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JUNE/JULY 2022

LONG

C VID Untangling the mysterious complication that’s upending countless lives 10

INSIDE PHARMACIST AND CLINIC COLLABORATION 8 UPDATED PEDIATRIC MILESTONES 20 7 WAYS TO MAXIMIZE YOUR TIME 22

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VOLUME 1 ISSUE 3

JUNE/JULY 2022

COLUMNS 18 FOCUS ON PEDIATRICS LISTEN UP A growing push toward judicious antibiotic stewardship has shifted the first-line treatment approach for pediatric ear infections

20 UPDATED PEDIATRIC MILESTONES The CDC revises its developmental milestones for first time since 2004

COVER STORY

LONG

C VID

22 BEST PRACTICES 7 WAYS TO MAXIMIZE YOUR TIME How to make the most of every day

25 FOCUS ON MEN’S HEALTH ERECTILE DYSFUNCTION

Untangling the mysterious complication that’s upending countless lives

Clinicians need to provide realistic counseling about sex, aging, and cardiovascular health

DEPARTMENTS 4

EDITOR’S NOTE

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GUEST EDITORIAL:

28 CLINICAL CARE:

GASTROENTEROLOGY

GASTROESOPHAGEAL REFLUX DISEASE

CCA AND CCC

How to diagnose and treat this common condition

How the association and the magazine are working together

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31 CLINICAL CARE: DERMATOLOGY

GUEST EDITORIAL:

MANAGING POISON IVY Intense itch, individualized approach

INFORMATION THERAPY The power of clear communication in improving patient care

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GUEST EDITORIAL:

PHARMACIST AND CLINIC COLLABORATION Retail pharmacies can be ideally suited to promote team-based health-care delivery

FEATURE 13 TALKING TO PATIENTS ABOUT COUNTERFEIT DRUGS

33 SUPPLEMENT SPOTLIGHT MULTITASKING MAGNESIUM

Most patients don’t understand the extent of the problem or the risks it poses

This mineral could benefit a wide array of ailments

Convenient Care Clinician is published 5 times a year by EnsembleIQ, 8550 W. Bryn Mawr Ave, Suite 200, Chicago, IL 60631. Subscription rate in the United States: $70 one year; $136 two year; $14 single issue copy; Canada and Mexico: $92 one year; $162 two year; $16 single issue copy; Foreign: $100 one year; $186 two year; $16 single issue copy. Postage paid at Chicago, IL, and additional mailing offices. POSTMASTER: Please send address changes to Convenient Care Clinician, 8550 W. Bryn Mawr Ave, Suite 200, Chicago, IL 60631. Vol. 1 No. 1, February/March 2022. Copyright 2022 by EnsembleIQ. All rights reserved.

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EDITOR’S NOTE

When Politics Clash With Health Care

Carrie Adkins-Ali Executive Editor

Methotrexate (Otrexup, Xatmep, Trexall) is a life-changing drug for many people with lupus, rheumatoid arthritis (RA), inflammatory bowel disease, lymphoma, leukemia, and cancer, but reports are emerging that some women are no longer able to access it. The problem? The overturning of Roe v. Wade.

One of the many uses of methotrexate is to treat patients after an early pregnancy loss, including ectopic pregnancy and miscarriage, which puts it in the crosshairs of states with trigger laws that ban the use of abortifacients. Methotrexate is not prescribed for medical abortion (that combination is mifepristone and misoprostol), but states like Texas have specifically named it as an abortion-inducing drug. Technically, Texas allows the use of the drug for illnesses like RA and lupus, but some pharmacists and health-care providers are avoiding it altogether to avoid any appearance of playing a role in abortion. Texas also has a controversial bill that allows citizens to sue anyone, including a healthcare provider, who aids or abets abortion in any way. “... I can see why people are refusing,” a pharmacist wrote on the Reddit discussion board r/Pharmacy. “If [a registered pharmacist] RPh dispenses and patient is pregnant and RPh does not do their due diligence will the state sue them? Will they win? I spent ~150k on my degree and if I get sued and go to jail or lose my license, will that person or people with lupus pay for me to get another degree? No. So at the end of the day the first person I have to look out for is myself because no one else is looking out for me. … If there is any doubt that it could lead to litigation, it would be a hard no from me.”

Currently, when patients are prescribed methotrexate (as well as many other drugs that can cause fetal abnormalities), they’re told to use two forms of birth control to avoid pregnancy. But politicians in several conservative states have already indicated that they want to limit access to certain types of birth control next, specifically intrauterine devices and levonorgestrel (Plan B). Supreme Court Justice Clarence Thomas’ comment that several rulings, including the one that codified the right to contraception access, should be revisited, has sparked fears that birth control could be banned entirely in some states.

These trends could affect men’s health care, as well. “Although I cannot predict the future, places in the country to pass stricter antiabortion laws are likely to see fewer rheumatologists than other areas,” Nancy Lane, MD, told Healio. A shortage of rheumatologists will affect all patients equally, regardless of sex or beliefs about abortion.

If you have patients who can’t get their methotrexate, direct them to contact the Lupus Foundation of America at access@lupus.org or the American College of Rheumatology at advocacy@rheumatology.org. C

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An EnsembleIQ Publication 8550 W. Bryn Mawr Ave Suite 200 Chicago, IL 60631 Senior Vice President, Publisher John Kenlon (516) 650-2064, jkenlon@ensembleiq.com

EDITORIAL Editor-in-Chief | Editorial Director Nigel F. Maynard nigelmaynard@ensembleiq.com Executive Editor Carrie Adkins-Ali cadkinsali@ensembleiq.com

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EDITORIAL ADVISORY BOARD Nate Bronstein, MSEd, MPA, MSSP, Convenient Care Association Meggen Brown, MSN, FNP-BC, Kroger Health/The Little Clinic Kristene Diggins, DNP, FAANP, MBA, CNE, NEA-BC, CVS Health Tine Hansen-Turton, MGA, JD, FCPP, FAAN, Convenient Care Association Pete Nordeen, Bellin Health/Bellin FastCare Angela Patterson, DNP, FNP-BC, NEA-BC, FAANP, CVS Health Mark R. Watkins, MD, Kroger Health/ The Little Clinic

CORPORATE OFFICERS Chief Executive Officer, Jennifer Litterick Chief Financial Officer, Jane Volland Chief Human Resources Officer, Ann Jadown EVP, Operations, Derek Estey EVP, Content, Joe Territo

JUNE/JULY 2022

7/12/22 10:22 PM

GUEST COLUMN

BY NATHAN A. BRONSTEIN, MSED, MPA, MSSP

CCA and CCC: Mission-Aligned Partners Many readers have been asking, “What is the relationship between The Convenient Care Association (CCA) and the Convenient Care Clinician (CCC) magazine?” The truth is that the CCA has been looking to bring to life a publication for our industry for years. Finally, through a year-long collaboration with the business intelligence company, EnsembleIQ, the CCA helped to found our first of its kind, convenient care industryspecific magazine.

While the CCA does not “own” CCC, the creation of the magazine and e-newsletter now work as something of an extension to the communication efforts of our industry. The

CCC is our exclusive communications partner and is helping to tell our stories and take them further than we ever could on our own.

CCC audience has been steadily growing, but was originally created through specific sign-ups exclusively from the CCA network. We at the CCA also provided the initial content direction and advised the creation of CCC’s vision.

Today, the CCA and CCC leadership serve on one another’s boards, attend one another’s meetings, and both organizations openly share resources to support one another’s completely aligned vision. Both our association and CCC are here to represent the retail health industry and ensure that providers working in clinics are better able to continue to provide accessible, affordable, and high-quality health care to people everywhere.

That is perhaps why you will find our events, opportunities, educational outcomes, and leadership throughout the pages of this publication. Everything from the policy updates and initiatives we’re running behind the scenes, to the Exemplar Provider Award nominations, the new free CME educational opportunities, and more. CCC is our exclusive communications partner and is helping to tell our stories and take them further than we ever could on our own. Along the way, their specialized staff has been able to bring to life even more content and opportunities for everyone in our network as well.

As always, the CCA is here to continue advocating on behalf of the industry. With our partners at the CCC, we’ve never felt more emboldened to do our work. C

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GUEST COLUMN

BY KRISTENE DIGGINS, DNP, FAANP, MBA, CNE, NEA-BC

Information Therapy The power of clear communication in improving patient care As clinicians, one of the most significant values we can bring to patient care is information sharing.

In fact, I once worked with someone who said that our job was to provide “information therapy” to our patients.

Informed patients are powerful patients who can make enlightened choices based on the information they are given.1 And yet, I have also seen the detriment that too much information can have on patients.

Information Overload Thanks to modern technology and social networking, patients have access to an overwhelming amount of information about their symptoms or condition before they even present

to our offices. Patients receive information from health-service providers (hospitals, physicians), expert sources (patient associations, health insurers), and nonexpert sources (family, friends, magazines). A combination of information overload, information similarity, and information ambiguity can lead to patient confusion.1 Despite a wealth of information, much of the general population lacks the opportunity to develop basic health literacy.2 Often, patients depend on clinicians to simplify scientific jargon, provide reassurance, and clarify the essential details of their care. The way we communicate important information to our patients plays a vital role in determining health outcomes.3 Clinicians’ communication skills are critical in building strong therapeutic

Despite a wealth of information, much of the general population lacks the opportunity to develop basic health literacy.

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GUEST COLUMN

BY MIKE CLARK, POLICY DIRECTOR, CCA

Tips to Improve Communication • •

• • •

• • • •

Listen to patients and don’t interrupt when they’re speaking.

Encourage and answer questions. Instead of asking, “Do you have any questions?” try, “What questions do you have?”

Speak at a moderate pace.

Keep sentences short and stay on one topic at a time.

Use simple language, and avoid jargon or medical terminology (e.g., “high blood pressure” vs. “hypertension”).

Be specific and concrete.

Limit information to three to five key points.

Consider using simple illustrations to clarify concepts.

Ask patients to repeat important information back to you.

recommendations from providers can help reduce stress, improve health outcomes, and increase patient satisfaction.1 At the same time, we must also ensure that communication is a collaborative endeavor that allows the patient to be an active participant in their own care. Effective information sharing requires consideration of each individual patient’s needs.

As I consider this problem, I think about a young boy I was able to care for in Africa who’d had HIV from birth. When I attempted to share the side effects of his medication, he looked at me with big-eyed wonder. He then asked me, through an interpreter, to review again how to take the medication.

Evidently, my detailed review of his condition had prevented him from getting the most essential information: how to take his medication correctly.

When I focused only on how to take the medication, I saw the look of relief on his face. The boy had a big grin as I reviewed the steps clearly and concisely. Afterward, he quickly gathered his medication and left, skipping along the dirt path back toward his school.

