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Systemic Racism and Health Disparities: A Statement from Editors of Family Medicine Journals
The year 2020 was marked by historic protests across the United States and the globe sparked by the deaths of George Floyd, Ahmaud Arbery, Breonna Taylor, and so many other Black people. The protests heightened awareness of racism as a public health crisis and triggered an antiracism movement. Racism is a pervasive and systemic issue that has profound adverse effects on health.1,2 Racism is associated with poorer mental and physical health outcomes and negative patient experiences in the health care system.3,4 As evidenced by the current coronavirus pandemic, race is a sociopolitical construct that continues to disadvantage Black, Latinx, Indigenous, and other People of Color.5,6,7,8 The association between racism and adverse health outcomes has been discussed for decades in the medical literature, including the family medicine literature. Today there is a renewed call to action for family medicine, a specialty that emerged as a counterculture to reform mainstream medicine,9 to both confront systemic racism and eliminate health disparities. This effort will require collaboration, commitment, education, and transformative conversations around racism, health inequity, and advocacy so that we can better serve our patients and our communities.
The editors of several North American family medicine publications have come together to address this call to action and share resources on racism across our readerships. We acknowledge those members of the family medicine scholar community who have been fighting for equity consistent with the Black Lives Matter movement by writing about racism, health inequities, and personal experiences of practicing as Black family physicians. While we recognize that much more work is needed, we want to amplify these voices. We have compiled a bibliography of scholarship generated by the family medicine community on the topic of racism in medicine.
The collection can be accessed here.
While this list is likely not complete, it does include over 250 published manuscripts and demonstrates expertise as well as a commitment to addressing these complex issues. For example, in 2016, Dr. J. Nwando Olayiwola, chair of the Department of Family Medicine at Ohio State University, wrote an essay on her experiences taking care of patients as a Black family physician.10 In January of 2019, Family Medicine published an entire issue devoted to racism in education and training.11 Dr. Eduardo Medina, a family physician and public health scholar, co-authored a call to action in 2016 for health professionals to dismantle structural racism and support Black lives to achieve health equity. His recent 2020 article builds on that theme and describes the disproportionate deaths of Black people due to racial injustice and the COVID-19 pandemic as converging public health emergencies.12,13 In the wake of these emergencies a fundamental transformation is warranted, and family physicians can play a key role.
We, the editors of family medicine journals, commit to actively examine the effects of racism on society and health and to take action to eliminate structural racism in our editorial processes. As an intellectual home for our profession, we have a unique responsibility and opportunity to educate and continue the conversation about institutional racism, health inequities, and antiracism in medicine. We will take immediate steps to enact tangible advances on these fronts. We will encourage and mentor authors from groups underrepresented in medicine. We will ensure that content includes an emphasis on cultural humility, diversity and inclusion, implicit bias, and the impact of racism on medicine and health. We will recruit editors and editorial board members from groups underrepresented in medicine. We will encourage collaboration and accountability within our specialty to confront systemic racism through content and processes in all of our individual publications. We recognize that these are small steps in an ongoing process of active antiracism, but we believe these steps are crucial. As editors in family medicine, we are committed to progress toward equity and justice.
Simultaneously published in American Family Physician, Annals of Family Medicine, Canadian Family Physician, Family Medicine, FP Essentials, FPIN/Evidence Based Practice, FPM, Journal of the American Board of Family Medicine, The Journal of Family Practice, and PRiMER.
Acknowledgement –
The authors thank Renee Crichlow, MD, Byron Jasper, MD, MPH, and Victoria Murrain, DO, for their insightful comments on this editorial.
1. Institute of Medicine (US) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care, Smedley BD, Stith AY, Nelson AR, eds. Unequal treatment: confronting racial and ethnic disparities in health care. Washington, DC: National Academies Press; 2003.
2. Bailey ZD, Krieger N, Agénor M, Graves J, Linos N, Bassett MT. Structural racism and health inequities in the USA: evidence and interventions. Lancet. 2017;389(10077):1453-1463.
3. Ben J, Cormack D, Harris R, Paradies Y. Racism and health service utilisation: A systematic review and meta-analysis. PLoS One. 2017;12(12):e0189900.
4. Paradies Y, Ben J, Denson N, et al. Racism as a determinant of health: a systematic review and meta-analysis. PLoS One. 2015;10(9):e0138511.
5. American Academy of Family Physicians. Institutional racism in the health care system. Published 2019. Accessed Sept. 15, 2020. https://www.aafp.org/about/policies/all/institutional-racism.html.
6. Yaya S, Yeboah H, Charles CH, Otu A, Labonte R. Ethnic and racial disparities in COVID-19-related deaths: counting the trees, hiding the forest. BMJ Glob Health. 2020;5(6):e002913.
7. Egede LE, Walker RJ. Structural Racism, Social Risk Factors, and Covid-19 — A Dangerous Convergence for Black Americans [published online ahead of print, 2020 Jul 22]. N Engl J Med. 2020;10.1056/NEJMp2023616.
8. Centers for Disease Control and Prevention. Health equity considerations and racial and ethnic minority groups. Updated July 24, 2020. Accessed Sept. 15, 2020. https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/race-ethnicity.html
9. Stephens GG. Family medicine as counterculture. Fam Med. 1989;21(2):103-109.
10. Olayiwola JN. Racism in medicine: shifting the power. Ann Fam Med. 2016;14(3):267-269. https://doi.org/10.1370/afm.1932.
11. Saultz J, ed. Racism. Fam Med. 2019;51(1, theme issue):1-66.
12. Hardeman RR, Medina EM, Kozhimannil KB. Structural racism and supporting black lives - the role of health professionals. N Engl J Med. 2016;375(22):2113-2115. https://doi.org/10.1056/NEJMp1609535.
