January 2022 by San Diego Physician

Official Publication of SDCMS JANUARY 2022

Early Screening: The First Line of Defense Against Dementia

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Editor: James Santiago Grisolia, MD Editorial Board: James Santiago Grisolia, MD; David E.J. Bazzo, MD; Robert E. Peters, MD, PhD; William T-C Tseng, MD Marketing & Production Manager: Jennifer Rohr Art Director: Lisa Williams Copy Editor: Adam Elder OFFICERS President: Sergio R. Flores, MD President–Elect: Toluwalase (Lase) A. Ajayi, MD Secretary: Nicholas (Dr. Nick) J. Yphantides, MD, MPH Immediate Past President: Holly B. Yang, MD, MSHPEd, HMDC, FACP, FAAHPM

Contents JANUARY

VOLUME 109, NUMBER 1

GEOGRAPHIC DIRECTORS East County #1: Catherine A. Uchino, MD East County #2: Rakesh R. Patel, MD Hillcrest #1: Kyle P. Edmonds, MD Hillcrest #2: Steve H. Koh, MD (Board Representative to the Executive Committee) Kearny Mesa #1: Anthony E. Magit, MD, MPH Kearny Mesa #2: Alexander K. Quick, MD La Jolla #1: Preeti S. Mehta, MD (Board Representative to the Executive Committee) La Jolla #2: David E.J. Bazzo, MD, FAAFP La Jolla #3: Sonia L. Ramamoorthy, MD, FACS, FASCRS North County #1: Arlene J. Morales, MD North County #2: Christopher M. Bergeron, MD, FACS North County #3: Nina Chaya, MD South Bay #1: Paul J. Manos, DO South Bay #2: Maria T. Carriedo-Ceniceros, MD AT–LARGE DIRECTORS #1: Thomas J. Savides, MD #2: Kelly C. Motadel, MD, MPH #3: Irineo (Reno) D. Tiangco, MD #4: Miranda R. Sonneborn, MD #5: Stephen R. Hayden, MD (Delegation Chair) #6: Marcella (Marci) M. Wilson, MD #7: Karl E. Steinberg, MD, FAAFP #8: Alejandra Postlethwaite, MD ADDITIONAL VOTING DIRECTORS Medical Student: Jimmy Yu Resident: Nicole L. Herrick, MD Young Physician: Brian J. Rebolledo, MD Retired Physician: Mitsuo Tomita, MD CMA OFFICERS AND TRUSTEES Robert E. Wailes, MD William T–C Tseng, MD, MPH Sergio R. Flores, MD Timothy Murphy, MD AMA DELEGATES AND ALTERNATE DELEGATES District I: Mihir Y. Parikh, MD District I Alternate: Sergio R. Flores At-Large: Albert Ray, MD At-Large: Robert E. Hertzka, MD At-Large: Theodore M. Mazer, MD At-Large: Kyle P. Edmonds, MD At-Large: Holly B. Yang, MD, MSHPEd, HMDC, FACP, FAAHPM At-Large Alternate: David E.J. Bazzo, MD, FAAFP CMA DELEGATES District I: Karrar H. Ali, DO, MPH District I: Steven L.W. Chen, MD, FACS, MBA District I: Franklin M. Martin, MD, FACS District I: Vimal I. Nanavati, MD, FACC, FSCAI District I: Peter O. Raudaskoski, MD District I: Kosala Samarasinghe, MD District I: James H. Schultz, MD, MBA, FAAFP, FAWM, DiMM District I: Mark W. Sornson, MD District I: Wynnshang (Wayne) C. Sun, MD District I: Patrick A. Tellez, MD, MHSA, MPH RFS: Rachel Buehler Van Hollebeke, MD

Opinions expressed by authors are their own and not necessarily those of San Diego Physician or SDCMS. San Diego Physician reserves the right to edit all contributions for clarity and length as well as to reject any material submitted. Not responsible for unsolicited manuscripts. Advertising rates and information sent upon request. Acceptance of advertising in San Diego Physician in no way constitutes approval or endorsement by SDCMS of products or services advertised. San Diego Physician and SDCMS reserve the right to reject any advertising. Address all editorial communications to Editor@SDCMS.org. All advertising inquiries can be sent to DPebdani@SDCMS.org. San Diego Physician is published monthly on the first of the month. Subscription rates are $35.00 per year. For subscriptions, email Editor@SDCMS.org. [San Diego County Medical Society (SDCMS) Printed in the U.S.A.]

Features

Early Screening: The First Line of Defense Against Dementia By Michael Lobatz, MD

Pandemic Poses Short- and Long-Term Risks to Babies, Especially Boys By Liz Szabo

Departments

Briefly Noted: Access to Healthcare • Disability Insurance • Legal Issues

After ‘Appalling’ Death Toll in Nursing Homes, California Rethinks Its Funding By Samantha Young

Are We Testing for Omicron Wrong? By John Gever

Health Experts Worry CDC’s COVID Vaccination Rates Appear Inflated By Phil Galewitz

Taste Dysfunction May Linger After COVID-19 By Judy George

Treasure the Relationships By Adama Dyoniziak

Creating a Revitalized, Fulfilling World of Medicine By Helane Fronek, MD, FACP, FACPh

Classifieds

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BRIEFLY NOTED 2

JA NUA RY 2022

ACCESS TO HEALTHCARE

Champions for Health to Hold 3rd Annual Soirée Fundraiser on March 19 CHAMPIONS FOR HEALTH WILL HOLD

its third-annual soirée, “To Wellness and Beyond,” on Saturday, March 19. Champions for Health is SDCMS’s nonprofit organization committed to serving the medical needs of poor and underserved communities in San Diego County. This year’s event will start at 5 p.m. at the San Diego Air & Space Museum in Balboa Park. Champions for Health is dedicated to providing access to quality healthcare for very low-income and uninsured people of San Diego County. Champions offers free flu and COVID-19 vaccine clinics and health screening events, and provides pro-bono specialty medical services and surgeries. The annual soirée is attended by supporting San Diego County physicians and hospital community partners who are integral to the

mission of Champions for Health. This event raises funds for Champions’ flagship program, Project Access San Diego (PASD). Since 2008, PASD has facilitated more than $22 million in pro-bono specialty care, procedures, and surgeries in collaboration with a network of physicians, hospitals, and clinics across San Diego County. These life-saving services have been provided to more than 6,500 patients who have been able to regain their health, return to work, care for their families, and remain productive members of our community. Your support is greatly needed now more than ever, particularly with the heavy burden COVID-19 has placed on the very low-income and uninsured. Please visit championssoiree. org to purchase tickets and help this worthy cause.

DISABILITY INSURANCE

EDD Will Require Identity Verification for Physicians Certifying SDI Claims BY CALIFORNIA MEDICAL ASSOCIATION STAFF IN AN EFFORT TO COMBAT DISABILITY

insurance fraud, the California Employment Development Department (EDD) will soon begin requiring medical providers to verify their identities through ID.me before certifying State Disability Insurance (SDI) claims. ID.me is a trusted technology provider for the State of California and EDD. The company specializes in digital identity protection and meets the federal government’s highest standards for identity authentication. Beginning Jan. 10, 2022, if you have a certified SDI claim in 2021, you may be contacted by the EDD via email with details on how to verify

your identity through ID.me. Please note this email will come from an email address ending in @edd.ca.gov. If any additional characters are included in the email domain, the email is not coming from EDD. Physicians are reminded to remain vigilant in guarding against identity theft and phishing schemes. As scammers attempt to get personal information in many sophisticated and creative ways, EDD continues to enhance and update information on its Help Fight Fraud webpage. For more information on your role in certifying SDI claims, please visit edd.ca.gov/disability.