Our patients depend on us to have the intuition needed to support them in their decision-making process, one visit at a time. Full disclosure is key to ensuring our patients can give their informed consent to care, but we must also appreciate that relaying important information to our patients requires an intuitive, dynamic approach tailored to each specific case. C

relationships, which are predictors of patient recovery and satisfaction.4 All clinicians must be able to provide appropriate counsel and facilitate the exchange of essential information with patients. If we aren’t careful, the way we share information can indirectly increase patient confusion and lead to greater misinformation.5 Simplify the Message Often, my patients will ask me to just tell them what they need to do to proceed with their care. There is direct evidence that clear

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REFERENCES 1. Gebele C, Tscheulin DK, Lindenmeier J, Drevs F, Seemann AK. Applying the concept of consumer confusion to healthcare: development and validation of a patient confusion model. Health Serv Manage Res. 2014;27(1-2):10-21. doi: 10.1177/0951484814546959 2. Klerings I, Weinhandl AS, Thaler KJ. Information overload in healthcare: too much of a good thing? Z Evid Fortbild Qual Gesundhwes. 2015;109(4-5):285-290. doi:10.1016/j. zefq.2015.06.005 3. Dingley C, Daugherty K, Derieg MK, Persing R. Improving patient safety through provider communication strategy enhancements. In: Henriksen K, Battles JB, Keyes MA, Grady ML, eds. Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 3: Performance and Tools).

Agency for Healthcare Research and Quality (US). 2008. https://www.ncbi.nlm.nih.gov/books/NBK43663/ 4. Ha JF, Longnecker N. Doctor-patient communication: a review. Oschner J. 2010;10(1):38-43. https://www.ncbi.nlm. nih.gov/pmc/articles/PMC3096184/ 5. Peters E, Dieckmann N, Dixon A, Hibbard JH, Mertz CK. Less is more in presenting quality information to consumers.

Med Care Res Rev. 2007;64(2):169-190. doi:10.1177/10775587 070640020301

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7/11/22 11:11 PM

GUEST COLUMN

BY CATHY KUHN, PHARMD, BCACP, FAPHA

Pharmacist and Clinic Collaboration Settings like retail pharmacies can be ideally suited to promote team-based, patient-centric, digitally enhanced health-care delivery The current burden on patients and providers in the United States is overwhelming.

Each day brings more news of clinician burnout, provider shortages, and declining reimbursements. The health and wellness of patients also demands a close look. In response to the COVID-19 pandemic, per capita health spending in 2020 rose dramatically above its already high levels while health utilization comparatively plummeted.1 These metrics tell a story of a primary-care system that cannot, under strain, meet the needs of its participants. While the pandemic surely exacerbated these weaknesses, realistically, they have been growing in scope and severity for years. Health innovators have long talked about the necessity of better continuity and connection in delivery systems. But technologies to date have fallen short of the mark, and strategies for more inclusive approaches have yet to bridge the gaps between health professionals and their clinical colleagues, and between health professionals and patients.

Pharmacist and Clinic Collaboration With the influence of the pandemic and increasingly insistent calls for primary-care systems to evolve, there are distinct opportunities for pharmacists to connect with nurse practitioners and physician assistants who practice in convenient care clinics.

The successes and lessons learned from the growth of the clinic industry and related support of its primary clinicians can offer best practices for how to continue to evolve and optimize primary-care accessibility.

With the influence of the pandemic and increasingly insistent calls for primary-care systems to evolve, there are distinct opportunities for pharmacists to connect with nurse practitioners and physician assistants who practice in convenient care clinics.

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7/11/22 11:14 PM

GUEST COLUMN

BY MIKE CLARK, POLICY DIRECTOR, CCA

In the Deloitte Center for Health Solutions’ report, “The Pharmacist of the Future: Unlocking the Profession’s Potential to Improve Care,” the authors identified opportunities for pharmacists to be more systematically involved in multiple areas, including primary care, specialty care, digital health, and population-health analytics.2 They wrote: “If more pharmacists were to operate to the full potential of their professional education and skill sets, they could play an important role in elevating the wellbeing of health care consumers.”

To date, such innovative practice models have not been widely explored or adopted.

The positive interpretation of that lag is that savvy providers will be proactive about integrating pharmacy into their delivery models, capitalizing on the clinical, operational, and financial benefits.

A report prepared by Columbia University Mailman School of Public Health, with support from Express Scripts

Pharmacy, offers complementary conclusions to the cited Deloitte research, including the following statements:3 • “[P]harmacists are trusted to fill more direct patient care gaps, with 77.3% of patient respondents agreeing that the pharmacist is an integral member of the care team.”

• “83.7% of providers whose practice was part of a value-based payment model agreed that pharmacists should be regularly included in multidisciplinary teams that collaborate on patient care.”

When convenient care clinics began to proliferate, they were based on the premise that primary care could be delivered with quality, convenience, and easy access. Adding pharmacist collaboration into that equation further elevates the patient-provider experience. Clinical services that are appropriately coordinated contribute to better health outcomes and reduced costs. Facilitating connected care teams is good for patients, providers, and the health-care system. Settings like retail pharmacies can be ideally suited to promote team-based, patient-centric, digitally enhanced health-care delivery.

Digital Platforms Emerging digital platforms are equipped to begin to bring providers and patients together and provide accessible, actionable health information. Enabling clinical teams to coordinate across those platforms further solidifies efforts to establish continuity of care.

For instance, consider that, as assessed from 2015 to 2018, about 24% of Americans used three or more prescription medications within 30 days of the survey.4 These medications may or may not originate with the same prescribing provider. They are presumably likely to have been filled at the same pharmacy, assuming some level of geographic consistency.

Factor in periodic illnesses or the need for immunizations or over-the-counter interventions.

When that patient visits a convenient care clinic, having a shared clinical relationship from the physician to the nurse practitioner to the pharmacist helps diminish the chance for inappropriate medication interactions, and it smooths the way for patient education about medication adherence or lifestyle modifications. In short, creating pathways for efficient, patient-focused communication between health-care professionals can correlate with better patient outcomes and streamlined care.

Creative, Cooperative Care The constituents of the convenient care industry, who have consistently shown their interest in cooperative, creative problem-solving, are well-positioned to advocate for this level of collaborative health-care delivery. The components are already in place. Patients use and trust retail pharmacies for a range of functions. These centralized, community-based locations offer accessibility in both rural and urban environments. Implementing systems that generate multi-directional communication by, with, and through these qualified healthcare professionals may prove advantageous for all involved. C

REFERENCES 1. Kurani N, Ortaliza J, Wager E, Fox L, Amin K. How has U.S. spending on health care changed over time? Petersen-KFF Health System Tracker. Published February 25, 2022.

Accessed May 23, 2022.

2. Van Antwep G, Bhatt V, Myers G, Elsner N, Shah S. The pharmacist of the future: Unlocking the profession’s potential to improve patient care. Deloitte Insights. Accessed March 28, 2022. https://www2.deloitte.com/us/en/insights/industry/health-care/futureof-pharmacists.html 3. Express Scripts Pharmacy. The prescription of trust: Pharmacists transforming patient care. Accessed May 23, 2022. https://d17f9hu9hnb3ar.cloudfront.net/s3fspublic/2022-01/The%20Prescription%20of%20Trust-FINAL.pdf 4. Therapeutic drug use. U.S. Centers for Disease Control and Prevention. Page last reviewed October 20, 2021. Accessed May 23, 2022. https://www.cdc.gov/nchs/fastats/ drug-use-therapeutic.htm

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7/11/22 11:15 PM

COVER STORY

BY LESLIE GOLDMAN, MPH

LONG

C VID Untangling the mysterious complication that’s upending countless lives

Up to one-third of people who have had COVID-19 still have symptoms weeks—or even months—after their initial exposure to the virus. People with what’s now called long COVID may have started out with only mild symptoms. In some cases, the symptoms of long COVID, officially called post-acute sequelae of SARS-CoV-2 infection, are worse than the symptoms of the initial infection.

There is no consensus on the cause of long COVID, no test to diagnose it, and no known way to treat it other than mitigating the symptoms. Here’s what we do know: Symptoms The World Health Organization (WHO) defines long COVID as an illness occurring in people who have histories of probable or confirmed SARS-CoV-2 infection— usually within three months from the initial onset of COVID-19—with symptoms and effects that last for at least two months and cannot be explained by another diagnosis.1 The WHO lists long COVID symptoms as fatigue, shortness of breath, cognitive dysfunction (difficulty thinking clearly), or any other symptoms that have an impact on everyday functioning. Other common symptoms include cough, joint pain, chest pain, depression, muscle pain, headache, rapid heartbeat, and intermittent fever.

A study published in the Annals of Clinical and Translational Neurology in May reported that most people with long COVID continue to experience symptoms an average of 15 months after disease onset.2 The study only looked at people who had mild initial COVID-19 symptoms and did not need hospitalization.

Overall, there was no significant change in the reported frequencies of most of the symptoms between the first COVID evaluations and their follow-up appointments six to nine months later. For example: • Fatigue: 87% reported occurrence (first evaluation) vs. 81% (follow-up).

• Brain fog: 81% vs. 71%.

• Numbness/ tingling: 69% vs. 65%.

• Headache: 67% vs. 54%.

• Dizziness: 50% vs. 54%.

• Blurred vision: 34% vs. 44%.

• Tinnitus: 33% vs. 42%.

The reported frequencies of heart rate and blood pressure variations (35% vs.

56%) and gastrointestinal symptoms (27% vs. 48%) noticeably increased.

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At a Glance

“We were surprised by the persistence of most of the debilitating neurologic symptoms of our patients and by the late appearance of symptoms that suggest dysfunction of the autonomic nervous system,” Igor Koralnik, MD, chief of neuro-infectious diseases and global neurology at Northwestern Medicine, Chicago, said in a university press release.

Causes There have been many theories about the cause of long COVID-19. A 2021 study in the journal Pathogens found that about 70% of patients with long COVID had reactivated Epstein-Barr virus (EBV) particles in their blood samples. EBV is the virus that causes mononucleosis, but in most people, it causes mild or no symptoms, and it is so common that almost everyone has had the virus. EBV stays in the system and can be reactivated by physical stress, causing symptoms similar to long COVID. The researchers concluded that long COVID could be reactivated EBV.3 Another theory is that some SARS-CoV-2 particles remain in the body after the acute infection has cleared, and they continue to cause inflammation, or they trigger a person’s immune system to become hyperactive, which creates an abnormal immune response causing inflammation.

There might be multiple causes. For example, a hyperactive immune system might trigger reactivation of the EBV virus. Although evidence is mounting for the abnormal immune response theory, the jury is still out.4 On May 24, researchers reported in the Annals of Internal Medicine that diagnostic tests aren’t providing any answers. In a longitudinal study of patients at the NIH Clinical Center, Dr. Sneller’s team administered more than 150 tests but found no evidence of organ damage.5 In this regard, long COVID shows similarities to illnesses such as chronic fatigue syndrome and the post-infection syndromes of certain viral and bacterial infections.6 “It is time to insist on painstaking study and care of survivors of COVID-19,” Aluko A. Hope, MD, MSCE, wrote in response to the study.7 “Without a fuller understanding of pathophysiology and disease course, we must not allow normal objective tests to negate our patients’ subjective experiences.”