13. Hardeman RR, Medina EM, Boyd RW. Stolen breaths. N Engl J Med. 2020;383(3):197-199. 10.1056/NEJMp2021072.
The year 2020 was marked by historic protests across the United States and the globe sparked by the deaths of George Floyd, Ahmaud Arbery, Breonna Taylor, and so many other Black people. The protests heightened awareness of racism as a public health crisis and triggered an antiracism movement. Racism is a pervasive and systemic issue that has profound adverse effects on health.1,2 Racism is associated with poorer mental and physical health outcomes and negative patient experiences in the health care system.3,4 As evidenced by the current coronavirus pandemic, race is a sociopolitical construct that continues to disadvantage Black, Latinx, Indigenous, and other People of Color.5,6,7,8 The association between racism and adverse health outcomes has been discussed for decades in the medical literature, including the family medicine literature. Today there is a renewed call to action for family medicine, a specialty that emerged as a counterculture to reform mainstream medicine,9 to both confront systemic racism and eliminate health disparities. This effort will require collaboration, commitment, education, and transformative conversations around racism, health inequity, and advocacy so that we can better serve our patients and our communities.
The editors of several North American family medicine publications have come together to address this call to action and share resources on racism across our readerships. We acknowledge those members of the family medicine scholar community who have been fighting for equity consistent with the Black Lives Matter movement by writing about racism, health inequities, and personal experiences of practicing as Black family physicians. While we recognize that much more work is needed, we want to amplify these voices. We have compiled a bibliography of scholarship generated by the family medicine community on the topic of racism in medicine.
The collection can be accessed here.
While this list is likely not complete, it does include over 250 published manuscripts and demonstrates expertise as well as a commitment to addressing these complex issues. For example, in 2016, Dr. J. Nwando Olayiwola, chair of the Department of Family Medicine at Ohio State University, wrote an essay on her experiences taking care of patients as a Black family physician.10 In January of 2019, Family Medicine published an entire issue devoted to racism in education and training.11 Dr. Eduardo Medina, a family physician and public health scholar, co-authored a call to action in 2016 for health professionals to dismantle structural racism and support Black lives to achieve health equity. His recent 2020 article builds on that theme and describes the disproportionate deaths of Black people due to racial injustice and the COVID-19 pandemic as converging public health emergencies.12,13 In the wake of these emergencies a fundamental transformation is warranted, and family physicians can play a key role.
We, the editors of family medicine journals, commit to actively examine the effects of racism on society and health and to take action to eliminate structural racism in our editorial processes. As an intellectual home for our profession, we have a unique responsibility and opportunity to educate and continue the conversation about institutional racism, health inequities, and antiracism in medicine. We will take immediate steps to enact tangible advances on these fronts. We will encourage and mentor authors from groups underrepresented in medicine. We will ensure that content includes an emphasis on cultural humility, diversity and inclusion, implicit bias, and the impact of racism on medicine and health. We will recruit editors and editorial board members from groups underrepresented in medicine. We will encourage collaboration and accountability within our specialty to confront systemic racism through content and processes in all of our individual publications. We recognize that these are small steps in an ongoing process of active antiracism, but we believe these steps are crucial. As editors in family medicine, we are committed to progress toward equity and justice.
Simultaneously published in American Family Physician, Annals of Family Medicine, Canadian Family Physician, Family Medicine, FP Essentials, FPIN/Evidence Based Practice, FPM, Journal of the American Board of Family Medicine, The Journal of Family Practice, and PRiMER.
Acknowledgement –
The authors thank Renee Crichlow, MD, Byron Jasper, MD, MPH, and Victoria Murrain, DO, for their insightful comments on this editorial.
The year 2020 was marked by historic protests across the United States and the globe sparked by the deaths of George Floyd, Ahmaud Arbery, Breonna Taylor, and so many other Black people. The protests heightened awareness of racism as a public health crisis and triggered an antiracism movement. Racism is a pervasive and systemic issue that has profound adverse effects on health.1,2 Racism is associated with poorer mental and physical health outcomes and negative patient experiences in the health care system.3,4 As evidenced by the current coronavirus pandemic, race is a sociopolitical construct that continues to disadvantage Black, Latinx, Indigenous, and other People of Color.5,6,7,8 The association between racism and adverse health outcomes has been discussed for decades in the medical literature, including the family medicine literature. Today there is a renewed call to action for family medicine, a specialty that emerged as a counterculture to reform mainstream medicine,9 to both confront systemic racism and eliminate health disparities. This effort will require collaboration, commitment, education, and transformative conversations around racism, health inequity, and advocacy so that we can better serve our patients and our communities.
The editors of several North American family medicine publications have come together to address this call to action and share resources on racism across our readerships. We acknowledge those members of the family medicine scholar community who have been fighting for equity consistent with the Black Lives Matter movement by writing about racism, health inequities, and personal experiences of practicing as Black family physicians. While we recognize that much more work is needed, we want to amplify these voices. We have compiled a bibliography of scholarship generated by the family medicine community on the topic of racism in medicine.
The collection can be accessed here.
While this list is likely not complete, it does include over 250 published manuscripts and demonstrates expertise as well as a commitment to addressing these complex issues. For example, in 2016, Dr. J. Nwando Olayiwola, chair of the Department of Family Medicine at Ohio State University, wrote an essay on her experiences taking care of patients as a Black family physician.10 In January of 2019, Family Medicine published an entire issue devoted to racism in education and training.11 Dr. Eduardo Medina, a family physician and public health scholar, co-authored a call to action in 2016 for health professionals to dismantle structural racism and support Black lives to achieve health equity. His recent 2020 article builds on that theme and describes the disproportionate deaths of Black people due to racial injustice and the COVID-19 pandemic as converging public health emergencies.12,13 In the wake of these emergencies a fundamental transformation is warranted, and family physicians can play a key role.
