). This means that in 2018, almost 9 out of 10 adolescents were online multiple times a day, accessing social media sites, search engines, and/or “gaming” (Anderson & Jiang, 2018). Interestingly, this same 2018 survey demonstrated that teenagers are not aligned in their views of how social media has affected their journey to adulthood. In fact, 45% felt social media had neither a positive nor negative effect on their lives (Anderson & Jiang, 2018).

However, the increasing prevalence of mental illness in adolescents may tell a different story. Multiple qualitative and quantitative studies have shed more light on this topic.

Mental Health: Emerging Trends in Mental Illness and Technology

Adolescents are now at risk for feeling isolated and being openly rejected by their peers at any time of the day or night and on multiple different platforms with recent technological advancements. Feeling acceptance by peers and finding connectedness is an important aspect of adolescence which makes teenagers especially vulnerable to the negative impacts of technology (Mir, Novas, & Seymour, 2020). While causation has not been confirmed, there is research to support the correlation between the rise of social media sites and the increase of mental illnesses in adolescents (Mir, Novas, & Seymour, 2020). The overuse of social media can lead to sleep deprivation, online harassment, cyberbullying, and formation of distracting habits, all of which can further increase the risk for mental illness in an already vulnerable population (Hagan, Shaw, & Duncan, 2017).

Treatment: Can You Hear Me Now?

What can be done to aid the teens in these tumultuous times? Since 95% of people between the ages of 13 to 17 own a smartphone or have access to one, the solution lies in the problem: utilizing technology (Anderson & Jiang, 2018). Healthcare providers can gain new modalities of communication and novel ways to support adolescents from afar. Most computers and smartphones include video technology which means real time video conferencing, known as telehealth, is an accessible, relatively inexpensive option for treatment (Magnavita, 2018).

In fact, adolescents want technology involved in their healthcare. A Canadian study found that many adolescents reported a preference for telehealth and other alternative delivering strategies when accessing mental health services (Boydell et al, 2014). Another recent study found that adolescents actually prefer the use of technology – like email or texting – for communication in between visits as well (Radovic, 2017). A video conference or web based interaction can eliminate many barriers to seeking mental health services, like organizing travel logistics and overcoming the unease of a clinic setting. In this way, technology can create a comforting, open visit environment that empowers the teenager to take control of their illness – essentials to a successful outcome (Boydell et al, 2014).

Outcomes

In 2013, the Agency of Healthcare Research and Quality and the National Health Institute of Mental Health coordinated an expert panel to analyze mental health behavioral intervention technologies (Mohr, Burns, Schueller, Clarke, & Kinkman). The results supported web based interventions in the use of treating a broad range of mental health illnesses and encouraged the use of video conferencing (Mohr et al., 2013). Overall, the panel concluded that “virtual reality has shown good efficacy for anxiety and pediatric disorders”(Mohr et al., 2013, p. 1). The American Academy of Child and Adolescent Psychiatry argues that telehealth may even be more effective when treating ADHD and other severe mood disorders in children when an otherwise unavailable specialist would become an option (2017).        

Research: Are Apps the Future?

There is still much to explore about this new virtual field. The National Institute of Mental Health is investigating how to improve mental health treatment with the use of smartphone apps (2019). With the development of a “crisis center” app, adolescents are able to connect immediately and find aid with just a single tap of a finger (NIMH, 2019). Also working to avoid poor outcomes altogether, the NIMH is showing promise with passive symptom tracking apps that can predict mood episodes, like mania or depression spells, by analyzing the activity on phones (NIMH, 2019). In creating these apps, the negative effects often associated with mental illness exacerbations may be mitigated by early identification and subsequent attention from a healthcare provider. 

Interested in Learning More?