Treatment There are no evidence-based guidelines for long COVID yet, so treatment relies on supporting patients and managing symptoms. That means taking time with patients, listening to them, and considering all of their symptoms.

• Some of the most successful treatments are mindbody therapies like yoga, meditation, and focused breathing, notes Joseph D. Zibrak, MD, an assistant professor of medicine at Harvard Medical School’s Beth Israel Deaconess Medical Center and a team member of that institution’s critical illness and COVID-19 survivorship program.

• People who suffer from anxiety or depression due to long COVID may benefit from working with a mental-health-care provider.

• Patients with fatigue and weakness may benefit from balance and gait

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•

•

•

•

People with even mild cases of COVID-19 can experience fatigue, brain fog, dizziness, and more for many months.

•

The average “long-hauler” still has symptoms 15 months after first becoming infected with the coronavirus.

•

There are no evidence-based treatment guidelines for long COVID yet. Treatment is supportive.

training, upper- and lower-body strengthening exercises, and aerobic exercise and reconditioning for improved pulmonary health.

The virus disrupts autonomic nervous system function, which can result in orthostatic intolerance or in difficulty maintaining blood pressure and pulse, according to Jacob Teitelbaum, MD, an internist who’s authored several studies on the treatment of fibromyalgia and chronic fatigue syndrome. Increasing salt and water intake and using medium-pressure compression stockings can help treat orthostatic intolerance, he notes.

Dr. Teitelbaum also suggests that his patients take curcumin to reduce inflammation and low-dose naltrexone to decrease brain fog by addressing a condition called microglial activation.

Patients can also seek further evaluation and treatment based on the organ system potentially impacted by long COVID. For example, consider referring a patient with shortness of breath to a pulmonologist. Alternatively, consider referring patients to a COVID specialty center (see sidebar on next page). C

JUNE/JULY 2022

7/12/22 10:24 PM

COVER STORY

Hospitals and Health Systems with COVID Specialty Centers Alabama • UAB Medicine

• • • • •

• Spaulding Rehabilitation Hospital

California • Cedars-Sinai • Providence St. Jude Medical Center • UCSF Health • UC Davis Health • Pomona Valley Hospital Medical Center Colorado • UCHealth

Minnesota • M Health Fairview Montana • Benefis Health System

Nevada • Renown Health

Florida • University of Miami Health System • Watson Clinic Georgia • Piedmont Healthcare Hawaii • The Queen’s Health System Illinois • UChicago Medicine • Rush University Medical Center • Loyola Medicine • UI Health • Advocate Health Care • Northwestern Medicine • Shirley Ryan AbilityLab • Edward-Elmhurst Health • SIU School of Medicine

Oregon • Oregon Health & Science University Pennsylvania • Penn Medicine • St. Luke’s University Health Network • Temple Health • University of Pittsburgh Medical Center • Allegheny Health Network

Michigan • C.S. Mott Children’s Hospital • Michigan Medicine

New Hampshire • Dartmouth Hitchcock Medical Center

Connecticut • Yale New Haven Hospital • Nuvance Health • Hartford HealthCare

Ohio The MetroHealth System Cleveland Clinic University Hospitals UC Health Ohio State University Wexner Medical Center

Texas • Baylor College of Medicine • UTMB Health • Houston Methodist Hospital • UT Health Virginia • Inova Health System

New Jersey • Deborah Heart and Lung Center • Hackensack Meridian Health • Atlantic Health System • Saint Peter’s Healthcare System New York • Westchester Medical Center • Mount Sinai Health System • Montefiore Medical Center • Ellenville Regional Hospital • NYU Langone Health

Washington, D.C. • George Washington University

Data from Becker’s Hospital Review, February 2022 List is not all-inclusive https://www.beckershospitalreview.com/ patient-safety-outcomes/13-hospitalshealth-systems-that-have-launched-postcovid-19-clinics.html

REFERENCES 1. World Health Organization. A clinical case definition of post COVID19 condition by a Delphi consensus, 6 October 2021. Published October 6, 2021. Accessed May 24, 2022. https://www.who.int/publications/i/item/ WHO-2019-nCoV-Post_COVID-19_condition-Clinical_case_definition-2021.1

Indiana • Parkview Health

2. Ali ST, Kang AK, Patel TR, et al. Evolution of neurologic symptoms in non-hospitalized COVID-19 “long haulers”. Annals of Clinical and Translational Neurology. Published May 24, 2022. Accessed May 24, 2022.doi:10.1002/acn3.51570

Iowa • Mercy Medical Center • University of Iowa Hospitals & Clinics

3. Gold JE, Okyay RA, Licht WE, Hurley DJ. Investigation of long COVID prevalence and its relationship to Epstein-Barr virus reactivation. Pathogens. 2021;10(6):763. Accessed May 24, 2022. doi:10.3390/pathogens10060763

Kansas • University of Kansas Medical Center Kentucky • Norton Children’s Hospital Maryland • University of Maryland Baltimore Washington Medical Center • Johns Hopkins Medicine • Kennedy Krieger Institute Massachusetts • Emerson Hospital

4. Powell A. Hints of a long COVID wave as Omicron fades. Harvard Gazette. Published February 14, 2022. Accessed May 24, 2022. https://news.harvard.edu/gazette/ story/2022/02/harvard-experts-expect-new-wave-of-long-covid-cases/ 5. Sneller MC, Liang CJ, Marques AR, et al. A longitudinal study of COVID-19 sequelae and immunity: baseline findings. Ann Intern Med. Published May 23, 2022. Accessed May 24, 2022. doi:10.7326/M21-4905 6. George J. Despite extensive evaluations, long COVID causes remain unclear. MedPage Today. Published May 23, 2022. Accessed May 24, 2022. https://www.medpagetoday.com/ infectiousdisease/covid19/98885 7. Hope AA. Understanding and improving recovery from COVID-19. Ann Intern Med. Published May 23, 2022. Accessed May 24, 2022. doi:10.7326/M22-1492

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JUNE/JULY 2022

7/11/22 11:17 PM

FEATURE: MEDICATION MATTERS

BY BILL GOTTLIEB

Talking to Patients About Counterfeit Drugs Most patients don’t understand the extent of the problem or the risks it poses The World Health Organization (WHO) estimates that 1% of all medications used by consumers in high-income countries are counterfeit. The United States, despite its rigorous process of drug approval and monitoring, is not immune to this global phenomenon.

“Counterfeit drugs are a widespread problem—a problem more significant than most people realize—globally and in the U.S.,” says Jack Fincham, PhD, RPh, a professor at the Osher

Lifelong Learning Institute at the University of Arizona and dean emeritus of the University of Kansas School of Pharmacy in Tucson, Arizona. In fact, the WHO estimate is probably low, says C. Michael White, PharmD, professor and chair in the department of pharmacy practice at the University of Connecticut School of Pharmacy in Storrs, Connecticut.

Even if the WHO estimate is accurate, it won’t be for long: The worldwide share of counterfeit medications is steadily increasing.

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FEATURE: MEDICATION MATTERS

“Broken supply chains, strong demand for medicines … and limited capacities of law enforcement officials” are all contributing to “illicit trade in fake pharmaceuticals,” according to a report from the Organisation for Economic Co-operation and Development.1 Patients Are Easily Fooled Because it’s such a widespread problem, it’s important to talk to your patients about counterfeit drugs. Research shows that most consumers don’t understand the extent of the problem—and the risk.

For example, in a study published in the Journal of Internet Medical Research, researchers told more than 1,900 people that a neighborhood pharmacy charged $165 for a one-month supply of the fictitious drug Beozine.2 The participants were then directed to two internet pharmacy websites, created for the study, on which the prices were $37.99 and $57.60 for a one-month supply. Both sites had a number of features that the Food and Drug Administration says are red flags for internet drug purchases, including allowing the purchase of prescription drugs without a valid prescription, not having a U.S. licensed pharmacist available to answer questions, offering prices too good to be true, and sending unsolicited email offers.3 The participants were asked to indicate if each site was a good place to buy the drug, on a scale of 0 to 10, with 0 being very bad and 10 being very good. Half of the participants who reviewed the first pharmacy website chose a rating above five, signifying that they judged it a good or very good place to buy the drug. More than 22% said they would recommend the first pharmacy site to family and friends.

“This study shows that you can’t just leave consumers to their own devices and hope they’ll understand the nuances of online pharmacies and counterfeit drugs well enough to make an informed decision,” says Dr. White.

To help your patients minimize the risk of receiving counterfeit drugs, you need to understand the nature and scope of the problem.

At a Glance •

Up to 1% of medications in highincome countries are counterfeit.

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Counterfeit drugs can enter the traditional supply chain and be sold at pharmacies unbeknownst to prescribing doctors, pharmacists, and patients.

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Don’t assume your patients are filling the prescriptions you write in your store’s pharmacy. They might fill them at online pharmacies instead, which are the largest source of counterfeit drugs.

COUNTERFEIT DRUGS ARE A WIDESPREAD PROBLEM—A PROBLEM MORE SIGNIFICANT THAN MOST PEOPLE REALIZE.

What Are Counterfeit Drugs?

It’s relatively easy to define counterfeit money or counterfeit paintings— they’re visual imitations, made to simply look like the real things. But counterfeit medications are much more than mere look-alikes, with the key characteristics of counterfeit drugs falling generally into one or more of six categories, says Dr. Fincham:

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The second, far more common source of counterfeit medications for Americans are rogue online pharmacies.

There are now more than 50,000 of these internet pharmacies—and almost none of them are legitimate businesses.

• Incorrect ingredients.

• Insufficient or inactive ingredients.

• Active ingredients that are different from those described on the package.

• Expiration dates that are past or nonexistent.

• Fake packaging.

• Abnormal levels of impurities.

Targets of counterfeiting include every type of medication—brand name and generic, prescription and over-the-counter. Although any medication can be counterfeited, the most common are high-cost, high-demand medications such as chemotherapeutic drugs, antibiotics, vaccines, erectile dysfunction drugs, weight-loss aids, hormones, analgesics, steroids, antihistamines, antivirals, and antianxiety drugs, says Dr. White.

How Do Counterfeits Reach Consumers?

Fake drugs typically end up the hands of consumers in one of two ways. Counterfeit drugs can enter the traditional supply chain and be sold at pharmacies unbeknownst to the prescribing doctors, the pharmacists, and the patients, says Dr. White. Over the last five years, there were 1,750 such incidents of counterfeit drug entering the traditional supply chain in North America, he says. They included 2 million counterfeit oral contraceptive tablets lacking active ingredients that were intercepted as they were being smuggled into the United States and the recall of 18 million atorvastatin (Lipitor) tablets after the detection of a huge smuggling operation that compromised the Lipitor brand name. “Additionally, patients with breast cancer received counterfeit bevacizumab (Avastin) without any active ingredients, patients with anemia received counterfeit erythrocyte-stimulating drugs without active ingredients, and patients on blood thinners received tainted heparin products that caused anaphylactoid reactions that resulted in more than 80 deaths.”