We, the editors of family medicine journals, commit to actively examine the effects of racism on society and health and to take action to eliminate structural racism in our editorial processes. As an intellectual home for our profession, we have a unique responsibility and opportunity to educate and continue the conversation about institutional racism, health inequities, and antiracism in medicine. We will take immediate steps to enact tangible advances on these fronts. We will encourage and mentor authors from groups underrepresented in medicine. We will ensure that content includes an emphasis on cultural humility, diversity and inclusion, implicit bias, and the impact of racism on medicine and health. We will recruit editors and editorial board members from groups underrepresented in medicine. We will encourage collaboration and accountability within our specialty to confront systemic racism through content and processes in all of our individual publications. We recognize that these are small steps in an ongoing process of active antiracism, but we believe these steps are crucial. As editors in family medicine, we are committed to progress toward equity and justice.
Simultaneously published in American Family Physician, Annals of Family Medicine, Canadian Family Physician, Family Medicine, FP Essentials, FPIN/Evidence Based Practice, FPM, Journal of the American Board of Family Medicine, The Journal of Family Practice, and PRiMER.
Acknowledgement –
The authors thank Renee Crichlow, MD, Byron Jasper, MD, MPH, and Victoria Murrain, DO, for their insightful comments on this editorial.
1. Institute of Medicine (US) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care, Smedley BD, Stith AY, Nelson AR, eds. Unequal treatment: confronting racial and ethnic disparities in health care. Washington, DC: National Academies Press; 2003.
2. Bailey ZD, Krieger N, Agénor M, Graves J, Linos N, Bassett MT. Structural racism and health inequities in the USA: evidence and interventions. Lancet. 2017;389(10077):1453-1463.
3. Ben J, Cormack D, Harris R, Paradies Y. Racism and health service utilisation: A systematic review and meta-analysis. PLoS One. 2017;12(12):e0189900.
4. Paradies Y, Ben J, Denson N, et al. Racism as a determinant of health: a systematic review and meta-analysis. PLoS One. 2015;10(9):e0138511.
5. American Academy of Family Physicians. Institutional racism in the health care system. Published 2019. Accessed Sept. 15, 2020. https://www.aafp.org/about/policies/all/institutional-racism.html.
6. Yaya S, Yeboah H, Charles CH, Otu A, Labonte R. Ethnic and racial disparities in COVID-19-related deaths: counting the trees, hiding the forest. BMJ Glob Health. 2020;5(6):e002913.
7. Egede LE, Walker RJ. Structural Racism, Social Risk Factors, and Covid-19 — A Dangerous Convergence for Black Americans [published online ahead of print, 2020 Jul 22]. N Engl J Med. 2020;10.1056/NEJMp2023616.
8. Centers for Disease Control and Prevention. Health equity considerations and racial and ethnic minority groups. Updated July 24, 2020. Accessed Sept. 15, 2020. https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/race-ethnicity.html
9. Stephens GG. Family medicine as counterculture. Fam Med. 1989;21(2):103-109.
10. Olayiwola JN. Racism in medicine: shifting the power. Ann Fam Med. 2016;14(3):267-269. https://doi.org/10.1370/afm.1932.
11. Saultz J, ed. Racism. Fam Med. 2019;51(1, theme issue):1-66.
12. Hardeman RR, Medina EM, Kozhimannil KB. Structural racism and supporting black lives - the role of health professionals. N Engl J Med. 2016;375(22):2113-2115. https://doi.org/10.1056/NEJMp1609535.
13. Hardeman RR, Medina EM, Boyd RW. Stolen breaths. N Engl J Med. 2020;383(3):197-199. 10.1056/NEJMp2021072.
1. Institute of Medicine (US) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care, Smedley BD, Stith AY, Nelson AR, eds. Unequal treatment: confronting racial and ethnic disparities in health care. Washington, DC: National Academies Press; 2003.
2. Bailey ZD, Krieger N, Agénor M, Graves J, Linos N, Bassett MT. Structural racism and health inequities in the USA: evidence and interventions. Lancet. 2017;389(10077):1453-1463.
3. Ben J, Cormack D, Harris R, Paradies Y. Racism and health service utilisation: A systematic review and meta-analysis. PLoS One. 2017;12(12):e0189900.
4. Paradies Y, Ben J, Denson N, et al. Racism as a determinant of health: a systematic review and meta-analysis. PLoS One. 2015;10(9):e0138511.
5. American Academy of Family Physicians. Institutional racism in the health care system. Published 2019. Accessed Sept. 15, 2020. https://www.aafp.org/about/policies/all/institutional-racism.html.
6. Yaya S, Yeboah H, Charles CH, Otu A, Labonte R. Ethnic and racial disparities in COVID-19-related deaths: counting the trees, hiding the forest. BMJ Glob Health. 2020;5(6):e002913.
7. Egede LE, Walker RJ. Structural Racism, Social Risk Factors, and Covid-19 — A Dangerous Convergence for Black Americans [published online ahead of print, 2020 Jul 22]. N Engl J Med. 2020;10.1056/NEJMp2023616.
8. Centers for Disease Control and Prevention. Health equity considerations and racial and ethnic minority groups. Updated July 24, 2020. Accessed Sept. 15, 2020. https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/race-ethnicity.html
9. Stephens GG. Family medicine as counterculture. Fam Med. 1989;21(2):103-109.
10. Olayiwola JN. Racism in medicine: shifting the power. Ann Fam Med. 2016;14(3):267-269. https://doi.org/10.1370/afm.1932.
11. Saultz J, ed. Racism. Fam Med. 2019;51(1, theme issue):1-66.
12. Hardeman RR, Medina EM, Kozhimannil KB. Structural racism and supporting black lives - the role of health professionals. N Engl J Med. 2016;375(22):2113-2115. https://doi.org/10.1056/NEJMp1609535.
13. Hardeman RR, Medina EM, Boyd RW. Stolen breaths. N Engl J Med. 2020;383(3):197-199. 10.1056/NEJMp2021072.
Educational interventions improve outcomes for children with asthma
Asthma education interventions for children may result in modest improvement in a wide range of clinical outcomes. Interventions should target children with more severe asthma and teach them to use objective measures of lung function, such as peak flow for self-monitoring instead of symptombased self-monitoring.
