Address Medical Mistrust to Recruit Minorities to COVID-19 Trials

To end HIV and control COVID-19, medicine must earn back the trust of people in Black, Latinx, and Native American communities, said Jonathan Mermin, MD, MPH, director of the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention at the CDC.

During the closing plenary of the United States Conference on HIV/AIDS October 21, Mermin laid out four principles behind those actions to the audience of USCHA:

  • Actively work with communities most affected by health inequities

  • Make plans to address them transparent

  • Work with community members on those plans and listen to their feedback

  • Do a good job

“Trust will come with proof of action,” he told the audience, watching virtually from their homes and offices.

But clinicians can take action in the exam room and during clinical trial recruitment to help the process along, said Russell Campbell, MA, deputy director of the Office of HIV/AIDS Network Coordination at the Fred Hutchinson Cancer Research Center, Seattle, Washington.

“Distrust in the medical and research establishment has deep roots,” he said during a presentation earlier in the week. To address this, clinicians must learn “culturally appropriate and meaningful engagement to influence the participation of historically underrepresented communities in healthcare and research.”

From Slavery to HeLa to Clinical Practice

Medical mistrust doesn’t stem only from the denial of treatment to the men who were part of the Tuskegee Syphilis Study. It also includes reckonings with the racist abuse of study participants by some of science’s most acclaimed leaders. Take, for instance, J. Marion Sims, MD, the so-called father of gynecology, who gained much of that information by experimenting without anesthesia on enslaved women; or Cornelius Rhoads, MD, whose name was removed from an award at the American Association for Cancer Research when objections grew concerning racist remarks Rhoads made about Puerto Rican patients in the 1930s. Or consider the story of Henrietta Lacks, the originator of the HeLa genes that have guided oncology research. Her genetic material was being mined for oncological insights without her permission and without compensation.

“The groups that have been systematically and intentionally denied treatment and known cures for diseases on behalf of research have just really taken the brunt,” Campbell said during a session role-playing best practices for addressing medical mistrust among potential clinical trial participants, conducted earlier in the conference.

“African Americans, American Indians, Puerto Ricans, Guatemalans, and others really still are heavily impacted by these abuses of research.”

And it shows in clinical outcomes. Research into HIV antiretroviral treatment adherence has found that medical mistrust was associated with a 76% likelihood that Black Americans living with HIV would be nonadherent to their treatments. But race-based medical mistrust drew into question the necessity of treatment at all.

A 2016 study in the journal AIDS Care found that although White gay men in Boston and primarily Black gay men in Jackson, Mississippi both reported concerns about side effects and lack of culturally appropriate care, it was the Black gay men in Jackson who expressed stronger medical mistrust

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Workers at 11 Tenet Healthcare Hospitals Across California Overwhelmingly Vote to Strike, Calling for Contract to Address Pandemic Safety

SEIU: Workers at 11 Tenet Healthcare Hospitals Across California Overwhelmingly Vote to Strike, Calling for Contract to Address Pandemic Safety

PR Newswire

LOS ANGELES, Oct. 27, 2020

Employees Want to Work with Tenet on a Contract that Ensures PPE, Staffing, and Clear Safety Protocols

LOS ANGELES, Oct. 27, 2020 /PRNewswire/ — Workers at 11 Tenet Healthcare hospitals in California have voted overwhelmingly to go on strike to demand that the giant hospital chain bargain in good faith with employees over health, safety, and other working conditions in their facilities, as caregivers continue to risk their lives caring for patients with COVID-19.

The strike vote covers 4,300 workers at the 11 facilities who are members of SEIU-United Healthcare Workers West. The vote margin was 96 percent in favor of the strike.

Tenet has rejected most of the workers’ proposals on pandemic safety. Workers are asking Tenet to go beyond the minimal federal guidelines to make sure the most comprehensive protections are in place.

“We are scared to come to work knowing we are at great risk of exposure to COVID-19,” said Gisella Thomas, a respiratory therapist at Desert Regional Medical Center in Palm Springs. “We want to work with management at our hospitals to increase protections for our health, our patients’ health, our families’ health, and the health of our communities. We have put forth a pandemic safety proposal that addresses issues workers are concerned about, like staffing, PPE, and increased COVID-19 testing for employees.” 

Tenet has made more than $1 billion in profits in the first three quarters of 2020 and received more than $250 million in taxpayer bailout money in California alone. Tenet’s Chief Executive Officer Ron Rittenmeyer was paid more than $24 million in 2019, and the chain’s president and chief operating officer Saum Sutaria was paid nearly $14 million.

“We are calling on Tenet to increase its investment in worker safety and staffing in the middle of the worst pandemic in over a century – to ensure the safety of healthcare workers, our patients, and our entire communities.”

The strike will occur at the following Tenet hospitals in California:

INDIO: John F. Kennedy Memorial Hospital
JOSHUA TREE: High Desert Medical Center
LAKEWOOD: Lakewood Regional Medical Center
LOS ALAMITOS: Los Alamitos Medical Center
MANTECA: Doctors Hospital of Manteca
MODESTO: Doctors Medical Center
PALM SPRINGS: Desert Regional Medical Center
SAN LUIS OBISPO: Sierra Vista Regional Medical Center
SAN RAMON: San Ramon Regional Medical Center
TEMPLETON: Twin Cities Community Hospital
TURLOCK: Emanuel Medical Center

SEIU-United Healthcare Workers West (SEIU-UHW) is one of the largest unions of hospital workers in the United States, with 97,000 members. Learn more at www.seiu-uhw.org.