TRUST

LEGAL ISSUES

Lawsuits Filed Over No Surprises Act BY CALIFORNIA MEDICAL ASSOCIATION STAFF THE AMERICAN MEDICAL ASSOCIATION (AMA) AND AMERICAN HOSPITAL

Association (AHA) have filed a lawsuit against the federal government over its misguided implementation of the No Surprises Act (NSA). The suit argues that the regulations are a clear deviation from the law as written and all but ensure that hospitals, physicians, and other providers will routinely be undercompensated by commercial insurers — and patients will have fewer choices for access to in-network services. AMA and AHA also asked the judge to stay the IDR process until a decision is made. Importantly, the lawsuit does not prevent the law’s core patient protections from moving forward and will not increase out-of-pocket costs to patients. It seeks only to force the administration to bring the regulations in line with the law before the dispute negotiations begin. A decision on the stay is not likely until January 2022. The Texas Medical Association (TMA) has also filed a lawsuit in Texas against the federal government over its implementation of NSA. The TMA lawsuit asks the court to restore the fair, balanced dispute resolution process that Congress created. The lawsuit also alleges a violation of the Administrative Procedure Act, which requires a formal notice and comment period in advance of finalizing such a rule. The agencies failed to solicit and incorporate comments from stakeholders for this crucial aspect of the law. Through the Physicians Advocacy Institute, the California Medical Association is filing an amicus brief in support of the TMA lawsuit.

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///////////////////////////////////////////////////////////////////////////////// DEMENTIA

TEWART, 76, CAME TO SEE

Early Screening: The First Line of Defense Against Dementia BY MICHAEL LOBATZ, MD 4

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me with his wife last week. He was referred by his primary care provider as his wife was concerned he seemed disoriented and forgetful. His PCP thought it was more serious than that. He was already in moderatestage dementia. He was uncertain why he was in my office, and an evaluation showed he had lost a great deal of cognitive function along with executive function skills. Marge, his wife, explained she had taken over the finances a couple years ago because “he just seemed to get the numbers wrong.” She was clearly distressed, and stressed out. Their children live on the East Coast, and saw changes in their dad in the past year, but did not know what to do. If Stewart had seen his primary care provider regularly, the changes might have been observed. Screening and evaluation could have facilitated a diagnosis of Stewart’s dementia, and allowed for a workup to rule out other potentially treatable causes such as tumor, vascular, or metabolic issues. After a diagnosis of dementia was made, it would have given him time to make important life decisions with Marge, alleviating some of her stress and uncertainty. They could have learned about dementia, and what to expect at various stages. They might have utilized resources like support groups and been part of a greater community that shared their struggles. They might have chosen to travel more, or made other choices, knowing life was going down the dementia path. Dementia is a degenerative disease that can span 10 to 20 years. Identifying the disease early in its progression is more important than ever given new treatments for early onset either already approved or on their way. While there are some FDA approved pharmaceuticals, cholinesterase inhibitors and memantine, these have mixed results and substantial side effects. These are focused on slowing the progression of the disease, but do not modify the disease. But those are the tools we physicians currently have, so we give it a go. The new monoclonal antibody therapies currently in clinical trials are purported to work only for Mild

//////////////////////////////////////////////////////////////////////////////// ALZHEIMER’S CLINICAL ROUNDTABLE Alzheimer’s Clinical Roundtable Recommended Screening for FOR Adult Cognitive Impairment RECOMMENDED SCREENINGAlgorithm ALGORITHM ADULT COGNITIVE IMPAIRMENT NOTE: Cognitive screening may be a part of a regular annual physical exam.

SCREENING VISIT

10 WARNING SIGNS

Generally due to concerns about cognition or function, noted by Patient, Family Member or Physician

1 Memory loss disrupts daily life

History Changes in cognition and/or function Ask about 10 Warning Signs

Conduct Cognitive Screen Assess for Red Flags Mini-Cog ≤3

ASSESS REVERSIBLE FACTORS • Depression • Hearing • Delirium • Alcohol • Medications • Uncontrolled illness or infection

RED FLAG SYMPTOMS

Optimal Conduct Informant Screen AD8 ≥2

IF PASS Reassure Patient & Family Note: Passing cognitive screen does not preclude a mild, early or subclinical problem. Consider rescreening in 12 months, or sooner if changes become more noticeable.

Rapid Progression (w/in 6 mos) Recent Sudden Changes Young Onset (<65)

2 Challenges in planning or problem solving 3 Difficulty completing familiar tasks 4 Confusion with time or place 5 Trouble understanding visual images or spatial relationships 6 Problems with words 7 Misplacing items and inability to retrace steps 8 Decreased or poor judgment 9 Withdrawal from work or social activities 10 Changes in mood and personality

IF FAIL COGNITIVE SCREEN OR RED FLAGS CONDUCT OR REVIEW RECENT LAB TESTS CBC, Comprehensive Metabolic Panel, TSH, B12

TREAT REVERSIBLE FACTORS

NO Reversible Factors

NO Improvement After Treating Reversible Factors

PROCEED TO EVALUATION

CONSIDER REFERRAL TO PSYCH IF SEVERE DEPRESSION

THE ALZHEIMER’S PROJECT https://championsforhealth.org/alzheimers

1919 Alzheimer's Project Booklet v12 092121.indd 5

Cognitive Impairment and early-stage Alzheimer’s disease. So getting a screening and diagnosis as early as possible will be more important than ever. As a neurologist, I know that caring for an individual with dementia can be time consuming and difficult. I am proud that, for the past seven years, a group of colleagues from multiple heath systems including Kaiser Permanente, Scripps Health, Sharp Healthcare, and UC San Diego have developed simple tools and resources to make this journey less arduous for the primary care provider. These resources are helpful for practitioners whose time is already impacted

9/21/21 5:01 PM

by their multiple responsibilities, and who care for the majority of older adults, particularly in light of the short supply of specialists. The Alzheimer’s Clinical Roundtable, which I chair, recently published our Third Edition of the Physician Guidelines for Screening, Evaluation & Management of Alzheimer’s Disease and Related Dementias. These guidelines will assist you to make better choices with your patient. The step-by-step algorithms are focused on what can get accomplished during a regular 12- to 15-minute visit, and what requires a longer follow-up visit. Some of the screening and evaluation instru-

ments can be conducted by RNs, NPs, or MAs during rooming to save the physician time. Input from the family member or caregiver is invaluable to an appropriate assessment, and an AD8 or IQCODE can be emailed in advance of the appointment when the caregiver can take their time to complete it without distractions. Some health systems conduct their Medicare Annual Wellness Visit by telephone and refer patients to their primary care provider when sufficient warning signs are noted. While designed as an informant survey, the AD8 has been used with patients in this context. Unfortunately, many individuals with cognitive decline are unaware of their memory and functional deficits. It is generally the “worried well” who complain of memory problems! The spouse or adult children are usually the ones who notice mom or dad is “slipping.” So it is critical that when physicians see a patient for a wellness visit or a specific health issue they take just a minute or two to assess the cognitive status, and request a follow-up visit for a cognitive screening or bring a staff member in to conduct the Mini-Cog test, which is a well-validated cognitive screening tool that can be conducted in three to five minutes. Let’s Talk About Screening The best way to start a conversation regarding cognitive status is during an annual visit, or a regular appointment that may be focused on another particular health issue. Sometimes the patient brings up memory concerns, but often it is a spouse or family member. And of course the provider’s observations when you are seeing a long-term patient. A couple quick questions: “Are you worried about your memory?” “Have you noticed a change in your memory since you saw me last that concerns you?” You can refer to the commonly used 10 Warning Signs as examples of questions. By bringing up the issue, the practitioner is normalizing attention to cognition, and encourages older patients to be aware of changes. It is helpful to impart key messages about brain health: the brain ages just like other body parts; cognitive aging is not a disease and is different than dementia; some cognitive functions

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///////////////////////////////////////////////////////////////////////////////// improve with age. The “worried well” will need reassurance their experience is part of normal aging. If the patient appointment is for a specific issue, after asking a couple initial questions, you may suggest a separate appointment to follow up with their cognitive concerns and give you adequate time for a screening exam, which can be easily conducted during a 12- to 15-minute appointment. Many physicians find it helpful to have their nurse or medical assistant run the patient through a MiniCog screening test either at the end of the appointment for another issue, or during rooming for the screening appointment; this practice is a great time-saver for both practitioner and patient.