Asthma education interventions for children may result in modest improvement in a wide range of clinical outcomes. Interventions should target children with more severe asthma and teach them to use objective measures of lung function, such as peak flow for self-monitoring instead of symptombased self-monitoring.
Asthma education interventions for children may result in modest improvement in a wide range of clinical outcomes. Interventions should target children with more severe asthma and teach them to use objective measures of lung function, such as peak flow for self-monitoring instead of symptombased self-monitoring.
Do dietary restrictions reduce fecal occult blood testing adherence?
BACKGROUND: Population-based screening for fecal occult blood has been shown to reduce mortality from colorectal cancer. Unfortunately, low fecal occult blood testing (FOBT) participation rates limit the potential impact of this screening intervention. One reason that patients choose not to complete and return their FOBT cards may be that they have difficulty following the recommended pretesting dietary restrictions. Substances that patients are often instructed to avoid before FOBT include red meat, fresh fruits and vegetables, vitamin C, iron, and nonsteroidal anti-inflammatory drugs.
POPULATION STUDIED: Participants in the studies included American Association of Retired Persons members (n=3783), patients of 32 Canadian Family Physicians (n=5003), patients in a single British general practice (n=153), patients aged 40 to 74 years not otherwise specified (n=634), and Veterans Affairs hospital patients (n=786).
STUDY DESIGN AND VALIDITY: Five randomized controlled trials were included in the meta-analysis. These trials were identified by a structured MEDLINE search augmented by hand searching and by contacting experts. All 5 studies randomized participants to either a dietary restrictions or no dietary restrictions arm before FOBT and reported screening completion rates for each arm. The authors do not specifically mention searching for unpublished trials, an important consideration in meta-analytic studies. Published studies are more likely to have positive results and this publication bias makes it more likely that the meta-analysis results will show a positive effect.
OUTCOMES MEASURED: The primary outcome was the difference between the completion rates of FOBT in the dietary restriction arm and the no dietary restriction arm. As a secondary outcome the investigators looked at positivity rates or the percentage of positive FOBT results among completed tests in each arm. Positivity rates are used here as a proxy for test specificity, which we would expect to be improved by dietary restriction.
RESULTS: When patients were counseled to avoid certain foods before obtaining a fecal sample, completion rates of FOBT across the studies ranged from 18.1% to 80.4%. This wide range of completion rates suggests heterogeneity in the interventions. It also suggests that factors other than dietary restriction may account for most of the difference in completion rates. Only one study showed a significant difference between the dietary restriction arm and the no dietary restriction arm. This study was the smallest of the 5 trials, and it had relatively complex dietary restrictions. There was no significant difference between positivity rates in any of the individual trials or in the pooled difference.
BACKGROUND: Population-based screening for fecal occult blood has been shown to reduce mortality from colorectal cancer. Unfortunately, low fecal occult blood testing (FOBT) participation rates limit the potential impact of this screening intervention. One reason that patients choose not to complete and return their FOBT cards may be that they have difficulty following the recommended pretesting dietary restrictions. Substances that patients are often instructed to avoid before FOBT include red meat, fresh fruits and vegetables, vitamin C, iron, and nonsteroidal anti-inflammatory drugs.
POPULATION STUDIED: Participants in the studies included American Association of Retired Persons members (n=3783), patients of 32 Canadian Family Physicians (n=5003), patients in a single British general practice (n=153), patients aged 40 to 74 years not otherwise specified (n=634), and Veterans Affairs hospital patients (n=786).
STUDY DESIGN AND VALIDITY: Five randomized controlled trials were included in the meta-analysis. These trials were identified by a structured MEDLINE search augmented by hand searching and by contacting experts. All 5 studies randomized participants to either a dietary restrictions or no dietary restrictions arm before FOBT and reported screening completion rates for each arm. The authors do not specifically mention searching for unpublished trials, an important consideration in meta-analytic studies. Published studies are more likely to have positive results and this publication bias makes it more likely that the meta-analysis results will show a positive effect.
OUTCOMES MEASURED: The primary outcome was the difference between the completion rates of FOBT in the dietary restriction arm and the no dietary restriction arm. As a secondary outcome the investigators looked at positivity rates or the percentage of positive FOBT results among completed tests in each arm. Positivity rates are used here as a proxy for test specificity, which we would expect to be improved by dietary restriction.
RESULTS: When patients were counseled to avoid certain foods before obtaining a fecal sample, completion rates of FOBT across the studies ranged from 18.1% to 80.4%. This wide range of completion rates suggests heterogeneity in the interventions. It also suggests that factors other than dietary restriction may account for most of the difference in completion rates. Only one study showed a significant difference between the dietary restriction arm and the no dietary restriction arm. This study was the smallest of the 5 trials, and it had relatively complex dietary restrictions. There was no significant difference between positivity rates in any of the individual trials or in the pooled difference.
BACKGROUND: Population-based screening for fecal occult blood has been shown to reduce mortality from colorectal cancer. Unfortunately, low fecal occult blood testing (FOBT) participation rates limit the potential impact of this screening intervention. One reason that patients choose not to complete and return their FOBT cards may be that they have difficulty following the recommended pretesting dietary restrictions. Substances that patients are often instructed to avoid before FOBT include red meat, fresh fruits and vegetables, vitamin C, iron, and nonsteroidal anti-inflammatory drugs.
POPULATION STUDIED: Participants in the studies included American Association of Retired Persons members (n=3783), patients of 32 Canadian Family Physicians (n=5003), patients in a single British general practice (n=153), patients aged 40 to 74 years not otherwise specified (n=634), and Veterans Affairs hospital patients (n=786).
