The Conversation -- Many Americans think of power outages as infrequent inconveniences, but that’s quickly changing. Nationwide, major power outages have increased tenfold since 1980, largely because of an aging electrical grid and damage sustained from severe storms as the planet warms.
At the same time, electricity demand is rising as the population grows and an increasing number of people use electricity to cool and heat their homes, cook their meals, and power their cars. A growing number of Americans also rely on electricity-powered medical equipment, such as oxygen concentrators to help with breathing, lifts for movement, and infusion pumps to deliver medications and fluids to their bodies.
For older adults and others with health conditions, a loss of power may be more than an inconvenience. It can be life-threatening.
We studyenvironmental health, including the effects of extreme heat and storms on people. In a new study, we analyzed data from New York City and the surrounding area to understand how severe weather drives power outages and who is most at risk, particularly in urban areas.
Low-Income Communities Often at Highest Risk
How quickly power returns in a community is often shaped by history.
Current policies can also exacerbate outages for these populations. For example, many electric utilities prioritize power restoration to regions with community assets, such as mass transit, hospitals, police or fire stations, and sewage and water stations, as well as regions with larger populations.
Though these guidelines appear neutral, they can inadvertently prolong outages for less populated areas and areas lacking resources, including these key assets. For example, following Tropical Storm Ida in September 2021, Con Edison outlined areas with important community assets as priorities for restoring power. Manhattan had power back within hours, while many low-income and largely Minority parts of Queens, the Bronx, and Brooklyn waited for days.
"
A 6- to 8-hour power-restoration threshold is particularly important for people who rely on electricity to power medical equipment.
Emerging evidence from studies on power outages in Texas, Florida, the Southeast, and a national study, along with our new research in New York, shows that outages especially burden communities that don’t have adequate funding.
Complex Weather and Battery-Life Thresholds
Across New York state, we found that 40% of all outages from 2017-2020 followed severe weather – heat, cold, wind, rainstorms, snowstorms, or lightning – within 8 hours. While each type of severe weather alone could lead to prolonged outages, in combination they resulted in much longer outages.
Statewide, for example, strong winds alone led to outages lasting 12 hours on average, and heavy precipitation resulted in outages lasting 6 hours on average. But when wind and precipitation happened simultaneously, the outages lasted closer to 17 hours on average.
We also looked at whether socially vulnerable communities faced more weather-driven outages than other communities. In short, the answer was yes, though the effects varied in different parts of the state and by the type of weather event.
In New York City, we found that heat-, precipitation- and wind-driven outages occurred more frequently in socially vulnerable communities, including in Harlem, Upper Manhattan, the South Bronx, and Eastern Queens. This matters because socially vulnerable neighborhoods have higher poverty rates and lower-quality housing. Community members may lack access to health care or suffer from underlying health conditions.
On average, the duration of precipitation-driven outages was longest in areas of the city with the highest social vulnerability. In neighborhoods with vulnerability scores in the top 25% – meaning the most vulnerable neighborhoods – outages lasted 12.4 hours on average, compared with 7.7 hours in those neighborhoods in the bottom 25%.
In rural parts of the state, outages related to downpours or snowstorms were also longest in areas with high social vulnerability.
Outages Are Quick to Follow Heat Spikes
As temperatures rise over the summer, it’s important for communities to consider the dangers that outages can present for disabled persons, older adults, and others with health conditions, particularly in socially vulnerable communities.
With the granular data we obtained from the State Department of Public Service, we could zoom in on how fast outages began following extreme weather.
Across the state, outages began quickly – within 6 hours of extremely hot temperatures spiking – likely as more people turned on their air conditioners. This means the outages likely occur while it is still hot, exposing individuals to extreme heat, without power for air conditioners or fans.
This outage trend will likely continue as climate change intensifies, bringing more frequent extreme weather to an aging grid in which many parts are nearing or surpassing their life spans.
There are steps communities and power providers can take to reduce people’s exposure to power outages and the health harms that can accompany them.
In the short term, cities can develop targeted plans for these communities to ensure that residents have ways to cool off during heat waves. That includes providing ample cooling centers, swimming pools, and public parks with shade trees. It can also include transportation support for older adults and others with mobility issues.