NIMH » Technology and the Future of Mental Health Treatment

NIMH » A BRIGHT Technological Future for Mental Health Trials

Social Media and Health Care Professionals: Benefits, Risks, and Best Practices

Using social media to engage adolescents and young adults with their health

Clinical Report—The Impact of Social Media on Children, Adolescents, and Families abstract

References

The American Academy of Child and Adolescent Psychiatry (AACAP) (2017, June). Delivery of Child and Adolescent Psychiatry Services Through Telepsychiatry. Retrieved September 29, 2020, from https://www.aacap.org/AACAP/Policy_Statements/2017/Delivery_of_Child_and_Adolescent_Psychiatry_Services_Through_Telepsychiatry.aspx

Anderson, M., & Jiang, J. (2018, May 31). Teens, Social Media & Technology 2018. Retrieved September 29, 2020, from https://www.pewresearch.org/internet/2018/05/31/teens-social-media-technology-2018/

Boydell, K. M., Hodgins, M., Pignatiello, A., Teshima, J., Edwards, H., & Willis, D. (2014). Using technology to deliver mental health services to children and youth: a scoping review. Journal of the Canadian Academy of Child and Adolescent Psychiatry = Journal de l’Academie canadienne de psychiatrie de l’enfant et de l’adolescent, 23(2), 87–99.

Hagan, J. F., Shaw, J. S., & Duncan, P. M. (2017). Promoting the Health and Safe Use of Social Media. In Bright futures: Guidelines for health supervision of infants, children, and adolescents (pp. 229-234). Elk Grove Village, IL, IL: Bright Futures/American Academy of Pediatrics.

Magnavita, J. J. (2018). How Can Technology Advance Mental Health Treatment? [Introduction]. In Using Technology in Mental Health Practice (pp. 3-10). Washington, DC, DC: American Psychological Association. doi:https://doi.org/10.1037/0000085-001

Mir, E., Novas, C., & Seymour, M., PhD. (2020, August 21). Social Media and Adolescents’ and Young Adults’ Mental Health. Retrieved September 29, 2020, from https://www.center4research.org/social-media-affects-mental-health

Mohr, D. C., Burns, M. N., Schueller, S. M., Clarke, G., & Klinkman, M. (2013). Behavioral intervention technologies: evidence review and recommendations for future research in mental health. General hospital psychiatry, 35(4), 332–338. https://doi.org/10.1016/j.genhosppsych.2013.03.008

The National Institute of Mental Health (2019, September). Technology and the Future of Mental Health Treatment. Retrieved September 29, 2020, from https://www.nimh.nih.gov/health/topics/technology-and-the-future-of-mental-health-treatment/index.shtml

Radovic, A., McCarty, C. A., Katzman, K., & Richardson, L. P. (2018). Adolescents’ Perspectives on Using Technology for Health: Qualitative Study. JMIR pediatrics and parenting, 1(1), e2. https://doi.org/10.2196/pediatrics.8677

Take Away Points

• Patients respond differently to therapeutic interventions based on genetic variations found across populations
• Genomic medicine has a potential role to reduce adverse drug reactions and improve medication efficacy
• With over 200 medications that are affected by genetic variations, the benefits of genomic medicine touch many different specialties and can have huge implications across healthcare

What is Genomic Medicine?

Genomic Medicine refers to a growing field of medicine that consists of using genomic information to influence medical decision making, clinical care, and how this affects health outcomes. An important component of this emerging field is the pharmacogenetics of medication. This is the study of how individuals respond differently to medications or drugs based on their genetic makeup.

In a time where treatment guidelines are developed from focusing on entire populations with big data research, the idea that we may base clinical decision making from an individual’s genetic makeup seems out of place in the exam room. However, this is far from the truth. “According to a US Food and Drug Administration (FDA) report from 2013, an astounding 38–75% of patients who have a common disease do not respond to treatment” (Zhang et al 2019). In addressing these treatment failures, genomic medicine could have great implications on improving quality of life and decreasing the ever-growing cost of healthcare.

