Bone densitometry scans may be a novel, noninvasive, and scalable way to identify older women at risk of developing dementia, new research suggests.

In an analysis of more than 900 study participants, women in their 70s with more advanced abdominal aortic calcification (AAC) seen on lateral spine images during dual-energy x-ray absorptiometry (DXA) had a two- to fourfold higher risk for late-life dementia than those with low AAC.

This finding was independent of cardiovascular risk factors and apolipoprotein E (APOE ) genotype.

“While these results are exciting, we now need to undertake further large screening studies in older men and women using this approach to show that the findings are generalizable to older men and can identify people with greater cognitive decline,” coinvestigator Marc Sim, PhD, Edith Cowan University, Joondalup, Australia, said in an interview.

“This will hopefully open the door to studies of early disease-modifying interventions,” Sim said.

The findings were published online in The Lancet Regional Health – Western Pacific. 
 

AAC and cognition

Late-life dementia occurring after age 80 is increasingly common because of both vascular and nonvascular risk factors.

Two recent studies in middle-aged and older men and women showed that AAC identified on bone densitometry was associated with poorer cognition, suggesting it may be related to cognitive decline and increased dementia risk.

This provided the rationale for the current study, Dr. Sim noted.

The researchers assessed AAC using DXA lateral spine images captured in the late 1990s in a prospective cohort of 958 older women who were participating in an osteoporosis study.

AAC was classified into established low, moderate, and extensive categories. At baseline, all women were aged 70 and older, and 45% had low AAC, 36% had moderate AAC, and 19% had extensive AAC.

Over 14.5 years, 150 women (15.7%) had a late-life hospitalization and/or died.
 

Improved risk prediction

Results showed that, compared with women who had low AAC, women with moderate and extensive AAC were more likely to experience late-life dementia hospitalization (9.3% low, 15.5% moderate, and 18.3% extensive) and death (2.8%, 8.3%, and 9.4%, respectively).

After multivariable adjustment, women with moderate AAC had a two- and threefold increased relative risk for late-life dementia hospitalization or death, compared with their peers who had low AAC.

Women with extensive AAC had a two- and fourfold increase in the adjusted relative risk for late-life dementia hospitalization or death.

“To our knowledge this is the first time it has been shown that AAC from these scans is related to late-life dementia,” Dr. Sim said.

“We demonstrated that AAC improved risk prediction in addition to cardiovascular risk factors and APOE genotype, a genetic risk factor for Alzheimer’s disease, the major form of dementia,” he added.

Dr. Sim noted “these additional lateral spine images” can be taken at the same time that hip and spine bone density tests are done.

“This provides an opportunity to identify AAC in large numbers of people,” he said.

He cautioned, however, that further studies with detailed dementia-related phenotypes, brain imaging, and measures of cognition are needed to confirm whether AAC will add value to dementia risk prediction.
 

‘Not surprising’

Commenting on the findings for this article, Claire Sexton, DPhil, senior director of scientific programs and outreach at the Alzheimer’s Association, Chicago, noted that AAC is a marker of atherosclerosis and is associated with vascular health outcomes.

Therefore, it is “not surprising it would be associated with dementia too. There’s been previous research linking atherosclerosis and Alzheimer’s disease,” Dr. Sexton said.  

“What’s novel about this research is that it’s looking at AAC specifically, which can be identified through a relatively simple test that is already in widespread use,” she added.

Dr. Sexton noted that “much more research” is now needed in larger, more diverse populations in order to better understand the link between AAC and dementia – and whether bone density testing may be an appropriate dementia-screening tool.

“The good news is vascular conditions like atherosclerosis can be managed through lifestyle changes like eating a healthy diet and getting regular exercise. And research tells us what’s good for the heart is good for the brain,” Dr. Sexton said.

The study was funded by Kidney Health Australia, Healthway Health Promotion Foundation of Western Australia, Sir Charles Gairdner Hospital Research Advisory Committee Grant, and the National Health and Medical Research Council of Australia. Dr. Sim and Dr. Sexton have reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Bone densitometry scans may be a novel, noninvasive, and scalable way to identify older women at risk of developing dementia, new research suggests.

In an analysis of more than 900 study participants, women in their 70s with more advanced abdominal aortic calcification (AAC) seen on lateral spine images during dual-energy x-ray absorptiometry (DXA) had a two- to fourfold higher risk for late-life dementia than those with low AAC.

This finding was independent of cardiovascular risk factors and apolipoprotein E (APOE ) genotype.

“While these results are exciting, we now need to undertake further large screening studies in older men and women using this approach to show that the findings are generalizable to older men and can identify people with greater cognitive decline,” coinvestigator Marc Sim, PhD, Edith Cowan University, Joondalup, Australia, said in an interview.

“This will hopefully open the door to studies of early disease-modifying interventions,” Sim said.

The findings were published online in The Lancet Regional Health – Western Pacific. 
 

AAC and cognition

Late-life dementia occurring after age 80 is increasingly common because of both vascular and nonvascular risk factors.

Two recent studies in middle-aged and older men and women showed that AAC identified on bone densitometry was associated with poorer cognition, suggesting it may be related to cognitive decline and increased dementia risk.

This provided the rationale for the current study, Dr. Sim noted.

The researchers assessed AAC using DXA lateral spine images captured in the late 1990s in a prospective cohort of 958 older women who were participating in an osteoporosis study.

AAC was classified into established low, moderate, and extensive categories. At baseline, all women were aged 70 and older, and 45% had low AAC, 36% had moderate AAC, and 19% had extensive AAC.

Over 14.5 years, 150 women (15.7%) had a late-life hospitalization and/or died.
 

Improved risk prediction

Results showed that, compared with women who had low AAC, women with moderate and extensive AAC were more likely to experience late-life dementia hospitalization (9.3% low, 15.5% moderate, and 18.3% extensive) and death (2.8%, 8.3%, and 9.4%, respectively).

After multivariable adjustment, women with moderate AAC had a two- and threefold increased relative risk for late-life dementia hospitalization or death, compared with their peers who had low AAC.

Women with extensive AAC had a two- and fourfold increase in the adjusted relative risk for late-life dementia hospitalization or death.

“To our knowledge this is the first time it has been shown that AAC from these scans is related to late-life dementia,” Dr. Sim said.

“We demonstrated that AAC improved risk prediction in addition to cardiovascular risk factors and APOE genotype, a genetic risk factor for Alzheimer’s disease, the major form of dementia,” he added.

Dr. Sim noted “these additional lateral spine images” can be taken at the same time that hip and spine bone density tests are done.

“This provides an opportunity to identify AAC in large numbers of people,” he said.

He cautioned, however, that further studies with detailed dementia-related phenotypes, brain imaging, and measures of cognition are needed to confirm whether AAC will add value to dementia risk prediction.
 

‘Not surprising’

Commenting on the findings for this article, Claire Sexton, DPhil, senior director of scientific programs and outreach at the Alzheimer’s Association, Chicago, noted that AAC is a marker of atherosclerosis and is associated with vascular health outcomes.

Therefore, it is “not surprising it would be associated with dementia too. There’s been previous research linking atherosclerosis and Alzheimer’s disease,” Dr. Sexton said.  

“What’s novel about this research is that it’s looking at AAC specifically, which can be identified through a relatively simple test that is already in widespread use,” she added.

Dr. Sexton noted that “much more research” is now needed in larger, more diverse populations in order to better understand the link between AAC and dementia – and whether bone density testing may be an appropriate dementia-screening tool.

“The good news is vascular conditions like atherosclerosis can be managed through lifestyle changes like eating a healthy diet and getting regular exercise. And research tells us what’s good for the heart is good for the brain,” Dr. Sexton said.

The study was funded by Kidney Health Australia, Healthway Health Promotion Foundation of Western Australia, Sir Charles Gairdner Hospital Research Advisory Committee Grant, and the National Health and Medical Research Council of Australia. Dr. Sim and Dr. Sexton have reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Bone densitometry scans may be a novel, noninvasive, and scalable way to identify older women at risk of developing dementia, new research suggests.

In an analysis of more than 900 study participants, women in their 70s with more advanced abdominal aortic calcification (AAC) seen on lateral spine images during dual-energy x-ray absorptiometry (DXA) had a two- to fourfold higher risk for late-life dementia than those with low AAC.

This finding was independent of cardiovascular risk factors and apolipoprotein E (APOE ) genotype.

“While these results are exciting, we now need to undertake further large screening studies in older men and women using this approach to show that the findings are generalizable to older men and can identify people with greater cognitive decline,” coinvestigator Marc Sim, PhD, Edith Cowan University, Joondalup, Australia, said in an interview.

“This will hopefully open the door to studies of early disease-modifying interventions,” Sim said.

The findings were published online in The Lancet Regional Health – Western Pacific. 
 

AAC and cognition

Late-life dementia occurring after age 80 is increasingly common because of both vascular and nonvascular risk factors.

Two recent studies in middle-aged and older men and women showed that AAC identified on bone densitometry was associated with poorer cognition, suggesting it may be related to cognitive decline and increased dementia risk.

This provided the rationale for the current study, Dr. Sim noted.

The researchers assessed AAC using DXA lateral spine images captured in the late 1990s in a prospective cohort of 958 older women who were participating in an osteoporosis study.

AAC was classified into established low, moderate, and extensive categories. At baseline, all women were aged 70 and older, and 45% had low AAC, 36% had moderate AAC, and 19% had extensive AAC.

Over 14.5 years, 150 women (15.7%) had a late-life hospitalization and/or died.
 

Improved risk prediction

Results showed that, compared with women who had low AAC, women with moderate and extensive AAC were more likely to experience late-life dementia hospitalization (9.3% low, 15.5% moderate, and 18.3% extensive) and death (2.8%, 8.3%, and 9.4%, respectively).

After multivariable adjustment, women with moderate AAC had a two- and threefold increased relative risk for late-life dementia hospitalization or death, compared with their peers who had low AAC.

Women with extensive AAC had a two- and fourfold increase in the adjusted relative risk for late-life dementia hospitalization or death.

“To our knowledge this is the first time it has been shown that AAC from these scans is related to late-life dementia,” Dr. Sim said.

“We demonstrated that AAC improved risk prediction in addition to cardiovascular risk factors and APOE genotype, a genetic risk factor for Alzheimer’s disease, the major form of dementia,” he added.

Dr. Sim noted “these additional lateral spine images” can be taken at the same time that hip and spine bone density tests are done.

“This provides an opportunity to identify AAC in large numbers of people,” he said.

He cautioned, however, that further studies with detailed dementia-related phenotypes, brain imaging, and measures of cognition are needed to confirm whether AAC will add value to dementia risk prediction.
 

‘Not surprising’

Commenting on the findings for this article, Claire Sexton, DPhil, senior director of scientific programs and outreach at the Alzheimer’s Association, Chicago, noted that AAC is a marker of atherosclerosis and is associated with vascular health outcomes.

Therefore, it is “not surprising it would be associated with dementia too. There’s been previous research linking atherosclerosis and Alzheimer’s disease,” Dr. Sexton said.  

“What’s novel about this research is that it’s looking at AAC specifically, which can be identified through a relatively simple test that is already in widespread use,” she added.

Dr. Sexton noted that “much more research” is now needed in larger, more diverse populations in order to better understand the link between AAC and dementia – and whether bone density testing may be an appropriate dementia-screening tool.

“The good news is vascular conditions like atherosclerosis can be managed through lifestyle changes like eating a healthy diet and getting regular exercise. And research tells us what’s good for the heart is good for the brain,” Dr. Sexton said.

The study was funded by Kidney Health Australia, Healthway Health Promotion Foundation of Western Australia, Sir Charles Gairdner Hospital Research Advisory Committee Grant, and the National Health and Medical Research Council of Australia. Dr. Sim and Dr. Sexton have reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

The Centers for Disease Control and Prevention (CDC) and the World Health Organization are investigating an outbreak of monkeypox cases that have occurred around the world in countries that do not have endemic monkeypox virus.^1,2 As of July 5, there have been 6924 cases documented in 52 countries, including 560 cases that have occurred in the United States.² In the United States, as well as globally, a large proportion of cases have been in men who have sex with men.

First, what is monkeypox? Monkeypox is an orthopox virus that is closely related to variola (smallpox) and vaccinia (the virus used in the smallpox vaccine). It is endemic in western and central Africa and is contracted by contact with an infected mammal (including humans). Transmission can occur through direct contact with infected body fluids or lesions, via infectious fomites, or through respiratory secretions (although this usually requires prolonged exposure).

What is the disease course? The incubation period is 4 to 17 days. The initial symptoms include fever, malaise, headache, sore throat, and lymphadenopathy. A rash erupts 1 to 4 days after the prodrome and progresses synchronously from macules to papules to vesicles and then to pustules, which eventually scab over and fall off. In some cases reported in the United States, the rash started in the groin and genital area.

Don’t be fooled by other exanthems. Monkeypox can be confused with chickenpox and molluscum contagiosum (MC). However, the lesions in chickenpox appear asynchronously (all 4 stages present at the same time) and the papules of MC contain a central pit.

Can monkeypox be prevented? There are currently 2 vaccines against orthopox viruses: ACAM2000 and Jynneos. Currently, these vaccines are routinely recommended only for those at occupational risk of orthopox exposure.³

What you should know—and do. Be alert for any patient who presents with a suspicious rash; if there is a possibility of monkeypox, the local public health department should be contacted. They will investigate and collect samples for laboratory testing and will elicit contact names and locations. If monkeypox is confirmed, they may offer close contacts 1 of the 2 vaccines, which if administered within 4 days of exposure can prevent infection.

Advise all patients confirmed to have monkeypox to self-isolate until all skin lesions have healed. Good infection control practices in the clinical setting will prevent spread to staff and other patients.

More information about monkeypox, including images of typical lesions—as well as an update on the current investigation in the United States and worldwide—can be found on the CDC website.⁴

The Centers for Disease Control and Prevention (CDC) and the World Health Organization are investigating an outbreak of monkeypox cases that have occurred around the world in countries that do not have endemic monkeypox virus.^1,2 As of July 5, there have been 6924 cases documented in 52 countries, including 560 cases that have occurred in the United States.² In the United States, as well as globally, a large proportion of cases have been in men who have sex with men.

First, what is monkeypox? Monkeypox is an orthopox virus that is closely related to variola (smallpox) and vaccinia (the virus used in the smallpox vaccine). It is endemic in western and central Africa and is contracted by contact with an infected mammal (including humans). Transmission can occur through direct contact with infected body fluids or lesions, via infectious fomites, or through respiratory secretions (although this usually requires prolonged exposure).

What is the disease course? The incubation period is 4 to 17 days. The initial symptoms include fever, malaise, headache, sore throat, and lymphadenopathy. A rash erupts 1 to 4 days after the prodrome and progresses synchronously from macules to papules to vesicles and then to pustules, which eventually scab over and fall off. In some cases reported in the United States, the rash started in the groin and genital area.

Don’t be fooled by other exanthems. Monkeypox can be confused with chickenpox and molluscum contagiosum (MC). However, the lesions in chickenpox appear asynchronously (all 4 stages present at the same time) and the papules of MC contain a central pit.