However, the second, far more common source of counterfeit medications for Americans is rogue online pharmacies. There are now more than 50,000 of these internet pharmacies—and almost none of them are legitimate businesses, says Dr. White. In fact, a study from the National Association of Boards of Pharmacy found that 95.8% of internet pharmacies, which are predominantly based outside of the United States, did not comply with U.S. federal or state regulations.4 But that hasn’t stopped consumers from using them. A 2016 survey by the Kaiser Family Foundation found that 8% of Americans—approximately 19 million people, at the time of the study—obtained prescription drugs from other countries.5 The Allure of Disreputable Internet Pharmacies According to Dr. White, patients could have any number of motives for using an online pharmacy. They might want to get their drug at home rather than at the store, or they might believe that an online drug is more potent or faster acting than what they can get in their area, or simply cheaper.

A study conducted by researchers at Washington University compared people using the narcotic painkiller tramadol (Ultram, ConZip) who obtained it via the traditional physician-pharmacist model to people who purchased the drug though an online no-prescription pharmacy. Of the study participants who used internet pharmacies, “55% … indicated that they did so for reasons related to accessibility of tramadol (eg, their doctor would not prescribe enough, they could not find a doctor who would prescribe it, or there was no other way to get it), 29% … did so for economic purposes

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FEATURE: MEDICATION MATTERS

How to Vet an Online Pharmacy The National Association of Boards of Pharmacy created a website that patients can use to verify whether an online pharmacy is legitimate—that is, whether it requires a valid written prescription from a doctor or other health-care provider, is licensed by a state board of pharmacy, has a pharmacist licensed in the United States available to answer questions, is located in the United States, and can provide a U.S. street address and phone number. The website URL is https://safe. pharmacy/buy-safely/

TARGETS OF COUNTERFEITING INCLUDE EVERY TYPE OF MEDICATION—BRAND NAME AND GENERIC, PRESCRIPTION AND OVER-THE-COUNTER.

(eg, they had no insurance, their medical plan would not cover it, or it was cheaper than other sources), and 16% … did so for other reasons (eg, anonymity or to prevent withdrawals).” 6 How to Talk to a Patient About Counterfeit Drugs There are many factors to consider when discussing counterfeit drugs with patients, including your own understanding of who is at greatest risk of using a counterfeit drug, what the dangers of using counterfeit medications are (see sidebar), and how and why patients might knowingly or unknowingly end up taking fake drugs.

Don’t make any assumptions. First, just because you’re writing one or more prescriptions for a patient, do not assume they’re getting all of their medications through you or through the pharmacist at your store. “They may be bypassing you as a clinician or bypassing the pharmacist,” says Dr. White.

For example, he says, you might be treating a patient for high blood pressure, but the patient is too embarrassed to tell you

that he also has erectile dysfunction, and he’s consequently getting his ED medications through an online pharmacy. Likewise, if you’ve recently stopped writing a patient prescriptions for an opioid painkiller, don’t take it for granted that the patient isn’t now getting those opioids online and ending up with potentially deadly counterfeit drugs.

Ask your patient if they are obtaining any drugs through an online pharmacy. This is not to shame them, but so that you can have a realistic discussion about achieving the best health outcomes.

Explain the telltale sign of a counterfeit drug. A patient might encounter a counterfeit drug at your pharmacy or online, and it’s good for them to understand the signs of a fake. Making counterfeit packaging and pills look real is relatively easy, explains Dr. White, but the coating of a counterfeit capsule can be a giveaway because it’s so hard to replicate. A real capsule drug has a waxy coating that feels smooth when the patient rubs it or puts it in their mouth. A fake capsule drug is unlikely to feel smooth when touched or swallowed. Ask your patient to report any such differences to you so you can alert the pharmacist, says Dr. Fincham.

Warn your patient about “Canadian” online pharmacies. As discussed earlier, almost all online pharmacies are untrustworthy, including pharmacies that claim to be Canadian.

“Many Americans think ‘Canadian’ online pharmacies are legit because Canadian health care is a match for the quality of U.S. health care,” says Dr. White. “But 99% of online pharmacies that say they are based in Canada are not based in Canada,” says Dr. Fincham. “Nor are they sourcing drugs approved for use by Canadian citizens,” adds Dr. White.

Discuss ways to make medications more affordable. To dissuade patients from resorting to using an internet pharmacy, it’s important to address one of the common motivations for doing so: the cost.

“Medications are incredibly expensive, and people are doing whatever they can to take the medications they’ve been prescribed—including using online pharmacies that advertise cheaper prices,” says Dr. Fincham.

“Many patients use online pharmacies because they think it’s the only way they’ll be able to afford their medication,” agrees Dr. White, who points to a study that shows 22% of seniors and 32% of uninsured patients engaged in cost-related medication nonadherence when getting their prescription medications.

Dr. White recommends discussing fiscal options with your patients: • Patient assistance programs, usually sponsored by pharmaceutical companies, allow some uninsured and underinsured people to obtain certain drugs at reduced or no cost if they enroll.

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If they’re currently taking brand-name drugs, they might be able to save money by switching to the generic versions.

In some cases, patients might find the cash price of a medication to be lower than their copay if they were to go through insurance.

When available, combination, two-ingredient products are often less expensive than paying for the two included drugs individually.

Review lower-cost treatment options that might be a little less effective, but that patients are more likely to be able to afford to take over the long-term.

Knowledge is Safety “If consumers were more knowledgeable about the potential risks of purchasing or using drugs procured from rogue pharmacies, they might be less willing to make these purchases,” says Dr. White. “And that’s why all health professionals need to actively tell patients about the dangers of counterfeit drugs during their encounters and direct them to information that explains the risks during patient care visits.”

Dr. Fincham seconds the motion: “It’s crucial to increase consumer awareness of the problems and true negative outcomes of drug counterfeiting.” C

What’s the Harm?

There are many ways counterfeit drugs can harm patients, says Dr. Fincham.

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Less effective medications. For obvious reasons, nearly all counterfeit medications don’t work as advertised. Moreover, if a patient unwittingly takes a fake drug and it doesn’t work, a practitioner might prescribe a different medication that doesn’t work as well as the one the patient was supposed to receive.

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Wasted money. A patient who takes a fake drug has spent money on a product that might be generic rather than brand name, or include smaller amounts of the active ingredient.

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Rebound effects. A patient who unknowingly stops taking a psychoactive drug, such as a benzodiazepine, by taking an ineffective fake drug can experience severe withdrawal symptoms.

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Toxicity. Counterfeit drugs can contain cancer-causing or otherwise toxic chemicals, like heavy metals. They’re also sometimes stored improperly, potentially causing harmful breakdown products to form.

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Death. The ultimate risk presented by counterfeits drugs is death, particularly from drug overdose. A recent study from the Centers for Disease Control and Prevention showed that 13% of overdose deaths from fentanyl—the leading cause of death for adults ages 18 to 45 in the United States—involved counterfeit pills.1

REFERENCES 1. Wilson S. Chair’s note: trade in fake medicines at the time of the COVID-19 pandemic. Summary of webinar: The COVID-19 Pandemic and Illicit Trade in Fake Medicines. June 10, 2020. https://www. oecd.org/gov/illicit-trade/oecd-fake-medicines-webinar-june-10summary-note.pdf 2. Ivanitskaya L, Brookins-Fisher J, O’Boyle I, Vibbert D, Erofeev D, Fulton L. Dirt cheap and without prescription: how susceptible are young US consumers to purchasing drugs from rogue internet pharmacies? J Med Internet Res. 2010;12(2):e11. doi:10.2196/ jmir.1520 3. White CM. Counterfeit drugs: a major issue for vulnerable citizens throughout the world and in the United States. J Am Pharm Assoc. 2021;61(1) e93-e98. doi:10.1016/j.japh.2020.04.020 4. National Association of Boards of Pharmacy. Internet Drug Outlet Identification Program: progress report for state and federal regulators. Published August 2017. Accessed May 23, 2022. https:// nabp.pharmacy/wp-content/uploads/2016/08/Internet-DrugOutlet-Report-August-2017.pdf 5. Kaiser Family Foundation. Kaiser health tracking poll: November 2016. Conducted November 15-21, 2016. https://files.kff.org/ attachment/Kaiser-Health-Tracking-Poll-November-2016-Topline

REFERENCE 1. O’Donnell J, Tanz LJ, Gladden RM, Davis NL, Bitting J. Trends in and characteristics of drug overdose deaths involving illicitly manufactured fentanyls — United States, 2019–2020. Morbidity and Mortality Weekly Report. 2021;70(50):1740-1746. doi:10.15585/ mmwr.mm7050e3

6. Cicero TJ, Ellis MS. Health outcomes in patients using no-prescription online pharmacies to purchase prescription drugs.

J Med Internet Res. 2012;14(6):e174. doi:10.2196/jmir.2236

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FOCUS ON PEDIATRIC: EAR INFECTIONS

BY MAUREEN SALAMON

Listen Up A growing push toward judicious antibiotic stewardship has shifted the first-line treatment approach for pediatric ear infections Acute otitis media—ear infection—is one of the most common illnesses evaluated by pediatric providers. It’s most prevalent in children who are between 3 and 24 months old, according to the American Medical Association.1 Often, an ear infection occurs when a common cold leads to swelling and congestion in the nose, throat, and eustachian tube, hindering normal fluid drainage from the ear. Allergies, bacterial infections, and other triggers can also lead to an ear infection.

The Retail Role When severe ear pain hits, children are often in enough distress to prompt parents to seek an immediate medical evaluation. Retail health clinics are wellpositioned to fit this need, experts say.

“Often, parents can’t get to their primary care provider on the day their child is having symptoms, so the retail clinic is a great, convenient option,” explains Holly Duddy, MS, RN, FNP-C, a family nurse practitioner at a CVS MinuteClinic in Salt Lake City, Utah.

Ashley Watson, MSN, FNP-C, a clinical practice coordinator for Kroger Health in Denver, says she sees many children for ear infection care in her retail clinic. “The diagnosis and treatment can be performed on-site, and we have all the necessary tools to look in the ears and even guide parents to the correct aisle for products for pain,” Watson says. “It’s nice to have one-stop shopping.”

Exam Confirms Diagnosis When combined with fever, ear pain should make you strongly consider the possibility that acute otitis media is the culprit, although “the pain could be many things,” Watson says.

Examining the ear with an otoscope is the diagnostic key. “We’re able to diagnose ear infection from what we see in that

At a Glance

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One of the most common illnesses evaluated by pediatric providers, acute otitis media is most prevalent in children who are between 3 and 24 months old.

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Often, ear infections don’t require antibiotic treatment.

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A child’s ear pain should be addressed and can usually be managed with nonsteroidal anti-inflammatory drugs.

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Ear Infection 911 If a child has any of the following symptoms, an emergency room visit is in order:

scope—whether the ear canal is inflamed, the eardrum is punctured, or if it’s not an infection.” If the ear is infected, you’ll likely see a bulging red eardrum and may see pus behind it or draining from it.