10 Warning Signs of Cognitive Decline 1. Memory loss disrupts daily life 2. Challenges in planning or problem solving 3. Difficulty completing familiar tasks 4. Confusion with time or place 5. Trouble understanding visual images or spatial relationships 6. Problems with words 7. Misplacing items and inability to retrace steps 8. Decreased or poor judgment 9. Withdrawal from work or social activities 10. Changes in mood and personality

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What Can Older Adults Do About Cognitive Deficits? The first step is to get screened. And whether the individual is a “worried well” or is facing dementia, the same guidelines apply to any individual who wants to maintain their health. Eat a healthy diet filled with fresh fruits and vegetables. While a Mediterranean-style diet meets this criteria, there is no specific recommended diet plan. Incorporate physical exercise; 30 minutes a day, five days a week. Any activity that gets the heart going is good for the brain. Keep up social connections, as isolation and depression can appear as dementia and can trigger brain function decline. That could mean taking up a new hobby that also increases brain function, like bridge or a book club. The Clinical Roundtable has also created easy handouts that the provider can put into their EMR and then attach to the after-visit summary with quick tips. They are available in five languages on the website. Getting involved in a clinical trial is of critical importance for advancing care in the years and decades to come. We ask that you encourage patients to do so, and the list of available clinical trials is posted on clinicaltrials.gov. What Is the Difference Between Mild Cognitive Impairment and Dementia? This is probably the question you will be asked most frequently. Mild Cognitive Impairment (MCI) is characterized by one or more areas of cognitive impairment (most commonly memory and executive function) with minimal impairment of instrumental activities of daily living (IADL) that does not cross the threshold for a dementia diagnosis. MCI can be the first cognitive expression of Alzheimer’s disease or may be secondary to other disease processes, such as neurologic, vascular, systemic, or psychiatric disorders that can cause cognitive deficits. While persons with MCI are at a higher risk of progressing to dementia, MCI does not necessarily lead to dementia; the cumulative incidence for developing dementia among individuals older than 65 with MCI followed for two years is 14.9%. Persons with MCI may remain stable, return to neurologi-

cally intact, or progress to dementia. The important factor is to follow through the screening algorithm to assess reversible factors that may be presenting as cognitive deficits. When Should Practitioners Continue With a Full Evaluation? During the screening exam, should the practitioner note the Red Flag Symptoms — rapid progression within six months, recent sudden changes, or young onset (<65) — an evaluation is warranted. Same for failing the MiniCog or AD8, as well as no improvement after assessing and treating reversible factors. It is then recommended to order labs and schedule time for a 45-minute appointment for cognitive evaluation. (More on this protocol in upcoming articles.) Should the primary care provider not feel they have the resources to follow the patient through diagnosis and potential disclosure, it may be appropriate to refer to a neurologist, geriatric psychiatrist, or geriatrician. Tools to Facilitate Patient Care The Alzheimer’s Project Clinical Roundtable has created a plethora of tools for primary care providers who are under time constraints. The Clinical Guidelines (link) includes all the screening and evaluation instruments, as well as algorithms for screening, evaluation, and management of behavioral symptoms of cognitive decline. The mobile application, AlxDxRx, was named one of the top 10 medical mobile applications when it was released in 2017. It has since been revised to add instruments and caregiver care tools. A number of free, on-demand CME webinars have recently been updated and are available on the ChampionsforHealth.org/alzheimers website, with special thanks to and partnership with The Doctors Company. The website also has links to train medical staff on how to conduct the Mini-Cog and MOCA with patients. Dr. Lobatz is a board-certified neurologist in private practice affiliated with Scripps Health and The Neurology Center. He is a former board member of the San Diego County Medical Society and a 17-year member.

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Pandemic Poses Shortand Long-Term Risks to Babies, Especially Boys BY LIZ SZABO

JA NUA RY 2022

BOUT 1 IN 8 CALIFORNIANS

who have died of COVID lived in a nursing home. They were among the state’s most frail residents: nearly 9,400 mothers, fathers, grandparents, aunts, and uncles whom Californians entrusted to a nursing home’s care. An additional 56,275 confirmed COVID cases among nursing home residents weren’t fatal. The pandemic has created a hostile environment for pregnant people and their babies. Stress levels among expectant mothers have soared. Pregnant women with COVID are five times as likely as uninfected pregnant people to require intensive care and 22 times as likely to

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die. Infected moms are four times as likely to have a stillborn child. Yet some of the pandemic’s greatest threats to infants’ health may not be apparent for years or even decades. That’s because babies of COVIDinfected moms are 60% more likely to be born very prematurely, which increases the danger of infant mortality and longterm disabilities such as cerebral palsy, asthma, and hearing loss, as well as a child’s risk of adult disease, including depression, anxiety, heart disease and kidney disease. Studies have linked fever and infection during pregnancy to developmental and psychiatric conditions such as autism, depression, and schizophrenia.

“Some of these conditions do not show up until middle childhood or early adult life, but they have their origins in fetal life,” says Dr. Evdokia Anagnostou, a child neurologist at Holland Bloorview Kids Rehabilitation Hospital and a pediatrics professor at the University of Toronto. For fetuses exposed to COVID, the greatest danger is usually not the coronavirus itself, but the mother’s immune system. Both severe COVID infections and the strain of the pandemic can expose fetuses to harmful inflammation, which can occur when a mother’s immune system is fighting a virus or when stress hormones send nonstop alarm signals. Prenatal inflammation “changes the way the brain develops and, depending on the timing of the infection, it can change the way the heart or kidneys develop,” Dr. Anagnostou says. Although health officials have strongly recommended COVID vaccines for pregnant people, only 35% are fully vaccinated. At least 150,000 pregnant people have been diagnosed with COVID; more than 25,000 of them have been hospitalized, and 249 have died, according to the Centers for Disease Control and Prevention. Although most babies will be fine, even a small increase in the percentage of children with special medical or educational needs could have a large effect on the population, given the huge number of COVID infections, Dr. Anagnostou says. “If someone has a baby who is doing well, that is what they should focus on,” Anagnostou says. “But from a public health point of view, we need to follow women who experienced severe COVID and their babies to understand the impact.” Learning From History Researchers in the United States and other countries are already studying “the COVID generation” to see whether these children have more health issues than those conceived or born before 2020. Previous crises have shown that the challenges fetuses face in the womb — such as maternal infections,

hunger, stress, and hormone-disrupting chemicals — can leave a lasting imprint on their health, as well as that of their children and grandchildren, says Dr. Frederick Kaskel, director of pediatric nephrology at the Children’s Hospital at Montefiore. People whose mothers were pregnant during surges in the 1918 influenza pandemic, for example, had poorer health throughout their lives compared with Americans born at other times, says John McCarthy, a medical student at Albert Einstein College of Medicine who co-wrote a recent review in JAMA Pediatrics with Dr. Kaskel. Researchers don’t know exactly which moms were infected with pandemic flu, McCarthy says. But women who were pregnant during major surges — when infection was widespread — had children with higher rates of heart disease or diabetes. These children were also less successful in school, less economically productive, and more likely to live with a disability. Because organ systems develop during different periods of pregnancy, fetuses exposed during the first trimester may face different risks than those exposed toward the end of pregnancy, McCarthy says. For example, people born in the fall of 1918 were 50% more likely than others to develop kidney disease; that may reflect an exposure to the pandemic in the third trimester, while the kidneys were still developing. Nearly two years into the COVID pandemic, researchers have begun to publish preliminary observations of infants exposed to COVID infections and stress before birth. Although Dr. Anagnostou notes that it’s too early to reach definitive conclusions, “there is evidence that babies born to moms with severe COVID infections have changes to their immune system,” she says. “It’s enough to make us worry a little bit.” Damaging a Fetal Security System The good news about the coronavirus is that it seldom crosses the placenta, the organ tasked with protecting a developing fetus from infections and providing it with oxygen. So moms with COVID

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///////////////////////////////////////////////////////////////////////////////// rarely give the virus to their children before birth. That’s important, because some viruses that directly infect the fetus — such as Zika — can cause devastating birth defects, says Dr. Karin NielsenSaines, a specialist in pediatric infectious diseases at UCLA’s David Geffen School of Medicine. But studies also suggest that inflammation from a mother’s COVID infection can injure the placenta, says Dr. Jeffery Goldstein, an assistant professor of pathology at Northwestern University’s Feinberg School of Medicine. In a study published last year, Dr. Goldstein and his co-authors found that placentas from COVID-infected moms had more abnormal blood vessels than placentas from patients without COVID, making it harder for them to deliver sufficient oxygen to the fetus. Placental damage can also lead to preeclampsia, a serious complication of pregnancy that can cause a mother’s blood pressure to spike. Preeclampsia occurs when blood vessels in the placenta don’t develop or function properly, forcing the mother’s heart to work harder to get blood to the fetus, which may not receive enough oxygen and nutrients. Preeclampsia also predisposes women to heart attacks and strokes later in life. Rewiring the Immune System In some cases, COVID also appears to rewire a baby’s immune response, Dr. Nielsen-Saines says. In an October study in the journal Cell Reports Medicine, Dr. Nielsen-Saines and her co-authors found that infants born to people with severe COVID infections had a different mix of immune cells and proteins than other babies. None of the newborns tested positive for the coronavirus. The immune changes are concerning, Dr. Nielsen-Saines says, because this pattern of immune cells and proteins has previously been found in infants with respiratory problems and in some cases poor neurodevelopment. Notably, all the babies in her study appear healthy, says Nielsen-Saines, who plans to follow them for three years to see 10