Can monkeypox be prevented? There are currently 2 vaccines against orthopox viruses: ACAM2000 and Jynneos. Currently, these vaccines are routinely recommended only for those at occupational risk of orthopox exposure.³

What you should know—and do. Be alert for any patient who presents with a suspicious rash; if there is a possibility of monkeypox, the local public health department should be contacted. They will investigate and collect samples for laboratory testing and will elicit contact names and locations. If monkeypox is confirmed, they may offer close contacts 1 of the 2 vaccines, which if administered within 4 days of exposure can prevent infection.

Advise all patients confirmed to have monkeypox to self-isolate until all skin lesions have healed. Good infection control practices in the clinical setting will prevent spread to staff and other patients.

More information about monkeypox, including images of typical lesions—as well as an update on the current investigation in the United States and worldwide—can be found on the CDC website.⁴

The Centers for Disease Control and Prevention (CDC) and the World Health Organization are investigating an outbreak of monkeypox cases that have occurred around the world in countries that do not have endemic monkeypox virus.^1,2 As of July 5, there have been 6924 cases documented in 52 countries, including 560 cases that have occurred in the United States.² In the United States, as well as globally, a large proportion of cases have been in men who have sex with men.

First, what is monkeypox? Monkeypox is an orthopox virus that is closely related to variola (smallpox) and vaccinia (the virus used in the smallpox vaccine). It is endemic in western and central Africa and is contracted by contact with an infected mammal (including humans). Transmission can occur through direct contact with infected body fluids or lesions, via infectious fomites, or through respiratory secretions (although this usually requires prolonged exposure).

What is the disease course? The incubation period is 4 to 17 days. The initial symptoms include fever, malaise, headache, sore throat, and lymphadenopathy. A rash erupts 1 to 4 days after the prodrome and progresses synchronously from macules to papules to vesicles and then to pustules, which eventually scab over and fall off. In some cases reported in the United States, the rash started in the groin and genital area.

Don’t be fooled by other exanthems. Monkeypox can be confused with chickenpox and molluscum contagiosum (MC). However, the lesions in chickenpox appear asynchronously (all 4 stages present at the same time) and the papules of MC contain a central pit.

Can monkeypox be prevented? There are currently 2 vaccines against orthopox viruses: ACAM2000 and Jynneos. Currently, these vaccines are routinely recommended only for those at occupational risk of orthopox exposure.³

What you should know—and do. Be alert for any patient who presents with a suspicious rash; if there is a possibility of monkeypox, the local public health department should be contacted. They will investigate and collect samples for laboratory testing and will elicit contact names and locations. If monkeypox is confirmed, they may offer close contacts 1 of the 2 vaccines, which if administered within 4 days of exposure can prevent infection.

Advise all patients confirmed to have monkeypox to self-isolate until all skin lesions have healed. Good infection control practices in the clinical setting will prevent spread to staff and other patients.

More information about monkeypox, including images of typical lesions—as well as an update on the current investigation in the United States and worldwide—can be found on the CDC website.⁴

Concerns about the potential harm resulting from overzealous training regimens and performance schedules for young elite athletes seems to come in cycles much like the Olympics. But, more recently, the media attention has become more intense fueled by the very visible psychological vulnerabilities of some young gymnasts, tennis players, and figure skaters. Accusations of physical and psychological abuse by team physicians and coaches continue to surface with troubling regularity.

A recent article in the Wall St. Journal explores a variety of initiatives aimed at redefining the relationship between youth sports and the physical and mental health of its elite athletes. (Louise Radnofsky, The Wall Street Journal, June 9, 2022).

An example of the new awareness is the recent invitation of Peter Donnelly, PhD, an emeritus professor at the University of Toronto and long-time advocate for regulatory protections for youth athletes, to deliver a paper at a global conference in South Africa devoted to the elimination of child labor. Referring to youth sports, Dr. Donnelly observes “What if McDonalds had the same accident rate? ... There would be huge commissions of inquiry, regulations, and policies.” He suggests that the United Nations Convention on the Rights of the Child might be a mechanism to address the problem.

Writing in the Marquette University Sports Law Review in 2015, Kristin Hoffman, a law student at the time, suggested that the federal Fair Labor Standards Act or state child labor laws could be used to restructure sports like gymnastics or figure skating with tarnished histories. California law prohibits child actors from working more than 5 hours a day on school days and 7 hours on nonschool days but says little about child athletes. On paper, the National Collegiate Athletic Association limits college athletes to 20 hours participation per week but teenagers on club teams are not limited and may sometimes practice 30 hours or more.

Regulation in any form is a tough sell in this country. Coaches, parents, and athletes caught up in the myth that more repetitions and more touches on the ball are always the ticket to success will argue that most elite athletes are self-motivated and don’t view the long hours as a hardship.

Exactly how many are self-driven and how many are being pushed by parents and coaches is unknown. Across the street from us lived a young girl who, despite not having the obvious physical gifts, was clearly committed to excel in sports. She begged her parents to set up lights to allow her to practice well into the evening. She went on to have a good college career as a player and a very successful career as a Division I coach. Now in retirement, she is very open about her mental health history that in large part explains her inner drive and her subsequent troubles.

We need to be realistic in our hope for regulating the current state of youth sports out of its current situation. State laws that put reasonable limits on the hourly commitment to sports much like the California child actor laws feel like a reasonable goal. However, as physicians for these young athletes we must take each child – and we must remind ourselves that they are still children – as an individual.

When faced with patients who are clearly on the elite sport pathway, our goal is to protect their health – both physical and mental. If they are having symptoms of overuse we need to help them find alternative activities that will rest their injuries but still allow them to satisfy their competitive zeal. However, we must be ever alert to the risk that what appears to be unusual self-motivation may be instead a warning that pathologic obsession and compulsion lurk below the surface.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

Concerns about the potential harm resulting from overzealous training regimens and performance schedules for young elite athletes seems to come in cycles much like the Olympics. But, more recently, the media attention has become more intense fueled by the very visible psychological vulnerabilities of some young gymnasts, tennis players, and figure skaters. Accusations of physical and psychological abuse by team physicians and coaches continue to surface with troubling regularity.

A recent article in the Wall St. Journal explores a variety of initiatives aimed at redefining the relationship between youth sports and the physical and mental health of its elite athletes. (Louise Radnofsky, The Wall Street Journal, June 9, 2022).

An example of the new awareness is the recent invitation of Peter Donnelly, PhD, an emeritus professor at the University of Toronto and long-time advocate for regulatory protections for youth athletes, to deliver a paper at a global conference in South Africa devoted to the elimination of child labor. Referring to youth sports, Dr. Donnelly observes “What if McDonalds had the same accident rate? ... There would be huge commissions of inquiry, regulations, and policies.” He suggests that the United Nations Convention on the Rights of the Child might be a mechanism to address the problem.

Writing in the Marquette University Sports Law Review in 2015, Kristin Hoffman, a law student at the time, suggested that the federal Fair Labor Standards Act or state child labor laws could be used to restructure sports like gymnastics or figure skating with tarnished histories. California law prohibits child actors from working more than 5 hours a day on school days and 7 hours on nonschool days but says little about child athletes. On paper, the National Collegiate Athletic Association limits college athletes to 20 hours participation per week but teenagers on club teams are not limited and may sometimes practice 30 hours or more.

Regulation in any form is a tough sell in this country. Coaches, parents, and athletes caught up in the myth that more repetitions and more touches on the ball are always the ticket to success will argue that most elite athletes are self-motivated and don’t view the long hours as a hardship.

Exactly how many are self-driven and how many are being pushed by parents and coaches is unknown. Across the street from us lived a young girl who, despite not having the obvious physical gifts, was clearly committed to excel in sports. She begged her parents to set up lights to allow her to practice well into the evening. She went on to have a good college career as a player and a very successful career as a Division I coach. Now in retirement, she is very open about her mental health history that in large part explains her inner drive and her subsequent troubles.

We need to be realistic in our hope for regulating the current state of youth sports out of its current situation. State laws that put reasonable limits on the hourly commitment to sports much like the California child actor laws feel like a reasonable goal. However, as physicians for these young athletes we must take each child – and we must remind ourselves that they are still children – as an individual.

When faced with patients who are clearly on the elite sport pathway, our goal is to protect their health – both physical and mental. If they are having symptoms of overuse we need to help them find alternative activities that will rest their injuries but still allow them to satisfy their competitive zeal. However, we must be ever alert to the risk that what appears to be unusual self-motivation may be instead a warning that pathologic obsession and compulsion lurk below the surface.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

Concerns about the potential harm resulting from overzealous training regimens and performance schedules for young elite athletes seems to come in cycles much like the Olympics. But, more recently, the media attention has become more intense fueled by the very visible psychological vulnerabilities of some young gymnasts, tennis players, and figure skaters. Accusations of physical and psychological abuse by team physicians and coaches continue to surface with troubling regularity.

A recent article in the Wall St. Journal explores a variety of initiatives aimed at redefining the relationship between youth sports and the physical and mental health of its elite athletes. (Louise Radnofsky, The Wall Street Journal, June 9, 2022).

An example of the new awareness is the recent invitation of Peter Donnelly, PhD, an emeritus professor at the University of Toronto and long-time advocate for regulatory protections for youth athletes, to deliver a paper at a global conference in South Africa devoted to the elimination of child labor. Referring to youth sports, Dr. Donnelly observes “What if McDonalds had the same accident rate? ... There would be huge commissions of inquiry, regulations, and policies.” He suggests that the United Nations Convention on the Rights of the Child might be a mechanism to address the problem.

Writing in the Marquette University Sports Law Review in 2015, Kristin Hoffman, a law student at the time, suggested that the federal Fair Labor Standards Act or state child labor laws could be used to restructure sports like gymnastics or figure skating with tarnished histories. California law prohibits child actors from working more than 5 hours a day on school days and 7 hours on nonschool days but says little about child athletes. On paper, the National Collegiate Athletic Association limits college athletes to 20 hours participation per week but teenagers on club teams are not limited and may sometimes practice 30 hours or more.

Regulation in any form is a tough sell in this country. Coaches, parents, and athletes caught up in the myth that more repetitions and more touches on the ball are always the ticket to success will argue that most elite athletes are self-motivated and don’t view the long hours as a hardship.

Exactly how many are self-driven and how many are being pushed by parents and coaches is unknown. Across the street from us lived a young girl who, despite not having the obvious physical gifts, was clearly committed to excel in sports. She begged her parents to set up lights to allow her to practice well into the evening. She went on to have a good college career as a player and a very successful career as a Division I coach. Now in retirement, she is very open about her mental health history that in large part explains her inner drive and her subsequent troubles.

We need to be realistic in our hope for regulating the current state of youth sports out of its current situation. State laws that put reasonable limits on the hourly commitment to sports much like the California child actor laws feel like a reasonable goal. However, as physicians for these young athletes we must take each child – and we must remind ourselves that they are still children – as an individual.

When faced with patients who are clearly on the elite sport pathway, our goal is to protect their health – both physical and mental. If they are having symptoms of overuse we need to help them find alternative activities that will rest their injuries but still allow them to satisfy their competitive zeal. However, we must be ever alert to the risk that what appears to be unusual self-motivation may be instead a warning that pathologic obsession and compulsion lurk below the surface.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

Every time Nathan Chomilo, MD, uses a clinical decision support tool, he tells his patients they have a choice: He can input their race or keep that field blank.

Until recently, many clinicians didn’t question the use of race as a datapoint in tools used to make decisions about diagnosis and care. But that is changing.

“I’ve almost universally had patients appreciate that someone actually told them that their kidney function was being scored differently because of the color of their skin or how they were identified in the medical chart along lines of race,” Dr. Chomilo, an adjunct assistant professor of pediatrics at the University of Minnesota Medical School, Minneapolis, said.

Dr. Chomilo is referring to the estimated glomerular filtration rate (eGFR), which combines results from a blood test with factors such as age, sex, and race to calculate kidney function.

The eGFR weighed an input of “African American” as automatically indicating a higher concentration of serum creatinine than a non African American patient on the basis of the unsubstantiated idea that Black people have more creatinine in their blood at baseline.

The calculator creates a picture of a Black patient who is not as sick as a White patient with the same levels of kidney failure. But race is based on the color of a patient’s skin, not on genetics or other clinical datapoints.

“I often use my own example of being a biracial Black man: My father’s family is from Cameroon, my mother’s family is from Norway. Are you going to assign my kidneys or my lungs to my mom’s side or my dad’s side? That’s not clear at all in the way we use race in medicine,” Dr. Chomilo, an executive committee member on the section on minority health equity and inclusion at the American Academy of Pediatrics (AAP), said.

Long before the COVID-19 pandemic so publicly exposed the depths of inequality in morbidity and mortality in the United States, health advocates had been pointing out these disparities in tools used by medical professionals. But efforts to recognize that race is a poor proxy for genetics is in its infancy.

In May, the AAP published a policy statement that kicked off its examination of clinical guidelines and policies that include race as a biological proxy. A committee for the society is combing through each guideline or calculator, evaluating the scientific basis for the use of race, and examining whether a stronger datapoint could be used instead.

The eGFR is perhaps the best example of a calculator that’s gone through the process: Health care stakeholders questioned the use of race, and investigators went back to study whether race was really a good datapoint. It wasn’t, and Dr. Chamilo’s hospital joined many others in retiring the calculator.

But the eGFR is one of countless clinical tools – from rudimentary algorithms to sophisticated machine-learning instruments – that change the course of care in part on the basis of race in the same way datapoints such as weight, age, and height are used to inform decisions about patient management. But unlike race, height, weight, and age can be objectively measured. A physician either makes a guess, or a patient enters their race on a form. And while that can be useful on a population level, race does not equal genetics or any other measurable datapoint.

In a study published in JAMA Pediatrics, researchers reviewed 414 clinical practice guidelines from sources such as PubMed and MetaLib.gov. Almost 1 in 6 guidelines included race in an inappropriate way, such as by conflating race as a biological risk factor or establishing testing or treatment thresholds using race.
 

Waiting for alternatives

The University of Maryland Medical System last year embarked on a project similar to the AAP initiative but within its own system. The first use of race to be eliminated was in the eGFR. The health system also recently removed the variable from a tool for diagnosing urinary tract infections (UTIs) in children younger than 2 years.

Part of that tool includes deciding to perform a catheterized urine test. If a doctor chose “White” as the race, the tool would recommend the test. If the doctor chose “Black,” the tool would recommend to not test. Joseph Wright, MD, MPH, chief health equity officer at University of Maryland Medical System, said this step in the tool is based on the unproven assumption that young Black children had a lower likelihood of UTIs than their White peers.

“We simply want folks to not by default lob race in as a decisionmaking point when we have, with a little bit more scientific diligence, the ability to include better clinical variables,” Dr. Wright, who is also an adjunct professor of health policy and management at the University of Maryland School of Public Health, College Park, said.

The developers of the UTI tool recently released a revised version that removes race in favor of two new medical datapoints: whether the patient has had a fever for over 48 hours, and whether the patient has previously had a UTI.

The process of re-examining tools, coming up with new datapoints, and implementing changes is not simple, according to Dr. Wright.

“This is just the baby step to fix the algorithms, because we’re all going to have to examine our own house, where these calculators live, whether it’s in a textbook, whether it’s in an electronic health record, and that’s the heavy lift,” he said. “All sources of clinical guidance have to be scrutinized, and it’s going to literally take years to unroot.”

Electronic medical record vendor Cerner said it generally revises its algorithms after medical societies make changes, then communicates those fixes to providers.