Cytochrome P450 Genetic Variation and Prescribing Medications

Cytochrome P450, a group of enzymes that are responsible for the metabolism of medications and expressed according to genotypes, may be a key player in decreasing adverse drug reactions. In understanding the way patients metabolize drugs differently, we may be able to predict reactions and avoid adverse events. For instance, the FDA has recommended that HLA testing be performed prior to initiating carbamazepine, given as a first line treatment for epilepsy. The HLA genotype is associated with an increased risk for Stevens Johnson Syndrome/Toxic Epidermal Necrolysis, as well as other adverse effects from carbamazepine (Dean, 2015). Another way genetic variation can affect clinical practice is when selecting antiplatelet medications. Researchers have discovered different CYP2C19 genotypes, and each genotype metabolizes clopidogrel at different speeds (Lynch, 2007). By understanding which genotype confers poor versus intermediate versus “normal” metabolization of clopidogrel, clinicians can predict which antiplatelet medication may be more or less effective.

Drug selection may become more informed and subsequent outcomes may improve with this type of decision making. Furthermore, by using genetic variation to influence drug development and selection, adverse drug reactions, currently responsible for 7-14% of hospitalizations, may be decreased and avoided altogether (Center for Drug Evaluation and Research, 2018). From warfarin to fluoxetine, the FDA has identified over 200 medications that may be affected by genetic variation and may warrant genetic testing prior to initiation in the future (Center for Drug Evaluation and Research, 2020). It is not inconceivable to believe that genetic testing will be the norm prior to selecting any medication.

Implications for the Future

Drug selection just scratches the surface for the future of genomic medicine. No matter the specialty, genomic medicine is finding a foothold. The National Human Genome Research Institute is conducting research on how genetic variation can affect oncology, metabolic, cardiovascular, and infectious treatment plans (Accomplishments in Genomic Medicine, 2018). In allowing clinicians to predict outcomes based on objective information (our DNA), genomic medicine holds promise in improving therapeutic responses to treatments and increasing the efficacy and safety of our treatments.

Interested in Learning More?

NIH National Institute of General Medical Sciences – “Pharmacogenenomics”

NIH U.S. Library of Medicine – “What is Pharmacogenomics?”

NIH National Human Genome Research Institute – “Genomics and Medicine”

FDA U.S. Food & Drug Administration – “Table of Pharmacogenomic Biomarkers in Drug Labeling”

REFERENCES

Accomplishments in Genomic Medicine. (2020, July 29). Retrieved September 01, 2020, from https://www.genome.gov/health/Genomics-and-Medicine/accomplishments

Center for Drug Evaluation and Research. (2018, March 06). Preventable Adverse Drug Reactions: A Focus on Drug Interactions. Retrieved September 01, 2020, from https://www.fda.gov/drugs/drug-interactions-labeling/preventable-adverse-drug-reactions-focus-drug-interactions

Center for Drug Evaluation and Research. (2020, August 18). Table of Pharmacogenomic Biomarkers. Retrieved September 01, 2020, from https://www.fda.gov/drugs/science-and-research-drugs/table-pharmacogenomic-biomarkers-drug-labeling

Dean, L. (2015). Carbamazepine Therapy and HLA Genotype. Medical Genetics Summaries [Internet]. doi:https://www.ncbi.nlm.nih.gov/books/NBK321445/

Zhang, H., Klareskog, L., Matussek, A., Pfister, S. M., & Benson, M. (2019). Translating genomic medicine to the clinic: Challenges and opportunities. Genome Medicine, 11(1). doi:https://genomemedicine.biomedcentral.com/articles/10.1186/s13073-019-0622-1

Lynch T, Price A. (2007). The effect of cytochrome P450 metabolism on drug response, interactions, and adverse effect. American Fam Physician, 76(3):391-396.

Take Away Points

• Vulvovaginitis affects many women throughout their lifetime and the availability of over-the-counter treatments may lead to self-diagnosis or delays in care.
• The approach to treating the causes of vulvovaginitis should be comprehensive.
• The three most common causes of vaginitis symptoms include vulvovaginal candidiasis, bacterial vaginosis, and trichomoniasis.
• Effective and approved treatments recommended for vulvovaginitis should be selected based on identification of the etiology.