In the long term, reducing these risks means updating the power grid, weatherizing buildings, planting trees to reduce urban heat island effects and investing in distributed energy resources, such as solar power and batteries for energy storage.
We believe this work should prioritize communities that most need these updates, following the lead of New York state’s Weatherization Assistance Program, which aims to improve energy efficiency for low-income households.
This article is republished from The Conversation under a Creative Commons license.
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Case 1
A 58-year-old woman presents for evaluation of palmar blisters that appeared 2 months ago. The blisters are intensely pruritic and the severity of itching waxes and wanes. The patient is otherwise healthy, enjoys gardening, and frequently handles plants and soil without gloves. She has a long history of “sensitive skin” but reports not using moisturizer frequently. On physical examination, many deep-seated small subcutaneous vesicles (resembling the pearls of tapioca pudding) are seen scattered on the bilateral palms, coalescing into tense blisters in certain areas. Mild diffuse xerosis of the skin is noted.
Can you diagnose this condition?
Bullous tinea manuum
Irritant contact dermatitis
Palmoplantar pustular psoriasis
Dyshidrotic Eczema
Answer: Dyshidrotic Eczema
Dyshidrotic eczema (DE) is a clinical variant of palmoplantar dermatitis presenting as a pruritic vesiculobullous eruption affecting the palms or soles. The term dyshidrosis was first used to describe this entity in 1873 by English dermatologist Tilbury Fox, who mistakenly attributed the condition to a disorder of sweat glands.1 In 1876, Sir Jonathan Hutchinson described the same condition under the name of cheiropompholyx: cheiro derives from the Greek for hand and pompholyx from the Greek for bubble.1 Although understanding of the pathophysiologic mechanism has evolved with time, the terms dyshidrosis and pompholyx are both still in use.1-3
The exact incidence and prevalence of DE is difficult to ascertain. In an analysis of insurance claims data from the IBM MarketScan Commercial Database, which currently includes information from 50 million Americans, 35,000 people were diagnosed with DE in 2018.4 Among these patients there was a slight female predominance and the average age of diagnosis is in the 4th decade of life.4 Children were the least common age group diagnosed with DE.4 In this same study, the most common occupations of DE patients were in the service industry or in manufacturing.4
The mechanism of DE is not fully understood. Contrary to what the name dyshidrosis would suggest, DE is not caused by sweat duct pathology. However, DE patients often have coexisting palmoplantar hyperhidrosis that can exacerbate their DE, likely because of a contributory irritant reaction.2 Some authors consider DE to be merely a manifestation of other conditions that can cause hand dermatitis (eg, atopic dermatitis, allergic or irritant contact dermatitis, etc) rather than its own disease entity.3 Reported triggers include ingestion of certain substances, such as nickel, intravenous immunoglobulin (IVIG) administration, stress, heat, and sunlight.3
Clinically, acute DE is characterized by the sudden onset of tense deep-seated vesicles that can coalesce into bullae, symmetrically distributed on the palms or soles but often favoring the lateral digits, with intense pruritus. The vesicles are classically described as appearing like the pearls of tapioca pudding.2,3,5 The condition usually involves episodes of relapse and remission, and vesicles often resolve with desquamation of thick scales.3
Histologically, intense spongiosis is seen that can progress to intraepidermal vesicle formation. Sweat glands are normal.3,6
Diagnosis of DE is primarily clinical. Skin conditions that must be excluded include bullous tinea manuum or pedis, allergic or irritant contact dermatitis, scabies, and palmoplantar pustular psoriasis.
Tinea manuum is frequently accompanied by tinea pedis or onychomycosis; therefore, the patient’s feet should be checked. Scraping of scale with potassium hydroxide (KOH) preparation can be performed to look for fungal hyphae, or a swab for fungal culture can be collected. Although it is a more invasive test, a biopsy may reveal fungal hyphae in the stratum corneum.6
Psoriatic nail manifestations such as pitting, onycholysis, or ridging, classic psoriasiform lesions observed elsewhere on the body, or family history of psoriasis can raise suspicion for palmoplantar pustular psoriasis (PPPP), rather than DE.7 Smoking, tumor necrosis factor alpha inhibitors (TNF-α), and lithium have all been associated with PPPP.2,7 Histologic evaluation can help distinguish PPPP from DE; PPPP demonstrates neutrophils in the stratum corneum forming pustules and minimal spongiosis.2,6
A careful social history that considers the patient’s occupation and hobbies should be taken to investigate potential allergen or irritant exposures and to exclude contributory contact dermatitis. Patch testing for common allergens may be considered.