Rebecca C. Winokur, MD, MPH, lead physician executive and health equity service line leader at Cerner, explained that if doctors ordered an eGFR a year ago and then another today, the results might be different because of the new code that eliminates race.

“The numbers are so different, how do you know that the patient may or may not have the same function?” Dr. Winokur said.

Dr. Winokur said the company is trying to determine at which point a message should pop up in the records workflow that would inform clinicians that they may be comparing apples to cherries. The company also is reconsidering the use of race in tools that estimate the probability of a successful vaginal birth after prior cesarean delivery, a calculator that predicts the risk of urethral stones in patients with flank pain, and another that measures lung function to help diagnose pulmonary disease.

In addition to managing the logistics of removing race, health institutions also need buy-in from clinicians. At Mass General Brigham, Boston, Thomas Sequist, MD, MPH, chief medical officer, is leading a project to examine how the system uses race in calculators.

“People struggle mainly with, well, if we shouldn’t use this calculator, what should we use, because we need a calculator. And that’s a legitimate question,” Dr. Sequist said in an interview. “If we’re going to stop using this race-based calculator, I still need to know what dose of medication I give my patient. We’re not going to pull any of these calculators until we have a safe and reliable alternative.”

For each calculator, relevant specialty chiefs come to the table with Dr. Sequist and his team; current projects include examining bone density screenings and cardiac risk scores. A large part of the work is communicating the lack of science behind the inclusion of race as a variable.

“It’s hard because these tools have been in existence for decades, and people are used to using them,” Dr. Sequist said. “So this is a big-change management project.”

Some clinicians also have difficulty discerning why their health system may stratify patient outcomes by race while providers are being told that race is being removed from the calculators they use every day. The key difference is that stratifying outcomes by race illuminates systemic problems that can be targeted by a health system.

For instance, if readmission rates are higher for Black patients overall after surgery, the reason might be that nurses are not delivering the same level of care to them as they are to non-Black patients, possibly because of hidden bias. Or, perhaps Black patients at a hospital have less access to transportation for follow-up appointments after surgery. The potential reasons can be investigated, and solutions can be created.

“If you look at a population level, what you’re looking for is not for the evidence of race as a biological construct,” Dr. Chomilo said. “You’re looking for the impact of racism on populations, and that’s the difference: It’s racism, not race.”

A version of this article first appeared on Medscape.com.

Every time Nathan Chomilo, MD, uses a clinical decision support tool, he tells his patients they have a choice: He can input their race or keep that field blank.

Until recently, many clinicians didn’t question the use of race as a datapoint in tools used to make decisions about diagnosis and care. But that is changing.

“I’ve almost universally had patients appreciate that someone actually told them that their kidney function was being scored differently because of the color of their skin or how they were identified in the medical chart along lines of race,” Dr. Chomilo, an adjunct assistant professor of pediatrics at the University of Minnesota Medical School, Minneapolis, said.

Dr. Chomilo is referring to the estimated glomerular filtration rate (eGFR), which combines results from a blood test with factors such as age, sex, and race to calculate kidney function.

The eGFR weighed an input of “African American” as automatically indicating a higher concentration of serum creatinine than a non African American patient on the basis of the unsubstantiated idea that Black people have more creatinine in their blood at baseline.

The calculator creates a picture of a Black patient who is not as sick as a White patient with the same levels of kidney failure. But race is based on the color of a patient’s skin, not on genetics or other clinical datapoints.

“I often use my own example of being a biracial Black man: My father’s family is from Cameroon, my mother’s family is from Norway. Are you going to assign my kidneys or my lungs to my mom’s side or my dad’s side? That’s not clear at all in the way we use race in medicine,” Dr. Chomilo, an executive committee member on the section on minority health equity and inclusion at the American Academy of Pediatrics (AAP), said.

Long before the COVID-19 pandemic so publicly exposed the depths of inequality in morbidity and mortality in the United States, health advocates had been pointing out these disparities in tools used by medical professionals. But efforts to recognize that race is a poor proxy for genetics is in its infancy.

In May, the AAP published a policy statement that kicked off its examination of clinical guidelines and policies that include race as a biological proxy. A committee for the society is combing through each guideline or calculator, evaluating the scientific basis for the use of race, and examining whether a stronger datapoint could be used instead.

The eGFR is perhaps the best example of a calculator that’s gone through the process: Health care stakeholders questioned the use of race, and investigators went back to study whether race was really a good datapoint. It wasn’t, and Dr. Chamilo’s hospital joined many others in retiring the calculator.

But the eGFR is one of countless clinical tools – from rudimentary algorithms to sophisticated machine-learning instruments – that change the course of care in part on the basis of race in the same way datapoints such as weight, age, and height are used to inform decisions about patient management. But unlike race, height, weight, and age can be objectively measured. A physician either makes a guess, or a patient enters their race on a form. And while that can be useful on a population level, race does not equal genetics or any other measurable datapoint.

In a study published in JAMA Pediatrics, researchers reviewed 414 clinical practice guidelines from sources such as PubMed and MetaLib.gov. Almost 1 in 6 guidelines included race in an inappropriate way, such as by conflating race as a biological risk factor or establishing testing or treatment thresholds using race.
 

Waiting for alternatives

The University of Maryland Medical System last year embarked on a project similar to the AAP initiative but within its own system. The first use of race to be eliminated was in the eGFR. The health system also recently removed the variable from a tool for diagnosing urinary tract infections (UTIs) in children younger than 2 years.

Part of that tool includes deciding to perform a catheterized urine test. If a doctor chose “White” as the race, the tool would recommend the test. If the doctor chose “Black,” the tool would recommend to not test. Joseph Wright, MD, MPH, chief health equity officer at University of Maryland Medical System, said this step in the tool is based on the unproven assumption that young Black children had a lower likelihood of UTIs than their White peers.

“We simply want folks to not by default lob race in as a decisionmaking point when we have, with a little bit more scientific diligence, the ability to include better clinical variables,” Dr. Wright, who is also an adjunct professor of health policy and management at the University of Maryland School of Public Health, College Park, said.

The developers of the UTI tool recently released a revised version that removes race in favor of two new medical datapoints: whether the patient has had a fever for over 48 hours, and whether the patient has previously had a UTI.

The process of re-examining tools, coming up with new datapoints, and implementing changes is not simple, according to Dr. Wright.

“This is just the baby step to fix the algorithms, because we’re all going to have to examine our own house, where these calculators live, whether it’s in a textbook, whether it’s in an electronic health record, and that’s the heavy lift,” he said. “All sources of clinical guidance have to be scrutinized, and it’s going to literally take years to unroot.”

Electronic medical record vendor Cerner said it generally revises its algorithms after medical societies make changes, then communicates those fixes to providers.

Rebecca C. Winokur, MD, MPH, lead physician executive and health equity service line leader at Cerner, explained that if doctors ordered an eGFR a year ago and then another today, the results might be different because of the new code that eliminates race.

“The numbers are so different, how do you know that the patient may or may not have the same function?” Dr. Winokur said.

Dr. Winokur said the company is trying to determine at which point a message should pop up in the records workflow that would inform clinicians that they may be comparing apples to cherries. The company also is reconsidering the use of race in tools that estimate the probability of a successful vaginal birth after prior cesarean delivery, a calculator that predicts the risk of urethral stones in patients with flank pain, and another that measures lung function to help diagnose pulmonary disease.

In addition to managing the logistics of removing race, health institutions also need buy-in from clinicians. At Mass General Brigham, Boston, Thomas Sequist, MD, MPH, chief medical officer, is leading a project to examine how the system uses race in calculators.

“People struggle mainly with, well, if we shouldn’t use this calculator, what should we use, because we need a calculator. And that’s a legitimate question,” Dr. Sequist said in an interview. “If we’re going to stop using this race-based calculator, I still need to know what dose of medication I give my patient. We’re not going to pull any of these calculators until we have a safe and reliable alternative.”

For each calculator, relevant specialty chiefs come to the table with Dr. Sequist and his team; current projects include examining bone density screenings and cardiac risk scores. A large part of the work is communicating the lack of science behind the inclusion of race as a variable.

“It’s hard because these tools have been in existence for decades, and people are used to using them,” Dr. Sequist said. “So this is a big-change management project.”

Some clinicians also have difficulty discerning why their health system may stratify patient outcomes by race while providers are being told that race is being removed from the calculators they use every day. The key difference is that stratifying outcomes by race illuminates systemic problems that can be targeted by a health system.

For instance, if readmission rates are higher for Black patients overall after surgery, the reason might be that nurses are not delivering the same level of care to them as they are to non-Black patients, possibly because of hidden bias. Or, perhaps Black patients at a hospital have less access to transportation for follow-up appointments after surgery. The potential reasons can be investigated, and solutions can be created.

“If you look at a population level, what you’re looking for is not for the evidence of race as a biological construct,” Dr. Chomilo said. “You’re looking for the impact of racism on populations, and that’s the difference: It’s racism, not race.”

A version of this article first appeared on Medscape.com.

Every time Nathan Chomilo, MD, uses a clinical decision support tool, he tells his patients they have a choice: He can input their race or keep that field blank.

Until recently, many clinicians didn’t question the use of race as a datapoint in tools used to make decisions about diagnosis and care. But that is changing.

“I’ve almost universally had patients appreciate that someone actually told them that their kidney function was being scored differently because of the color of their skin or how they were identified in the medical chart along lines of race,” Dr. Chomilo, an adjunct assistant professor of pediatrics at the University of Minnesota Medical School, Minneapolis, said.

Dr. Chomilo is referring to the estimated glomerular filtration rate (eGFR), which combines results from a blood test with factors such as age, sex, and race to calculate kidney function.

The eGFR weighed an input of “African American” as automatically indicating a higher concentration of serum creatinine than a non African American patient on the basis of the unsubstantiated idea that Black people have more creatinine in their blood at baseline.

The calculator creates a picture of a Black patient who is not as sick as a White patient with the same levels of kidney failure. But race is based on the color of a patient’s skin, not on genetics or other clinical datapoints.

“I often use my own example of being a biracial Black man: My father’s family is from Cameroon, my mother’s family is from Norway. Are you going to assign my kidneys or my lungs to my mom’s side or my dad’s side? That’s not clear at all in the way we use race in medicine,” Dr. Chomilo, an executive committee member on the section on minority health equity and inclusion at the American Academy of Pediatrics (AAP), said.

Long before the COVID-19 pandemic so publicly exposed the depths of inequality in morbidity and mortality in the United States, health advocates had been pointing out these disparities in tools used by medical professionals. But efforts to recognize that race is a poor proxy for genetics is in its infancy.

In May, the AAP published a policy statement that kicked off its examination of clinical guidelines and policies that include race as a biological proxy. A committee for the society is combing through each guideline or calculator, evaluating the scientific basis for the use of race, and examining whether a stronger datapoint could be used instead.

The eGFR is perhaps the best example of a calculator that’s gone through the process: Health care stakeholders questioned the use of race, and investigators went back to study whether race was really a good datapoint. It wasn’t, and Dr. Chamilo’s hospital joined many others in retiring the calculator.

But the eGFR is one of countless clinical tools – from rudimentary algorithms to sophisticated machine-learning instruments – that change the course of care in part on the basis of race in the same way datapoints such as weight, age, and height are used to inform decisions about patient management. But unlike race, height, weight, and age can be objectively measured. A physician either makes a guess, or a patient enters their race on a form. And while that can be useful on a population level, race does not equal genetics or any other measurable datapoint.

In a study published in JAMA Pediatrics, researchers reviewed 414 clinical practice guidelines from sources such as PubMed and MetaLib.gov. Almost 1 in 6 guidelines included race in an inappropriate way, such as by conflating race as a biological risk factor or establishing testing or treatment thresholds using race.
 

Waiting for alternatives

The University of Maryland Medical System last year embarked on a project similar to the AAP initiative but within its own system. The first use of race to be eliminated was in the eGFR. The health system also recently removed the variable from a tool for diagnosing urinary tract infections (UTIs) in children younger than 2 years.

Part of that tool includes deciding to perform a catheterized urine test. If a doctor chose “White” as the race, the tool would recommend the test. If the doctor chose “Black,” the tool would recommend to not test. Joseph Wright, MD, MPH, chief health equity officer at University of Maryland Medical System, said this step in the tool is based on the unproven assumption that young Black children had a lower likelihood of UTIs than their White peers.

“We simply want folks to not by default lob race in as a decisionmaking point when we have, with a little bit more scientific diligence, the ability to include better clinical variables,” Dr. Wright, who is also an adjunct professor of health policy and management at the University of Maryland School of Public Health, College Park, said.

The developers of the UTI tool recently released a revised version that removes race in favor of two new medical datapoints: whether the patient has had a fever for over 48 hours, and whether the patient has previously had a UTI.

The process of re-examining tools, coming up with new datapoints, and implementing changes is not simple, according to Dr. Wright.

“This is just the baby step to fix the algorithms, because we’re all going to have to examine our own house, where these calculators live, whether it’s in a textbook, whether it’s in an electronic health record, and that’s the heavy lift,” he said. “All sources of clinical guidance have to be scrutinized, and it’s going to literally take years to unroot.”

Electronic medical record vendor Cerner said it generally revises its algorithms after medical societies make changes, then communicates those fixes to providers.

Rebecca C. Winokur, MD, MPH, lead physician executive and health equity service line leader at Cerner, explained that if doctors ordered an eGFR a year ago and then another today, the results might be different because of the new code that eliminates race.

“The numbers are so different, how do you know that the patient may or may not have the same function?” Dr. Winokur said.

Dr. Winokur said the company is trying to determine at which point a message should pop up in the records workflow that would inform clinicians that they may be comparing apples to cherries. The company also is reconsidering the use of race in tools that estimate the probability of a successful vaginal birth after prior cesarean delivery, a calculator that predicts the risk of urethral stones in patients with flank pain, and another that measures lung function to help diagnose pulmonary disease.

In addition to managing the logistics of removing race, health institutions also need buy-in from clinicians. At Mass General Brigham, Boston, Thomas Sequist, MD, MPH, chief medical officer, is leading a project to examine how the system uses race in calculators.

“People struggle mainly with, well, if we shouldn’t use this calculator, what should we use, because we need a calculator. And that’s a legitimate question,” Dr. Sequist said in an interview. “If we’re going to stop using this race-based calculator, I still need to know what dose of medication I give my patient. We’re not going to pull any of these calculators until we have a safe and reliable alternative.”

For each calculator, relevant specialty chiefs come to the table with Dr. Sequist and his team; current projects include examining bone density screenings and cardiac risk scores. A large part of the work is communicating the lack of science behind the inclusion of race as a variable.

“It’s hard because these tools have been in existence for decades, and people are used to using them,” Dr. Sequist said. “So this is a big-change management project.”

Some clinicians also have difficulty discerning why their health system may stratify patient outcomes by race while providers are being told that race is being removed from the calculators they use every day. The key difference is that stratifying outcomes by race illuminates systemic problems that can be targeted by a health system.

For instance, if readmission rates are higher for Black patients overall after surgery, the reason might be that nurses are not delivering the same level of care to them as they are to non-Black patients, possibly because of hidden bias. Or, perhaps Black patients at a hospital have less access to transportation for follow-up appointments after surgery. The potential reasons can be investigated, and solutions can be created.

“If you look at a population level, what you’re looking for is not for the evidence of race as a biological construct,” Dr. Chomilo said. “You’re looking for the impact of racism on populations, and that’s the difference: It’s racism, not race.”