Approach To Treatment

Many women will seek medical care at some point in their lives with symptoms of vulvovaginitis. Caused by inflammation, disruption in normal bacterial flora, or infection with a new pathogen, symptoms of vulvovaginitis can include pruritis, odor, abnormal discharge, and pain.  Symptoms alone are insufficient in determining the cause of vulvovaginitis, and widely available over-the-counter treatments can lead to self-diagnosis and delays in receiving proper treatment.¹ With that in mind, let’s take this opportunity to review the approach to treatment for vulvovaginitis.

What causes vulvovaginitis?

The three most common causes of vaginitis include vulvovaginal candidiasis, bacterial vaginosis, and trichomoniasis.  Other etiologies include sexually transmitted infections, autoimmune conditions, hormonal shifts, and allergic reactions.  Some symptoms of these conditions may overlap, which is why the approach to vulvovaginitis must include a thorough history, a physical examination, and proper laboratory testing.¹ Recurrent symptoms and/or symptoms unresponsive to treatment warrant a referral to a gynecologic specialist.

Vulvovaginal Candidiasis

Vulvovaginal candidiasis, most commonly caused by candida albicans, may also be caused by other fungal organisms including candida krusei or candida glabrata. Vulvovaginal candidiasis accounts for approximately 20-25% of vulvovaginitis cases.⁴  Approved over-the-counter antifungal treatments are widely available and include several topical creams and suppositories with varying concentrations and treatment lengths.  Oral and vaginal treatment options have been found to be equally efficacious in uncomplicated cases.⁴  The following table presents examples of available treatment options.

Considerations should be made when treating vulvovaginal candidiasis such as avoiding fluconazole during pregnancy especially during the first trimester, and considering use with topical “azoles” for 7 days, instead.³  Patients should be reminded that the oil-based topical treatments may weaken barrier contraceptives including condoms and diaphragms.  Sex partners are typically not infected and often do not require treatment.¹

Bacterial Vaginosis

Bacterial vaginosis, considered a polymicrobial infection, occurs when the proliferation of anaerobic bacteria in the vagina displace Lactobacillus species.  This environment is unable to support the hydrogen peroxide and normal organic acids that normally thrive within the vaginal flora.⁴  Identified organisms commonly associated with bacterial vaginosis include: Gardnerella vaginalis, Mycoplasma hominis, Ureaplasma, Prevotella species, and Mobiluncus species.^1,4  Bacterial vaginosis accounts for an estimated 40-50% of cases presenting with symptoms related to vaginal discharge.⁵

Diagnosis of bacterial vaginosis is made on the basis of Positive Amsel’s Criteria, where an individual must have at least three out of the four criteria: (1) thin, white, yellow homogenous discharge; (2) clue cells on wet mount microscopy; (3) a vaginal pH of >4.5; and (4) positive whiff test, or release of a fishy odor when 10% potassium hydroxide (KOH) is added to wet mount.³

The Bacterial Vaginosis in Adults/Adolescents: 2015 CDC STD Guidelines recommend the following regimens for the treatment of bacterial vaginosis.²

• Metronidazole 500 mg PO bid x7 days
• Metronidazole gel 0.75%, insert 5 grams intravaginally qd x 5 days
• Clindamycin 2% cream, insert 5 grams intravaginally qhs x 7 days

For those unable to complete the first-line treatments, alternative regimens have been identified.¹  Patients should be counseled on the avoidance of alcohol during and up to 72 hours after completing treatment with metronidazole.¹  While the routine treatment of sexual partners is not recommended, women should refrain from sexual intercourse during the treatment course of bacterial vaginosis.¹

Bacterial vaginosis may affect up to 20% of pregnant women.  Despite its high incidence, the U.S. Preventive Services Task Force (USPSTF) does not recommend routine screening as there is conflicting evidence of its impact on the risk of preterm delivery.⁷

Treating bacterial vaginosis is paramount as it lowers vulnerability to trichomoniasis, C. trachomatis, N. gonorrhoeae, HIV, and HSVII.¹ Additionally, testing for sexually transmitted infection, including HIV, is recommended in the standard management of patients with bacterial vaginosis.