Scabies can also present with acral vesiculopustules and intense pruritus. However, scabies classically presents with linear interdigital burrows representing the intracorneal path of the burrowing mite. Additional sites frequently involved in adult scabies, unlike DE, are the groin, axillae, umbilicus, areolae, and buttocks.2 Household contacts of scabies patients may also exhibit similar symptoms, whereas household contacts of DE patients would be expected to be unaffected. If scabies is suspected, mineral oil preparation of a skin scraping should be evaluated under the microscope to look for mites or scybala.2 A punch biopsy for H&E stain evaluation can sometimes capture a mite as well.
Initial treatment of DE primarily involves thick, bland emollients and topical corticosteroid application. Topical calcineurin inhibitors or topical retinoids may be helpful adjunctive therapy.3,5 Patients should be counseled to avoid common irritants such as household cleaners and prolonged water exposure, and to wear gloves during activities such as dishwashing and gardening. If patients have concomitant palmar or plantar hyperhidrosis, this should be treated as it can also help their DE.2 Patch testing can be considered to exclude contributory allergic contact dermatitis.
For chronic refractory cases recalcitrant to initial therapy, psoralen and UVA phototherapy (PUVA), dupilumab, oral retinoids, or systemic immunosuppressants can be considered.3,5,7
The patient in this case was prescribed clobetasol 0.05% ointment and instructed to apply twice daily, with petroleum jelly over top and under occlusion. She was advised to start wearing protective gloves while washing dishes and gardening. After several weeks she experienced marked improvement in her symptoms, continuing with daily petroleum jelly application and glove protection for maintenance. However, she still occasionally uses clobetasol 0.05% ointment twice daily as-needed for intermittent flares.
Case 2
A 42-year-old man with no significant past medical history presents for evaluation of a rash involving one of his hands and both feet that has been present for several months. The rash is intensely pruritic and the patient has tried over-the-counter 1% hydrocortisone cream, which offers mild benefit, but the rash worsens after discontinuation. Physical examination reveals scaly annular plaques in a moccasin distribution on the bilateral soles of the feet, thick yellow dystrophic toenails, and a scaly annular plaque on his left hand. On the hand and both feet, the plaques are studded with small 1-mm pustules.
Can you diagnose this condition?
Irritant contact dermatitis
Scabies
Bullous tinea
Palmoplantar pustular psoriasis
Answer: Bullous Tinea
Dermatophyte derives from the Greek meaning skin and plant. Dermatophytes are a group of filamentous fungi that cause cutaneous infections in humans and animals by infiltrating keratinized tissues. Dermatophyte infections likely have afflicted mammals since prehistoric times.9,10
The Sanskrit medical text Charaka Samhita from the 2nd century BC documents a condition, called Dadu, reminiscent of tinea corporis.9 Approximately 30 AD, the Roman medical encyclopedist Aulus Cornelius Celsus described a purulent scalp condition that was later dubbed “the kerion of Celsus,” a highly inflammatory form of tinea capitis.10 For centuries this group of cutaneous diseases have been called tineas, which is Latin for moths. This naming reflected the pathogenic entity’s noted predilection for keratinized tissues, like that of clothes-eating moths that also consume keratin in textiles, fabrics, rugs, etc.10 Given the frequently annular shape on the skin, the English word ringworm has been used for centuries to describe this same condition.10 In 1837, Polish physician Robert Remak discovered hyphae in favus, another severe form of tinea capitis, illuminating the fungal etiology of tinea conditions.10 In 1934, the American mycologist Chester Emmons proposed a taxonomic schema of dermatophytes that is still widely used today, which divided the group into 3 genera: Microsporum, Trichophyton, and Epidermophyton.9
In common nomenclature, a dermatophyte infection is called tinea followed by the Latin word indicating the cutaneous location affected. For example: tinea corporis is a dermatophyte infection of the body, tinea pedis is a dermatophyte infection of the foot, and tinea manuum is a dermatophyte infection of the hand.