Antibiotic Stewardship The American Academy of Pediatrics (AAP) last revised its treatment guidelines for uncomplicated ear infections occurring in children ages 6 months through 12 years in 2013. The recommendations, which also include more rigorous diagnostic criteria, were intended to lower unnecessary antibiotic use while guiding antibiotic selection and addressing pain relief. But the movement away from automatically treating pediatric ear infections with antibiotics has gained momentum in the last few years, reducing antibiotic prescriptions for this diagnosis by 75%, Watson notes.

Clinicians have focused much more on judicious antibiotic stewardship and accurate prescribing regimens due to AAP leadership, she says, though some parents still mistakenly believe antibiotic treatment is the first-line approach.

“Often, ear infections don’t require antibiotic treatment, and I think that’s the biggest misconception,” Watson says. Indeed, “watch and wait” is now the gold standard approach for pediatric ear infection care.

“For the first 48 hours of ear pain, most retail health clinics are going to recommend watching and waiting, using pain medications to alleviate the child’s discomfort,” Watson explains.

“If ear pain continues with fever, then the gold standard at that point would be prescribing antibiotics, specifically amoxicillin.”

Duddy says her treatment decisions depend on several factors, including the child’s age, the severity of the pain, and the presence or absence of fever. “Am I seeing cardinal signs, such as pus behind the membrane? Is the eardrum red and bulging? Are symptoms bilateral?” Duddy asks. “If the eardrum isn’t necessarily bulging, or if redness is there but it’s milder, ‘watch and wait’ is usually adequate, especially if it’s only one ear involved and there’s no fever.”

OTC and Home Remedies Regardless of whether antibiotic treatment is pursued, the child’s ear pain should be addressed. A wide range of over-thecounter (OTC) and home remedies can work alone or together to fill this need, Watson and Duddy say, with ibuprofen and acetaminophen topping the OTC list.

“We educate parents to rotate the two,” Watson explains.

“They can give ibuprofen every six hours and acetaminophen every four, but we often recommend rotating every four just so the child has adequate pain control.”

“We find that most parents don’t end up needing to use medications more often,” she adds, “but just knowing that they can dose their children more often than they’re used to can give peace of mind.”

Duddy discourages parents from using OTC antihistamines

Fever above 103.9 degrees Fahrenheit.

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Inability to keep down fluids.

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Stiff neck.

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Inability to fully open the jaw.

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Severe pain for which the parent cannot provide relief.

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Parental belief that something serious is wrong with the child.

or decongestants, which “haven’t been proven effective at this point for otitis media,” she notes. However, a saline nasal spray can sometimes help stem nasal secretions and decrease ear pressure. Warm ear compresses can also ease the pain.

When appropriate, Duddy doesn’t hesitate to suggest nonpharmaceutical approaches to parents whose children are in distress. “Distraction can be great. Give the child their favorite toy or let them watch their favorite movie,” she advises. “If it’s a younger child, holding and rocking the child can be soothing.”

And keeping the child upright instead of lying flat can lower intracranial pressure and reduce pain.

But even armed with this information, parents should still be told, for next time, that getting a formal diagnosis is integral to receiving proper pediatric ear-infection care, Watson says.

“The main thing is getting the child in for that evaluation, because there’s a chance the eardrum could rupture from all the swelling,” Watson adds.

Follow-Up Care Typically, a child’s ear pain will begin to ease within two to three days, and a follow-up is required in only a handful of circumstances, according to Watson and Duddy.

“Parents should follow up with their child’s pediatrician if the pain hasn’t improved in 48 to 72 hours,” Watson says, adding that returning to a retail clinic is an option, but “often [retail clinics will] have them go back to their pediatrician.”

Refer to an ear, nose, and throat (ENT) specialist if your otoscope exam reveals polyps inside the child’s ear or you feel further investigation is warranted, she adds.

Duddy says any child with recurrent ear infections should be referred to their pediatrician or an ENT, who may opt to surgically insert tubes into their eardrum to prevent fluid buildup and facilitate airflow. C

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REFERENCE 1. Paul CR, Moreno MA. Acute otitis media. JAMA Pediatr.

2020;174(3):308. doi:10.1001/jamapediatrics.2019.5664

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FOCUS ON PEDIATRIC MILESTONES

BY CAROL GIBSON, DNP, FNP-BC

Updated Pediatric Milestones The CDC revises its developmental milestones for the first time since 2004 Pediatric specialists and providers have made important progress over the past 15 years to quickly identify and treat children with developmental and behavioral disorders. For the first time since 2004, the American Academy of Pediatrics (AAP) and the Centers for Disease Control (CDC) and Prevention have revised the milestones used to identify developmental delays in the pediatric population.

Early Identification, Better Outcomes In a 2020 clinical report on pediatric development in the AAP journal Pediatrics, the authors wrote: “Early identification and intervention for developmental disorders are critical to the well-being of children.”

They went on to explain that said early identification can be achieved through regular developmental surveillance and screening by families and pediatric providers. According to the report, developmental surveillance should take place at every well-child visit and be implemented through use of standardized developmental screening tests. Through use of screening milestone checklists like the ones just revised by the AAP and CDC, children with known high-risk conditions or who have concerning screening results can be referred for early intervention.1 Limitations of Milestone Lists The CDC’s 2004 Learn the Signs, Act Early campaign created developmental surveillance milestone checklists that included warning signs and exhortations for parents and pediatric providers to “act early” when addressing possible delays and concerns.2 The developmental milestone checklists used “average-age” milestones— goals that the 50th percentile (i.e., half) of children were expected to reach at a given time. Many providers and parents using the milestones chose to use a waitand-see approach, which sometimes led to delays in diagnosis and treatment.3

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In a Pediatrics special article detailing the process behind the recent revisions, the authors explained that “[t]ypically, lists of milestones are uncited [and] are based on clinical opinion.” The articles went on: “Moreover, ages specified for individual milestones are inconsistent across sources.” Lists that give a median age at which children should reach a milestone can provide some insight into the behavior and development of an average child, but they can be too vague for many parents and pediatric providers. Notably, since average-age milestones predict what half of all children are expected to achieve by particular points in time, by the same token, they accept half of all children to not yet be at the milestones at the time they’re evaluated. This can lead to delays in the identification and treatment of potential issues.4 Updated Approach Based on the past 15 years of use, three major areas of revision were identified by the CDC and AAP:4 • Criteria for checklists were established to evaluate existing checklists.

• Milestones were expanded from representing the 50th percentile of children to the 25th percentile to ensure most kids can be expected to achieve the milestones by the relevant ages.

• New checklists for the 15- to 30-month range were added to complete the full two-month-to-five-years series of surveillance across early childhood.

Other changes to their milestone guidance include:3 • “Identifying additional social and emotional milestones (e.g., smiles on their own to get your attention, age 4 months).”

• “Removing vague language like ‘may’ or ‘begins’ when referring to certain milestones.”

• “Removing duplicate milestones.”

• “Providing new, open-ended questions to use in discussion with families (e.g., Is there anything that your child does or does not do that concerns you?).”

• “Revising and expanding tips and activities for developmental promotion and early relational health.”

Paul H. Lipkin, MD, FAAP, a member of the AAP Section on Developmental and Behavioral Pediatrics and Council on Children with Disabilities, participated in the revisions. In an AAP press release, he stated: “The earlier a child is identified with a developmental delay the better, as treatment as well as learning interventions can begin. At the same time, we don’t want to cause unnecessary confusion for families or professionals. Revising the guidelines with expertise and data from clinicians in the field accomplishes these goals.”3 C

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At a Glance •

In the past, the CDC’s developmental surveillance milestone checklists used “average-age” milestones— goals that the 50th percentile of children were expected to reach at a given time.

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In newly updated guidelines, those milestones were expanded from representing the 50th percentile of children to the 25th percentile to ensure most kids can be expected to achieve the milestones by the relevant ages.

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New checklists for the 15- to 30-month range have been added to complete the full two-month-to-five-years series of surveillance across early childhood.

REFERENCES 1. Lipkin PH, Macias MM; Council on Children with Disabilities, Section on Developmental and Behavioral Pediatrics. Promoting optimal development: identifying infants and young children with developmental disorders through developmental surveillance and screening. Pediatrics. 2020;145(1):e20193449. doi:10.1542/peds.2019-3449 2. Centers for Disease Control and Prevention.

“Learn the Signs. Act Early.” health education campaign. CDC. Updated July 14, 2020.

Accessed May 23, 2022. https://www.cdc.gov/ ncbddd/actearly/index.html 3. Schering S. CDC, AAP update developmental milestones for surveillance program. AAP News. February 8, 2022. Accessed May 23, 2022. https://publications.aap.org/aapnews/ news/19554/CDC-AAP-update-developmentalmilestones-for 4. Zubler JM, Wiggins LD, Macias MM, et al. Evidence-informed milestones for developmental surveillance tools. Pediatrics.

2022;149(3): e2021052138. doi:10.1542/ peds.2021-052138

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BEST PRACTICES

BY KAREN APPOLD

7 Ways to Maximize Your Time How to make the most of every day Work, family, hobbies, fitness, rest: We are constantly trying to cram the most into every day, with varying degrees of success. While we can’t add more hours to the day, we can use the limited time we do have wisely.

“Think about your time like you do money—as a precious, enormously valuable, and limited resource that needs to be consciously invested for the greatest possible

return,” says Kate Christie, bestselling author and the director and founder of the Time Stylers time-management consultancy in Melbourne, Australia.

So, how can you make the most of your time as a practitioner at a retail clinic? Consider these strategies from clinicians and time-management experts.

1.

Prioritize Tasks Once a week, make a master list of things to complete in the coming week, including any tasks that require periodic deadlines.

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At a Glance •

While we can’t add more hours to the day, we can use the limited time we do have wisely.

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Multitasking is a myth. We can do only one thing well at a time.

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Tools like lists, calendars, and voice recognition software can help improve organization and save time.

are consequences if you don’t meet them,” Christie says. “The other type of deadline is the hard one. Setting your own deadlines is about mind management: You need to be disciplined.”

3.

Revisit your list often to add and prioritize tasks. Next, make a shorter list of tasks for each day. This should include both personal and professional objectives.

“I keep a list with me as a reminder of what to focus on in between patient encounters,” says Kristene Diggins, DNP, MBA, FAANP, clinical trials lead preceptor at a CVS Health MinuteClinic. Between patients, you might want to fit in some work-related or personal tasks from your list.

2.

Set Deadlines Parkinson’s Law is an economic theory that states that a task will expand to fill the time available for its completion.

“If you have a month to complete a task, it will take a month to do it,” Christie explains. “If you have a week, you’ll finish it in a week. If you don’t have a deadline, a task won’t get done.

Set deadlines for every task you perform.”

There are two types of deadlines: those that are externally imposed—given by your boss or a client—and those that you set for yourself.

“Externally imposed deadlines are easy to meet because there

Stop Multitasking Multitasking, the act of trying to force your brain to perform two or more tasks simultaneously, doesn’t work. “In fact, the ability to successfully multitask is possessed by less than 2.5% of the human race,” Christie says.