STUDY DESIGN AND VALIDITY: Five randomized controlled trials were included in the meta-analysis. These trials were identified by a structured MEDLINE search augmented by hand searching and by contacting experts. All 5 studies randomized participants to either a dietary restrictions or no dietary restrictions arm before FOBT and reported screening completion rates for each arm. The authors do not specifically mention searching for unpublished trials, an important consideration in meta-analytic studies. Published studies are more likely to have positive results and this publication bias makes it more likely that the meta-analysis results will show a positive effect.
OUTCOMES MEASURED: The primary outcome was the difference between the completion rates of FOBT in the dietary restriction arm and the no dietary restriction arm. As a secondary outcome the investigators looked at positivity rates or the percentage of positive FOBT results among completed tests in each arm. Positivity rates are used here as a proxy for test specificity, which we would expect to be improved by dietary restriction.
RESULTS: When patients were counseled to avoid certain foods before obtaining a fecal sample, completion rates of FOBT across the studies ranged from 18.1% to 80.4%. This wide range of completion rates suggests heterogeneity in the interventions. It also suggests that factors other than dietary restriction may account for most of the difference in completion rates. Only one study showed a significant difference between the dietary restriction arm and the no dietary restriction arm. This study was the smallest of the 5 trials, and it had relatively complex dietary restrictions. There was no significant difference between positivity rates in any of the individual trials or in the pooled difference.
Can vaginal misoprostol be administered 1 to 3 days after mifepristone without loss of efficacy or an increase in adverse events?
BACKGROUND: The United States Food and Drug Administration (FDA) has approved the use of mifepristone (RU 486) in a protocol for early medical abortion.1 In that protocol, 600 μg of mifepristone is followed by 400 μg of oral misoprostol 48 hours later. Previous studies have shown that low-dose mifepristone (200 μg) followed 2 days later by 800 μg vaginal misoprostol has fewer side effects and is more effective than the approved protocol. Restricting administration of vaginal misoprostol to a narrow time window 2 days after the mifepristone dose may be inconvenient or unsafe.
POPULATION STUDIED: Healthy pregnant women aged 18 years and older who desired abortions were recruited from 16 sites including hospitals, abortion clinics, family practice offices, and gynecology offices. A total of 2295 women were recruited, and all underwent a transvaginal ultrasound to rule out ectopic pregnancy and to confirm fetal size consistent with a gestation of 56 days or less.
STUDY DESIGN AND VALIDITY: This is an unblinded randomized controlled trial with 3 arms. Subjects were assigned by concealed computer-generated randomization to self-administered 800 μg misoprostol vaginally either 1 (n=745), 2 (n=778), or 3 (n=772) days after a 200-μg dose of mifepristone.
OUTCOMES MEASURED: Complete medical abortion without surgical intervention was the primary outcome.
RESULTS: There was no statistically significant difference in the percentage of women who had complete medical abortions across the 3 groups. The percentages of complete medical abortions for the day 1 and day 2 groups were both 98% (95% confidence interval [CI], 97%-99%), and for the day 3 group it was 96% (95% CI, 95%-97%).
Low-dose mifepristone (200 μg) followed 1 to 3 days later by 800 μg of self-administered vaginal misoprostol is a safe and effective procedure for early medical abortion. Rigid adherence to the oral administration of misoprostol in a medical office 48 hours after mifepristone is not necessary either from a safety or efficacy perspective. Administration of misoprostol 1 or 2 days after mifepristone is preferable, since patients in the day 3 group found the wait less acceptable. Information is available on the Internet about FDA special requirements and approved protocols involving mifepristone.1
BACKGROUND: The United States Food and Drug Administration (FDA) has approved the use of mifepristone (RU 486) in a protocol for early medical abortion.1 In that protocol, 600 μg of mifepristone is followed by 400 μg of oral misoprostol 48 hours later. Previous studies have shown that low-dose mifepristone (200 μg) followed 2 days later by 800 μg vaginal misoprostol has fewer side effects and is more effective than the approved protocol. Restricting administration of vaginal misoprostol to a narrow time window 2 days after the mifepristone dose may be inconvenient or unsafe.
POPULATION STUDIED: Healthy pregnant women aged 18 years and older who desired abortions were recruited from 16 sites including hospitals, abortion clinics, family practice offices, and gynecology offices. A total of 2295 women were recruited, and all underwent a transvaginal ultrasound to rule out ectopic pregnancy and to confirm fetal size consistent with a gestation of 56 days or less.
STUDY DESIGN AND VALIDITY: This is an unblinded randomized controlled trial with 3 arms. Subjects were assigned by concealed computer-generated randomization to self-administered 800 μg misoprostol vaginally either 1 (n=745), 2 (n=778), or 3 (n=772) days after a 200-μg dose of mifepristone.
OUTCOMES MEASURED: Complete medical abortion without surgical intervention was the primary outcome.
RESULTS: There was no statistically significant difference in the percentage of women who had complete medical abortions across the 3 groups. The percentages of complete medical abortions for the day 1 and day 2 groups were both 98% (95% confidence interval [CI], 97%-99%), and for the day 3 group it was 96% (95% CI, 95%-97%).
Low-dose mifepristone (200 μg) followed 1 to 3 days later by 800 μg of self-administered vaginal misoprostol is a safe and effective procedure for early medical abortion. Rigid adherence to the oral administration of misoprostol in a medical office 48 hours after mifepristone is not necessary either from a safety or efficacy perspective. Administration of misoprostol 1 or 2 days after mifepristone is preferable, since patients in the day 3 group found the wait less acceptable. Information is available on the Internet about FDA special requirements and approved protocols involving mifepristone.1
BACKGROUND: The United States Food and Drug Administration (FDA) has approved the use of mifepristone (RU 486) in a protocol for early medical abortion.1 In that protocol, 600 μg of mifepristone is followed by 400 μg of oral misoprostol 48 hours later. Previous studies have shown that low-dose mifepristone (200 μg) followed 2 days later by 800 μg vaginal misoprostol has fewer side effects and is more effective than the approved protocol. Restricting administration of vaginal misoprostol to a narrow time window 2 days after the mifepristone dose may be inconvenient or unsafe.