Trichomoniasis

Trichomoniasis is a protozoal infection caused by trichomonas vaginalis (T. vaginalis) and is the most common nonviral sexually transmitted infection in the world.⁶  Its incidence increases one’s chance of acquiring HIV by 2-3 fold.¹ The treatment recommended for trichomoniasis is a single-dose nitroimidazole.  Either metronidazole 2 grams orally in a single dose or tinidazole 2 grams orally in a single dose are preferred but if these are not tolerated or if the individual is pregnant, metronidazole may be given as 500 mg twice daily for 7 days.¹ Again, patients should be counseled on the avoidance of alcohol during and up to 72 hours after treatment completion.  Sexual partners should be treated and sexual intercourse avoided until both sexual partners have completed treatment.  Follow-up testing is recommended for all women 3 months following the initial treatment.¹

For more information:

The American College of Obstetricians and Gynecologists (ACOG) – “Vaginitis”

CDC 2015 Sexually Transmitted Diseases Treatment Guidelines – “Diseases Characterized by Vaginal Discharge”

Paladine HL, Desai UA. Vaginitis: Diagnosis and Treatment. Am Fam Physician. 2018;97(5):321-329.

References:

1. Diseases Characterized by Vaginal Discharge – 2015 STD Treatment Guidelines. (2015, June 4). https://www.cdc.gov/std/tg2015/vaginal-discharge.htm.
2. Bacterial Vaginosis in Adults/Adolescents: 2015 CDC STD Guidelines | epocrates Guideline Synopsis.
3. Colonna, C. (2020, July 13). Amsel Criteria. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK542319/.
4. Paladine HL, Desai UA. Vaginitis: Diagnosis and Treatment. Am Fam Physician. 2018;97(5):321-329.
5. Sobel, J. D. (2020, May 26). Bacterial vaginosis: Treatment. (R. L. Barbieri & K. Eckler, Eds.). https://www.uptodate.com/contents/bacterial-vaginosis-treatment?search=bacterial vaginosis&source=search_result&selectedTitle=1~108&usage_type=default&display_rank=1.
6. Sobel, J. D. (2020, June 30). Trichomoniasis. (R. L. Barbieri & K. Eckler, Eds.). https://www.uptodate.com/contents/trichomoniasis?search=trichomoniasis&source=search_result&selectedTitle=1~87&usage_type=default&display_rank=1.
7. Hainer BL, Gibson MV. Vaginitis. Am Fam Physician. 2011;83(7):807-815.

COVID-19 remains center stage, and efforts to contain it endanger our focus on other conditions, including obesity, which is known to lead to many serious, life-threatening co-morbidities.

• Obesity is defined by a BMI of ≥30Kg/m² and abdominal obesity is defined by a waist circumference of ≥40 in. for men and ≥35 in. for women. Both BMI and waist circumference may vary according to racial norms.
• 33% of adults and 17% of adolescents and children in the US are clinically obese.
• Causative factors include genetic inheritance, culture and environment, socioeconomic status, some medications, and long illness or injury recuperations, among others.
• Diet and exercise are essential components of treatment:

• • • Caloric intake of 1000-1200 kcal/day for women and 1200-1500 kcal/day for men
    • Initially, a low carbohydrate diet, followed at about 6 months with a high protein/low carbohydrate diet
    • Activity: 30 minutes a day, 5 days a week. Moderate activity such as walking, bicycling on level ground, and swimming are recommended, with level of difficulty and duration increased as tolerated

• Adjunct psychological therapies, either web-based or in-office consultations can be effective in treating causes and challenges of an obesity diagnosis
• Medications that have been shown to be effective are:

• • • Orlistat, 60 mg PO TID
    • Phentermine/topiramate combination, initial 14-day dose 3.75 mg (phentermine)/23 mg (topiramate)PO QD, then 7.5 mg/46 mg PO QD for 12 weeks. If weight loss is ≤3% of baseline, discontinue or escalate as follows:
      • • 11.25 mg/69 mg PO QD x14 days, then 15 mg/92 mg PO QD for 10 more weeks. If     weight loss is ≤5% after 12 weeks, discontinue.
        • Maintenance dose is 7.5mg Phentermine/46 mg Topiramate or 15 mg/92 mg PO QD
    • Liraglutide: escalated doses initially 0.6 mg SQ QD; add 0.6 mg weekly until the maintenance dose of 3 mg SQ QD is reached
    • Naltrexone/bupropion HCl combination: 8 mg (naltrexone)/90 mg (bupropion) PO QD initially, increased to maintenance dose of 16MG/180 mg BID