It is estimated that one-fourth of the world population suffers from superficial fungal infections, and the majority of these are dermatophyte infections.11-13 According to the US Centers for Disease Control and Prevention (CDC), there were nearly 5 million outpatient visits for dermatophyte infections in the US between 2005 and 2014.11 Most tinea infections occur in adults, except for tinea capitis, which is more common in childhood.14 Risk factors for dermatophyte infection include warm humid climates, living environments with poor hygienic conditions and crowding, male sex, diabetes mellitus, and household contacts with tinea infections.11,12,14
Dermatophytes can be transmitted to humans from other humans, animals, or environmental sources like soil.14 Dermatophytes produce keratinases that enable them to infiltrate the stratum corneum.14 Areas of compromised skin barrier are at increased risk for dermatophyte invasion.14 The most common dermatophytes causing tinea manuum are Trichophyton rubrum, Trichophyton mentagrophytes, and Epidermophyton floccosum.14 Generally, the incubation period for a dermatophyte infection is 1 to 3 weeks, followed by the development of an erythematous scaling plaque that may be annular with central clearing.14 Tinea infections are typically pruritic.
Compared with other tinea infections, tinea manuum often involves minimal inflammation and manifests predominantly with scale. However, tinea manuum can alternatively present with prominent scale, even involving vesicles or pustules (as with the patient in this case).14 In cases of tinea manuum, there is often concomitant tinea pedis, so the feet should be examined as well. Tinea manuum is rarely associated with onychomycosis of the fingernails.14
To diagnose tinea manuum, a clinical examination is often sufficient in classic cases. If the patient also has concomitant tinea pedis or if the scaly plaque on the hand is very annular, the diagnosis of tinea manuum may be obvious. However, scraping the scale for KOH preparation can be helpful; if fungal hyphae are seen under the microscope, this may help diagnose a dermatophyte infection. In indeterminate cases where the clinical examination and KOH preparation are not diagnostic, a punch biopsy can be performed.
Histology of dermatophytosis typically shows a spongiotic epidermis with fungal hyphae in the stratum corneum. When vesicles or pustules are present clinically, intra-epidermal vesicles or pustules may be present on histology.6
The differential diagnosis of vesiculobullous tinea manuum includes allergic or irritant contact dermatitis, scabies, or palmoplantar pustular psoriasis. Scraping of scale for KOH preparation would not reveal fungal hyphae in these other conditions. Additionally, a biopsy of these other entities would not show fungal hyphae in the stratum corneum. Typical scabies on the hands has interdigital linear burrows representing the path of the mite, and co-involvement of intertriginous regions is common in adults with scabies.2 Mineral oil preparation of a scraped burrow in scabies often captures the mites or scybala, a finding not present in tinea. Allergic or irritant contact dermatitis usually improves with limited topical steroids and continued avoidance of triggering exposures. If a tinea infection is incorrectly diagnosed as eczematous condition and treated with topical steroids, transient improvement is seen followed by prominent flare after steroid withdrawal; this phenomenon is called “tinea incognito.” Patients with palmoplantar pustular psoriasis may demonstrate other stigmata of psoriasis, such as nail pitting or psoriatic lesions elsewhere on the body.7
Treatment of tinea manuum is similar to the treatment of other dermatophyte infections. If the tinea manuum is mild and limited in extent, topical antifungals with antidermatophyte activity such as terbinafine 1% cream can be used for several weeks. If the tinea manuum is severe, or if there is extensive tinea infection elsewhere (such as tinea pedis or onychomycosis), then a course of oral antifungals such as terbinafine should be considered. Other oral antifungal agents with antidermatophyte activity include fluconazole, itraconazole, and griseofulvin.14
Fungal culture for speciation and sensitivities can be considered at the time of diagnosis or if the condition is refractory to first-line empiric antifungal treatment.