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whether these early signals translate into developmental delays, such as problems talking, walking, or interacting with others. “How big of a difference does any of this make in the baby?” asks Dr. Anagnostou. “We won’t know for a few years. All we can do is try to be as prepared as possible.” Increasing the Risk for Boys Boys could face higher risks from COVID, even before birth. Males are generally more vulnerable than females as fetuses and newborns; they’re more likely to be born prematurely and to die as infants. Preterm boys also have a higher risk of disability and death. But coronavirus infection poses special dangers, says Sabra Klein, a professor of molecular microbiology and immunology at the Johns Hopkins Bloomberg School of Public Health. That’s because boys are disproportionately affected by conditions linked to maternal infections. Boys are four times as likely as girls to be diagnosed with autism or attention deficit hyperactivity disorder, for example, while men are 75% more likely than women to develop schizophrenia. Scientists don’t fully understand why boys appear more fragile in the womb, although testosterone — which can dampen immune response — may play a role, says Dr. Kristina Adams Waldorf, a professor of obstetrics and gynecology at the University of Washington. Men generally mount weaker immune responses than women and more often develop severe COVID infections. Recent research suggests boys with COVID are more likely than girls to become seriously ill or develop a rare inflammatory condition called multisystem inflammatory syndrome. New research on COVID could help illuminate this vulnerability. In a study published in October, researchers found that the sex of a fetus influences the way its placenta responds to COVID, as well as how its mother’s immune system responds. Pregnant people infected with COVID made fewer antibodies against the coronavirus if they were carrying

male fetuses than if they were carrying females. Mothers also transferred fewer antibodies to boys than to girls, says Dr. Andrea Edlow, senior author of the study and a maternal-fetal medicine specialist at Massachusetts General Hospital. When examining the placentas of male fetuses after delivery, researchers found changes that could leave boys less protected against damaging inflammation. The sex of a fetus can influence its mother’s response to other illnesses, as well. For example, research shows that pregnant women with asthma have worse symptoms if they’re carrying a female. Women carrying males are slightly more likely to develop gestational diabetes. Dr. Edlow explains that her findings raise questions about the “cross talk” between mother and baby. “The mom’s immune system is sensing there is a male fetus,” she says. “And the fetus is actively communicating with the mom’s immune system.” Boosting Toxic Stress Rates of depression and stress among pregnant women have increased dramatically during the pandemic. That’s concerning because chronic stress can lead to inflammation, affecting the babies of both infected and uninfected women, Dr. Anagnostou says. Studies consistently show that infants born to mothers who experience significant stress during pregnancy have higher rates of short- and longterm health damage — including heart defects and obesity — than babies born to women with less stress. “We know that inflammation directly influences the way a baby’s brain develops,” says Elinor Sullivan, an associate professor in psychiatry at Oregon Health & Science University. Lockdowns, travel restrictions, and physical distancing left many pregnant women without the support of family and friends. The stress of losing a loved one, a job, or a home further heightens the risks to moms and babies, says Sullivan, who is following children born during the pandemic for five years. In research that has not yet been published, Sullivan found that babies of

//////////////////////////////////////////////////////////////////////////////// women who were pregnant during the pandemic showed more sadness and negative emotions in the first year of life compared with infants of women who were pregnant before the pandemic. The findings show the importance of helping and protecting pregnant people before and after delivery, says Sullivan, who conducted a separate study that found women who received more social support were less depressed. Italian researchers are also studying the effect of maternal stress on infants’ behavior, as well as the way their genes are regulated. Although stress-related inflammation doesn’t alter the structure of a baby’s genes, it can influence whether they’re turned on and off, says Livio Provenzi, a psychologist at the C. Mondino National Institute of Neurology Foundation in Pavia, Italy. In Provenzi’s study of 163 motherbaby pairs, he found differences in how genes that regulate the stress response were activated. Genes that help people respond to stress were more likely to be turned off in babies whose moms reported the most stress during pregnancy. The same moms also reported that their babies cried more and were fussier when they were three months old. Researchers usually prefer to make inperson observations of babies as they interact with their mothers, Provenzi says. But because of the pandemic, Provenzi asked mothers to fill out questionnaires about infant behavior. He plans to observe mothers and babies in person when the children are 12 months old. While vaccinating pregnant people is the best way to protect them and their fetuses from the virus, Dr. Anagnostou says, society needs to do more to preserve expectant mothers’ mental health. “We can’t escape the fact that we’ve lived through two years of a pandemic,” Dr. Anagnostou says. “But we can think about opportunities for reducing the risk.” Liz Szabo focuses on the quality of patient care as a senior correspondent for Kaiser Health News, where this article first appeared.

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///////////////////////////////////////////////////////////////////////////////// COVID-19

After ‘Appalling’ Death Toll in Nursing Homes, California Rethinks Its Funding BY SAMANTHA YOUNG

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BOUT 1 IN 8 CALIFORNIANS

who have died of COVID lived in a nursing home. They were among the state’s most frail residents: nearly 9,400 mothers, fathers, grandparents, aunts, and uncles whom Californians entrusted to a nursing home’s care. An additional 56,275 confirmed COVID cases among nursing home residents weren’t fatal. “The number of COVID infections and deaths that happened in skilled nursing facilities in California is truly appalling,” Jim Wood, a Democrat who chairs the state Assembly Health Committee, said

//////////////////////////////////////////////////////////////////////////////// at a recent hearing he convened on nursing homes. “I expect better from us.” COVID-19’s unrelenting spread exposed deep, systemic problems with the quality of care — or lack thereof — at nursing homes across the country. In the nation’s most populous state, the industry’s track record during the pandemic is spurring leaders to radically rethink how it pays and oversees them. Governor Gavin Newsom’s administration is drafting a proposal to tie state funding more directly to performance: Among the state’s roughly 1,200 skilled nursing facilities, those that meet new quality standards would get a larger share of state funding than those that don’t. But exactly how the Golden State would measure quality care and allocate the roughly $5.45 billion a year that nursing homes collectively receive is far from settled — and promises to spark one of 2022’s biggest healthcare fights. When the legislature debates those details as part of state budget negotiations, the nursing home industry vows to oppose any proposal tying Medicaid payments to quality metrics such as staffing levels, pay, and turnover. In fact, the industry plans to argue it needs more money to deliver better results — and it wields substantial power in the Capitol. In the past decade, it has spent at least $10 million to influence lawmakers and has given one or more political donations to Newsom and at least 105 current members of the 120-member legislature, according to a KHN analysis of campaign finance records. But patient advocates and family members who lost loved ones in nursing facilities during the pandemic are mobilizing a counterattack to convince lawmakers that now is the time to overhaul the system. “There are a lot of problems people have complained about for a long time,” says Charlene Harrington, a professor emerita of social and behavioral sciences at the University of California, San Francisco, and an expert on nursing homes. “This is an opportunity to correct those problems.” At least 140,790 COVID deaths have been reported in U.S. nursing homes,

according to the latest data from the Centers for Disease Control and Prevention. Older adults have a heightened risk of dying of COVID, and the coronavirus spreads more easily in institutional settings such as nursing homes and assisted-living facilities. That’s one reason Craig Cornett, CEO of the California Association of Health Facilities, thinks blaming nursing homes for high COVID infection rates, especially early in the pandemic, is unfair. Not only are their residents naturally at higher risk than the rest of the public, he says, but the facilities were forced to accept hospital transfer patients who had not been tested for the virus, they couldn’t get adequate supplies of personal protective equipment, and they suffered as staff members got COVID in the community and then brought it into work. Cornett also pointed to federal statistics that show California has among the lowest nursing home COVID death rates in the country and one of the highest staff vaccination rates. But multiple studies in California and elsewhere have found that nursing homes with fewer nursing staff members experienced significantly higher COVID infection and death rates. That devastating outcome is bolstering

a two-decades-long argument by patient advocates that nursing homes must hire more workers. “Some of these problems that we saw in the pandemic could have been avoided if nursing homes had adequate staffing,” says Harrington, who coauthored a December 2020 study for the California Health Care Foundation that showed nursing homes with lower staffing levels earlier that year had twice the COVID case rates than those with higher staffing levels. (California Healthline is an editorially independent publication of the foundation.) Some lawmakers and patient advocates suggest that the best way to improve care is to boost staffing, and that the best way to achieve that is to alter the complicated formulas that determine the daily rate nursing homes are paid by Medicaid, the government insurance program that covers about two-thirds of nursing home residents. Currently, Medicaid reimburses a portion of what nursing homes spend on staff, administrative and other expenses, paying them a higher proportion for staff costs than administrative costs. Facilities can receive bonus payments for meeting quality standards — although the bonuses are limited and have been criticized for not boosting performance