POPULATION STUDIED: Healthy pregnant women aged 18 years and older who desired abortions were recruited from 16 sites including hospitals, abortion clinics, family practice offices, and gynecology offices. A total of 2295 women were recruited, and all underwent a transvaginal ultrasound to rule out ectopic pregnancy and to confirm fetal size consistent with a gestation of 56 days or less.
STUDY DESIGN AND VALIDITY: This is an unblinded randomized controlled trial with 3 arms. Subjects were assigned by concealed computer-generated randomization to self-administered 800 μg misoprostol vaginally either 1 (n=745), 2 (n=778), or 3 (n=772) days after a 200-μg dose of mifepristone.
OUTCOMES MEASURED: Complete medical abortion without surgical intervention was the primary outcome.
RESULTS: There was no statistically significant difference in the percentage of women who had complete medical abortions across the 3 groups. The percentages of complete medical abortions for the day 1 and day 2 groups were both 98% (95% confidence interval [CI], 97%-99%), and for the day 3 group it was 96% (95% CI, 95%-97%).
Low-dose mifepristone (200 μg) followed 1 to 3 days later by 800 μg of self-administered vaginal misoprostol is a safe and effective procedure for early medical abortion. Rigid adherence to the oral administration of misoprostol in a medical office 48 hours after mifepristone is not necessary either from a safety or efficacy perspective. Administration of misoprostol 1 or 2 days after mifepristone is preferable, since patients in the day 3 group found the wait less acceptable. Information is available on the Internet about FDA special requirements and approved protocols involving mifepristone.1
Can we reduce the use of echocardiography by using other clinical information to identify patients at very low risk for left ventricular systolic dysfunction?
BACKGROUND: About one third of all echocardiograms are ordered to evaluate left ventricular (LV) dysfunction. If other clinical markers could be used to identify patients at very low risk for LV dysfunction, some of these echocardiograms would be unnecessary. Eliminating unnecessary echocardiograms might help control health care costs without reducing the quality of care.
POPULATION STUDIED: The study sample consisted of 330 consecutive inpatients who underwent echocardiography to evaluate LV dysfunction. Of these subjects, 300 had an electrocardiogram (EKG) within 1 week before the echocardiogram, and the other 30 subjects who did not have EKGs were eliminated from the sample.
STUDY DESIGN AND VALIDITY: Variables related to medical history, physical examination, chest radiography, and EKG findings were identified using chart review. These variables were analyzed using a logistic regression model to determine which variables could be used to identify patients at very low risk for LV dysfunction on subsequent echocardiogram. EKGs were evaluated for the following abnormalities: Q waves, poor R-wave progression, LV hypertrophy, S-T segment abnormalities, left bundle branch block, or a paced rhythm. Subjects who had none of these abnormalities were classified as having normal EKGs. A patient with a right bundle branch block or a rate disturbances could have been classified as having a normal EKG. The regression model and sample size are appropriate for this type of analysis. The model could be strengthened by validating it using similar subjects not involved in the initial development of the model.
OUTCOMES MEASURED: The primary outcome was LV systolic dysfunction defined as an echocardiogram with an LV ejection fraction less than 0.45 as assessed by an echocardiographer blinded to other clinical information.
RESULTS: Of the 300 patients, 124 (41%) had LV systolic dysfunction on echocardiogram. The variables found to be important predictors of LV dysfunction were male sex, cardiomegaly on chest radiograph, and left bundle branch block on EKG. Of the 300 subjects, 118 (39%) had normal EKGs. Only 2 subjects with normal EKG findings had LV dysfunction on echocardiography. One had a right bundle branch block and known valvular disease. The other patient had undergone cardiac bypass surgery between the time the EKG was recorded and the time the echocardiograph was performed.
Hospitalized patients with normal EKGs are very unlikely to have LV dysfunction. Echocardiograms ordered specifically to eval-uate LV dysfunction in these patients are unnecessary. These results have not been confirmed in outpatients and may not apply.
BACKGROUND: About one third of all echocardiograms are ordered to evaluate left ventricular (LV) dysfunction. If other clinical markers could be used to identify patients at very low risk for LV dysfunction, some of these echocardiograms would be unnecessary. Eliminating unnecessary echocardiograms might help control health care costs without reducing the quality of care.
POPULATION STUDIED: The study sample consisted of 330 consecutive inpatients who underwent echocardiography to evaluate LV dysfunction. Of these subjects, 300 had an electrocardiogram (EKG) within 1 week before the echocardiogram, and the other 30 subjects who did not have EKGs were eliminated from the sample.
STUDY DESIGN AND VALIDITY: Variables related to medical history, physical examination, chest radiography, and EKG findings were identified using chart review. These variables were analyzed using a logistic regression model to determine which variables could be used to identify patients at very low risk for LV dysfunction on subsequent echocardiogram. EKGs were evaluated for the following abnormalities: Q waves, poor R-wave progression, LV hypertrophy, S-T segment abnormalities, left bundle branch block, or a paced rhythm. Subjects who had none of these abnormalities were classified as having normal EKGs. A patient with a right bundle branch block or a rate disturbances could have been classified as having a normal EKG. The regression model and sample size are appropriate for this type of analysis. The model could be strengthened by validating it using similar subjects not involved in the initial development of the model.
OUTCOMES MEASURED: The primary outcome was LV systolic dysfunction defined as an echocardiogram with an LV ejection fraction less than 0.45 as assessed by an echocardiographer blinded to other clinical information.
RESULTS: Of the 300 patients, 124 (41%) had LV systolic dysfunction on echocardiogram. The variables found to be important predictors of LV dysfunction were male sex, cardiomegaly on chest radiograph, and left bundle branch block on EKG. Of the 300 subjects, 118 (39%) had normal EKGs. Only 2 subjects with normal EKG findings had LV dysfunction on echocardiography. One had a right bundle branch block and known valvular disease. The other patient had undergone cardiac bypass surgery between the time the EKG was recorded and the time the echocardiograph was performed.