Trying to multitask is like serving two masters: “Neither gets 100% of your concentration, which decreases your efficiency and the quality of your work,” says Marsha Egan, CPCU, CSP, PCC, chief executive officer of the Egan Group, a workplace productivity consultancy in Nantucket, Massachusetts. “Focus 100% on a selected task, even if it’s just for a few minutes.”

Whenever possible, delegate. “Reassigning tasks is an effective way to not only expand your impact but also train other people in your organization so they can handle more tasks,” Egan says.

4.

Eliminate Distractions Interruptions are a huge waste of time. “Once interrupted, it can take up to 23 minutes to refocus on the task you were interrupted from,” Christie says. While interruptions can’t be eliminated, you should consider turning off digital distractions such as the dings, pings, and flashes of email and text notifications whenever you can.

Marguerite Galindo, DNP, FNP-C, director of education at a MinuteClinic in Gilbert, Arizona, says that when she learns of a personal matter that will require her attention while at work, she writes it down for later. “This allows me to put it out of my mind and know that I won’t forget about it,” she explains, freeing her to focus on her professional work.

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BEST PRACTICES

The Power of “No” Every time someone asks you to do something, there’s an associated opportunity cost. “Your time is money, and if you take something on, you will need to forego something else,” Christie says. “It can be hard to turn down a request for help because many of us are simply programmed to want to help.”

Kousek recommends using one of these responses if you’re unable to or simply don’t want to say “yes” to a request: •

“I wish I could, but I don’t have time.”

•

“Thanks for thinking of me, but I’m unable to.”

•

“Sorry, but that’s not something I do.”

•

“It’s a good idea, but I’m afraid I will have to pass for now.”

5.

Take Advantage of Technology The right tools, apps, and software can allow you to do a lot more in less time. When you think of something that you need to do later, grab your smartphone and email yourself or add a reminder to your calendar, says Susan Kousek, owner of Balanced Spaces LLC, a professional organizing company in Reston, Virginia. To save time, experiment with using the dictation feature on your smartphone for notes, calendar entries, emails, and the like. “The more you use [the dictation feature], the easier it becomes,” she adds.

Dr. Galindo uses a laptop and two additional monitors, which allows her to increase her efficiency by studying multiple windows at once. She uses Microsoft Outlook’s calendar functionality to set deadlines and reminders.

Using cloud-based file-sharing applications like Microsoft OneDrive, she can share documents with her team and view them simultaneously.

Meaghan Gasparri, MSN, FNP-C, a family nurse practitioner at a MinuteClinic in North Smithfield, Rhode Island, strives to use technology to its greatest capacity, especially her practice’s electronic medical record system. “Creating templates to document common treatment plans and physical assessments is a timesaver,” she says.

6.

Evaluate Your Use of Time We all have ebbs and flows of energy. For a morning person, a task that may take 10 minutes in the morning may take 30 if done at the end of the day. Identify when you have the most energy and concentration and plan to perform energy-consuming tasks then, says Kousek. Conversely, plan easier or more relaxing tasks for when you have a lull in energy.

Both at home and in the clinic, if you consistently run out of time, track how you’re using it to see which tasks are taking too long. “If, for example, patient visits often go overtime, think about ways to keep people on topic, such as by making your questions for them focused,” says Kousek.

7.

Schedule Time for Yourself Your brain is not designed to work without rest and recovery. The brain consumes about 20% of the body’s calories. That energy needs to be replenished, and your brain needs to rest.

Current research indicates that the best type of break is when you completely shift your focus from the task at hand to a short activity that boosts positive emotions: meditating, going for a walk, sitting in the sun or under a tree, or daydreaming.

If your schedule doesn’t allow for regular breaks, seize a short break when you can, says Christie. Stepping away from a task for even two or three minutes will improve your productivity and decrease your error rate.

To take time to reset, Gasparri might close her door after seeing a patient or get lunch somewhere other than the clinic’s lunchroom to escape her work environment. “When I leave at the end of the day, oftentimes I haven’t completed every item on my to-do list; however, because I prioritize and delegate tasks, I can determine an end to my workday,” she says. C

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FOCUS ON MEN’S HEALTH

BY BILL GOTTLIEB

Erectile Dysfunction Clinicians need to provide realistic counseling about sex, aging, and cardiovascular health By age 50, half of all men experience erectile dysfunction (ED)—the inability to reliably achieve and maintain an erection sufficient for intercourse.

Younger men are affected, too: A study in The

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Journal of Sexual Medicine found that 26% of men showing up at the doctor’s office with ED as their primary complaint were under the age of 40.1 The pandemic may be increasing those percentages.

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FOCUS ON MEN’S HEALTH

BY BILL GOTTLIEB

At a Glance •

ED medications work 65% to 85% of the time—not 100%.

•

Cialis, a long-lasting erection medication, is often the best choice for couples.

•

A flexible approach to sexual intimacy can alleviate performance anxiety and improve the experience for all involved.

A study in the February 2022 issue of Sexual Medicine analyzed health data from more than 460,000 men, with and without COVID-19, and found that those who had been infected were 20% more likely to develop ED.2 “Clinicians should consider evaluating erectile dysfunction among men with recent COVID-19 diagnoses and counsel them regarding the risk of developing erectile dysfunction,” the researchers concluded.2 More Than a Pill No matter a patient’s age or COVID-19 status, the treatment for ED is straightforward, right? Just prescribe a phosphodiesterase 5 inhibitor, such as sildenafil (Viagra), vardenafil (Levitra), or tadalafil (Cialis), and your patient will go away happy. Well, that might not be the case.

“While many men have been helped by an erection medication, many others have been disappointed,” says Barry W. McCarthy, PhD, a clinical psychologist, marriage and sex therapist, professor of psychology at American University, and author of more than 20 books on sexuality, including Coping with Erectile Dysfunction: How to Regain Confidence & Enjoy Great Sex. That’s because ED medications work 65% to 85% of the time—not 100%, Dr. McCarthy says. In fact, that unrealistic expectation is a main reason men stop using ED medication.

Further, ED medications will not return patients to the erections of their youth—another common but mistaken belief.

Setting Realistic Expectations Along with prescribing an ED medication, Dr. McCarthy recommends that clinicians provide realistic counseling about sex and aging, covering the following points with patients: Aging affects erections. “There’s a reason there are so few older athletes in competitive sports like basketball, baseball, and football—a man’s body no longer functions with the power and precision it did when he was in his teens and 20s,” says Dr. McCarthy.

“By the age of 50, a man requires direct stimulation to have an erection … Not getting a predictable, spontaneous erection 100% of the time doesn’t mean a man can’t have great sex any more than he should stop playing basketball just because he can’t play like he did when he was in his 20s. He simply has to play with a different kind of style.”

An older man’s erection often goes away and returns—and that’s perfectly normal. During a sexual occasion, an older man’s erection is likely to come and go. That’s only a problem if he thinks it is and considers sex a pass-fail test that he’s failing.

“Knowing that an erection that has gone away will return

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FOCUS ON MEN’S HEALTH

BY BILL GOTTLIEB

again is the best way to fight panic about losing an erection,” says Dr. McCarthy. “It gives a man some control over his experience. It lets a man feel confident that if he relaxes and receives stimulation, his erection is likely to return.”

Develop flexible scenarios with sexual partners. Even if the erection doesn’t return—or occur in the first place—it’s not the end of the world. The patient should develop a flexible scenario for his sexual occasions, says Dr. McCarthy. “If intercourse doesn’t happen, rather than apologizing or panicking, the patient should transition to erotic non-intercourse or sensual cuddling.” Taking this approach, he adds, means the patient will probably have a lot more sex into his 50s and well beyond.

“Sex isn’t about passing or failing the ‘intercourse test,’” emphasizes Dr. McCarthy. “It’s about giving and receiving pleasure. That might include intercourse and orgasms—and it might not.”

Let partners choose the moment of penetration. Most men who take erection medication think that as soon as they get an erection, they should use it.

“That is absolutely the wrong strategy,” says Dr. McCarthy.

“If a man lets his partner decide on the moment of penetration, it removes performance anxiety, a major reason for ED.” For long-lasting success, patients should bring their sexual partners to the clinic. This can be a difficult request to make, but it’s an important one: There is a lot of evidence that ED is more successfully treated when couples work on the problem together, Dr. McCarthy says. The most important point to make when both partners are in the room: ED is not any partner’s fault, nor is it caused by a lack of attraction. The main cause is performance anxiety, he adds. And the best way to get over performance anxiety is to approach sex with the “flexible,” “good enough” approaches described above. C

ED May Signify Health Concerns “The real benefit of ED medications is that it brings men to the doctor,” says Stephen Lamm, MD, medical director of the Preston Robert Tisch Center for Men’s Health at NYU Langone Health. “Women go to a clinician much more than men—but ED is important to men, and a reason why they will actually see a clinician.”

That visit is an opportunity for you to make a big difference in a man’s life, because the sexual issue that brought the patient to your door is just a component of overall health and wellness.

“You can’t separate the penis from the rest of the body,” says Dr. Lamm. “A man’s erection is the single best indicator of his overall wellness—because an erection requires healthy blood vessels, healthy nerves, and healthy hormones.

“When a man’s erection wavers,” Dr. Lamm says, “it’s often the earliest sign of compromised health— particularly the health of a man’s blood vessels.

For example, clinicians need to be aware that ED is an early-warning indicator of any underlying cardiovascular problems that may be developing.”

In fact, a five-year study in the journal Circulation found that, compared with men who didn’t have ED, men with ED were far more likely to have a heart attack or stroke, be hospitalized for heart failure, and die of cardiovascular disease.3

REFERENCES 1. Capogrosso P, Colicchia M, Ventimiglia E, et al. One patient out of four with newly diagnosed erectile dysfunction is a young man—worrisome picture from the everyday clinical practice.

J Sex Med. 2013;10(7):1833-1841. doi:10.1111/jsm.12179 2. Chu KY, Nackeeran S, Horodyski L, Masterson TA, Ramasamy R. COVID-19 infection is associated with new onset erectile dysfunction: insights from a national registry. Sex Med. 2022;10(1):100478. doi:10.1016/j.esxm.2021.100478

“Does the man have underlying cardiovascular disease, neurological problems, or metabolic problems?” asks Dr. Lamm. “Well, this is the opportunity to find out—and not just give the man a prescription for Viagra.”

By addressing problems such as high blood pressure and high cholesterol, you’ll likely be giving your patient many more years of life in addition to addressing his sexual concerns.

3. Uddin SMI, Mirbolouk M, Dardari Z, et al. Erectile dysfunction as an independent predictor of future cardiovascular events: the multi-ethnic study of atherosclerosis. Circulation.

