Bipolar disorder (BD) is linked to a sixfold increased risk of early death from external causes and a twofold increased risk of dying prematurely from somatic disease than the general population, a new study shows.

In addition, patients with BD are three times more likely to die prematurely of all causes, compared with the general population, with alcohol-related diseases contributing to more premature deaths than cardiovascular disease (CVD), diabetes, and cancer.

The study results emphasize the need for personalized approaches to risk prediction and prevention of premature cause-specific mortality over the life-course of individuals with BD, lead investigator Tapio Paljärvi, PhD, an epidemiologist at Niuvanniemi Hospital in Kuopio, Finland, told this news organization.

The findings were published online in BMJ Mental Health.
 

Alcohol a major contributor to early death

A number of studies have established that those with BD have twice the risk of dying prematurely, compared with those without the disorder.

To learn more about the factors contributing to early death in this patient population, the investigators analyzed data from nationwide Finnish medical and insurance registries. They identified and tracked the health of 47,000 patients, aged 15-64 years, with BD between 2004 and 2018.

The average age at the beginning of the monitoring period was 38 years, and 57% of the cohort were women.

To determine the excess deaths directly attributable to BD, the researchers compared the ratio of deaths observed over the monitoring period in those with BD to the number expected to die in the general population, also known as the standard mortality ratio.

Of the group with BD, 3,300 died during the monitoring period. The average age at death was 50, and almost two-thirds (65%, or 2,137) of those who died were men.

Investigators grouped excess deaths in BD patients into two categories – somatic and external.

Of those with BD who died from somatic or disease-related causes, alcohol caused the highest rate of death (29%). The second-leading cause was heart disease and stroke (27%), followed by cancer (22%), respiratory diseases (4%), and diabetes (2%).

Among the 595 patients with BD who died because of alcohol consumption, liver disease was the leading cause of death (48%). The second cause was accidental alcohol poisoning (28%), followed by alcohol dependence (10%).

The leading cause of death from external causes in BD patients was suicide (58%, or 740), nearly half of which (48%) were from an overdose with prescribed psychotropic medications.

Overall, 64%, or 2,104, of the deaths in BD patients from any cause were considered excess deaths, that is, the number of deaths above those expected for those without BD of comparable age and sex.

Most of the excess deaths from somatic illness were either from alcohol-related causes (40%) – a rate three times higher than that of the general population – CVD (26%), or cancer (10%).
 

High suicide rate

When the team examined excess deaths from external causes, they found that 61% (651) were attributable to suicide, a rate eight times higher than that of the general population.

“In terms of absolute numbers, somatic causes of death represented the majority of all deaths in BD, as also reported in previous research,” Dr. Paljärvi said.

“However, this finding reflects the fact that in many high-income countries most of the deaths are due to somatic causes; with CVD, cancers, and diseases of the nervous system as the leading causes of death in the older age groups,” he added.

Dr. Paljärvi advised that clinicians treating patients with BD balance therapeutic response with potentially serious long-term medication side effects, to prevent premature deaths.

A stronger emphasis on identifying and treating comorbid substance abuse is also warranted, he noted.

Dr. Paljärvi noted that the underlying causes of the excess somatic mortality in people with BD are not fully understood, but may result from the “complex interaction between various established risk factors, including tobacco use, alcohol abuse, physical inactivity, unhealthy diet, obesity, hypertension, etc.”

Regarding the generalizability of the findings, he said many previous studies have been based only on inpatient data and noted that the current study included individuals from various sources including inpatient and outpatient registries as well as social insurance registries.

“While the reported excess all-cause mortality rates are strikingly similar across populations globally, there is a paucity of more detailed cause-specific analyses of excess mortality in BD,” said Dr. Paljärvi, adding that these findings should be replicated in other countries, including the United States.
 

Chronic inflammation

Commenting on the findings, Benjamin Goldstein, MD, PhD, professor of psychiatry and pharmacology at the University of Toronto, noted that there are clear disparities in access to, and quality of care among, patients with BD and other serious mental illnesses.