A version of this article first appeared on Medscape.com.

The Diagnosis: Molluscum Contagiosum

A tangential shave removal with electrocautery was performed. Histopathology demonstrated numerous eosinophilic intracytoplasmic inclusion bodies (Figure), confirming a diagnosis of molluscum contagiosum (MC).

Molluscum contagiosum is a common poxvirus infection that is transmitted through fomites, contact, or self-inoculation.1 This infection most frequently occurs in school-aged children younger than 8 years^1-3; peak incidence is 6 years of age.^2,3 The worldwide estimated prevalence in children is 5.1% to 11.5%.^1,3 In children cohabitating with others infected by MC, approximately 40% of households experienced a spread of infection; the risk of transmission is not associated with greater number of lesions.⁴ In adults, infection most commonly occurs in the setting of immunodeficiency or as a sexually transmitted infection in immunocompetent patients.³ Molluscum contagiosum infection classically presents as 1- to 3-mm, flesh- or white-colored, dome-shaped, smooth papules with central umbilication.¹ Lesions often occur in clusters or lines, indicating local spread. The trunk, extremities, and face are areas that frequently are involved.^2,3

Atypical presentations of MC infection can occur, as demonstrated by our case. Involvement of hair follicles by the infection can result in follicular induction.^1,5 Secondary infection can mimic abscess formation.¹ Inflamed MC lesions demonstrating the “beginning of the end” sign often are mistaken for primary infection, which is thought to be an inflammatory immune response to the virus.⁶ Lesions located on the eye or eyelid can present as unilateral conjunctivitis, conjunctival or corneal nodules, eyelid abscesses, or chalazions.¹ Giant MC is a nodular variant of this infection measuring larger than 1 cm in size that can present similar to epidermoid cysts, condyloma acuminatum, or verruca vulgaris.^1,7 Other reported mimicked conditions include basal cell carcinoma, trichoepithelioma, appendageal tumors, keratoacanthoma, foreign body granulomas, nevus sebaceous, or ecthyma.^1,3 Molluscum contagiosum also has been reported to present as large ulcerative growths.⁸ In immunocompromised patients, deep fungal infection is another mimicker.1 Lesions on the plantar surfaces of the feet often are misdiagnosed as plantar verruca and present with pain during ambulation.⁹

The diagnosis of MC is clinical, with additional diagnostic tools reserved for more challenging situations.¹ In cases with atypical presentations, dermoscopy may aid diagnosis through visualization of orifices and vascular patterns including crown, radial, and punctiform vessels.¹⁰ Biopsy or fine-needle aspiration also can be utilized as a diagnostic tool. Histopathology often reveals pathognomonic intracytoplasmic inclusions or Henderson-Paterson bodies.^8,10 The appearance of MC can mimic other conditions that should be included in the differential diagnosis. Pyogenic granuloma often presents as a benign red papule that may grow rapidly and become pedunculated, sometimes with bleeding and crusting, though histology reveals groups of proliferating capillaries.¹¹ More than half of amelanotic melanomas present in the papulonodular form as vascular or ulcerated nodules, and others may appear as erythematous macules. Diagnosis of amelanotic melanoma is made through histologic examination, which reveals atypical melanocytes in nests or cords, in conjunction with immunohistochemical stains such as S-100.12 Spitz nevi often appear as round, dome-shaped papules that most commonly are red, pink, or fleshcolored. They appear histologically similar to melanoma with nests of atypical melanocytes and nuclear atypia.¹³

A variety of treatment modalities can be used for MC including cantharidin, curettage, and cryotherapy.¹⁴ Imiquimod no longer is recommended due to a lack of demonstrated superiority over placebo in recent studies as well as its adverse effects.³ Topical retinoids have been recommended; however, their use frequently is limited by local irritation.^3,14 Cantharidin is the most frequently utilized treatment by pediatric dermatologists. Most health care providers report subjective satisfaction with its results and efficacy, though some side effects may occur including discomfort and temporary changes in pigmentation. Treatment for MC is not required, as the condition is self-limiting.¹⁴ Therapy often is reserved for those with extensive disease, complications from lesions, cosmetic or psychological concerns, or genital involvement given the potential for sexual transmission.³ Time to resolution without treatment varies and is more prolonged in immunocompromised patients. Mean time to resolution in immunocompetent hosts has been reported as 13.3 months, but most infections are noted to clear within 2 to 4 years.^1,4 Although resolution without treatment occurs, transmission to others and negative impact on quality of life (QOL) can occur and support the need for treatment. Greater impact on QOL was observed in females, those with more lesions, and patients with a longer duration of symptoms. Moderate impact on QOL was reported in 28% of patients (n=301), and severe effects were reported in 11%.⁴

In conclusion, MC is a common, benign, treatable cutaneous viral infection that often presents as small, flesh-colored papules in children. Its appearance can mimic a variety of other conditions. In cases with abnormal presentations, definitive diagnosis with pathology can be important to differentiate MC from more dangerous etiologies that may require further treatment.

The Diagnosis: Molluscum Contagiosum

A tangential shave removal with electrocautery was performed. Histopathology demonstrated numerous eosinophilic intracytoplasmic inclusion bodies (Figure), confirming a diagnosis of molluscum contagiosum (MC).

Molluscum contagiosum is a common poxvirus infection that is transmitted through fomites, contact, or self-inoculation.1 This infection most frequently occurs in school-aged children younger than 8 years^1-3; peak incidence is 6 years of age.^2,3 The worldwide estimated prevalence in children is 5.1% to 11.5%.^1,3 In children cohabitating with others infected by MC, approximately 40% of households experienced a spread of infection; the risk of transmission is not associated with greater number of lesions.⁴ In adults, infection most commonly occurs in the setting of immunodeficiency or as a sexually transmitted infection in immunocompetent patients.³ Molluscum contagiosum infection classically presents as 1- to 3-mm, flesh- or white-colored, dome-shaped, smooth papules with central umbilication.¹ Lesions often occur in clusters or lines, indicating local spread. The trunk, extremities, and face are areas that frequently are involved.^2,3

Atypical presentations of MC infection can occur, as demonstrated by our case. Involvement of hair follicles by the infection can result in follicular induction.^1,5 Secondary infection can mimic abscess formation.¹ Inflamed MC lesions demonstrating the “beginning of the end” sign often are mistaken for primary infection, which is thought to be an inflammatory immune response to the virus.⁶ Lesions located on the eye or eyelid can present as unilateral conjunctivitis, conjunctival or corneal nodules, eyelid abscesses, or chalazions.¹ Giant MC is a nodular variant of this infection measuring larger than 1 cm in size that can present similar to epidermoid cysts, condyloma acuminatum, or verruca vulgaris.^1,7 Other reported mimicked conditions include basal cell carcinoma, trichoepithelioma, appendageal tumors, keratoacanthoma, foreign body granulomas, nevus sebaceous, or ecthyma.^1,3 Molluscum contagiosum also has been reported to present as large ulcerative growths.⁸ In immunocompromised patients, deep fungal infection is another mimicker.1 Lesions on the plantar surfaces of the feet often are misdiagnosed as plantar verruca and present with pain during ambulation.⁹

The diagnosis of MC is clinical, with additional diagnostic tools reserved for more challenging situations.¹ In cases with atypical presentations, dermoscopy may aid diagnosis through visualization of orifices and vascular patterns including crown, radial, and punctiform vessels.¹⁰ Biopsy or fine-needle aspiration also can be utilized as a diagnostic tool. Histopathology often reveals pathognomonic intracytoplasmic inclusions or Henderson-Paterson bodies.^8,10 The appearance of MC can mimic other conditions that should be included in the differential diagnosis. Pyogenic granuloma often presents as a benign red papule that may grow rapidly and become pedunculated, sometimes with bleeding and crusting, though histology reveals groups of proliferating capillaries.¹¹ More than half of amelanotic melanomas present in the papulonodular form as vascular or ulcerated nodules, and others may appear as erythematous macules. Diagnosis of amelanotic melanoma is made through histologic examination, which reveals atypical melanocytes in nests or cords, in conjunction with immunohistochemical stains such as S-100.12 Spitz nevi often appear as round, dome-shaped papules that most commonly are red, pink, or fleshcolored. They appear histologically similar to melanoma with nests of atypical melanocytes and nuclear atypia.¹³

A variety of treatment modalities can be used for MC including cantharidin, curettage, and cryotherapy.¹⁴ Imiquimod no longer is recommended due to a lack of demonstrated superiority over placebo in recent studies as well as its adverse effects.³ Topical retinoids have been recommended; however, their use frequently is limited by local irritation.^3,14 Cantharidin is the most frequently utilized treatment by pediatric dermatologists. Most health care providers report subjective satisfaction with its results and efficacy, though some side effects may occur including discomfort and temporary changes in pigmentation. Treatment for MC is not required, as the condition is self-limiting.¹⁴ Therapy often is reserved for those with extensive disease, complications from lesions, cosmetic or psychological concerns, or genital involvement given the potential for sexual transmission.³ Time to resolution without treatment varies and is more prolonged in immunocompromised patients. Mean time to resolution in immunocompetent hosts has been reported as 13.3 months, but most infections are noted to clear within 2 to 4 years.^1,4 Although resolution without treatment occurs, transmission to others and negative impact on quality of life (QOL) can occur and support the need for treatment. Greater impact on QOL was observed in females, those with more lesions, and patients with a longer duration of symptoms. Moderate impact on QOL was reported in 28% of patients (n=301), and severe effects were reported in 11%.⁴

In conclusion, MC is a common, benign, treatable cutaneous viral infection that often presents as small, flesh-colored papules in children. Its appearance can mimic a variety of other conditions. In cases with abnormal presentations, definitive diagnosis with pathology can be important to differentiate MC from more dangerous etiologies that may require further treatment.

The Diagnosis: Molluscum Contagiosum

A tangential shave removal with electrocautery was performed. Histopathology demonstrated numerous eosinophilic intracytoplasmic inclusion bodies (Figure), confirming a diagnosis of molluscum contagiosum (MC).

Molluscum contagiosum is a common poxvirus infection that is transmitted through fomites, contact, or self-inoculation.1 This infection most frequently occurs in school-aged children younger than 8 years^1-3; peak incidence is 6 years of age.^2,3 The worldwide estimated prevalence in children is 5.1% to 11.5%.^1,3 In children cohabitating with others infected by MC, approximately 40% of households experienced a spread of infection; the risk of transmission is not associated with greater number of lesions.⁴ In adults, infection most commonly occurs in the setting of immunodeficiency or as a sexually transmitted infection in immunocompetent patients.³ Molluscum contagiosum infection classically presents as 1- to 3-mm, flesh- or white-colored, dome-shaped, smooth papules with central umbilication.¹ Lesions often occur in clusters or lines, indicating local spread. The trunk, extremities, and face are areas that frequently are involved.^2,3

Atypical presentations of MC infection can occur, as demonstrated by our case. Involvement of hair follicles by the infection can result in follicular induction.^1,5 Secondary infection can mimic abscess formation.¹ Inflamed MC lesions demonstrating the “beginning of the end” sign often are mistaken for primary infection, which is thought to be an inflammatory immune response to the virus.⁶ Lesions located on the eye or eyelid can present as unilateral conjunctivitis, conjunctival or corneal nodules, eyelid abscesses, or chalazions.¹ Giant MC is a nodular variant of this infection measuring larger than 1 cm in size that can present similar to epidermoid cysts, condyloma acuminatum, or verruca vulgaris.^1,7 Other reported mimicked conditions include basal cell carcinoma, trichoepithelioma, appendageal tumors, keratoacanthoma, foreign body granulomas, nevus sebaceous, or ecthyma.^1,3 Molluscum contagiosum also has been reported to present as large ulcerative growths.⁸ In immunocompromised patients, deep fungal infection is another mimicker.1 Lesions on the plantar surfaces of the feet often are misdiagnosed as plantar verruca and present with pain during ambulation.⁹

The diagnosis of MC is clinical, with additional diagnostic tools reserved for more challenging situations.¹ In cases with atypical presentations, dermoscopy may aid diagnosis through visualization of orifices and vascular patterns including crown, radial, and punctiform vessels.¹⁰ Biopsy or fine-needle aspiration also can be utilized as a diagnostic tool. Histopathology often reveals pathognomonic intracytoplasmic inclusions or Henderson-Paterson bodies.^8,10 The appearance of MC can mimic other conditions that should be included in the differential diagnosis. Pyogenic granuloma often presents as a benign red papule that may grow rapidly and become pedunculated, sometimes with bleeding and crusting, though histology reveals groups of proliferating capillaries.¹¹ More than half of amelanotic melanomas present in the papulonodular form as vascular or ulcerated nodules, and others may appear as erythematous macules. Diagnosis of amelanotic melanoma is made through histologic examination, which reveals atypical melanocytes in nests or cords, in conjunction with immunohistochemical stains such as S-100.12 Spitz nevi often appear as round, dome-shaped papules that most commonly are red, pink, or fleshcolored. They appear histologically similar to melanoma with nests of atypical melanocytes and nuclear atypia.¹³

A variety of treatment modalities can be used for MC including cantharidin, curettage, and cryotherapy.¹⁴ Imiquimod no longer is recommended due to a lack of demonstrated superiority over placebo in recent studies as well as its adverse effects.³ Topical retinoids have been recommended; however, their use frequently is limited by local irritation.^3,14 Cantharidin is the most frequently utilized treatment by pediatric dermatologists. Most health care providers report subjective satisfaction with its results and efficacy, though some side effects may occur including discomfort and temporary changes in pigmentation. Treatment for MC is not required, as the condition is self-limiting.¹⁴ Therapy often is reserved for those with extensive disease, complications from lesions, cosmetic or psychological concerns, or genital involvement given the potential for sexual transmission.³ Time to resolution without treatment varies and is more prolonged in immunocompromised patients. Mean time to resolution in immunocompetent hosts has been reported as 13.3 months, but most infections are noted to clear within 2 to 4 years.^1,4 Although resolution without treatment occurs, transmission to others and negative impact on quality of life (QOL) can occur and support the need for treatment. Greater impact on QOL was observed in females, those with more lesions, and patients with a longer duration of symptoms. Moderate impact on QOL was reported in 28% of patients (n=301), and severe effects were reported in 11%.⁴

In conclusion, MC is a common, benign, treatable cutaneous viral infection that often presents as small, flesh-colored papules in children. Its appearance can mimic a variety of other conditions. In cases with abnormal presentations, definitive diagnosis with pathology can be important to differentiate MC from more dangerous etiologies that may require further treatment.

Radiating chest pain, shortness of breath, nausea, lightheadedness. Everyone knows the telltale signs of a myocardial infarction. Yet a new study shows that despite this widespread recognition, heart attacks aren’t attended to quickly across the board. Historically, the study says, women and people of color wait longer to access emergency care for a heart attack.

Researchers from the University of California, San Francisco published these findings in the Annals of Emergency Medicine. The study used the Office of Statewide Health Planning and Development dataset to gather information on 453,136 cases of heart attack in California between 2005 and 2015. They found that over time, differences in timely treatment between the demographics narrowed, but the gap still existed.

Rawpixel/iStock/Getty Images

By 2015, timely treatment increased across the board, but there were still discrepancies, with 76.7% of men and 66.8% of women with STEMI undergoing timely angiography and 56.3% of men and 45.9% of women with NSTEMI undergoing timely angiography. Also in 2015, 75.2% of White patients and 69.2% of Black patients underwent timely angiography for STEMI.