The patient in this case was treated with oral terbinafine (250 mg/d) and counseled to discontinue any topical steroid use. An oral, extended terbinafine course of 12 weeks was chosen because of concomitant onychomycosis along with the tinea manuum. The patient experienced full resolution of his tinea manuum and tinea pedis several weeks into his treatment course. Six months after his treatment, his toenails grew out with a normal appearance.
Table. Dyshidrotic Eczema vs Tinea Manuum
Dyshidrotic Eczema
Tinea Manuum
Clinical Presentation
Pruritus?
Yes
Yes
Usually bilateral on hands?
Yes
No
Tinea pedis often present?
No
Yes
KOH preparation
Negative for fungal hyphae
Positive for fungal hyphae
Histology
Intense spongiosis, intra-epidermal vesicle
Fungal hyphae in stratum corneum, intraepidermal vesicle or subcorneal pustule
Further tests
-Patch testing -Biopsy
-Fungal culture -Biopsy
Treatment
-Thick, bland emollients - High potency topical steroids - Avoidance of exposures that could worsen condition (eg, water, common allergens) -Treat hyperhidrosis, if present - If refractory consider phototherapy, dupilumab
- If limited/mild: topical antifungals such as terbinafine cream - If severe/extensive: oral antifungals
KOH, potassium hydroxide preparation
Leah Douglas, MD, is a dermatology resident at Baylor Collegeof Medicine, in Houston, Texas.
April was Stress Awareness Month, the perfect excuse to get stress under control. Although cardiologists may recognize the undeniable link between stress and heart health, they’re far from immune to its harmful effects. Mindfulness is a promising way for physicians and patients to find relief.
Mindfulness is an ancient practice gaining steady traction in modern medicine. This cost-effective intervention improves quality of life and reduces health care costs and hospitalizations.1 In addition, mindfulness interventions don’t interfere with existing treatment plans but may enhance their efficacy.
Although mindfulness can be packaged into different formats (meditation, yoga, or as part of cognitive behavioral therapy), the basic principle involves actively focusing on the present to relax the body and mind.
The time has come for overstressed physicians to teach by example through practicing mindfulness. If you’re still not convinced, here’s the evidence.
Taking control of the heart-mind connection
The relationship between stress and cardiovascular health is complex. When the body perceives a threat or experiences stress, it triggers a cascade of physiological responses, including the release of stress hormones such as cortisol and epinephrine. These hormones spike heart rates, raise blood pressure, elevate blood sugar, and boost inflammation.
Chronic stress, characterized by persistent activation of the body's stress responses, can assault the cardiovascular system over time. Research has established a clear link between chronic stress and an increased risk for hypertension, heart disease, and stroke. Moreover, stress worsens existing cardiovascular conditions, making management and treatment more challenging.
The impact of stress on heart health is well-established. Although mindfulness has become a popular buzzword in health and wellness spaces, it’s not necessarily a common practice. Fortunately, basic mindfulness exercises can be done anywhere, anytime. All you need is a few minutes in a quiet space.
To practice mindful meditation, follow these steps:
Sit down, close your eyes, and practice deep, slow breathing.
Consciously relax each muscle group, starting with the lower body.
As you work your way up, shrug your shoulders and roll your head in different directions.
Choose a calming word and say it quietly with each exhalation, like “peace.”
Continue for 5 to 10 minutes. As your thoughts wander, refocus back on meditating.2
Group mindfulness programs can increase accountability for regular practice. Making a conscious effort to focus on the present and clear your mind can turn almost any steady-state activity into a mindfulness exercise, including walking, swimming, and bike riding.2 Participating in mind-body activities helps harness the benefits of mindfulness while providing the added benefit of some physical exercise, through tai chi and yoga, for example.
Is mindfulness worth it?
While most physicians agree that their patients would benefit from mindfulness practices, carving out time for mindfulness isn’t always a priority for doctors themselves. Knowing in real numbers how mindfulness can impact health helps build a case for it.