SA NDIEGOPH YSICI A N.ORG

///////////////////////////////////////////////////////////////////////////////// at facilities that need it most. The California Department of Health Care Services, which administers the state’s Medicaid program, called MediCal, is drafting a plan that would do away with the bonus payments and integrate quality measures into the daily Medi-Cal payment rates nursing homes receive. The department is considering multiple ways to measure quality, spokesperson Anthony Cava said in a statement: Nursing homes that offer more staff education and training could receive higher per diem rates, as could those that have more staff and less staff turnover. That’s a nonstarter for the nursing home industry, which doesn’t consider staffing to be an appropriate measure of how well residents do. Rather, Cornett, whose lobbying group represents more than 800 nursing homes, said facilities should be graded on the number of patient falls and infections, as well as patients’ abilities to perform daily activities. “We want more staff and want to pay our staff,” Cornett says. “But we need the state to change the system so we can get more money into the staffing line. And that’s going to require a higher amount of money.” Nursing homes warn that a heavy focus on staffing misses other critical costs of running a facility safely. Even under the current reimbursement system, they say, facilities are scraping by. “Not all of the costs in a facility are for staff,” says Mark Johnson, an attorney for Brius Healthcare, one of the largest nursing chains in California. “Skilled nursing facilities, like other healthcare providers, have a variety of costs including medical supplies, consulting, real estate, taxes, administrative services, overhead, and many others.” Whether lawmakers will be sympathetic to the industry’s plea for more money is questionable. They are increasingly demanding transparency about how skilled nursing facilities make and spend their money. Like hospitals and other healthcare providers, nursing facilities have received billions of dollars in federal COVID relief funding to help offset the costs of hiring temporary workers, testing and protec14

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tive gear. It isn’t lost on lawmakers that this $12 billion industry is attracting a growing number of private investors who are buying ownership shares in their facilities. “That tells me there’s money out there, there’s profit out there,” said Wood, who also sits on the budget subcommittee that will review the administration’s proposal. “Private equity is not going to go into facilities if they don’t have a chance to make a pretty significant return.” There’s a lot at stake for the roughly 400,000 residents of nursing homes in the state — and for the industry, which is a big spender and a powerful force in Sacramento. The California Association of Health Facilities has given just over $2 million in contributions and spent $5.67 million lobbying lawmakers in the past 10 years, from Jan. 1, 2011, through Sept. 30, 2021, according to records filed with the California Secretary of State’s office. And Cornett, its CEO, is a veteran of the state Capitol who worked as the top budget aide to four former Assembly speakers and two Senate leaders. During that time frame, 50 of California’s largest individual and corporate nursing home owners and operators have given a combined $2.6 million directly to lawmakers, the Republican and Democratic state political parties, and ballot measures. That figure is likely an undercount because it is difficult to identify everyone with an ownership stake in a nursing home or chain. Facilities are often partially owned by real estate investors, venture capital firms and other business interests not listed on government records. Cornett downplayed his industry’s influence and said trial lawyers are the players with deep pockets and are funding the patient advocates, an allegation those groups dispute. But a 2018 report by the California State Auditor found that the three largest private operators — Brius Healthcare, Plum Healthcare Group, and Longwood Management Corp. — are highly profitable. Their combined 2006 net income of $10 million grew to between $35 million and $54 million by 2015, the most recent year the state audi-

tor analyzed. Patient advocates say those profits negate the industry’s argument for needing more taxpayer dollars. “To some extent, the state is being bamboozled with this idea that the money that they’re paying now is not enough to do the job that we’ve asked them to do,” says Tony Chicotel, an attorney with California Advocates for Nursing Home Reform. “The bottom line is it goes to profit.” Methodology KHN analyzed campaign finance records filed with the California Secretary of State’s office from Jan. 1, 2011, through Sept. 30, 2021. We downloaded contributions made by the California Association of Health Facilities, the organization that represents the industry in Sacramento. To determine how much nursing homes have contributed directly to political campaigns, we identified 50 of California’s largest individual and corporate skilled nursing home owners using data published by the Centers for Medicare & Medicaid Services. We connected those owners to nursing home chains and management companies that run nursing homes. We then searched each entity and individual on the secretary of state’s website to see if they made any political contributions. We did not include money they gave to the California Association of Health Facilities to ensure we did not double-count contributions. To track lobbying, we created a spreadsheet of expenses reported on lobbying disclosure forms from Jan. 1, 2011, through Sept. 30, 2021, also available on the secretary of state’s website, by the California Association of Health Facilities. None of the nursing home companies we identified spent any money directly lobbying lawmakers. Instead, they gave money to the association. Phillip Reese, an assistant professor of journalism at California State University-Sacramento, contributed to this report. This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

//////////////////////////////////////////////////////////////////////////////// INFECTIOUS DISEASE COVID-19

Are We Testing for Omicron Wrong? South African Study Suggests Nasal Swabs Aren’t the Best Way BY JOHN GEVER

F CONFIRMED IN FOLLOW-UP

research and if the diagnostics industry can pivot quickly enough, findings from a South African study could make COVID-19 testing a lot easier for patients and healthcare workers, as the SARS-CoV-2 Omicron variant becomes the dominant source of infection. In a manuscript posted to the medRxiv preprint server on Dec. 24, 2021, researchers from the University of Cape Town reported that saliva samples yielded more accurate results in PCR analyses when Omicron was involved compared with those collected via nasal swabs. When patients carried the Delta variant, on the other hand, nasal swabs were more accurate, according to the group, led by Diana Hardie, MBChB, MMedPath, who also heads the diagnostic virology laboratory at Groote Schuur Hospital. The findings came from an analysis of 382 patients tested at Groote Schuur from August through this month, with viral whole-genome sequencing performed on isolates from those with positive results.

Just over 300 were tested prior to Omicron’s emergence, with 31 testing positive for the Delta variant. Another 74 arrived at the hospital after Omicron became common, of whom 36 were positive for that variant. All patients had both saliva and mid-turbinate nasal samples taken for RT-PCR analysis. The “gold standard” for positivity in the study was detection of SARS-CoV-2 RNA with either swab. For the Delta variant, the positive percent agreement for each sampling method, in comparison with this “gold standard,” was 71% for saliva and 100% for the nasal swabs. But this was reversed for Omicron, with 100% agreement between saliva samples and the gold standard, but only 86% for nasal swabs. Nasal swabs have been the standard for COVID-19 screening and diagnosis ever since the virus was discovered, but that may no longer be appropriate in an Omicron-dominated pandemic landscape, the authors concluded. “These findings suggest that the pat-

tern of viral shedding during the course of infection is altered for Omicron with higher viral shedding in saliva relative to nasal samples resulting in improved diagnostic performance of saliva swabs,” Hardie and colleagues wrote. They noted, as have others, that Omicron is distinguished by “more than 50 distinct mutations.” These seem to have resulted in increased infectivity, but they could also affect other aspects of the virus’s behavior, including the tissues it may prefer to infect. With that in mind, Hardie’s group pointed to a recent lab study from Hong Kong (as yet unpublished but highlighted in a press release) indicating that Omicron is less likely to lodge in the lung compared with earlier variants. This not only suggests that Omicron is less lethal, but also that the many mutations confer “altered tissue tropism.” However, while saliva sampling may be easier to perform than nasal swabbing, the researchers noted that it’s not as simple as spitting in a cup. At Groote Schuur, patients were instructed to swab the inside of the mouth — both cheeks, above and below the tongue, the gums, and hard palate — for a total of at least 30 seconds. They were also told not to eat, drink, smoke, or chew anything for at least 30 minutes beforehand. Another point to consider is that, in the U.S. and most other countries, testing has been predicated primarily on nasal swabs. Although some saliva-based tests have been authorized and are commercially available, the vast majority of currently accessible kits for healthcare use and for at-home self-testing rely on nasal swabs. It would likely take months to retool the supply chain to prioritize saliva sampling — by which time Omicron may have been supplanted by another variant with its own unique characteristics. John Gever was managing editor of MedPage Today, where this article first appeared, from 2014 to 2021 and is now a regular contributor.