Although differences in care decreased between the demographics, the gap still exists. Whereas this dataset only extends to 2015, this trend may still persist today, says Robert Glatter, MD, an emergency medicine physician at Lenox Hill Hospital, New York, who was not involved in the study. Therefore, physicians need to consider this bias when treating patients. “The bottom line is that we continue to have much work to do to achieve equality in managing not only medical conditions but treating people who have them equally,” Dr. Glatter said.

“Raising awareness of ongoing inequality in care related to gender and ethnic disparities is critical to drive change in our institutions,” he emphasized. “We simply cannot accept the status quo.”

The study was funded by the National Heart, Lung, and Blood Institute of the National Institutes of Health. Dr. Glatter and the authors declared no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Radiating chest pain, shortness of breath, nausea, lightheadedness. Everyone knows the telltale signs of a myocardial infarction. Yet a new study shows that despite this widespread recognition, heart attacks aren’t attended to quickly across the board. Historically, the study says, women and people of color wait longer to access emergency care for a heart attack.

Researchers from the University of California, San Francisco published these findings in the Annals of Emergency Medicine. The study used the Office of Statewide Health Planning and Development dataset to gather information on 453,136 cases of heart attack in California between 2005 and 2015. They found that over time, differences in timely treatment between the demographics narrowed, but the gap still existed.

Rawpixel/iStock/Getty Images

By 2015, timely treatment increased across the board, but there were still discrepancies, with 76.7% of men and 66.8% of women with STEMI undergoing timely angiography and 56.3% of men and 45.9% of women with NSTEMI undergoing timely angiography. Also in 2015, 75.2% of White patients and 69.2% of Black patients underwent timely angiography for STEMI.

Although differences in care decreased between the demographics, the gap still exists. Whereas this dataset only extends to 2015, this trend may still persist today, says Robert Glatter, MD, an emergency medicine physician at Lenox Hill Hospital, New York, who was not involved in the study. Therefore, physicians need to consider this bias when treating patients. “The bottom line is that we continue to have much work to do to achieve equality in managing not only medical conditions but treating people who have them equally,” Dr. Glatter said.

“Raising awareness of ongoing inequality in care related to gender and ethnic disparities is critical to drive change in our institutions,” he emphasized. “We simply cannot accept the status quo.”

The study was funded by the National Heart, Lung, and Blood Institute of the National Institutes of Health. Dr. Glatter and the authors declared no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Radiating chest pain, shortness of breath, nausea, lightheadedness. Everyone knows the telltale signs of a myocardial infarction. Yet a new study shows that despite this widespread recognition, heart attacks aren’t attended to quickly across the board. Historically, the study says, women and people of color wait longer to access emergency care for a heart attack.

Researchers from the University of California, San Francisco published these findings in the Annals of Emergency Medicine. The study used the Office of Statewide Health Planning and Development dataset to gather information on 453,136 cases of heart attack in California between 2005 and 2015. They found that over time, differences in timely treatment between the demographics narrowed, but the gap still existed.

Rawpixel/iStock/Getty Images

By 2015, timely treatment increased across the board, but there were still discrepancies, with 76.7% of men and 66.8% of women with STEMI undergoing timely angiography and 56.3% of men and 45.9% of women with NSTEMI undergoing timely angiography. Also in 2015, 75.2% of White patients and 69.2% of Black patients underwent timely angiography for STEMI.

Although differences in care decreased between the demographics, the gap still exists. Whereas this dataset only extends to 2015, this trend may still persist today, says Robert Glatter, MD, an emergency medicine physician at Lenox Hill Hospital, New York, who was not involved in the study. Therefore, physicians need to consider this bias when treating patients. “The bottom line is that we continue to have much work to do to achieve equality in managing not only medical conditions but treating people who have them equally,” Dr. Glatter said.

“Raising awareness of ongoing inequality in care related to gender and ethnic disparities is critical to drive change in our institutions,” he emphasized. “We simply cannot accept the status quo.”

The study was funded by the National Heart, Lung, and Blood Institute of the National Institutes of Health. Dr. Glatter and the authors declared no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Two genes that have been linked separately to rare intestinal diseases appear to share a functional relationship. The genes have independently been linked to osteo-oto-hepato-enteric (O2HE) syndrome and microvillus inclusion disease (MVID), which are characterized by congenital diarrhea and, in some patients, intrahepatic cholestasis.

It appears that one gene, UNC45A, is directly responsible for the proper function of the protein encoded by the other gene, called MYO5B, according to investigators, who published their findings in Cellular and Molecular Gastroenterology and Hepatology. UNC45A is a chaperone protein that helps proteins fold properly. It has been linked to O2HE patients experiencing congenital diarrhea and intrahepatic cholestasis. The mutation has been identified in four patients from three different families with O2HE, which can also present with sensorineural hearing loss and bone fragility. Cellular analyses have shown that the mutation leads to reduction in protein expression by 70%-90%.

Intestinal symptoms similar to those in O2HE have also been described in diseases caused by mutations in genes that encode the myosin motor proteins that are involved in cellular protein trafficking. This group of disorders includes MVID. The researchers hypothesized that the UNC45A mutation in O2HE might lead to similar symptoms as MVID and others through the altered protein’s failure to assist in the folding of myosin proteins, although to date only the myosin IIa protein has been shown to be a target of UNC45A.

To investigate the possibility, they examined in more detail the relationship between UNC45A and intestinal symptoms. There are various known mutations in myosin proteins. Some have been linked to deafness, but these do not appear to contribute to intestinal symptoms since patients with myelin-related inherited deafness don’t typically have diarrhea. Bone fragility, also sometimes caused by myosin mutations, also appears to be unrelated to intestinal symptoms.

Previous experiments in yeast suggest that the related gene UNC45 may serve as a chaperone for type V myosin: Loss of a yeast version of UNC45 caused a type V myosin called MYO4P to be mislocalized in yeast. In zebrafish, reduction in intestinal levels of the UNC45A gene or the fish’s version of MYO5B interfered with development of intestinal folds.

The researchers used CRISPR-Cas9 gene editing and site-directed mutagenesis in intestinal epithelial and liver cell lines to investigate the relationships between UNC45A and MYO5B mutants. UNC45A depletion or introduction of the UNC45A mutation found in patients led to lower MYO5B expression. Within epithelial cells, loss of UNC45A led to changes in MYO5B–linked processes that are known to play a role in MVID pathogenesis. These included alteration of microvilli development and interference with the location of rat sarcoma–associated binding protein (RAB) 11A–positive recycling endosomes. When normal UNC45A was reintroduced to these cells, MYO5B expression returned. Reintroduction of either UNC45A or MYO5B repaired the alterations to recycling endosome position and microvilli development.

Loss of UNC45A did not appear to affect transcription of the MYO5B gen, which suggests a suggesting a functional interaction between the two at a protein level.

UNC45A has been shown to destabilize microtubules. Exposure of a kidney epithelial cell line to the microtubule-stabilizing drug taxol also led to displacement of RAB11A-positve recycling endosomes, though the specific changes were different than what is seen in MYO5B mutants. The researchers were unable to validate the findings in tissue derived from O2HE patients because of insufficient material, but they maintain that the cell lines used have proven to be highly predictive for the cellular characteristics of MVID.

Overall, the study suggests that reductions in MYO5B and subsequent changes to the cellular processes that depend on it may underlie the intestinal symptoms in O2HE.

The researchers noted that O2HE patients have different phenotypes. Of the four patients they studied, three had severe chronic diarrhea and required parenteral nutrition. One patient later had the diarrhea resolve and her sister did not have diarrhea at all. This heterogeneity in severity and duration of clinical symptoms may be driven by differences in the molecular effects of patient-specific mutations. The two siblings had mutations in a different region of the UNC45A gene than the other two participants.

“Taken together, this study revealed a functional relationship between UNC45A and MYO5B protein expression, thereby connecting two rare congenital diseases with overlapping intestinal symptoms at the molecular level,” the authors wrote.

The authors reported that they had no conflicts of interest.

This article was updated 7/13/22.

Two genes that have been linked separately to rare intestinal diseases appear to share a functional relationship. The genes have independently been linked to osteo-oto-hepato-enteric (O2HE) syndrome and microvillus inclusion disease (MVID), which are characterized by congenital diarrhea and, in some patients, intrahepatic cholestasis.

It appears that one gene, UNC45A, is directly responsible for the proper function of the protein encoded by the other gene, called MYO5B, according to investigators, who published their findings in Cellular and Molecular Gastroenterology and Hepatology. UNC45A is a chaperone protein that helps proteins fold properly. It has been linked to O2HE patients experiencing congenital diarrhea and intrahepatic cholestasis. The mutation has been identified in four patients from three different families with O2HE, which can also present with sensorineural hearing loss and bone fragility. Cellular analyses have shown that the mutation leads to reduction in protein expression by 70%-90%.

Intestinal symptoms similar to those in O2HE have also been described in diseases caused by mutations in genes that encode the myosin motor proteins that are involved in cellular protein trafficking. This group of disorders includes MVID. The researchers hypothesized that the UNC45A mutation in O2HE might lead to similar symptoms as MVID and others through the altered protein’s failure to assist in the folding of myosin proteins, although to date only the myosin IIa protein has been shown to be a target of UNC45A.

To investigate the possibility, they examined in more detail the relationship between UNC45A and intestinal symptoms. There are various known mutations in myosin proteins. Some have been linked to deafness, but these do not appear to contribute to intestinal symptoms since patients with myelin-related inherited deafness don’t typically have diarrhea. Bone fragility, also sometimes caused by myosin mutations, also appears to be unrelated to intestinal symptoms.

Previous experiments in yeast suggest that the related gene UNC45 may serve as a chaperone for type V myosin: Loss of a yeast version of UNC45 caused a type V myosin called MYO4P to be mislocalized in yeast. In zebrafish, reduction in intestinal levels of the UNC45A gene or the fish’s version of MYO5B interfered with development of intestinal folds.

The researchers used CRISPR-Cas9 gene editing and site-directed mutagenesis in intestinal epithelial and liver cell lines to investigate the relationships between UNC45A and MYO5B mutants. UNC45A depletion or introduction of the UNC45A mutation found in patients led to lower MYO5B expression. Within epithelial cells, loss of UNC45A led to changes in MYO5B–linked processes that are known to play a role in MVID pathogenesis. These included alteration of microvilli development and interference with the location of rat sarcoma–associated binding protein (RAB) 11A–positive recycling endosomes. When normal UNC45A was reintroduced to these cells, MYO5B expression returned. Reintroduction of either UNC45A or MYO5B repaired the alterations to recycling endosome position and microvilli development.

Loss of UNC45A did not appear to affect transcription of the MYO5B gen, which suggests a suggesting a functional interaction between the two at a protein level.

UNC45A has been shown to destabilize microtubules. Exposure of a kidney epithelial cell line to the microtubule-stabilizing drug taxol also led to displacement of RAB11A-positve recycling endosomes, though the specific changes were different than what is seen in MYO5B mutants. The researchers were unable to validate the findings in tissue derived from O2HE patients because of insufficient material, but they maintain that the cell lines used have proven to be highly predictive for the cellular characteristics of MVID.

Overall, the study suggests that reductions in MYO5B and subsequent changes to the cellular processes that depend on it may underlie the intestinal symptoms in O2HE.

The researchers noted that O2HE patients have different phenotypes. Of the four patients they studied, three had severe chronic diarrhea and required parenteral nutrition. One patient later had the diarrhea resolve and her sister did not have diarrhea at all. This heterogeneity in severity and duration of clinical symptoms may be driven by differences in the molecular effects of patient-specific mutations. The two siblings had mutations in a different region of the UNC45A gene than the other two participants.

“Taken together, this study revealed a functional relationship between UNC45A and MYO5B protein expression, thereby connecting two rare congenital diseases with overlapping intestinal symptoms at the molecular level,” the authors wrote.

The authors reported that they had no conflicts of interest.

This article was updated 7/13/22.

Two genes that have been linked separately to rare intestinal diseases appear to share a functional relationship. The genes have independently been linked to osteo-oto-hepato-enteric (O2HE) syndrome and microvillus inclusion disease (MVID), which are characterized by congenital diarrhea and, in some patients, intrahepatic cholestasis.

It appears that one gene, UNC45A, is directly responsible for the proper function of the protein encoded by the other gene, called MYO5B, according to investigators, who published their findings in Cellular and Molecular Gastroenterology and Hepatology. UNC45A is a chaperone protein that helps proteins fold properly. It has been linked to O2HE patients experiencing congenital diarrhea and intrahepatic cholestasis. The mutation has been identified in four patients from three different families with O2HE, which can also present with sensorineural hearing loss and bone fragility. Cellular analyses have shown that the mutation leads to reduction in protein expression by 70%-90%.

Intestinal symptoms similar to those in O2HE have also been described in diseases caused by mutations in genes that encode the myosin motor proteins that are involved in cellular protein trafficking. This group of disorders includes MVID. The researchers hypothesized that the UNC45A mutation in O2HE might lead to similar symptoms as MVID and others through the altered protein’s failure to assist in the folding of myosin proteins, although to date only the myosin IIa protein has been shown to be a target of UNC45A.

To investigate the possibility, they examined in more detail the relationship between UNC45A and intestinal symptoms. There are various known mutations in myosin proteins. Some have been linked to deafness, but these do not appear to contribute to intestinal symptoms since patients with myelin-related inherited deafness don’t typically have diarrhea. Bone fragility, also sometimes caused by myosin mutations, also appears to be unrelated to intestinal symptoms.

Previous experiments in yeast suggest that the related gene UNC45 may serve as a chaperone for type V myosin: Loss of a yeast version of UNC45 caused a type V myosin called MYO4P to be mislocalized in yeast. In zebrafish, reduction in intestinal levels of the UNC45A gene or the fish’s version of MYO5B interfered with development of intestinal folds.

The researchers used CRISPR-Cas9 gene editing and site-directed mutagenesis in intestinal epithelial and liver cell lines to investigate the relationships between UNC45A and MYO5B mutants. UNC45A depletion or introduction of the UNC45A mutation found in patients led to lower MYO5B expression. Within epithelial cells, loss of UNC45A led to changes in MYO5B–linked processes that are known to play a role in MVID pathogenesis. These included alteration of microvilli development and interference with the location of rat sarcoma–associated binding protein (RAB) 11A–positive recycling endosomes. When normal UNC45A was reintroduced to these cells, MYO5B expression returned. Reintroduction of either UNC45A or MYO5B repaired the alterations to recycling endosome position and microvilli development.

Loss of UNC45A did not appear to affect transcription of the MYO5B gen, which suggests a suggesting a functional interaction between the two at a protein level.

UNC45A has been shown to destabilize microtubules. Exposure of a kidney epithelial cell line to the microtubule-stabilizing drug taxol also led to displacement of RAB11A-positve recycling endosomes, though the specific changes were different than what is seen in MYO5B mutants. The researchers were unable to validate the findings in tissue derived from O2HE patients because of insufficient material, but they maintain that the cell lines used have proven to be highly predictive for the cellular characteristics of MVID.

Overall, the study suggests that reductions in MYO5B and subsequent changes to the cellular processes that depend on it may underlie the intestinal symptoms in O2HE.