“Taking heart disease as an example, disparities exist at virtually every point of contact, ranging from the point of preventive care to the time it takes to be assessed in the ER, to the likelihood of receiving cardiac catheterization, to the quality of postdischarge care,” said Dr. Goldstein.

He also noted that CVD occurs in patients with BD, on average, 10-15 years earlier than the general population. However, he added, “there is important evidence that when people with BD receive the same standard of care as those without BD their cardiovascular outcomes are similar.”

Dr. Goldstein also noted that inflammation, which is a driver of cardiovascular risk, is elevated among patients with BD, particularly during mania and depression.

“Given that the average person with BD has some degree of mood symptoms about 40% of the time, chronically elevated inflammation likely contributes in part to the excess risk of heart disease in bipolar disorder,” he said.

Dr. Goldstein’s team’s research focuses on microvessels. “We have found that microvessel function in both the heart and the brain, determined by MRI, is reduced among teens with BD,” he said.

His team has also found that endothelial function in fingertip microvessels, an indicator of future heart disease risk, varies according to mood states.

“Collectively, these findings suggest the microvascular problems may explain, in part, the extra risk of heart disease beyond traditional risk factors in BD,” he added.

The study was funded by a Wellcome Trust Senior Clinical Research Fellowship and by the Oxford Health Biomedical Research Centre. Dr. Paljärvi and Dr. Goldstein report no relevant financial relationships.

A version of this article appeared on Medscape.com.

Bipolar disorder (BD) is linked to a sixfold increased risk of early death from external causes and a twofold increased risk of dying prematurely from somatic disease than the general population, a new study shows.

In addition, patients with BD are three times more likely to die prematurely of all causes, compared with the general population, with alcohol-related diseases contributing to more premature deaths than cardiovascular disease (CVD), diabetes, and cancer.

The study results emphasize the need for personalized approaches to risk prediction and prevention of premature cause-specific mortality over the life-course of individuals with BD, lead investigator Tapio Paljärvi, PhD, an epidemiologist at Niuvanniemi Hospital in Kuopio, Finland, told this news organization.

The findings were published online in BMJ Mental Health.
 

Alcohol a major contributor to early death

A number of studies have established that those with BD have twice the risk of dying prematurely, compared with those without the disorder.

To learn more about the factors contributing to early death in this patient population, the investigators analyzed data from nationwide Finnish medical and insurance registries. They identified and tracked the health of 47,000 patients, aged 15-64 years, with BD between 2004 and 2018.

The average age at the beginning of the monitoring period was 38 years, and 57% of the cohort were women.

To determine the excess deaths directly attributable to BD, the researchers compared the ratio of deaths observed over the monitoring period in those with BD to the number expected to die in the general population, also known as the standard mortality ratio.

Of the group with BD, 3,300 died during the monitoring period. The average age at death was 50, and almost two-thirds (65%, or 2,137) of those who died were men.

Investigators grouped excess deaths in BD patients into two categories – somatic and external.

Of those with BD who died from somatic or disease-related causes, alcohol caused the highest rate of death (29%). The second-leading cause was heart disease and stroke (27%), followed by cancer (22%), respiratory diseases (4%), and diabetes (2%).

Among the 595 patients with BD who died because of alcohol consumption, liver disease was the leading cause of death (48%). The second cause was accidental alcohol poisoning (28%), followed by alcohol dependence (10%).

The leading cause of death from external causes in BD patients was suicide (58%, or 740), nearly half of which (48%) were from an overdose with prescribed psychotropic medications.

Overall, 64%, or 2,104, of the deaths in BD patients from any cause were considered excess deaths, that is, the number of deaths above those expected for those without BD of comparable age and sex.

Most of the excess deaths from somatic illness were either from alcohol-related causes (40%) – a rate three times higher than that of the general population – CVD (26%), or cancer (10%).
 

High suicide rate

When the team examined excess deaths from external causes, they found that 61% (651) were attributable to suicide, a rate eight times higher than that of the general population.

“In terms of absolute numbers, somatic causes of death represented the majority of all deaths in BD, as also reported in previous research,” Dr. Paljärvi said.