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COVID VACCINATION PUBLIC HEALTH

Health Experts Worry CDC’s COVID Vaccination Rates Appear Inflated BY PHIL GALEWITZ

OR NEARLY A MONTH, THE

Centers for Disease Control and Prevention’s online vaccine tracker has shown that virtually everyone 65 and older in the United States — 99.9% — has received at least one COVID vaccine dose. That would be remarkable if true. But health experts and state officials say it’s certainly not. They note that the CDC, as of Dec. 5, 2021, has recorded more seniors at least partly vaccinated — 55.4 million — than there are people in that age group — 54.1 million, according to the latest census data from 2019. The CDC’s vaccination rate for residents 65 and older is also significantly higher than the 89% vaccination rate found in a poll conducted in November by KFF. Similarly, a YouGov poll, conducted last month for The Economist, found 83% of people 65 and up said 16

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they had received at least an initial dose of vaccine. And the CDC counts 21 states as having almost all their senior residents at least partly vaccinated (99.9%). But several of those states show much lower figures in their vaccine databases, including California, with 86% inoculated, and West Virginia, with nearly 90% as of Dec. 6, 2021. The questionable CDC data on seniors’ vaccination rates illustrate one of the potential problems health experts have flagged about CDC’s COVID vaccination data. Knowing with accuracy what proportion of the population has rolled up sleeves for a COVID shot is vital to public health efforts, says Dr. Howard Forman, a professor of public health at Yale University School of Medicine. “These numbers matter,” he says, particularly amid efforts to increase the rates

of booster doses administered. As of Dec. 5, 2021, about 47% of people 65 and older had received a booster shot since the federal government made them available in September. “I’m not sure how reliable the CDC numbers are,” Dr. Forman says, pointing to the discrepancy between state data and the agency’s 99.9% figure for seniors, which he says can’t be correct. “You want to know the best data to plan and prepare and know where to put resources in place — particularly in places that are grossly undervaccinated.” Getting an accurate figure on the proportion of residents vaccinated is difficult for several reasons. The CDC and states may be using different population estimates. State data may not account for residents who get vaccinated in a state other than where they live or in clinics located in federal facilities, such as prisons, or those managed by the Veterans Health Administration or Indian Health Service. CDC officials said the agency may not be able to determine whether a person is receiving a first, second, or booster dose if their shots were received in different states or even from providers within the same city or state. This can cause the CDC to overestimate first doses and underestimate booster doses, CDC spokesperson Scott Pauley says. “There are challenges in linking doses when someone is vaccinated in different jurisdictions or at different providers because of the need to remove personally identifiable information (de-identify) data to protect people’s privacy,” according to a footnote on the CDC’s COVID vaccine data tracker webpage. “This means that, even with the high-quality data CDC receives from jurisdictions and federal entities, there are limits to how CDC can analyze those data.” On its dashboard, the CDC has capped the percentage of the population that has received vaccine at 99.9%. But Pauley said its figures could be off for multiple reasons, such as the census denominator not including everyone who currently resides in a particular county, like part-time residents, or potential data-reporting errors. Liz Hamel, vice president and director of public opinion and survey research at KFF, agrees it’s highly unlikely 99.9% of seniors have been vaccinated. She said the differences between CDC vaccination

rates and those found in KFF and other polls are significant. “The truth may be somewhere in between,” she says. Hamel notes the KFF vaccination rates tracked closely with CDC’s figures in the spring and summer but began diverging in fall, just as booster shots became available. KFF surveys show the percentage of adults at least partly vaccinated changed little from September to November, moving from 72% to 73%. But CDC data shows an increase from 75% in September to 81% in mid-November. As of Dec. 5, the CDC says 83.4% of adults were at least partly vaccinated. William Hanage, an associate professor of epidemiology at Harvard University, says such discrepancies call into question that CDC figure. He said getting an accurate figure on the percentage of seniors vaccinated is important because that age group is most vulnerable to severe consequences of COVID, including death.

“It is important to get them right because of the much-talked-about shift from worrying about cases to worrying about severe outcomes like hospitalizations,” Hanage says. “The consequences of cases will increasingly be determined by the proportion of unvaccinated and unboosted, so having a good handle on this is vital for understanding the pandemic.” For example, CDC data shows New Hampshire leads the country in vaccination rates with about 88% of its total population at least partly vaccinated. The New Hampshire vaccine dashboard shows 61.1% of residents are at least partly vaccinated, but the state is not counting all people who get their shots in pharmacies due to data-collection issues, says Jake Leon, spokesperson for the state Department of Health and Human Services. In addition, Pennsylvania health officials say they have been working with the CDC to correct vaccination-rate

figures on the federal website. The state is trying to remove duplicate vaccination records to make sure the dose classification is correct — from initial doses through boosters, says Mark O’Neil, spokesperson for the state health department. As part of the effort, in late November the CDC reduced the percentage of adults in the state who had at least one dose from 98.9% to 94.6%. It also lowered the percentage of seniors who are fully vaccinated from 92.5% to 84%. However, the CDC has not changed its figure on the proportion of seniors who are partly vaccinated. It remains 99.9%. The CDC dashboard says that 3.1 million seniors in Pennsylvania were at least partly vaccinated as of Dec. 5. The latest census data shows Pennsylvania has 2.4 million people 65 and older. Phil Galewitz is a senior correspondent for Kaiser Health News, where this article first appeared.

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INFECTIOUS DISEASE COVID-19

Taste Dysfunction May Linger After COVID-19 Loss of Taste Not Always Due to Loss of Smell BY JUDY GEORGE

ASTE DYSFUNCTION MAY

linger after acute COVID-19 infection and may not necessarily be a consequence of olfactory dysfunction, a cross-sectional study in Italy showed. In a group of people who reported losing their sense of taste for months after they had COVID, 42% were found to have true hypogeusia, reported Paolo BoscoloRizzo, MD, of the University of Trieste in Italy, and co-authors. Most people with post-COVID hypogeusia also had olfactory impairment, but about 3% did not, the researchers wrote in JAMA Otolaryngology-Head & Neck Surgery. “The classical thinking is that loss of taste in most cases directly results from a loss of smell,” Joshua Levy, MD, MPH, of Emory University School of Medicine in Atlanta, who wasn’t involved with the study, told MedPage Today. “What we’re seeing unique to COVID is that there can be a direct impact on taste that’s separate from the loss of smell,” he continued. “It looks like the ACE receptors, which are the viral points of entry, are not only located adjacent to the olfactory nerves but may even be related to some of the taste receptors, so there can be a direct insult to taste without a disruption in smell.” Temporary loss of smell and taste often occurs after SARS-CoV-2 infection, with some patients reporting dysfunction long after the acute phase of the disease. Self-reported olfactory function and psychophysical tests have shown