The researchers noted that O2HE patients have different phenotypes. Of the four patients they studied, three had severe chronic diarrhea and required parenteral nutrition. One patient later had the diarrhea resolve and her sister did not have diarrhea at all. This heterogeneity in severity and duration of clinical symptoms may be driven by differences in the molecular effects of patient-specific mutations. The two siblings had mutations in a different region of the UNC45A gene than the other two participants.

“Taken together, this study revealed a functional relationship between UNC45A and MYO5B protein expression, thereby connecting two rare congenital diseases with overlapping intestinal symptoms at the molecular level,” the authors wrote.

The authors reported that they had no conflicts of interest.

This article was updated 7/13/22.

Jamestown, Colo., is a small mountain town several miles up through Lefthand Canyon out of Boulder, in the Rocky Mountains. The canyon roads are steep, winding, and narrow, and peopled by brightly clad cyclists struggling up the hill and flying down faster than the cars. The road through Jamestown is dusty in the summer with brightly colored oil barrels strategically placed in the middle of the single road through town. Slashed across their sides: “SLOW DOWN! Watch out for our feral children!”

Wild child or hothouse child? What is the best choice? Women bear the brunt of this deciding, whether they are working outside of the home, or stay-at-home caregivers, or both. Women know they will be blamed if they get it wrong.

Society has exacted a tall order on women who choose to have children. Patriarchal norms ask (White) women who choose both to work and have children, if they are really a “stay-at-home” mother who must work, or a “working” mother who prefers work over their children. The underlying attitude can be read as: “Are you someone who prioritizes paid work over caregiving, or are you someone who prioritizes caregiving over work?” You may be seen as a bad mother if you prioritize work over the welfare of your child. If you prioritize your child over your work, then you are not a reliable, dedicated worker. The working mother can’t win.

Woman’s central question is what kind of mother should I be? Mothers struggle with this question all their lives; when their child has difficulties, society’s question is what did you do wrong with your child? Mothers internalize the standard of the “good mother” and are aware of each minor transgression that depicts them as the “bad mother.” It is hard to escape the impossible perfectionistic standard of the good mother. But perhaps it has come time to push back on the moral imbalance.
 

Internalized sexism

As women move out of the home into the workplace, the societal pressures to maintain the status quo bear down on women, trying to keep them in their place.

Social pressures employ subtle “technologies of the self,” so that women – as any oppressed group – learn to internalize these technologies, and monitor themselves.¹ This is now widely accepted as internalized sexism, whereby women feel that they are not good enough, do not have the right qualifications, and are “less” than the dominant group (men). This phenomenon is also recognized when racial and ethnic biases are assimilated unconsciously, as internalized racism. Should we also have internalized “momism”?

Women are caught between trying to claim their individualism as well as feeling the responsibility to be the self-denying mother. Everyone has an opinion about the place of women. Conservative activist Phyllis Schlafly considered “women’s lib” to be un-American, citing women in the military and the establishment of federal day care centers as actions of a communist state. A similar ideology helped form the antifeminist organization Concerned Women for America, which self-reports that it is the largest American public policy women’s organization. Formed in opposition to the National Organization for Women, CWA is focused on maintaining the traditional family, as understood by (White) evangelical Christians.

An example similar to CWA is the Council of Biblical Manhood and Womanhood. It was established to help evangelical Christian churches defend themselves against an accommodation of secular feminism and also against evangelical feminism (which pushes for more equality in the church). It promotes complementarianism – the idea that masculinity and femininity are ordained by God and that men and women are created to complement each other.

At the other extreme, the most radical of feminists believe in the need to create a women-only society where women would be free from the patriarchy. Less angry but decidedly weirder are the feminists called “FEMEN” who once staged a protest at the Vatican where topless women feigned intercourse with crucifixes, chanting slogans against the pope and religion.

Most women tread a path between extremes, a path which is difficult and lonely. Without a firm ideology, this path is strewn with doubts and pitfalls. Some career-oriented women who have delayed motherhood, knowing that they will soon be biologically past their peak and possibly also without a partner, wonder if they should become single mothers using sperm donation. For many women, the workplace does not offer much help with maternity leave or childcare. Even when maternity leave is available, there is a still a lack of understanding about what is needed.

“Think of it as caregiver bias. If you just extend maternity leave, what is implied is that you’re still expecting me to be the primary source of care for my child, when in fact my partner wants to share the load and will need support to do so as well,” said Pamela Culpepper, an expert in corporate diversity and inclusion.²

Intensive mothering

When the glamor of the workplace wears off and/or when the misogyny and the harassment become too much, women who have the financial stability may decide to return to the role of the stay-at-home mother. Perhaps, in the home, she can feel fulfilled. Yet, young American urban and suburban mothers now parent under a new name – “intensive mothering.”

Conducting in-depth interviews of 38 women of diverse backgrounds in the United States, Sharon Hays found women describing their 2- to 4-year-old children as innocent and priceless, and believing that they – the mothers – should be primarily responsible for rearing their children, using “child-rearing methods that are child centered, expert guided, emotionally absorbing, labor intensive, and financially expensive.”³ Ms. Hays clarified four beliefs that were common to all the women in the study: mothers are more suitable caregivers than fathers; mothering should be child centered; parenting consists of a set of skills that need to be learned; and parenting is labor-intensive but an emotionally fulfilling activity.

Hays wondered if this type of mothering developed as the last defense against “the impoverishment of social ties, communal obligations and unremunerated commitments.”³ She suggested that women succumbing to social pressures to return to the home is yet another example of how society is set up to benefit men, capitalism, political leaders, and those who try to maintain a “traditional” form of family life.³ Ms. Hays concluded that the practice of intensive mothering is a class-based practice of privileged white women, entangled with capitalism in that the buying of “essential” baby products is equated with good mothering. She found this ideology to be oppressive of all women, regardless of their social class, ethnic background, household composition, and financial situation. Ms. Hays noted that many women experience guilt for not matching up to these ideals.

In “Dead End Feminism,” Elisabeth Badinter asks if the upheaval in the role of women has caused so much uncertainty that it is easier for women to regress to a time when they were in the home and knew themselves as mothers. They ask if this has been reinforced by the movement to embrace all things natural, eschewing the falseness of chemicals and other things that threaten Mother Earth.⁴

Whatever type of parenting a woman chooses, you can be sure that she, not the father, will be held accountable. There is no escaping the power of the mother: she will continue to symbolize all that is good and bad as the embodiment of the Mother Archetype. All of this is the background against which you will see the new mother in the family. She will not articulate her dilemma, that is your role as the family psychiatrist.

Dr. Heru is professor of psychiatry at the University of Colorado at Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (New York: Routledge, 2013). She has no conflicts of interest to disclose. Contact Dr. Heru at [email protected].

References

1. Martin LH et al (eds.). Technologies of the Self: A Seminar with Michel Foucault. University of Massachusetts Press: Amherst, Mass.: University of Massachusetts Press, 2022.

2. How Pamela Culpepper Is Changing The Narrative Of Women In The Workplace. Huffpost. 2020 Mar 6. https://www.huffpost.com/entry/pamela-culpepper-diversity-inclusion-empowerment_n_5e56b6ffc5b62e9dc7dbc307.

3. Hays S. Cultural Contradictions of Motherhood. Yale University Press: New Haven, Conn.: Yale University Press, 1996.

4. Badinter E. (translated by Borossa J). Dead End Feminism. Malden, Mass.: Polity Press, 2006.

Jamestown, Colo., is a small mountain town several miles up through Lefthand Canyon out of Boulder, in the Rocky Mountains. The canyon roads are steep, winding, and narrow, and peopled by brightly clad cyclists struggling up the hill and flying down faster than the cars. The road through Jamestown is dusty in the summer with brightly colored oil barrels strategically placed in the middle of the single road through town. Slashed across their sides: “SLOW DOWN! Watch out for our feral children!”

Wild child or hothouse child? What is the best choice? Women bear the brunt of this deciding, whether they are working outside of the home, or stay-at-home caregivers, or both. Women know they will be blamed if they get it wrong.

Society has exacted a tall order on women who choose to have children. Patriarchal norms ask (White) women who choose both to work and have children, if they are really a “stay-at-home” mother who must work, or a “working” mother who prefers work over their children. The underlying attitude can be read as: “Are you someone who prioritizes paid work over caregiving, or are you someone who prioritizes caregiving over work?” You may be seen as a bad mother if you prioritize work over the welfare of your child. If you prioritize your child over your work, then you are not a reliable, dedicated worker. The working mother can’t win.

Woman’s central question is what kind of mother should I be? Mothers struggle with this question all their lives; when their child has difficulties, society’s question is what did you do wrong with your child? Mothers internalize the standard of the “good mother” and are aware of each minor transgression that depicts them as the “bad mother.” It is hard to escape the impossible perfectionistic standard of the good mother. But perhaps it has come time to push back on the moral imbalance.
 

Internalized sexism

As women move out of the home into the workplace, the societal pressures to maintain the status quo bear down on women, trying to keep them in their place.

Social pressures employ subtle “technologies of the self,” so that women – as any oppressed group – learn to internalize these technologies, and monitor themselves.¹ This is now widely accepted as internalized sexism, whereby women feel that they are not good enough, do not have the right qualifications, and are “less” than the dominant group (men). This phenomenon is also recognized when racial and ethnic biases are assimilated unconsciously, as internalized racism. Should we also have internalized “momism”?

Women are caught between trying to claim their individualism as well as feeling the responsibility to be the self-denying mother. Everyone has an opinion about the place of women. Conservative activist Phyllis Schlafly considered “women’s lib” to be un-American, citing women in the military and the establishment of federal day care centers as actions of a communist state. A similar ideology helped form the antifeminist organization Concerned Women for America, which self-reports that it is the largest American public policy women’s organization. Formed in opposition to the National Organization for Women, CWA is focused on maintaining the traditional family, as understood by (White) evangelical Christians.

An example similar to CWA is the Council of Biblical Manhood and Womanhood. It was established to help evangelical Christian churches defend themselves against an accommodation of secular feminism and also against evangelical feminism (which pushes for more equality in the church). It promotes complementarianism – the idea that masculinity and femininity are ordained by God and that men and women are created to complement each other.

At the other extreme, the most radical of feminists believe in the need to create a women-only society where women would be free from the patriarchy. Less angry but decidedly weirder are the feminists called “FEMEN” who once staged a protest at the Vatican where topless women feigned intercourse with crucifixes, chanting slogans against the pope and religion.

Most women tread a path between extremes, a path which is difficult and lonely. Without a firm ideology, this path is strewn with doubts and pitfalls. Some career-oriented women who have delayed motherhood, knowing that they will soon be biologically past their peak and possibly also without a partner, wonder if they should become single mothers using sperm donation. For many women, the workplace does not offer much help with maternity leave or childcare. Even when maternity leave is available, there is a still a lack of understanding about what is needed.

“Think of it as caregiver bias. If you just extend maternity leave, what is implied is that you’re still expecting me to be the primary source of care for my child, when in fact my partner wants to share the load and will need support to do so as well,” said Pamela Culpepper, an expert in corporate diversity and inclusion.²

Intensive mothering

When the glamor of the workplace wears off and/or when the misogyny and the harassment become too much, women who have the financial stability may decide to return to the role of the stay-at-home mother. Perhaps, in the home, she can feel fulfilled. Yet, young American urban and suburban mothers now parent under a new name – “intensive mothering.”

Conducting in-depth interviews of 38 women of diverse backgrounds in the United States, Sharon Hays found women describing their 2- to 4-year-old children as innocent and priceless, and believing that they – the mothers – should be primarily responsible for rearing their children, using “child-rearing methods that are child centered, expert guided, emotionally absorbing, labor intensive, and financially expensive.”³ Ms. Hays clarified four beliefs that were common to all the women in the study: mothers are more suitable caregivers than fathers; mothering should be child centered; parenting consists of a set of skills that need to be learned; and parenting is labor-intensive but an emotionally fulfilling activity.

Hays wondered if this type of mothering developed as the last defense against “the impoverishment of social ties, communal obligations and unremunerated commitments.”³ She suggested that women succumbing to social pressures to return to the home is yet another example of how society is set up to benefit men, capitalism, political leaders, and those who try to maintain a “traditional” form of family life.³ Ms. Hays concluded that the practice of intensive mothering is a class-based practice of privileged white women, entangled with capitalism in that the buying of “essential” baby products is equated with good mothering. She found this ideology to be oppressive of all women, regardless of their social class, ethnic background, household composition, and financial situation. Ms. Hays noted that many women experience guilt for not matching up to these ideals.

In “Dead End Feminism,” Elisabeth Badinter asks if the upheaval in the role of women has caused so much uncertainty that it is easier for women to regress to a time when they were in the home and knew themselves as mothers. They ask if this has been reinforced by the movement to embrace all things natural, eschewing the falseness of chemicals and other things that threaten Mother Earth.⁴

Whatever type of parenting a woman chooses, you can be sure that she, not the father, will be held accountable. There is no escaping the power of the mother: she will continue to symbolize all that is good and bad as the embodiment of the Mother Archetype. All of this is the background against which you will see the new mother in the family. She will not articulate her dilemma, that is your role as the family psychiatrist.

Dr. Heru is professor of psychiatry at the University of Colorado at Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (New York: Routledge, 2013). She has no conflicts of interest to disclose. Contact Dr. Heru at [email protected].

References

1. Martin LH et al (eds.). Technologies of the Self: A Seminar with Michel Foucault. University of Massachusetts Press: Amherst, Mass.: University of Massachusetts Press, 2022.

2. How Pamela Culpepper Is Changing The Narrative Of Women In The Workplace. Huffpost. 2020 Mar 6. https://www.huffpost.com/entry/pamela-culpepper-diversity-inclusion-empowerment_n_5e56b6ffc5b62e9dc7dbc307.

3. Hays S. Cultural Contradictions of Motherhood. Yale University Press: New Haven, Conn.: Yale University Press, 1996.

4. Badinter E. (translated by Borossa J). Dead End Feminism. Malden, Mass.: Polity Press, 2006.

Jamestown, Colo., is a small mountain town several miles up through Lefthand Canyon out of Boulder, in the Rocky Mountains. The canyon roads are steep, winding, and narrow, and peopled by brightly clad cyclists struggling up the hill and flying down faster than the cars. The road through Jamestown is dusty in the summer with brightly colored oil barrels strategically placed in the middle of the single road through town. Slashed across their sides: “SLOW DOWN! Watch out for our feral children!”

Wild child or hothouse child? What is the best choice? Women bear the brunt of this deciding, whether they are working outside of the home, or stay-at-home caregivers, or both. Women know they will be blamed if they get it wrong.

Society has exacted a tall order on women who choose to have children. Patriarchal norms ask (White) women who choose both to work and have children, if they are really a “stay-at-home” mother who must work, or a “working” mother who prefers work over their children. The underlying attitude can be read as: “Are you someone who prioritizes paid work over caregiving, or are you someone who prioritizes caregiving over work?” You may be seen as a bad mother if you prioritize work over the welfare of your child. If you prioritize your child over your work, then you are not a reliable, dedicated worker. The working mother can’t win.

Woman’s central question is what kind of mother should I be? Mothers struggle with this question all their lives; when their child has difficulties, society’s question is what did you do wrong with your child? Mothers internalize the standard of the “good mother” and are aware of each minor transgression that depicts them as the “bad mother.” It is hard to escape the impossible perfectionistic standard of the good mother. But perhaps it has come time to push back on the moral imbalance.
 