2018;138(5):540-542. doi:10.1161/CIRCULATIONAHA.118.033990

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CLINICAL CARE: GASTROENTEROLOGY

BY MAUREEN SALAMON

Gastroesophageal Reflux Disease How to diagnose and treat this common condition Gastroesophageal reflux disease affects approximately one in five Americans and is one of the most commonly diagnosed digestive conditions in the United States.1 GERD strikes when the lower esophageal sphincter—a band of muscle around the bottom of the esophagus—weakens, allowing food and stomach acid to flow backward. Inflammation of the esophageal lining follows, and patients can experience heartburn, chest pain, difficulty swallowing, regurgitation,

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chronic cough, tooth decay, laryngitis, and new or worsening asthma.

Patients Head to Retail Health In many cases, a retail health clinic is a GERD patient’s first point of access to health care, experts say.

“Especially since the pandemic, it’s more of a challenge for patients to get into their primary care provider,” says Connie Deeter, MS, FNP, a nurse practitioner at CVS MinuteClinic in

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Springfield, Missouri. “They don’t want a long wait time, so I think patients are coming in more savvy and learning more about the ease of access through retail health clinics.”

Emily Mathews, MS, FNP-BC, a clinical practice coordinator with Kroger Health in Waterville, Ohio, sees her fair share of GERD patients as well.

“Some may have that constant feeling of heartburn and wonder: Is it serious? Should I see my primary care provider?” Mathews explains. “When they struggle with it for weeks or months and can’t get into their PCP for an appointment, they may decide to go to a retail health clinic.”

Diagnosis To begin the diagnostic process, Mathews says she records the patient’s clinical history, performs a physical exam, and inquires about symptoms that are specifically characteristic of GERD, such as worsening heartburn after eating, lying down, or bending forward. Deeter recommends asking how long any such potential GERD symptoms have persisted and what alleviates or aggravates them.

Some GERD symptoms, such as chest pain, are also common symptoms of far more serious conditions like heart problems, so it’s important to be alert to a possible emergent situation. Similarly, fever, projectile vomiting, or worsening abdominal pain should all be swiftly evaluated.

“One of the things we do really well in retail health is being a front line for patient evaluation. We have to make that determination: Is this more of an urgent or emergent care situation? Are they having chest pain? It’s one of the top things to rule out,” Deeter says. When necessary, don’t hesitate to reach out to a collaborating physician or direct patients to urgent or emergent care.

At a Glance •

GERD is one of the most commonly diagnosed digestive conditions in the United States.

•

For the vast majority of patients with GERD symptoms, an overthe-counter proton pump inhibitor can combine both diagnosis and treatment.

•

Some GERD symptoms, such as chest pain, are also common symptoms of far more serious conditions like heart problems, so it’s important to be alert to a possible emergent situation.

One of the things we do really well in retail health is being a front line for patient evaluation.

Some GERD symptoms, such as chest pain, are also common symptoms of far more serious conditions like heart problems, so it’s important to be alert to a possible emergent situation.

Treatment The vast majority of patients with GERD-like symptoms, however, are likely to indeed have the condition. For them, treating symptoms with over-thecounter proton pump inhibitors (PPIs) to reduce stomach acid production is a way to combine both diagnosis and treatment, Mathews says. Appropriate medications for adults include omeprazole (Prilosec), lansoprazole (Prevacid), and esomeprazole (Nexium). For children, calcium carbonate (Tums) is usually effective. Start patients with clear signs of GERD on an eight-week trial of a PPI, Matthews says.

“There isn’t really additional testing or treatments, and it’s beneficial for

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CLINICAL CARE: GASTROENTEROLOGY

BY MAUREEN SALAMON

patients because they can start with something that’s over-thecounter and low cost,” Matthews says.

If OTC products don’t alleviate GERD symptoms after eight weeks, try a prescription-strength PPI such as pantoprazole (Protonix). If patients develop new or worsening symptoms during that eight-week period, have them follow-up with their PCP or return to the retail clinic. Mathews suggests retail clinicians collaborate with the patient’s PCP. “It’s something we do on a daily basis,” Mathews says, adding that her clinic sends a “visit note” to PCPs for every patient who reports having one. “We want to be a great augmentation of primary care. We have that convenience factor, but we still want their PCP to be their PCP.”

When patients struggle with GERD for weeks or months and can’t get into their PCP for an appointment, they may decide to go to a retail health clinic.

Vigilance Needed While up to 70% of GERD cases are nonerosive,2 the condition has significant potential to lead to Barrett’s esophagus—cell changes in the esophageal lining that can turn cancerous—or to erosive esophagitis. That’s why stubborn cases of GERD should be referred to a gastroenterologist for further testing and tailored treatment.

“A lot of patients don’t realize or understand the true seriousness of [GERD],” says Deeter, elaborating that “longterm complications can develop.” C

REFERENCES 1. El-Serag HB, Sweet S, Winchester CC, Dent J. Update on the epidemiology of gastroesophageal reflux disease: a systematic review. Gut. 2014;63(6):871–880. doi:10.1136/ gutjnl-2012-304269

Lifestyle Modifications Some basic lifestyle modifications can help manage GERD. The American College of Gastroenterology offers several suggestions for people afflicted with the condition: • When sleeping, elevate the head of the bed or use a wedge under the upper body.

• Refrain from eating within two to three hours of bedtime—especially high-fat foods.

• Avoid common heartburn triggers, such as chocolate, caffeine, alcohol, and spicy foods.

• If body mass index is 25 or greater or there is a recent history of weight gain, lose weight.

• Stop tobacco use, if applicable.

Sometimes, however, patients come to a retail health clinic because they’ve already tried and failed to alleviate their GERD symptoms with diet and lifestyle changes.

“Some say they’re already using a wedge to elevate the head of the bed or they’re drinking milk to reduce acid,” Deeter explains. “We’re often the next step for them.” If patients have exhausted the possibilities afforded by lifestyle modifications, consider starting them on eightweek trials of over-the-counter proton pump inhibitors.

Other patients protest that they can’t just eliminate certain habits, regardless of how they might contribute to GERD symptoms. Mathews and Deeter counsel those patients accordingly.

“If they can’t give up that first morning coffee, tell them to drink it while upright and know they might have more symptoms right after,” Mathews says. “Make sure patients are aware of their triggers. I think patients are usually receptive to making small life changes.”

2. Patel D, Fass R, Vaezi M. Untangling nonerosive reflux disease from functional heartburn. Clin Gastroenterol Hepatol.

2021;19(7):1314–1326. doi:10.1016/j.cgh.2020.03.057

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CLINICAL CARE: DERMATOLOGY

BY MAUREEN SALAMON

Managing Poison Ivy Intense itch, individualized approach Even before you examine patients with poison ivy, they’re often easy to spot as they wander down store aisles: They’re laser-focused on finding something— anything—that might stop their incessant itching. That’s precisely what makes a retail clinic the ideal next stop for those with this ubiquitous skin rash, experts say.

Poison ivy, poison sumac, and poison oak cause allergic reactions in as many as 50 million Americans each year, according to the American Skin Association.1 About 85% of people are allergic to the plants, making it the most common allergic reaction in the United States, with 10% to 15% of allergic people experiencing severe reactions.1 In fact, so many people have had an itchy run-in with poison ivy that many patients seeking care in retail clinics already know what’s ailing them based on past experiences.

“In the spring, summer and fall, we see an enormous amount of poison ivy in a retail health setting,” reports Megan Hart, APRN, CPC, a clinical practice

At a Glance •

Poison ivy, poison sumac, and poison oak cause allergic reactions in as many as 50 million Americans each year.

•

Prescription steroid creams, such as triamcinolone, can be effective if only small areas of skin are affected, but oral or injectable steroids may be needed for widespread rash.

•

Secondary skin infections are the primary complication of poison ivy.

coordinator for Kroger Health in Versailles, Kentucky. “[T]hey come in not necessarily to confirm the diagnosis, but to say: ‘I’m itching so bad: Please help me.’”

Some patients may also find it too difficult to secure an appointment for poison ivy care at a busy primary care practice, points out R. Brent Holman, MSN, APRN, FNP-C, a nurse practitioner at CVS Health MinuteClinic in Greenville, South Carolina.

“If they see that a retail clinic is available, they might decide then and there to get their rash checked out,” Holman says. “We’re set up in the community to meet these needs.”

A Straightforward Diagnosis The intense itching that brings patients into retail clinics to begin with is typically accompanied by additional, equally conspicuous symptoms, making a poison ivy rash a straightforward diagnosis. Frequently sharing accounts of recent gardening or farm work, patients will display skin that’s red and angry and often swollen, marked with fluidfilled blisters in a line or streak-like pattern, Hart and Holman say.

Patients so-afflicted have not necessarily ignored the hard-learned mantra, “leaves of three, let it be.” While poison ivy’s telltale rash—triggered by a colorless, odorless substance in its sap called urushiol—can develop hours or days after someone’s skin makes contact with the plant, urushiol and its attendant rash is just as easily transmitted via pet fur, tools, garden gloves, or any other materials that’ve come in contact with poison ivy.

“A lot of the diagnosis is listening to their backstory and history of how their rash came to be,” Hart explains. “I’ll ask them questions about what they’ve eaten or if they’ve taken anything in order to rule out other conditions.”

“Mostly it’s the presentation of the

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CLINICAL CARE: DERMATOLOGY

BY MAUREEN SALAMON

Myth-Buster Despite what many people believe, the fluid that weeps from poison ivy blisters isn’t contagious, so it’s incapable of spreading the rash to other parts of the body or to other people.

rash,” she continues. “Poison ivy has a very prominent, vesicular, blistery appearance that tends to show up in areas of exposed skin such as the lower legs, forearms, and hands, though we do see it quite a bit on the face.”

A Range of Treatments By the time they begin searching for an OTC product to soothe their itch, poison ivy patients often require more than non-prescription remedies to make a dent in their symptoms.

“OTC products don’t usually give great benefits,” Holman explains. “Many times, patients come to us past the point when the symptoms are tolerable for them, so they’re really looking for relief.”

“If they’re coming to us, they’re usually pretty far into the course of the rash,” Hart concurs. “The vesicles have already broken out or they have weeping blisters. They’re generally pretty miserable when they get to us.”

Because of this, Hart often opts for first-line treatment with a course of oral prednisone. Holman frequently does the same, depending on the amount of skin covered by the poison ivy rash and whether especially vulnerable areas, such as the face, groin, or neck, are compromised.

Prescription steroid creams, such as triamcinolone (Aristocort), can also be effective if only smaller areas of skin are affected, “but if it’s more diffuse, with legs and arms covered, we’ll tend toward a 15-day course of oral steroid treatment or injectable steroids,” Hart explains.

That doesn’t mean that OTC remedies are completely useless for poison ivy care. A wide array potentially offer a mild reprieve, including hydrocortisone cream, calamine lotion, and oatmeal bath salts.1 Antihistamine Options Antihistamines are a perennial OTC favorite for irksome ailments, but their efficacy in treating poison ivy rash is limited.

Antihistamines such as diphenhydramine might cause drowsiness, allowing poison ivy patients to ignore their itch while sleeping, but don’t actually target the itch itself since it’s not histamine-based, Holman says.

“Some oral antihistamines like Zyrtec can sometimes help with kids to reduce poison ivy itch, but they’re not generally seen to be as beneficial as older antihistamines such as Benadryl or chlorpheniramine,” he adds.