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poor agreement in past studies, but gustatory function has not been studied as extensively, Boscolo-Rizzo and colleagues noted. The researchers evaluated 105 patients with self-reported altered sense of taste that lasted more than three months after acute SARS-CoV-2 infection. Almost all (94%) self-reported an associated olfactory impairment. Patients had a median age of 45, and 76% were women. Nearly all (98%) had mildly symptomatic COVID-19 with no evidence of pneumonia. Psychophysical evaluations were performed a median of 226 days after illness onset. Orthonasal olfactory function was measured using the extended Sniffin’ Sticks test battery; gustatory evaluation was performed using the Taste Strips test; and retronasal olfactory function was tested using 20 powdered tasteless aromas. For orthonasal function, Threshold, Discrimination, and Identification (TDI) scores indicated normosmia (TDI ≥30.75), hyposmia (TDI 16.25-30.5), or anosmia (TDI ≤16.0). For taste, Taste Strips Score (TSS) identified hypogeusia (TSS <9 points) and normogeusia (TSS ≥9 points). Based on TSS, the prevalence of hypogeusia was 41.9%, which dropped to 28.6% when scores were related to participants’ age. Only three out of 105 patients (2.9%) had hypogeusia and were normosmic at psychophysical evaluation. Among the 61 patients who were normogeusic, 83.6% had a TDI score less

than 30.75, and 26.2% had a retronasal score less than 12. Only 16.4% had both normal orthonasal and retronasal olfactory function. Olfactory training may help patients whose problems stem from smell loss, but additional strategies may be needed for patients with lingering gustatory impairment, Boscolo-Rizzo and co-authors noted. “An awareness that we need to expand our treatment from beyond just smell is very important,” Levy said. “That would mean we look for other causes like vitamin deficiencies, things that don’t really relate to someone who had COVID.” There’s a need for therapies to address taste dysfunction, Levy added. “We don’t have good options to address this smaller group of patients with disrupted taste but intact smell,” he said. The study had several limitations, Boscolo-Rizzo and colleagues noted. It lacked an age-matched control group and evaluated different patients at different time points. Using a single sensory technique to characterize taste function may have produced false-negative results, and dysgeusia, phantogeusia, parosmia, and phantosmia were not addressed in the study. In addition, most participants had mildly symptomatic COVID-19, and the sample mainly consisted of women; results may not apply to others. Judy George is a senior staff writer for MedPage Today, where this article first appeared.

CHAMPIONS FOR HEALTH

Treasure the Relationships BY ADAMA DYONIZIAK

anulfo P. was a healthy 44-yearold with three children ranging from ages 13 to 23, working at a fumigation company. He played soccer, visited the park with his family, and created community through his church. Then in June 2018, he started to see red bubbles in his vision that began a life-changing journey. “I changed on the inside,” he says. “I was depressed and frustrated with myself. My eldest son had to become the family provider. Every family member was taking turns helping me.” His wife, Roselia, started working the night shift. “We had to make drastic changes in our home so it would be safe for Ranulfo to get around,” she explains. “We knew the operation Ranulfo needed was expensive, and we were losing hope.” Scared for Ranulfo’s vision, his family rushed him to the emergency room, where Dr. Nikolas London happened to be covering a rotation for a colleague. “I will do everything possible to help you with your problem,” Dr. London told

Ranulfo. He treated Ranulfo and referred him to Project Access. Dr. London, an ophthalmologist with Retina Specialists of San Diego, has volunteered with Project access since 2013, generously providing 109 patients with pro bono consultations and procedures. “I don’t remember when I didn’t want to be a physician,” explains Dr. London. He knew right away in medical school that he wanted to be a surgeon. “Being a Project Access volunteer is a very important part of my career in San Diego. The work is extremely meaningful to me. I try to help patients and share the journey with them.” “Dr. London has been an angel that God sent — he is the miracle I asked God for,” Ranulfo says. Since his surgery in November, Ranulfo’s vision has greatly improved. He’s able to go on walks on his own and be less dependent on his family for everyday tasks. He feels much more relaxed in his own home — happier and more secure. Ranulfo and his family said repeatedly: “I

am very grateful for the people who make Project Access possible. It gives us and others hope who are going through problems and don’t have resources. Thank you for supporting your neighbor.” “The best thing about being a physician is that I treasure the relationships with my patients. I try to make a difference in their lives,” Dr. London says. He always says yes to helping Project Access patients. So much so that Dr. London has been reaching out to Project Access each year to provide holiday gift baskets of presents and meals, truly going above and beyond. Away from work, Dr. London cherishes time with his wife and their three young boys. They love traveling to rustic and exotic places, exploring new restaurants, camping and hiking, or simply spending quiet nights at home playing board games, solving puzzle boxes, or learning magic tricks. Since 2008, Project Access has facilitated $21 million in care for 6,500-plus uninsured patients just like Ranulfo by providing free consultations and surgeries — all thanks to the dedication, time, and talent of our volunteer physicians. For every $1 spent on program expenses, we provide $10 in donated services — a return on investment of 1,000%! To help Project Access patients by donating to Champions for Health, please visit www. championsforhealth.org/donate. Adama Dyoniziak is executive director of Champions for Health.

Left: Ranulfo and his wife, Roselia. Above: Dr. Nikolas London.

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PERSONAL AND PROFESSIONAL DEVELOPMENT

Creating a Revitalized, Fulfilling World of Medicine BY HELANE FRONEK, MD, FACP, FACPH

S WE TURN THE PAGE ON

2021, it’s normal to think about how we want the new year to be. After 18 months of chaos, uncertainty, fear, and disruption, it’s understandable to dream about a different type of future. And while chaos and uncertainty are uncomfortable, they often open the way to significant change. The status quo has already been disrupted. Instead of returning to what was, what do we want going forward? Many physicians remain deeply dissatisfied with the practice of medicine, resulting in serious attrition and mental health consequences. Mired in uncompensated, frustrating conversations with insurance companies as reimbursements decline and our autonomy disappears, physicians are now judged primarily on productivity and feel devalued, intensifying feelings of moral injury: the true foundation of burnout. While we disapprove of the direction medicine is going, we can feel powerless to redirect this ship. Where do we really want to go, and how can we overcome the powerful winds pushing us in a direction that feels so distressing? The first step on the journey from despair to satisfaction is to reconnect with our values. The value of service attracted many of us to medicine. How much does your current practice allow you to care for people in the ways you imagined you would? What would allow you to feel you are truly helping your patients, staff, and colleagues? Mandating years of intense training and then limiting our time with patients so we don’t have the opportunity to put our knowledge and experience to use is, frankly, idiotic. Imagine for a moment you have made some changes 20

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and are now serving people in meaningful ways. What feelings would you experience that you don’t feel now? What would it mean to you to be doing this? Clear, projected futures can be powerful motivating forces as we strive to create change in our lives. What other important principles or activities are missing in your life and career? Some values that feel trampled in today’s medical environment include learning, respect, doing the right thing, justice, adventure, camaraderie, and collaboration. There seems to be no time or space for these, yet even a modest invest-

ment adds up. By reading five minutes a day, we add 30 hours of reading to our year. Practicing an athletic or musical skill daily for 15–30 minutes can result in new, enjoyable levels of ability over time. Creation of small groups of like-minded physicians to discuss and strategize ways to shift the direction of medicine can provide support, encouragement, actionable ideas, and the power of numbers in promoting a more satisfying future for both physicians and patients alike. Years of arduous training demonstrated that we are focused, hardworking, resourceful, resilient, and capable in many realms. While many of us focused these powers primarily on delivering good patient care, it’s now time to emerge from the chaos and put these strengths to use creating a future in which physicians feel healthy, respected, valued, and are given the opportunity to be the healers we want to be. Dr. Fronek is an assistant clinical professor of medicine at UC San Diego School of Medicine and a Certified Physician Development Coach.