Internalized sexism

As women move out of the home into the workplace, the societal pressures to maintain the status quo bear down on women, trying to keep them in their place.

Social pressures employ subtle “technologies of the self,” so that women – as any oppressed group – learn to internalize these technologies, and monitor themselves.¹ This is now widely accepted as internalized sexism, whereby women feel that they are not good enough, do not have the right qualifications, and are “less” than the dominant group (men). This phenomenon is also recognized when racial and ethnic biases are assimilated unconsciously, as internalized racism. Should we also have internalized “momism”?

Women are caught between trying to claim their individualism as well as feeling the responsibility to be the self-denying mother. Everyone has an opinion about the place of women. Conservative activist Phyllis Schlafly considered “women’s lib” to be un-American, citing women in the military and the establishment of federal day care centers as actions of a communist state. A similar ideology helped form the antifeminist organization Concerned Women for America, which self-reports that it is the largest American public policy women’s organization. Formed in opposition to the National Organization for Women, CWA is focused on maintaining the traditional family, as understood by (White) evangelical Christians.

An example similar to CWA is the Council of Biblical Manhood and Womanhood. It was established to help evangelical Christian churches defend themselves against an accommodation of secular feminism and also against evangelical feminism (which pushes for more equality in the church). It promotes complementarianism – the idea that masculinity and femininity are ordained by God and that men and women are created to complement each other.

At the other extreme, the most radical of feminists believe in the need to create a women-only society where women would be free from the patriarchy. Less angry but decidedly weirder are the feminists called “FEMEN” who once staged a protest at the Vatican where topless women feigned intercourse with crucifixes, chanting slogans against the pope and religion.

Most women tread a path between extremes, a path which is difficult and lonely. Without a firm ideology, this path is strewn with doubts and pitfalls. Some career-oriented women who have delayed motherhood, knowing that they will soon be biologically past their peak and possibly also without a partner, wonder if they should become single mothers using sperm donation. For many women, the workplace does not offer much help with maternity leave or childcare. Even when maternity leave is available, there is a still a lack of understanding about what is needed.

“Think of it as caregiver bias. If you just extend maternity leave, what is implied is that you’re still expecting me to be the primary source of care for my child, when in fact my partner wants to share the load and will need support to do so as well,” said Pamela Culpepper, an expert in corporate diversity and inclusion.²

Intensive mothering

When the glamor of the workplace wears off and/or when the misogyny and the harassment become too much, women who have the financial stability may decide to return to the role of the stay-at-home mother. Perhaps, in the home, she can feel fulfilled. Yet, young American urban and suburban mothers now parent under a new name – “intensive mothering.”

Conducting in-depth interviews of 38 women of diverse backgrounds in the United States, Sharon Hays found women describing their 2- to 4-year-old children as innocent and priceless, and believing that they – the mothers – should be primarily responsible for rearing their children, using “child-rearing methods that are child centered, expert guided, emotionally absorbing, labor intensive, and financially expensive.”³ Ms. Hays clarified four beliefs that were common to all the women in the study: mothers are more suitable caregivers than fathers; mothering should be child centered; parenting consists of a set of skills that need to be learned; and parenting is labor-intensive but an emotionally fulfilling activity.

Hays wondered if this type of mothering developed as the last defense against “the impoverishment of social ties, communal obligations and unremunerated commitments.”³ She suggested that women succumbing to social pressures to return to the home is yet another example of how society is set up to benefit men, capitalism, political leaders, and those who try to maintain a “traditional” form of family life.³ Ms. Hays concluded that the practice of intensive mothering is a class-based practice of privileged white women, entangled with capitalism in that the buying of “essential” baby products is equated with good mothering. She found this ideology to be oppressive of all women, regardless of their social class, ethnic background, household composition, and financial situation. Ms. Hays noted that many women experience guilt for not matching up to these ideals.

In “Dead End Feminism,” Elisabeth Badinter asks if the upheaval in the role of women has caused so much uncertainty that it is easier for women to regress to a time when they were in the home and knew themselves as mothers. They ask if this has been reinforced by the movement to embrace all things natural, eschewing the falseness of chemicals and other things that threaten Mother Earth.⁴

Whatever type of parenting a woman chooses, you can be sure that she, not the father, will be held accountable. There is no escaping the power of the mother: she will continue to symbolize all that is good and bad as the embodiment of the Mother Archetype. All of this is the background against which you will see the new mother in the family. She will not articulate her dilemma, that is your role as the family psychiatrist.

Dr. Heru is professor of psychiatry at the University of Colorado at Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (New York: Routledge, 2013). She has no conflicts of interest to disclose. Contact Dr. Heru at [email protected].

References

1. Martin LH et al (eds.). Technologies of the Self: A Seminar with Michel Foucault. University of Massachusetts Press: Amherst, Mass.: University of Massachusetts Press, 2022.

2. How Pamela Culpepper Is Changing The Narrative Of Women In The Workplace. Huffpost. 2020 Mar 6. https://www.huffpost.com/entry/pamela-culpepper-diversity-inclusion-empowerment_n_5e56b6ffc5b62e9dc7dbc307.

3. Hays S. Cultural Contradictions of Motherhood. Yale University Press: New Haven, Conn.: Yale University Press, 1996.

4. Badinter E. (translated by Borossa J). Dead End Feminism. Malden, Mass.: Polity Press, 2006.

In an unprecedented year when income increased for all specialties, pediatricians did better than most, according to a recent survey by Medscape.

Pediatricians reported an average income of $244,000 for 2021, an increase of 10.4% over 2020 that was topped by only three of the 29+ specialties included in the poll. Medscape also noted that, for the first time in the 11 years it’s been conducting these physician compensation surveys, “all specialties have seen an increase in income.”

At least some of that positive news can be traced back to the reduced impact of COVID-19. “Compensation for most physicians is trending back up as demand for physicians accelerates. The market for physicians has done a complete 180 over just 7 or 8 months,” James Taylor of AMN Healthcare’s physician and leadership solutions division said in Medscape Pediatrician Compensation Report 2022.

The 10% increase in pediatricians’ income, however, was not enough to reach the average for primary care physicians, $260,000, which was up by 7.4% over 2020. It was enough, though, to move pediatricians from the bottom of the earnings-by-specialty list, where they were last year, to next-to-last this year (public health/preventive medicine, with average earnings of $243,000 in 2021, is not shown in the graph).

The gender gap in earnings left male pediatricians’ income 26% higher than their female counterparts, slightly above the gap of 25% for primary care physicians and 24% for all physicians. For specialists, the gap was 31% in favor of men, based on data from 13,064 Medscape member physicians who participated in the survey, which was conducted online from Oct. 5, 2021, to Jan. 19, 2022. For the record, 57% of the pediatricians who responded were women.

The gaps and low income averages were enough, it seems, to keep pediatricians fairly negative regarding their feelings on compensation. Only 47% think they were fairly compensated in 2021, higher only than diabetes/endocrinology and nephrology. Among the other primary care specialties, internal medicine and ob.gyn. were slightly higher at 49% and family medicine was 55% – still just middle of the pack, compared with public health/preventive medicine at 72%, Medscape said in the report.
 

Would you do it again?

Moving to the less-economic aspects of the survey, respondents also were asked if they would choose medicine again as a career. Once more pediatricians were low on the scale, as only 70% said that they would enter medicine again, down from 77% last year and lower than this year’s average of 73% average for all physicians.

When they were asked if they would choose pediatrics again as a specialty, the response was a bit more positive: 84% said yes. That middle-of-the-pack showing was well ahead of internal medicine (63%) and family medicine (68%), but well below dermatology (99%) and orthopedics (97%), which are “among the top groups in our survey year after year,” Medscape said.

Did the administrative challenges of medical practice have an effect on those answers? Pediatrician respondents said that they spend 14.9 hours per week on paperwork and administration, close to the average of 15.5 hours for all physicians. The internists, who are least likely to choose their original specialty again, spend 18.7 hours on paperwork each week, while dermatologists, the most likely to repeat their first choice, have just 11.9 hours of paperwork per week.

The exact number of pediatricians involved in the survey was not provided, but they made up about 8% of the total cohort, which works out to somewhere between 1,000 and 1,100 individuals. All respondents had to be practicing in the United States, and compensation was analyzed for full-time physicians only. The sampling error is ±0.86% at a 95% confidence level.

In an unprecedented year when income increased for all specialties, pediatricians did better than most, according to a recent survey by Medscape.

Pediatricians reported an average income of $244,000 for 2021, an increase of 10.4% over 2020 that was topped by only three of the 29+ specialties included in the poll. Medscape also noted that, for the first time in the 11 years it’s been conducting these physician compensation surveys, “all specialties have seen an increase in income.”

At least some of that positive news can be traced back to the reduced impact of COVID-19. “Compensation for most physicians is trending back up as demand for physicians accelerates. The market for physicians has done a complete 180 over just 7 or 8 months,” James Taylor of AMN Healthcare’s physician and leadership solutions division said in Medscape Pediatrician Compensation Report 2022.

The 10% increase in pediatricians’ income, however, was not enough to reach the average for primary care physicians, $260,000, which was up by 7.4% over 2020. It was enough, though, to move pediatricians from the bottom of the earnings-by-specialty list, where they were last year, to next-to-last this year (public health/preventive medicine, with average earnings of $243,000 in 2021, is not shown in the graph).

The gender gap in earnings left male pediatricians’ income 26% higher than their female counterparts, slightly above the gap of 25% for primary care physicians and 24% for all physicians. For specialists, the gap was 31% in favor of men, based on data from 13,064 Medscape member physicians who participated in the survey, which was conducted online from Oct. 5, 2021, to Jan. 19, 2022. For the record, 57% of the pediatricians who responded were women.

The gaps and low income averages were enough, it seems, to keep pediatricians fairly negative regarding their feelings on compensation. Only 47% think they were fairly compensated in 2021, higher only than diabetes/endocrinology and nephrology. Among the other primary care specialties, internal medicine and ob.gyn. were slightly higher at 49% and family medicine was 55% – still just middle of the pack, compared with public health/preventive medicine at 72%, Medscape said in the report.
 

Would you do it again?

Moving to the less-economic aspects of the survey, respondents also were asked if they would choose medicine again as a career. Once more pediatricians were low on the scale, as only 70% said that they would enter medicine again, down from 77% last year and lower than this year’s average of 73% average for all physicians.

When they were asked if they would choose pediatrics again as a specialty, the response was a bit more positive: 84% said yes. That middle-of-the-pack showing was well ahead of internal medicine (63%) and family medicine (68%), but well below dermatology (99%) and orthopedics (97%), which are “among the top groups in our survey year after year,” Medscape said.

Did the administrative challenges of medical practice have an effect on those answers? Pediatrician respondents said that they spend 14.9 hours per week on paperwork and administration, close to the average of 15.5 hours for all physicians. The internists, who are least likely to choose their original specialty again, spend 18.7 hours on paperwork each week, while dermatologists, the most likely to repeat their first choice, have just 11.9 hours of paperwork per week.

The exact number of pediatricians involved in the survey was not provided, but they made up about 8% of the total cohort, which works out to somewhere between 1,000 and 1,100 individuals. All respondents had to be practicing in the United States, and compensation was analyzed for full-time physicians only. The sampling error is ±0.86% at a 95% confidence level.

In an unprecedented year when income increased for all specialties, pediatricians did better than most, according to a recent survey by Medscape.

Pediatricians reported an average income of $244,000 for 2021, an increase of 10.4% over 2020 that was topped by only three of the 29+ specialties included in the poll. Medscape also noted that, for the first time in the 11 years it’s been conducting these physician compensation surveys, “all specialties have seen an increase in income.”

At least some of that positive news can be traced back to the reduced impact of COVID-19. “Compensation for most physicians is trending back up as demand for physicians accelerates. The market for physicians has done a complete 180 over just 7 or 8 months,” James Taylor of AMN Healthcare’s physician and leadership solutions division said in Medscape Pediatrician Compensation Report 2022.

The 10% increase in pediatricians’ income, however, was not enough to reach the average for primary care physicians, $260,000, which was up by 7.4% over 2020. It was enough, though, to move pediatricians from the bottom of the earnings-by-specialty list, where they were last year, to next-to-last this year (public health/preventive medicine, with average earnings of $243,000 in 2021, is not shown in the graph).

The gender gap in earnings left male pediatricians’ income 26% higher than their female counterparts, slightly above the gap of 25% for primary care physicians and 24% for all physicians. For specialists, the gap was 31% in favor of men, based on data from 13,064 Medscape member physicians who participated in the survey, which was conducted online from Oct. 5, 2021, to Jan. 19, 2022. For the record, 57% of the pediatricians who responded were women.

The gaps and low income averages were enough, it seems, to keep pediatricians fairly negative regarding their feelings on compensation. Only 47% think they were fairly compensated in 2021, higher only than diabetes/endocrinology and nephrology. Among the other primary care specialties, internal medicine and ob.gyn. were slightly higher at 49% and family medicine was 55% – still just middle of the pack, compared with public health/preventive medicine at 72%, Medscape said in the report.
 

Would you do it again?

Moving to the less-economic aspects of the survey, respondents also were asked if they would choose medicine again as a career. Once more pediatricians were low on the scale, as only 70% said that they would enter medicine again, down from 77% last year and lower than this year’s average of 73% average for all physicians.

When they were asked if they would choose pediatrics again as a specialty, the response was a bit more positive: 84% said yes. That middle-of-the-pack showing was well ahead of internal medicine (63%) and family medicine (68%), but well below dermatology (99%) and orthopedics (97%), which are “among the top groups in our survey year after year,” Medscape said.

Did the administrative challenges of medical practice have an effect on those answers? Pediatrician respondents said that they spend 14.9 hours per week on paperwork and administration, close to the average of 15.5 hours for all physicians. The internists, who are least likely to choose their original specialty again, spend 18.7 hours on paperwork each week, while dermatologists, the most likely to repeat their first choice, have just 11.9 hours of paperwork per week.

The exact number of pediatricians involved in the survey was not provided, but they made up about 8% of the total cohort, which works out to somewhere between 1,000 and 1,100 individuals. All respondents had to be practicing in the United States, and compensation was analyzed for full-time physicians only. The sampling error is ±0.86% at a 95% confidence level.

It is projected that by 2050, 1.6 billion women in the world will have reached menopause or the postmenopausal period, a significant increase, compared with a billion women in 2020. Of all menopausal women, around 75% are affected by troublesome menopause symptoms, such as hot flashes and night sweats.

Around 84% of postmenopausal women experience genitourinary symptoms, such as vulvovaginal atrophy and incontinence.

Menopausal hormone therapy (MHT) is the most effective treatment for managing these symptoms; however, its effects on numerous aspects of female health remain uncertain, in particular with regard to breast cancer. The influence of MHT on breast cancer remains unsettled, with discordant findings from observational studies and randomized clinical trials, a factor that affects the decisions made by doctors concerning hormone therapy in menopausal women.
 

Background

Conjugated equine estrogens (CEEs) were introduced into clinical practice in the 1940s. For decades, MHT was the main treatment in conventional medicine for the symptoms of menopause. MHT was used in Western countries for about 600 million women starting from 1970, and it progressively increased during the 1990s. Professional organizations recommended MHT for the prevention of osteoporosis and chronic heart disease (CHD), and a third of prescriptions were for women older than 60 years.