• Surgery or balloon insertion are appropriate for patients with BMI ≥ 40 and for those with BMI ≥ 35 with co-morbidities.

For more information:

https://www.aace.com/files/obesity/final-appendix.pdf

https://www.rethinkobesity.com/pdfs/aace-guidelines-brochure.html

https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight

https://www.nhlbi.nih.gov/health-pro/guidelines/current/obesity-guidelines/e_textbook/txgd/4142.htm

Article Takeaways:

• There are over 15 known tick-borne diseases in the United States alone. NPs should have a working knowledge of tick-borne illnesses in order to diagnose them quickly and efficiently.
• Lyme Disease is the most common and widely recognized of the tick-borne illnesses. It is crucial for NPs to know how to differentiate between the various stages of Lyme Disease and identify common symptoms, as well as how to identify the process for laboratory testing to screen for and confirm a diagnosis of Lyme Disease. 
• Early treatment is essential for all tick-borne diseases, so prescribing the right medications is the top priority for NPs.

____________________________________________________________________________________________________________

There are over 15 known tick-borne diseases in the United States alone and transmission can happen in as little as five minutes (Center for Disease Control). Due to rising global temperatures and urbanization, among other factors, the tick population continues to grow as does the discovery of lesser known tick-borne diseases (CDC). 

It is crucial for NPs to have a working knowledge of the clinical presentation of tick-borne illnesses at various stages and the diagnostic testing and treatment guidelines recommended for best outcomes. 

Identifying Tick-Borne Disease

Though there are many tick-borne illnesses in the United States, reported cases of Lyme disease, spotted fever rickettsiosis (including Rocky Mountain spotted fever), and Powassan virus disease in particular have steadily increased (CDC). 

Lyme disease is the most common vector-borne disease in the United States. It is caused by the bacterium Borrelia burgdorferi and rarely, Borrelia mayonii, and is transmitted to humans through the bite of infected black-legged ticks. Typical symptoms include fever, headache, fatigue, and the classic erythema migrans rash. If left untreated, the infection can spread to joints, the heart, and the nervous system (CDC).

Blacklegged ticks that carry Lyme disease primarily live in the Northeast, Midwest and Mid-Atlantic states and along the West Coast, so patients in these locations are at a higher risk. And because ticks tend to inhabit wooded areas, those who spend more time outdoors in the spring and summer are more likely to contract the disease. If the tick is not discovered and removed by the patient within 24 hours, their risk of contraction increases.

Blacklegged tick (deer tick)

Rocky Mountain spotted fever (RMSF) is a potentially deadly bacterial disease spread through the bite of an infected tick and is seen only in the Western Hemisphere. Common symptoms include fever, headache, myalgias, and a rash on the palms and soles. The rash will initially consist of small, flat, pink macules that will eventually progress to dark, raised papules. The lesions may develop petechiae. NPs should ask about the history of possible exposure to ticks, as an actual bite may have gone unnoticed (CDC).

Palmar rash from RMSF

Less commonly known, Powassan virus can be extremely dangerous as many people infected do not have symptoms. Even for those experiencing symptoms, onset can range from one week to one month from the time of tick bite. Initial symptoms can include fever, headache, vomiting, and weakness. In severe cases, Powassan virus can cause encephalitis or meningitis. Powassan is deadly 10% of the time and 50% of those who survive have long-term sequelae (CDC). It is most commonly found in the northeast and upper midwest states.

To learn which ticks are prevalent in your geographic location, consult the CDC’s resource here.

As the most common and widely recognized of the tick-borne illnesses, Lyme Disease will be discussed further below. 