Hospitalized patients with normal EKGs are very unlikely to have LV dysfunction. Echocardiograms ordered specifically to eval-uate LV dysfunction in these patients are unnecessary. These results have not been confirmed in outpatients and may not apply.
BACKGROUND: About one third of all echocardiograms are ordered to evaluate left ventricular (LV) dysfunction. If other clinical markers could be used to identify patients at very low risk for LV dysfunction, some of these echocardiograms would be unnecessary. Eliminating unnecessary echocardiograms might help control health care costs without reducing the quality of care.
POPULATION STUDIED: The study sample consisted of 330 consecutive inpatients who underwent echocardiography to evaluate LV dysfunction. Of these subjects, 300 had an electrocardiogram (EKG) within 1 week before the echocardiogram, and the other 30 subjects who did not have EKGs were eliminated from the sample.
STUDY DESIGN AND VALIDITY: Variables related to medical history, physical examination, chest radiography, and EKG findings were identified using chart review. These variables were analyzed using a logistic regression model to determine which variables could be used to identify patients at very low risk for LV dysfunction on subsequent echocardiogram. EKGs were evaluated for the following abnormalities: Q waves, poor R-wave progression, LV hypertrophy, S-T segment abnormalities, left bundle branch block, or a paced rhythm. Subjects who had none of these abnormalities were classified as having normal EKGs. A patient with a right bundle branch block or a rate disturbances could have been classified as having a normal EKG. The regression model and sample size are appropriate for this type of analysis. The model could be strengthened by validating it using similar subjects not involved in the initial development of the model.
OUTCOMES MEASURED: The primary outcome was LV systolic dysfunction defined as an echocardiogram with an LV ejection fraction less than 0.45 as assessed by an echocardiographer blinded to other clinical information.
RESULTS: Of the 300 patients, 124 (41%) had LV systolic dysfunction on echocardiogram. The variables found to be important predictors of LV dysfunction were male sex, cardiomegaly on chest radiograph, and left bundle branch block on EKG. Of the 300 subjects, 118 (39%) had normal EKGs. Only 2 subjects with normal EKG findings had LV dysfunction on echocardiography. One had a right bundle branch block and known valvular disease. The other patient had undergone cardiac bypass surgery between the time the EKG was recorded and the time the echocardiograph was performed.
Hospitalized patients with normal EKGs are very unlikely to have LV dysfunction. Echocardiograms ordered specifically to eval-uate LV dysfunction in these patients are unnecessary. These results have not been confirmed in outpatients and may not apply.
Homemade Spacers Useful in Asthma Treatment
CLINICAL QUESTION: Which types of homemade spacers are most effective for inhaled b-agonist delivery in children with acute asthma exacerbations?
BACKGROUND: Multiple studies have demonstrated that for acute asthma exacerbations, metered dose inhalers (MDIs) with attached valved spacers are as effective, if not more effective, than nebulizers. Homemade spacers made from more readily available plastic bottles or polystyrene cups are sometimes substituted for conventional spacers. This study compares clinical outcomes using conventional spacers with 3 types of homemade spacers in children with acute asthma exacerbations.
POPULATION STUDIED: A total of 88 children aged 5 to 13 years who were experiencing an acute asthma attack were recruited from a Cape Town, South Africa, hospital emergency department. All subjects had a baseline peak expiratory flow rate (PEFR) between 20% and 80% predicted. The children were stratified by severity, with a PEFR of higher than 59% considered mild and a rate lower than 60% considered moderate. Patients who had used b-agonist medication within 4 hours of presentation were excluded.
STUDY DESIGN AND VALIDITY: This was a randomized trial comparing 4 spacer options: conventional valved spacers, plastic drink bottles sealed to the MDI with glue, plastic drink bottles that were not sealed, and polystyrene cups. To make the spacers, a heated wire in the shape of the MDI mouthpiece was pressed to the base of the bottle or cup to make a hole into which the MDI was inserted. Pulmonary function tests (PFTs) were performed at baseline and again after treatment with a b-agonist delivered by MDI and the assigned spacer type. Those patients who did not improve to at least 70% of predicted PEFR were given a nebulizer treatment with the same medication. Those nonresponders had a third set of PFTs after the nebulizer treatment. The investigators who evaluated outcomes were blinded to the treatment arm.
OUTCOMES MEASURED: The authors list 4 primary outcomes: change in a clinical asthma severity score, percent change in PFTs, failure to increase PEFR to higher than 70% of predicted, and change in PEFR with nebulizer treatment in nonresponders.
RESULTS: The pooled analysis, combining the mild and moderate groups, showed significant differences by spacer type for change in PFTs. For this combined group, the polystyrene cup resulted in minimal improvement in PFTs, while the other 3 spacer types showed significantly larger increases. When the mild severity group was analyzed separately, there were no significant differences by spacer type in any of the outcomes. For the moderate severity group, significant differences were found in change in PFTs, number of responders, and response to nebulizer for initial nonresponders. In all significant results in this moderate group, the conventional spacer performed the best and the polystyrene cup the worst, with the unsealed bottle somewhat more effective than the cup but less effective than the sealed bottle.
Delivery of b-agonist medication to patients with asthma attacks can be most effectively accomplished with an MDI combined with a conventional valved spacer. If conventional spacers are not available, a homemade spacer can be made from a 500-mL plastic drink bottle. A tight seal between the MDI and the bottle seems to increase the efficiency of medication delivery. For patients with moderate asthma symptoms, spacers made out of polystyrene cups are much less effective than spacers made out of plastic bottles or conventional spacers.
CLINICAL QUESTION: Which types of homemade spacers are most effective for inhaled b-agonist delivery in children with acute asthma exacerbations?