Against this background, the National Institutes of Health launched randomized trials of MHT through the Women’s Health Initiative (WHI) to test whether the association with reduced risk for CHD found in observational studies was real and to obtain reliable information on the overall risks and benefits regarding the prevention of chronic disease for postmenopausal women aged 50-79 years.

The WHI trials tested standard-dose oral CEEs with and without standard-dose continuous medroxyprogesterone acetate (EPT). In 2002, the results of the WHI studies raised a series of concerns about the long-term safety of MHT, in particular the finding of an increased risk of breast cancer for women undergoing therapy. That risk exceeded the benefits from reductions in hip fractures and colorectal cancer.

The WHI findings received wide attention. Prescriptions for MHT dropped precipitously after 2002 and continued to decline in subsequent years. Declines were most marked for standard-dose EPT and in older women. The results of the CEE study were less negative, compared with those for EPT, as they showed no effect on CHD, a nonsignificant reduction in the risk of breast cancer, and a more favorable risk-benefit ratio for younger women, compared with older women. A decade later, it had become widely accepted that MHT should not be used for the prevention of chronic disease in older women; however, short-term use for treatment of vasomotor symptoms remains an accepted indication.
 

Risks and outcomes

Emerging from a series of WHI reports are complex models on the effect of hormonal therapy on the risk and outcome of breast cancer. In one study, women with an intact uterus received CEEs plus medroxyprogesterone acetate (MPA). An increase in the risk of breast cancer was observed over a median of 5.6 years of treatment, followed by a moderate reduction, with the risk increasing after 13 years of cumulative follow-up. For women treated with CEE alone, the reduction in risk observed over an average of 7.2 years of treatment was maintained for 13 years of follow-up.

Results from observational studies contrast with those from randomized controlled trials, particularly those concerning the use of estrogens only. A meta-analysis by the Collaborative Group on Hormonal Factors in Breast Cancer showed that both EPT and CEE were associated with a higher risk of breast neoplasia. Results of the Million Women Study showed a higher death rate.
 

Treatment methods and duration

Information from prospective studies on the effects of commencing MHT at various ages between 40 and 59 years show that for women who commenced treatment at any time within this age range, the relative risk was similar and was highly significant for all ages. Few women had started MHT treatment well after menopause at ages 60-69 years, and their excess risks during years 5-14 of current use were significant for estrogen-progestogen but not for estrogen-only MHT.

If these associations are largely causal, then for women of average weight in developed countries, 5 years of MHT, starting at age 50 years, would increase breast cancer incidence at ages 50-69 years by about 1 in every 50 users of estrogen plus daily progestogen preparations; 1 in every 70 users of estrogen plus intermittent progestogen preparations; and 1 in every 200 users of estrogen-only preparations. The corresponding excesses from 10 years of MHT would be about twice as great.

During 5-14 years of MHT use, the RRs were similarly increased if MHT use had started at ages 40-44 years, 45-49 years, 50-54 years, and 55-59 years; RRs appeared to be attenuated if MHT use had started after age 60 years. They were also attenuated by adiposity, particularly for estrogen-only MHT (which had little effect in obese women). After MHT use ceased, some excess risk of breast cancer persisted for more than a decade; this is directly correlated with the duration of treatment.

Therefore, it can be expected that the effects of MHT may vary between participants on the basis of age or time since menopause, as well as treatments (MHT type, dose, formulation, duration of use, and route of administration). Regarding formulation effects on the risk of breast cancer, new evidence shows an increased risk of 28%. Progestogens appeared to be differentially associated with breast cancer (micronized progesterone: odds ratio, 0.99; 95% confidence interval 0.55-1.79; synthetic progestin: OR, 1.28; 95% CI, 1.22-1.35). When prescribing MHT, micronized progesterone may be the safer progestogen to use.

In conclusion, MHT has a complex balance of benefits and risk on various health outcomes. Some effects differ qualitatively between ET and EPT. Regarding use of MHT, consideration should be given to the full range of effects, along with patients’ values and preferences. The overall quality of existing systematic reviews is moderate to poor. Clinicians should evaluate their scientific strength before considering applying their results in clinical practice. Regarding use of any hormone therapy regimen, consideration should be given to the full range of risk and benefits and should involve shared decisionmaking with the patient. It should be recognized that risk-benefit balance is altered by factors such as age, time from menopause, oophorectomy status, and prior hysterectomy and that some outcomes persist and there is some attenuation after stopping use.

This article was translated from Univadis Italy.

A version of the article appeared on Medscape.com.

It is projected that by 2050, 1.6 billion women in the world will have reached menopause or the postmenopausal period, a significant increase, compared with a billion women in 2020. Of all menopausal women, around 75% are affected by troublesome menopause symptoms, such as hot flashes and night sweats.

Around 84% of postmenopausal women experience genitourinary symptoms, such as vulvovaginal atrophy and incontinence.

Menopausal hormone therapy (MHT) is the most effective treatment for managing these symptoms; however, its effects on numerous aspects of female health remain uncertain, in particular with regard to breast cancer. The influence of MHT on breast cancer remains unsettled, with discordant findings from observational studies and randomized clinical trials, a factor that affects the decisions made by doctors concerning hormone therapy in menopausal women.
 

Background

Conjugated equine estrogens (CEEs) were introduced into clinical practice in the 1940s. For decades, MHT was the main treatment in conventional medicine for the symptoms of menopause. MHT was used in Western countries for about 600 million women starting from 1970, and it progressively increased during the 1990s. Professional organizations recommended MHT for the prevention of osteoporosis and chronic heart disease (CHD), and a third of prescriptions were for women older than 60 years.

Against this background, the National Institutes of Health launched randomized trials of MHT through the Women’s Health Initiative (WHI) to test whether the association with reduced risk for CHD found in observational studies was real and to obtain reliable information on the overall risks and benefits regarding the prevention of chronic disease for postmenopausal women aged 50-79 years.

The WHI trials tested standard-dose oral CEEs with and without standard-dose continuous medroxyprogesterone acetate (EPT). In 2002, the results of the WHI studies raised a series of concerns about the long-term safety of MHT, in particular the finding of an increased risk of breast cancer for women undergoing therapy. That risk exceeded the benefits from reductions in hip fractures and colorectal cancer.

The WHI findings received wide attention. Prescriptions for MHT dropped precipitously after 2002 and continued to decline in subsequent years. Declines were most marked for standard-dose EPT and in older women. The results of the CEE study were less negative, compared with those for EPT, as they showed no effect on CHD, a nonsignificant reduction in the risk of breast cancer, and a more favorable risk-benefit ratio for younger women, compared with older women. A decade later, it had become widely accepted that MHT should not be used for the prevention of chronic disease in older women; however, short-term use for treatment of vasomotor symptoms remains an accepted indication.
 

Risks and outcomes

Emerging from a series of WHI reports are complex models on the effect of hormonal therapy on the risk and outcome of breast cancer. In one study, women with an intact uterus received CEEs plus medroxyprogesterone acetate (MPA). An increase in the risk of breast cancer was observed over a median of 5.6 years of treatment, followed by a moderate reduction, with the risk increasing after 13 years of cumulative follow-up. For women treated with CEE alone, the reduction in risk observed over an average of 7.2 years of treatment was maintained for 13 years of follow-up.

Results from observational studies contrast with those from randomized controlled trials, particularly those concerning the use of estrogens only. A meta-analysis by the Collaborative Group on Hormonal Factors in Breast Cancer showed that both EPT and CEE were associated with a higher risk of breast neoplasia. Results of the Million Women Study showed a higher death rate.
 

Treatment methods and duration

Information from prospective studies on the effects of commencing MHT at various ages between 40 and 59 years show that for women who commenced treatment at any time within this age range, the relative risk was similar and was highly significant for all ages. Few women had started MHT treatment well after menopause at ages 60-69 years, and their excess risks during years 5-14 of current use were significant for estrogen-progestogen but not for estrogen-only MHT.

If these associations are largely causal, then for women of average weight in developed countries, 5 years of MHT, starting at age 50 years, would increase breast cancer incidence at ages 50-69 years by about 1 in every 50 users of estrogen plus daily progestogen preparations; 1 in every 70 users of estrogen plus intermittent progestogen preparations; and 1 in every 200 users of estrogen-only preparations. The corresponding excesses from 10 years of MHT would be about twice as great.

During 5-14 years of MHT use, the RRs were similarly increased if MHT use had started at ages 40-44 years, 45-49 years, 50-54 years, and 55-59 years; RRs appeared to be attenuated if MHT use had started after age 60 years. They were also attenuated by adiposity, particularly for estrogen-only MHT (which had little effect in obese women). After MHT use ceased, some excess risk of breast cancer persisted for more than a decade; this is directly correlated with the duration of treatment.

Therefore, it can be expected that the effects of MHT may vary between participants on the basis of age or time since menopause, as well as treatments (MHT type, dose, formulation, duration of use, and route of administration). Regarding formulation effects on the risk of breast cancer, new evidence shows an increased risk of 28%. Progestogens appeared to be differentially associated with breast cancer (micronized progesterone: odds ratio, 0.99; 95% confidence interval 0.55-1.79; synthetic progestin: OR, 1.28; 95% CI, 1.22-1.35). When prescribing MHT, micronized progesterone may be the safer progestogen to use.

In conclusion, MHT has a complex balance of benefits and risk on various health outcomes. Some effects differ qualitatively between ET and EPT. Regarding use of MHT, consideration should be given to the full range of effects, along with patients’ values and preferences. The overall quality of existing systematic reviews is moderate to poor. Clinicians should evaluate their scientific strength before considering applying their results in clinical practice. Regarding use of any hormone therapy regimen, consideration should be given to the full range of risk and benefits and should involve shared decisionmaking with the patient. It should be recognized that risk-benefit balance is altered by factors such as age, time from menopause, oophorectomy status, and prior hysterectomy and that some outcomes persist and there is some attenuation after stopping use.

This article was translated from Univadis Italy.

A version of the article appeared on Medscape.com.

It is projected that by 2050, 1.6 billion women in the world will have reached menopause or the postmenopausal period, a significant increase, compared with a billion women in 2020. Of all menopausal women, around 75% are affected by troublesome menopause symptoms, such as hot flashes and night sweats.

Around 84% of postmenopausal women experience genitourinary symptoms, such as vulvovaginal atrophy and incontinence.

Menopausal hormone therapy (MHT) is the most effective treatment for managing these symptoms; however, its effects on numerous aspects of female health remain uncertain, in particular with regard to breast cancer. The influence of MHT on breast cancer remains unsettled, with discordant findings from observational studies and randomized clinical trials, a factor that affects the decisions made by doctors concerning hormone therapy in menopausal women.
 

Background

Conjugated equine estrogens (CEEs) were introduced into clinical practice in the 1940s. For decades, MHT was the main treatment in conventional medicine for the symptoms of menopause. MHT was used in Western countries for about 600 million women starting from 1970, and it progressively increased during the 1990s. Professional organizations recommended MHT for the prevention of osteoporosis and chronic heart disease (CHD), and a third of prescriptions were for women older than 60 years.

Against this background, the National Institutes of Health launched randomized trials of MHT through the Women’s Health Initiative (WHI) to test whether the association with reduced risk for CHD found in observational studies was real and to obtain reliable information on the overall risks and benefits regarding the prevention of chronic disease for postmenopausal women aged 50-79 years.

The WHI trials tested standard-dose oral CEEs with and without standard-dose continuous medroxyprogesterone acetate (EPT). In 2002, the results of the WHI studies raised a series of concerns about the long-term safety of MHT, in particular the finding of an increased risk of breast cancer for women undergoing therapy. That risk exceeded the benefits from reductions in hip fractures and colorectal cancer.

The WHI findings received wide attention. Prescriptions for MHT dropped precipitously after 2002 and continued to decline in subsequent years. Declines were most marked for standard-dose EPT and in older women. The results of the CEE study were less negative, compared with those for EPT, as they showed no effect on CHD, a nonsignificant reduction in the risk of breast cancer, and a more favorable risk-benefit ratio for younger women, compared with older women. A decade later, it had become widely accepted that MHT should not be used for the prevention of chronic disease in older women; however, short-term use for treatment of vasomotor symptoms remains an accepted indication.
 

Risks and outcomes

Emerging from a series of WHI reports are complex models on the effect of hormonal therapy on the risk and outcome of breast cancer. In one study, women with an intact uterus received CEEs plus medroxyprogesterone acetate (MPA). An increase in the risk of breast cancer was observed over a median of 5.6 years of treatment, followed by a moderate reduction, with the risk increasing after 13 years of cumulative follow-up. For women treated with CEE alone, the reduction in risk observed over an average of 7.2 years of treatment was maintained for 13 years of follow-up.

Results from observational studies contrast with those from randomized controlled trials, particularly those concerning the use of estrogens only. A meta-analysis by the Collaborative Group on Hormonal Factors in Breast Cancer showed that both EPT and CEE were associated with a higher risk of breast neoplasia. Results of the Million Women Study showed a higher death rate.
 

Treatment methods and duration

Information from prospective studies on the effects of commencing MHT at various ages between 40 and 59 years show that for women who commenced treatment at any time within this age range, the relative risk was similar and was highly significant for all ages. Few women had started MHT treatment well after menopause at ages 60-69 years, and their excess risks during years 5-14 of current use were significant for estrogen-progestogen but not for estrogen-only MHT.

If these associations are largely causal, then for women of average weight in developed countries, 5 years of MHT, starting at age 50 years, would increase breast cancer incidence at ages 50-69 years by about 1 in every 50 users of estrogen plus daily progestogen preparations; 1 in every 70 users of estrogen plus intermittent progestogen preparations; and 1 in every 200 users of estrogen-only preparations. The corresponding excesses from 10 years of MHT would be about twice as great.

During 5-14 years of MHT use, the RRs were similarly increased if MHT use had started at ages 40-44 years, 45-49 years, 50-54 years, and 55-59 years; RRs appeared to be attenuated if MHT use had started after age 60 years. They were also attenuated by adiposity, particularly for estrogen-only MHT (which had little effect in obese women). After MHT use ceased, some excess risk of breast cancer persisted for more than a decade; this is directly correlated with the duration of treatment.

Therefore, it can be expected that the effects of MHT may vary between participants on the basis of age or time since menopause, as well as treatments (MHT type, dose, formulation, duration of use, and route of administration). Regarding formulation effects on the risk of breast cancer, new evidence shows an increased risk of 28%. Progestogens appeared to be differentially associated with breast cancer (micronized progesterone: odds ratio, 0.99; 95% confidence interval 0.55-1.79; synthetic progestin: OR, 1.28; 95% CI, 1.22-1.35). When prescribing MHT, micronized progesterone may be the safer progestogen to use.

In conclusion, MHT has a complex balance of benefits and risk on various health outcomes. Some effects differ qualitatively between ET and EPT. Regarding use of MHT, consideration should be given to the full range of effects, along with patients’ values and preferences. The overall quality of existing systematic reviews is moderate to poor. Clinicians should evaluate their scientific strength before considering applying their results in clinical practice. Regarding use of any hormone therapy regimen, consideration should be given to the full range of risk and benefits and should involve shared decisionmaking with the patient. It should be recognized that risk-benefit balance is altered by factors such as age, time from menopause, oophorectomy status, and prior hysterectomy and that some outcomes persist and there is some attenuation after stopping use.

This article was translated from Univadis Italy.

A version of the article appeared on Medscape.com.