Numerous studies have demonstrated that calming the mind calms the body. A 2013 review of 9 studies published in the AHA journal Hypertension found meditation reduces systolic blood pressure by 4.7 mm Hg and diastolic by 3.2 mm Hg.2 In another study, 5 minutes of daily meditation positively affected heart rate variability. This measure of heart attack and stroke in those without cardiovascular disease showed improvements within just 10 days of consistent meditation practice.2
In another meta-analysis, which included 16 studies and 1,476 adults, mindfulness-based interventions significantly improved psychological distress, enhancing self-awareness, attention, and emotional regulation.3 This review observed more drastic impacts on blood pressure, with an average 14 mm Hg reduction in systolic and a 5 mm Hg decrease in diastolic readings for participants in mindfulness-based intervention versus control groups.
Most recently, a 2024 meta-analysis of 12 randomized controlled trials confirmed that structured mindfulness-based intervention programs effectively reduce blood pressure in participants with prehypertension and hypertension.4 These benefits were more pronounced in men. The researchers noted, “In addition, the results also support previous studies which showed that MBIs [mindfulness-based interventions] can lower blood pressure in patients with other diseases, such as breast cancer survivors, coronary heart disease, and diabetic patients.”
By promoting relaxation responses, mindfulness modulates stress hormone levels, counteracting the harmful physical effects of chronic stress. It targets emotional distress, helping prevent disease and slow disease progression.
In a systematic review of mindfulness interventions for patients with heart failure, researchers concluded that practicing mindfulness is “beneficial for patients with heart failure in reducing depression and anxiety and enhancing health-related quality of life in the short term.”1 Some studies noted improvements in physical symptoms like fatigue, unsteadiness, dizziness, and breathlessness. In 1 of the studies reviewed, researchers observed sustained positive effects on depression and anxiety lasting 3 months and 6 months after the completion of mindfulness programs.
Although the long-term effects aren’t always documented in studies, there’s no downside to practicing mindfulness, and the potential for ongoing benefits makes developing a mindfulness habit worthwhile.
Why cardiologists need mindfulness
Physicians, as caregivers entrusted with the health and well-being of others, often find themselves navigating high-pressure environments fraught with stressors. From demanding workloads and long hours to the emotional toll of patient care, the medical profession is inherently predisposed to stress and burnout.
Studies show physician burnout is at an all-time high, and cardiologists are no exception. One survey of almost 6,000 cardiologists found that 42% of cardiologists feel burned out, and 83% have symptoms of colloquial depression.5 While 16.9% of cardiologists surveyed reported having a mental illness, only 34.2% attempted to get help. The top cited barriers stopping cardiologists from seeking mental health support included privacy concerns (34.5%), time constraints (30.8%), shame (29.5%), and fears about how it would impact their professional advancement (28.6%).
Although mindfulness isn’t a sufficient replacement for mental health treatment, it’s a practical option with the potential to improve cardiologists’ everyday lives. By integrating mindfulness practices into their daily routines, physicians can develop a greater self-awareness, emotional regulation, and compassion for patients.
Prioritizing self-care and stress management sets a positive example for patients and colleagues, reinforcing the importance of holistic health practices. Cardiologists can lead the way in championing initiatives that promote a culture of well-being and mindfulness among others.
Stress Awareness Month isn’t just for patients. Cardiologists can harness the power of mindfulness and other stress management strategies to improve their lives. By learning and doing mindful meditation, cardiologists promote the highest level of heart health care for themselves and others.
A 46-year-old man presents to urgent care 2 weeks ago after a fall while working on a construction site. He was framing a house when he lost his balance and fell off a platform onto his right knee and left wrist. The wrist and right knee became significantly painful, which prompted him to present to an urgent care clinic. Radiographs of the wrist are taken at the clinic and are negative for a fracture. No images of the knee are taken at this initial visit. He is placed in a wrist splint and hinged knee brace to the right knee with instructions to weight bear as tolerated and follow up with orthopedics.
He presents to orthopedics with increasing right knee pain and instability. He denies having a previous knee injury and any current numbness to the right leg. On physical examination, he has gross instability about his knee with significant gapping medially with valgus stress. He has positive anterior drawer, positive posterior drawer, and positive Lachman test. He has palpable posterior tibialis and dorsal pedialis pulses and has good strength with dorsiflexion and plantar flexion of the toes and ankle. He is able to do a straight leg raise as well. Radiographs (AP and lateral view) are taken (Figures 1 and 2).
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