History and Clinical Presentation of Lyme Disease

When concerned about Lyme Disease, the NP should ask the patient about the likelihood of exposure to ticks, such as recent time spent in wooded areas, travel to affected areas, or if their pets recently had tick bites. The type and timing of symptoms matters as well. There are three stages of Lyme Disease and the symptoms of these stages may overlap or some patients may not experience all three stages. 

Erythema migrans

The Early Localized Lyme disease stage occurs 1-4 weeks after transmission. patients will commonly complain about flu-like symptoms, including fever, headaches and myalgia, as well as and swollen joints–particularly knees. They may also show general symptoms like chills, fatigue, and swollen lymph nodes. In most cases of Lyme, Erythema migrans (EM) appears as a red macule at the tick bite location and increases in size. 33% of EM lesions develop a central clearing, resembling a bullseye. The lesion may not be a perfect circle, may be warm and painful, and the center could be vesicular, pustular, or necrotic. Most Lyme-related lesions reach a diameter of 5 cm or more and appear one week after the bite (Rebman and Aucott). 

Erythema migrans

If Early Localized Lyme disease goes untreated, the infection can spread through the bloodstream and lymphatic system to the patient’s joints, nervous system, or cardiovascular system. As it spreads, symptoms will worsen and affect more parts of the body over the course of 1-3 months, becoming what is known as Early Disseminated Lyme disease (Bamm et al.). 

If still unrecognized and untreated for more than 4 months, the disease progresses to Late Lyme disease. Symptoms of Late Lyme disease may include: arthritis, numbness and tingling in the hands, feet, or back, extreme fatigue, poor control of facial muscles, problems with memory, mood, or sleep, and sometimes problems speaking, and in some cases, irregular heart rhythms.

Diagnosing Lyme Disease: 2-Step Laboratory Testing

The non-specific symptoms of Lyme Disease may make differentiating it from other illnesses difficult, especially if a tick bite was undetected or the erythema migrans rash misidentified. However, in symptomatic patients with a history of possible tick exposure (hiking, camping, other outdoor activities) or a rapidly appearing and long lasting rash, further testing for Lyme Disease should be considered. Isolating B. burgdorferi via culture or detecting serum antigens has proven difficult and unreliable for diagnosis, therefore current recommendation for diagnosis is a two step process to detect serum antibodies (Murray & Shapiro, 2010). 

The first test is an enzyme-linked immunosorbent assay (ELISA), which is a highly sensitive but not very specific test used to screen for the presence of antibodies against B. burgdorferi. If this test is negative, no further action is needed. If it is positive, a more specific Western Blot is indicated to assess for the presence of antibody “bands” against specific proteins of B. burgdorferi (this can all be done from the same blood sample). In patients with symptoms for less than a month, both IgM and IgG should be evaluated, with 2 of 3 possible bands indicating a positive result. In patients with symptoms lasting longer than one month, only IgG is important, with 5 out of 10 bands indicating disease (Murray & Shapiro, 2010). 

Figure 1 (Marques, 2015)

When used as recommended, this two step process is relatively helpful in diagnosing Lyme Disease, particularly in later stages, however there are potential problems to consider. False positive results are possible, as there may be some cross sensitivity with other antigens. More commonly, a false negative result will occur as the level of antibodies builds over time and may be too minimal to detect in early disease. Because of this, treatment should be started immediately for patients in which there is a strong suspicion of tick-borne illness and providers should not delay treatment while awaiting the appearance of a rash or confirmatory lab results (Marques, 2015).

Treatment of Early and Late Stage Lyme Disease

The Infectious Disease Society of America has guidelines in place for treatment of Lyme Disease based on timing since symptom onset and severity of symptoms. Both Early Localized disease (characterized by EM rash) and Early Disseminated disease (including cranial nerve involvement or carditis) can typically be treated with 14 days of oral doxycycline or amoxicillin. Cefuroxime can be used in patients with allergy to first line treatment. Azithromycin can also be considered for patients with doxycycline or amoxicillin allergy but has been shown to be less effective (Wormser et al, 2006). 