 

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Consensus Guidelines Address Inpatient Diabetes Technology

A new consensus statement offers detailed guidelines for inpatient use of continuous glucose monitors (CGM) and automated insulin delivery (AID) systems.

Aimed at clinicians, researchers, and hospital administrators, the open-access document was recently published by a multidisciplinary international panel of 24 experts in the Journal of Diabetes Science and Technology.

The statement includes 77 separate recommendations under five headings: 1) continued use of CGM by patients already using them at home, 2) initiation of CGM in hospital, 3) continuation of AID systems in hospital by patients already using them at home, 4) logistics and hands-on care of hospitalized patients using CGM and AID systems, and 5) data management of CGM and AID systems in hospital.

“This is the most comprehensive and up-to-date guideline on the use of diabetes technology in the hospital now,” lead author Rodolfo J. Galindo, MD, told Medscape Medical News in an interview.

“Overall, most experts believe that CGM and AID have the potential to overcome the current limitations of glycemic monitoring in the hospital to improve patient outcomes but we need research, first to get the approval and second to get widespread use,” said Galindo, medical chair of the hospital diabetes taskforce at Emory Healthcare System, Atlanta, Georgia. 

COVID-19 Changed Everything

The guideline is an update of a 2017 statement on hospital use of CGM. The new guideine adds AID systems — sometimes referred to as an artificial pancreas, which combines a CGM and insulin pump and uses an algorithm to guide insulin delivery — and is the first to be developed during the COVID-19 era.

The update had been planned prior to the pandemic, but the actual panel meeting took place in April 2020, after the US Food and Drug Administration allowed inpatient use of CGM despite lack of official approval.

“COVID-19 changed everything…We had to be more specific about how to implement CGM in these patients. The standard of care is hourly point-of-care glucose monitoring in the [ICU], and at least every 4 hours outside the ICU. With limited [personal protective equipment] and the burden on nursing it was unachievable,” Galindo explained.

In June 2020, Galindo and other guideline authors developed a COVID-19-specific document (also open-access), which goes more into detail about CGM and how to implement in-hospital use during the pandemic.

The current consensus guideline “provides a high-level review of the evidence by experts,” Galindo added.

Recommendations Cover Different Technologies and Hospital Settings

The panel “strongly” advises that hospital providers consult with an inpatient diabetes team, if available, to help manage patients already using CGM prior to admission. Among other recommendations, they list several situations in which CGM data should not be relied upon for management decisions, including severe hyper- or hypoglycemia, diabetic ketoacidosis, or in patients with skin infections near the sensor site.

The panel also call for more research into outcomes for CGM continuation in the hospital and optimal implementation of both CGM and point-of-care glucose testing. For hospitals, strong recommendations include developing standard CGM data reports and

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New guidelines address rise in opioid use during pregnancy

Opioid use in pregnancy has prompted new guidance from the American Academy of Pediatrics, aimed at improving care for women and newborns affected by their mothers’ drug use.

The number of affected women and infants has increased in recent years but they often don’t get effective treatment, and the pandemic may be worsening that problem, said Dr. Stephen Patrick, lead author of the academy report released Monday.

“While we have been talking about the opioid crisis for years, pregnant women and their newborns seldom make it to the top of the heap. Infants are receiving variable care and not getting connected to services,” said Patrick, a Vanderbilt University pediatrician.


The academy’s report says pregnant women should have access to opioid medication to treat opioid misuse. Two opioids, buprenorphine and methadone, are effective treatments but pregnant women often face stigma in using them and doctors who prescribe them are scarce.

The academy says hospitals should written protocols for assessing and treating opioid-affected newborns. Many don’t and practices vary widely.

Breastfeeding and other practices that promote bonding should be encouraged, and parent education and referral to services for affected newborns should be provided, the academy says. Its recommendations echo guidance from other medical groups and the U.S. government.

“This is a substantial public health problem that is still lacking solutions,” Patrick said.

According to the federal Centers for Disease Control and Prevention, 7% of U.S. women reported in 2019 that they had used prescription opioids during pregnancy. One in 5 of those women reported misusing the drugs while pregnant.

Some infants born to these women develop symptoms of opioid withdrawal, including tremors, fussiness and diarrhea.

By some U.S. estimates, nearly 80 affected infants are diagnosed every day on and the numbers have tripled in recent years.

Patrick has done research suggesting that these infants may be at risk for developmental delays, but says it’s possible those findings reflect use of alcohol or other drugs during pregnancy, poor prenatal care or stress.

“Getting into treatment may be getting even harder” because of the pandemic, he said. “There’s so much going on in the world that that issues involving opioid use are flying under the radar.”

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Follow AP Medical Writer Lindsey Tanner at @LindseyTanner.

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The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Department of Science Education. The AP is solely responsible for all content.

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