Scratching and Skin Infection Unchecked, the infamous scratching that accompanies poison ivy rash can lead to more serious problems, including skin infections.

While some amount of scratching is likely unavoidable, it’s important to work with patients to minimize it. Hart recommends that patients who’re struggling with scratching cover itchy skin with calamine lotion and dry dressings.

“I tell patients if they’ve got a pretty large area that’s blistered or

However, urushiol, the rash-inducing oily substance secreted by the poison ivy plant, “can actually stay on clothes for more than a year,” says R. Brent Holman, MSN, APRN, FNP-C, a nurse practitioner at CVS Health MinuteClinic in Greenville, South Carolina.

“Someone who’s gardening should remove their clothing when they come indoors and immediately put it in the washing machine, not the hamper. If they grabbed those unwashed clothes again, they could potentially re-expose themselves to the oil.”

weeping, to keep it covered until it crusts over, because that’s prime time to scratch and get a secondary infection,” she adds.

Indeed, secondary skin infections are the primary complication of poison ivy, Hart and Holman caution. Watch for fever and swollen, pus-filled skin lesions beyond the typical vesicle drainage.

Additionally, keep an eye out for clues like dirty fingernails that could be carrying bacteria to the site of the potential infection.

If you suspect a skin infection, oral antibiotics are the firstline treatment approach since topical antibiotic creams are often ineffective in such cases, Holman and Hart say.

A Note of Caution With most retail clinicians highly familiar with poison ivy and its remedies, it’s worth noting that treatment approaches largely haven’t changed much over the years. “Most clinicians see poison ivy so often, you stick with what works,” Hart says.

Likewise, most cases of poison ivy are so routine as to require no follow-up. But you should still be alert to red flags indicating that patients might require referral or even urgent care. Rarely, patients might develop shortness of breath or cellulitis, Holman says.

Additionally, “if any poison ivy develops on the face and there’s concern it’s headed toward the eye, that needs to be evaluated since it can get in the eye,” Holman explains. “A retail clinician can send the patient to an ophthalmologist if they need any further care or follow-up.” C

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REFERENCE 1. Poison ivy, sumac and oak. American Skin Association. https://www.americanskin.org/resource/poisonivy.php

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SUPPLEMENT SPOTLIGHT

BY BILL GOTTLIEB

Multitasking Magnesium This mineral could benefit a wide array of ailments “Magnesium is a remarkable mineral that doesn’t get anywhere near the credit it deserves for preventing and treating disease,” says Mary Ann Block, DO, founder and medical director of the Block Center in Fort Worth, Texas.

Magnesium is a cofactor in 80% of the body’s metabolic activities, including fundamentals such as energy production, blood sugar regulation, maintenance of electrolyte balance,

muscle function, nerve function, protein synthesis, and DNA and RNA synthesis, says Andrea Rosanoff, PhD, director of research and science information outreach at the Center for Magnesium Education and Research in Pahoa, Hawaii. Research suggests that low magnesium levels are linked to hypertension, cardiovascular disease, and Type 2 diabetes.

Hypertension Nearly half of all American adults have high blood pressure, which is the No. 1 risk factor for heart attack and stroke. In a paper

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SUPPLEMENT SPOTLIGHT

BY BILL GOTTLIEB

published in the American Journal of Clinical Nutrition, Dr. Rosanoff and her colleagues analyzed 11 studies on high blood pressure that, together, examined over 500 people with prediabetes, insulin resistance, or noncommunicable chronic diseases. They found that people who took a magnesium supplement (365 to 450 mg daily) had a significant reduction in both systolic and diastolic blood pressure: a mean of 4.18 mm Hg systolic and 2.27 mm Hg diastolic.1 Cardiovascular Disease Magnesium can help prevent cardiovascular disease, says Dr. Rosanoff. In a study that she helped conduct, people at high risk for magnesium deficiency were also found to be at an increased risk for cardiovascular disease.2 Additionally, the study linked low levels of magnesium to systemic inflammation—a risk factor for cardiovascular disease and many other chronic diseases, according to a 2019 paper published in Nature Medicine.3 Diabetes Some research suggests higher magnesium intakes might be associated with improved blood sugar regulation. In an analysis published in the British Journal of Nutrition on January 20, 2022, researchers reviewed the results of 18 studies on magnesium and blood sugar levels. They determined that “oral [magnesium] supplementation could have an effect on glycaemic control in [Type 2 diabetes mellitus] patients,” but cautioned that “the clinical trials so far are not sufficient to make guidelines for clinical practice.”4 In an analysis in the Journal of Human Nutrition and Dietetics, researchers found that magnesium supplementation had a favorable effect on cardiovascular risk factors associated with Type 2 diabetes, particularly among people with magnesium deficiency. They concluded: “Magnesium supplementation may decrease the risk [of Type 2 diabetes] associated cardiovascular diseases, although future large RCTs are needed for making robust guidelines for clinical practice.”5 Other Health Problems Perhaps due to the role magnesium plays in many systems and organs, some studies suggest that it might help with a range of other ailments, though the data is often inconclusive: Insomnia. In a 2021 analysis of past studies, researchers determined that people who took magnesium supplements fell asleep faster and slept longer, though they cautioned that all of the trials they analyzed “were at moderate-to-high risk of bias and outcomes were supported by low to very low quality of evidence.”6 Migraines. A cross-sectional analysis published in Headache reviewed health data from more than 3,600 people and found that people who had higher magnesium intakes had a lower risk of experiencing migraines.7 Nonalcoholic fatty liver disease. In a study published in the European Journal of Nutrition, scientists from Columbia University examined 25 years of health data from 2,685 people and found that people in the top quintile of magnesium intakes were 55% less likely to develop the disease than people in the lowest intake quintile.8 Stress. In a study published in the journal Stress and Health, people who had low magnesium levels and were under severe stress but were otherwise

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At a Glance •

Magnesium is a cofactor in 80% of the body’s metabolic activities, including fundamentals such as energy production, blood sugar regulation, maintenance of electrolyte balance, muscle function, nerve function, protein synthesis, and DNA and RNA synthesis.

•

Research suggests that low magnesium levels are linked to hypertension, cardiovascular disease, and Type 2 diabetes.

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Magnesium deficiency is uncommon, occurring in less than 2% of the population, but suboptimal intake is very common.

healthy took 300 mg of magnesium a day for eight weeks. Anxiety and depression scores significantly improved among the participants. “Magnesium supplementation … could provide a meaningful clinical benefit in daily life for individuals with stress and low magnesemia,” concluded the researchers.9 Suboptimal Intake Is Common Magnesium deficiency is uncommon, occurring in less than 2% of the population, says Dr. Rosanoff, but suboptimal intake is very common. According to the National Health and Nutrition Examination Survey, 79% of American adults do not meet their recommended daily allowance for magnesium: 400 to 420 for men and 310 to 320 for women—and these values, published in 1997, are low compared to the body’s need for magnesium.

“I consider the low intake of magnesium to be the single most important nutritional deficit in the United States,” says Jacob Teitelbaum, MD, an internist in Kona, Hawaii. That’s because a low intake could be playing a major role in the current epidemics of heart disease, stroke, and Type 2 diabetes, he notes.

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SUPPLEMENT SPOTLIGHT

AN ANALYSIS PUBLISHED IN HEADACHE FOUND THAT PEOPLE WHO HAD HIGHER MAGNESIUM INTAKES HAD A LOWER RISK OF EXPERIENCING MIGRAINES.

BY BILL GOTTLIEB

Recommending a Supplement Magnesium supplements are inexpensive and safe, says Dr. Rosanoff. For a person taking a magnesium supplement to prevent illness, Dr. Rosanoff recommends 350 mg daily.

If your patient has a clinical issue that magnesium might help, such as high blood pressure or blood sugar levels, Dr. Rosanoff thinks 600 mg daily in a single dose before bedtime is a good recommendation.

If that amount produces loose stools—a possible side effect of magnesium supplementation—the patient should divide the amount into two 300 mg doses or three 200 mg doses.

Or they should cut back on the single dose by 100 mg every few days, until their bowel movements normalize, Dr. Rosanoff notes.

Dr. Block routinely recommends 500 mg daily to her patients—increasing it gradually until the patient reaches bowel tolerance and then cutting back slightly until the bowel movements are again well-formed.

And don’t forget to remind patients to eat magnesium-rich foods, says Dr. Teitelbaum, who recommends leafy greens and nuts, especially almonds, as the best dietary sources of the mineral. Other foods rich in magnesium include dark chocolate, avocados, beans, whole grains, and bananas. C

REFERENCES 1. Dibaba DT, Xun P, Song Y, Rosanoff A, Shechter M, He K. The effect of magnesium supplementation on blood pressure in individuals with insulin resistance, prediabetes, or noncommunicable chronic diseases: a meta-analysis of randomized controlled trials. Am J Clin Nutr. 2017;106(3):921-929. doi:10.3945/ajcn.117.155291 2. Fan L, Zhu X, Rosanoff A, et al. Magnesium depletion score (MDS) predicts risk of systemic inflammation and cardiovascular mortality among US adults. J Nutr.

2021;151(8):2226-2235. doi:10.1093/jn/nxab138 3. Furman D, Campisi J, Verdin E, et al. Chronic inflammation in the etiology of disease across the life span. Nat Med. 2019;25(12):1822-1832. doi:10.1038/ s41591-019-0675-0 4. Asbaghi O, Moradi S, Kashkooli S, et al. The effects of oral magnesium supplementation on glycaemic control in patients with Type 2 diabetes: a systematic review and dose-response meta-analysis of controlled clinical trials. Br J Nutr. Published online January 20, 2022. doi:10.1017/S0007114521005201 5. Verma H, Garg R. Effect of magnesium supplementation on Type 2 diabetes associated cardiovascular risk factors: a systematic review and meta-analysis. J Hum Nutr Diet. 2017;30(5):621-633. doi:10.1111/jhn.12454 6. Mah J, Pitre T. Oral magnesium supplementation for insomnia in older adults: a systematic review & meta-analysis. BMC Complement Med Ther. 2021;21(1):125. doi:10.1186/s12906-021-03297-z 7. Slavin M, Li H, Khatri M, Frankenfeld C. Dietary magnesium and migraine in adults: a cross-sectional analysis of the National Health and Nutrition Examination Survey 2001-2004. Headache. 2021;61(2):276-286. doi:10.1111/head.14065 8. Lu L, Chen C, Li Y. Magnesium intake is inversely associated with risk of nonalcoholic fatty liver disease among American adults. Eur J Nutr. 2022;61(3):12451254. doi:10.1007/s00394-021-02732-8 9. Noah L, Dye L, Bois De Fer B, Mazur A, Pickering G, Pouteau E. Effect of magnesium and vitamin B6 supplementation on mental health and quality of life in stressed healthy adults: post-hoc analysis of a randomised controlled trial. Stress Health. 2021;37(5):1000-1009. doi:10.1002/smi.3051

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