BACKGROUND: Multiple studies have demonstrated that for acute asthma exacerbations, metered dose inhalers (MDIs) with attached valved spacers are as effective, if not more effective, than nebulizers. Homemade spacers made from more readily available plastic bottles or polystyrene cups are sometimes substituted for conventional spacers. This study compares clinical outcomes using conventional spacers with 3 types of homemade spacers in children with acute asthma exacerbations.
POPULATION STUDIED: A total of 88 children aged 5 to 13 years who were experiencing an acute asthma attack were recruited from a Cape Town, South Africa, hospital emergency department. All subjects had a baseline peak expiratory flow rate (PEFR) between 20% and 80% predicted. The children were stratified by severity, with a PEFR of higher than 59% considered mild and a rate lower than 60% considered moderate. Patients who had used b-agonist medication within 4 hours of presentation were excluded.
STUDY DESIGN AND VALIDITY: This was a randomized trial comparing 4 spacer options: conventional valved spacers, plastic drink bottles sealed to the MDI with glue, plastic drink bottles that were not sealed, and polystyrene cups. To make the spacers, a heated wire in the shape of the MDI mouthpiece was pressed to the base of the bottle or cup to make a hole into which the MDI was inserted. Pulmonary function tests (PFTs) were performed at baseline and again after treatment with a b-agonist delivered by MDI and the assigned spacer type. Those patients who did not improve to at least 70% of predicted PEFR were given a nebulizer treatment with the same medication. Those nonresponders had a third set of PFTs after the nebulizer treatment. The investigators who evaluated outcomes were blinded to the treatment arm.
OUTCOMES MEASURED: The authors list 4 primary outcomes: change in a clinical asthma severity score, percent change in PFTs, failure to increase PEFR to higher than 70% of predicted, and change in PEFR with nebulizer treatment in nonresponders.
RESULTS: The pooled analysis, combining the mild and moderate groups, showed significant differences by spacer type for change in PFTs. For this combined group, the polystyrene cup resulted in minimal improvement in PFTs, while the other 3 spacer types showed significantly larger increases. When the mild severity group was analyzed separately, there were no significant differences by spacer type in any of the outcomes. For the moderate severity group, significant differences were found in change in PFTs, number of responders, and response to nebulizer for initial nonresponders. In all significant results in this moderate group, the conventional spacer performed the best and the polystyrene cup the worst, with the unsealed bottle somewhat more effective than the cup but less effective than the sealed bottle.
Delivery of b-agonist medication to patients with asthma attacks can be most effectively accomplished with an MDI combined with a conventional valved spacer. If conventional spacers are not available, a homemade spacer can be made from a 500-mL plastic drink bottle. A tight seal between the MDI and the bottle seems to increase the efficiency of medication delivery. For patients with moderate asthma symptoms, spacers made out of polystyrene cups are much less effective than spacers made out of plastic bottles or conventional spacers.
CLINICAL QUESTION: Which types of homemade spacers are most effective for inhaled b-agonist delivery in children with acute asthma exacerbations?
BACKGROUND: Multiple studies have demonstrated that for acute asthma exacerbations, metered dose inhalers (MDIs) with attached valved spacers are as effective, if not more effective, than nebulizers. Homemade spacers made from more readily available plastic bottles or polystyrene cups are sometimes substituted for conventional spacers. This study compares clinical outcomes using conventional spacers with 3 types of homemade spacers in children with acute asthma exacerbations.
POPULATION STUDIED: A total of 88 children aged 5 to 13 years who were experiencing an acute asthma attack were recruited from a Cape Town, South Africa, hospital emergency department. All subjects had a baseline peak expiratory flow rate (PEFR) between 20% and 80% predicted. The children were stratified by severity, with a PEFR of higher than 59% considered mild and a rate lower than 60% considered moderate. Patients who had used b-agonist medication within 4 hours of presentation were excluded.
STUDY DESIGN AND VALIDITY: This was a randomized trial comparing 4 spacer options: conventional valved spacers, plastic drink bottles sealed to the MDI with glue, plastic drink bottles that were not sealed, and polystyrene cups. To make the spacers, a heated wire in the shape of the MDI mouthpiece was pressed to the base of the bottle or cup to make a hole into which the MDI was inserted. Pulmonary function tests (PFTs) were performed at baseline and again after treatment with a b-agonist delivered by MDI and the assigned spacer type. Those patients who did not improve to at least 70% of predicted PEFR were given a nebulizer treatment with the same medication. Those nonresponders had a third set of PFTs after the nebulizer treatment. The investigators who evaluated outcomes were blinded to the treatment arm.
OUTCOMES MEASURED: The authors list 4 primary outcomes: change in a clinical asthma severity score, percent change in PFTs, failure to increase PEFR to higher than 70% of predicted, and change in PEFR with nebulizer treatment in nonresponders.
RESULTS: The pooled analysis, combining the mild and moderate groups, showed significant differences by spacer type for change in PFTs. For this combined group, the polystyrene cup resulted in minimal improvement in PFTs, while the other 3 spacer types showed significantly larger increases. When the mild severity group was analyzed separately, there were no significant differences by spacer type in any of the outcomes. For the moderate severity group, significant differences were found in change in PFTs, number of responders, and response to nebulizer for initial nonresponders. In all significant results in this moderate group, the conventional spacer performed the best and the polystyrene cup the worst, with the unsealed bottle somewhat more effective than the cup but less effective than the sealed bottle.
Delivery of b-agonist medication to patients with asthma attacks can be most effectively accomplished with an MDI combined with a conventional valved spacer. If conventional spacers are not available, a homemade spacer can be made from a 500-mL plastic drink bottle. A tight seal between the MDI and the bottle seems to increase the efficiency of medication delivery. For patients with moderate asthma symptoms, spacers made out of polystyrene cups are much less effective than spacers made out of plastic bottles or conventional spacers.