CLASSIFIEDS VOLUNTEER OPPORTUNITIES

PHYSICIANS: HELP US HELP IMPROVE THE HEALTH LITERACY OF OUR SAN DIEGO COUNTY COMMUNITIES by giving a brief presentation (30–45 minutes) to area children, adults, seniors, or employees on a topic that impassions you. Be a part of Champions for Health’s Live Well San Diego Speakers Bureau and help improve the health literacy of those with limited access to care. For further details on how you can get involved, please email Andrew.Gonzalez@ChampionsFH.org. CHAMPIONS FOR HEALTH PROJECT ACCESS: Volunteer physicians are needed for the following specialties: endocrinology, ENT or head and neck, general surgery, GI, gynecology, neurology, ophthalmology, orthopedics, pulmonology, rheumatology, and urology. We are seeking these specialists throughout all regions of San Diego to support those that are uninsured and not eligible for MediCal receive short term specialty care. Commitment can vary by practice. The mission of Champions for Health’s Project Access is to improve community health, access to care for all, and wellness for patients and physicians through engaged volunteerism. Will you be a health CHAMPION today? For more information, contact Andrew Gonzalez at (858) 300-2787 or at Andrew.Gonzalez@ChampionsFH.org, or visit www.ChampionsforHealth.org. PHYSICIAN OPPORTUNITIES DERMATOLOGIST NEEDED: Premier dermatology practice in La Jolla seeking a part-time BC or BE dermatologist to join our team. Busy practice with significant opportunity for a motivated, entrepreneurial physician. Work with three energetic dermatologists and a highly trained staff in a positive work environment. We care about our patients and treat our staff like family. Opportunity to do medical/ surgical and cosmetic dermatology in an updated medical office with state-of-the art tools and instruments. Incentive plan will be a percentage based on production. If you are interested in finding out more information, please forward your C.V. to jmaas12@ hotmail.com RADY CHILDREN’S HOSPITAL - PEDIATRICIAN POSITIONS: Rady Children’s Hospital of San Diego seeking board-certified/eligible pediatricians or family practice physicians to join the Division of Emergency Medicine in the Department of Urgent Care (UC). Candidate will work at any of our six UC sites in San Diego and Riverside Counties. The position can be any amount of FTE (full-time equivalent) equal to or above 0.51 FTE. Must have an MD/DO or equivalent and must be board certified/eligible, have a California medical license or equivalent, PALS certification, and have a current DEA license. Contact Dr. Langley glangley@rchsd.org and Dr. Mishra smishra@rchsd.org. PER DIEM OBGYN LABORIST POSITION AVAILABLE: IGO Medical Group is seeking a per diem laborist to cover Labor and Delivery and emergency calls at Scripps Memorial Hospital in La Jolla. 70 deliveries/month. 24-hour shifts preferred but negotiable. Please send inquiries by email to IGO@ IGOMED.com. MEDICAL CONSULTANT – SAN DIEGO COUNTY: The County of San Diego, Health and Human Services Agency’s Public Health Services is looking for a Board Certified Family Practice or Internal Medicine physician for the Epidemiology and Communicable Disease Division. Under general direction, incumbents perform a variety of duties necessary for the identification, diagnosis, and control of communicable diseases within the popula-

tion. This position works closely with the medical and laboratory community, institutional settings, or hospital control practitioners. Learn more here: https://www.governmentjobs.com/careers/ sdcounty?keywords=21416207

KAISER PERMANENTE SAN DIEGO - PER DIEM PHYSIATRIST: Southern California Permanente Medical Group is an organization with strong values, which provides our physicians with the resources and support systems to ensure they can focus on practicing medicine, connecting with one another, and providing the best possible care to their patients. For consideration or to apply, visit https:// scpmgphysiciancareers.com/specialty/physicalmedicine-rehabilitation. For questions or additional information, please contact Michelle Johnson at 866-503-1860 or Michelle.S1.Johnson@kp.org. We are an AAP/EEO employer. PRIMARY CARE PHYSICIAN POSITION: San Diego Family Care is seeking a Primary Care Physician (MD/DO) at its Linda Vista location to provide direct outpatient care for acute and chronic conditions to a diverse adult population. San Diego Family Care is a federally qualified, culturally competent and affordable health center in San Diego, CA. Job duties include providing complete, high quality primary care, and participation in supporting quality assurance programs. Benefits include flexible schedules, no call requirements, a robust benefits package, and competitive salary. If interested, please email CV to sdfcinfo@sdfamilycare.org or call us at (858) 810- 8700. FAMILY MEDICINE OR INTERNAL MEDICINE PHYSICIAN: TrueCare is more than just a place to work; it feels like home. Sound like a fit? We’d love to hear from you! Visit our website at www.truecare. org. Under the direction of the Chief Medical Officer and the Lead Physician, ensure the provision of effective quality medical service to the patients of the Health center. The physician is responsible for assuring clinical procedures are continually and systematically followed, patient flow is enhanced, and customer service is extended to all patients at all times. PUBLIC HEALTH LABORATORY DIRECTOR: The County of San Diego is seeking a dynamic leader with a passion for building healthy communities. This is a unique opportunity for a qualified individual to work for a Level 3 Public Health Laboratory. The Public Health Services department, part of the County’s Health and Human Services Agency, is a local health department nationally accredited by the Public Health Accreditation Board and first of the urban health departments to be accredited. Public Health Laboratory Director-21226701UPH NEIGHBORHOOD HEALTHCARE MD, FAMILY PRACTICE AND INTERNISTS/HOSPITALISTS: Physicians wanted, beautiful Riverside County and San Diego County- High Quality Family Practice for a private-nonprofit outpatient clinic serving the communities of Riverside County and San Diego County. Work Full time schedule and receive paid family medical benefits. Malpractice coverage provided. Be part of a dynamic team voted ‘San Diego Top Docs’ by their peers. Please click the link to be directed to our website to learn more about our organization and view our careers page at www.Nhcare.org. PHYSICIAN WANTED: Samahan Health Centers is seeking a physician for their federally qualified community health centers that emerged over forty years ago. The agency serves low-income families and individuals in the County of San Diego in two (2) strategic areas with a high density population of Filipinos/Asian and other low-income, uninsured

individuals — National City (Southern San Diego County) and Mira Mesa (North Central San Diego). The physician will report to the Medical Director and provide the full scope of primary care services, including but not limited to diagnosis, treatment, coordination of care, preventive care and health maintenance to patients. For more information and to apply, please contact Clara Rubio at (844) 2002426 EXT 1046 or at crubio@samahanhealth.org. PRACTICE FOR SALE

OTOLARYNGOLOGY HEAD & NECK SURGERY SOLO PRACTICE FOR SALE: Otolaryngology Head & Neck Surgery solo practice located in the Ximed building on the Scripps Memorial Hospital La Jolla campus is for sale. The office is approximately 3,000 SF with 1 or 2 Physician Offices. It has 4 fully equipped exam rooms, an audio room, one procedure room, one conference room, one office manager room as well as in-house billing section, staff room and a bathroom. There is ample parking for staff and patients with close access to radiology and laboratory facilities. For further information please contact Christine Van Such at 858-354-1895 or email: mahdavim3@gmail.com OFFICE SPACE / REAL ESTATE AVAILABLE OFFICE AVAILABLE IN MISSION HILLS, UPTOWN SAN DIEGO: Close to Scripps Mercy and UCSD Hillcrest. Comfortable Arts and Crafts style home in upscale Mission Hills neighborhood. Converted and in use as medical/surgical office. Good for 1-2 practitioners with large waiting and reception area. 3 examination rooms, 2 physician offices and a small kitchen area. 1700 sq. ft. Available for full occupancy in March 2022. Contact by Dr. Balourdas at greg@thehanddoctor.com. OFFICE SPACE IN EL CENTRO, CA TO SHARE: Office in El Centro in excellent location, close to El Centro Regional Medical Centre Hospital is seeking Doctors of any specialty to share the office space. The office is fully furnished. It consists of 8 exam rooms, nurse station, Dr. office, conference room, kitchenette and beautiful reception. If you are interested or need more information please contact Katia at 760-427-3328 or email Feminacareo@gmail.com. OFFICE SPACE / REAL ESTATE WANTED MEDICAL OFFICE SUBLET DESIRED: Solo endocrinologist looking for updated bright office space in Encinitas or Carlsbad to share with another solo practitioner. Primary care, ENT, ob/gyn would be compatible fields. I would ideally have one consultation room and one small exam room but I am flexible. If the consultation room was large enough I could have an exam table in the same room and forgo the separate exam room. I have two staff members that will need a small space to answer phones and complete tasks. Please contact (858) 633-6959. NON-PHYSICIAN POSITIONS AVAILABLE ASSISTANT PUBLIC HEALTH LAB DIRECTOR: The County of San Diego is currently accepting applications for Assistant Public Health Lab Director. The future incumbent for Assistant Public Health Lab Director will assist in managing public health laboratory personnel who perform laboratory activities for the purpose of identifying, controlling, and preventing disease in the community, as well as assist with the development and implementation of policy and procedures relating to the control and prevention of disease and other health threats. Please visit the County of San Diego website for more information and to apply online.

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NOVEMBER/DECEMBER 2019 Official Publication of SDCMS

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Artificial Intelligence and Medicine THE DEBATE

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