Late Stage disease may respond well to oral antibiotics as well, but for more serious symptoms requiring hospitalization (such as meningitis or complete heart block), intravenous antibiotics may be needed, most commonly ceftriaxone (Wormser et al, 2006). 

Non-steroidal antiinflammatory medications are useful as supportive care, particularly for joint pain (Murray and Shapiro, 2010). 

Table 1 (Wormser et al, 2006) (CDC). 

References: 

1. Bamm VV, Ko JT, Mainprize IL, Sanderson VP, Wills MKB. Lyme Disease Frontiers: Reconciling Borrelia Biology and Clinical Conundrums. Pathogens. 2019;8(4):299. Published 2019 Dec 16. doi:10.3390/pathogens8040299
2. Center for Disease Control and Prevention. (2017). Tick-borne disease of the United States: A reference manual for healthcare providers, 4th ed. Retrieved from: https://www.cdc.gov/lyme/resources/TickborneDiseases.pdf
3. Center for Disease Control and Prevention. Research on doxycycline and tooth staining. Retrieved from: https://www.cdc.gov/rmsf/doxycycline/index.html
4. Gluckman, S. (2017). Rocky mountain spotted fever (and other tick-borne diseases). The Clinical Advisor. Retrieved from: https://www.clinicaladvisor.com/home/decision-support-in-medicine/critical-care-medicine/rocky-mountain-spotted-fever-and-other-tick-borne-diseases/
5. Marques A. R. (2015). Laboratory diagnosis of Lyme disease: advances and challenges. Infectious disease clinics of North America, 29(2), 295–307. https://doi.org/10.1016/j.idc.2015.02.005 
6. Moore, Karen S. (2014), Lyme Disease: Diagnosis, Treatment Guidelines, and Controversy, The Journal for Nurse Practitioners, DOI: https://doi.org/10.1016/j.nurpra.2014.09.021
7. Murray, T. S., & Shapiro, E. D. (2010). Lyme disease. Clinics in laboratory medicine, 30(1), 311–328. https://doi.org/10.1016/j.cll.2010.01.003 
8. Rebman AW, Aucott JN. Post-treatment Lyme Disease as a Model for Persistent Symptoms in Lyme Disease. Front Med (Lausanne). 2020;7:57. Published 2020 Feb 25. doi:10.3389/fmed.2020.00057  
9. Wormser GP, Dattwyler RJ, Shapiro ED, et al. The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America [published correction appears in Clin Infect Dis. 2007 Oct 1;45(7):941]. Clin Infect Dis. 2006;43(9):1089-1134. https://doi.org/10.1086/508667 

It’s July and summertime activities are at hand. Cookouts, pool parties, summer camps, trips to the beach and road trips are usually the norm this time of year. With COVID-19 now part of our lives, what does the new normal look like for summer? Activities that wouldn’t have required a thought about safety now present challenges. As healthcare providers you know the importance of continuing to adhere to the precautions set out by the CDC and other health experts. Social distancing, wearing masks, washing hands frequently, and staying home if you feel sick should all still be practiced during outdoor summertime activities. With just a little planning, these activities can still be enjoyed.

After a long winter spent largely in our homes, many of us need to get outdoors for the sake of our health, both physical and mental. Certain aspects of quarantine like stress, too much time indoors, too few social interactions, and unhealthy coping mechanisms can actually dampen our immune systems. Read more for tips to combat this.

As we’ve seen recently many people across the US are actively refusing to wear masks and social distance. This is unfortunate as we are now seeing spikes in states where businesses reopened earlier than was advised. Some cities are seeing their highest one-day case counts. This resurgence along with a predicted new wave in the fall paints a gloomy picture.

Healthcare workers have been our heroes so far during this crisis, and it looks like that heroism is here to stay for a while. The next stage of heroism may take the form of setting a good example for the rest of us. Front-line workers following preventative guidelines in public while outdoors, as well as educating and reminding patients, can help in improving compliance with state and local orders.

Enjoy the summer and stay safe!