“However, this finding reflects the fact that in many high-income countries most of the deaths are due to somatic causes; with CVD, cancers, and diseases of the nervous system as the leading causes of death in the older age groups,” he added.

Dr. Paljärvi advised that clinicians treating patients with BD balance therapeutic response with potentially serious long-term medication side effects, to prevent premature deaths.

A stronger emphasis on identifying and treating comorbid substance abuse is also warranted, he noted.

Dr. Paljärvi noted that the underlying causes of the excess somatic mortality in people with BD are not fully understood, but may result from the “complex interaction between various established risk factors, including tobacco use, alcohol abuse, physical inactivity, unhealthy diet, obesity, hypertension, etc.”

Regarding the generalizability of the findings, he said many previous studies have been based only on inpatient data and noted that the current study included individuals from various sources including inpatient and outpatient registries as well as social insurance registries.

“While the reported excess all-cause mortality rates are strikingly similar across populations globally, there is a paucity of more detailed cause-specific analyses of excess mortality in BD,” said Dr. Paljärvi, adding that these findings should be replicated in other countries, including the United States.
 

Chronic inflammation

Commenting on the findings, Benjamin Goldstein, MD, PhD, professor of psychiatry and pharmacology at the University of Toronto, noted that there are clear disparities in access to, and quality of care among, patients with BD and other serious mental illnesses.

“Taking heart disease as an example, disparities exist at virtually every point of contact, ranging from the point of preventive care to the time it takes to be assessed in the ER, to the likelihood of receiving cardiac catheterization, to the quality of postdischarge care,” said Dr. Goldstein.

He also noted that CVD occurs in patients with BD, on average, 10-15 years earlier than the general population. However, he added, “there is important evidence that when people with BD receive the same standard of care as those without BD their cardiovascular outcomes are similar.”

Dr. Goldstein also noted that inflammation, which is a driver of cardiovascular risk, is elevated among patients with BD, particularly during mania and depression.

“Given that the average person with BD has some degree of mood symptoms about 40% of the time, chronically elevated inflammation likely contributes in part to the excess risk of heart disease in bipolar disorder,” he said.

Dr. Goldstein’s team’s research focuses on microvessels. “We have found that microvessel function in both the heart and the brain, determined by MRI, is reduced among teens with BD,” he said.

His team has also found that endothelial function in fingertip microvessels, an indicator of future heart disease risk, varies according to mood states.

“Collectively, these findings suggest the microvascular problems may explain, in part, the extra risk of heart disease beyond traditional risk factors in BD,” he added.

The study was funded by a Wellcome Trust Senior Clinical Research Fellowship and by the Oxford Health Biomedical Research Centre. Dr. Paljärvi and Dr. Goldstein report no relevant financial relationships.

A version of this article appeared on Medscape.com.

Bipolar disorder (BD) is linked to a sixfold increased risk of early death from external causes and a twofold increased risk of dying prematurely from somatic disease than the general population, a new study shows.

In addition, patients with BD are three times more likely to die prematurely of all causes, compared with the general population, with alcohol-related diseases contributing to more premature deaths than cardiovascular disease (CVD), diabetes, and cancer.

The study results emphasize the need for personalized approaches to risk prediction and prevention of premature cause-specific mortality over the life-course of individuals with BD, lead investigator Tapio Paljärvi, PhD, an epidemiologist at Niuvanniemi Hospital in Kuopio, Finland, told this news organization.

The findings were published online in BMJ Mental Health.
 

Alcohol a major contributor to early death

A number of studies have established that those with BD have twice the risk of dying prematurely, compared with those without the disorder.

To learn more about the factors contributing to early death in this patient population, the investigators analyzed data from nationwide Finnish medical and insurance registries. They identified and tracked the health of 47,000 patients, aged 15-64 years, with BD between 2004 and 2018.

The average age at the beginning of the monitoring period was 38 years, and 57% of the cohort were women.

To determine the excess deaths directly attributable to BD, the researchers compared the ratio of deaths observed over the monitoring period in those with BD to the number expected to die in the general population, also known as the standard mortality ratio.

Of the group with BD, 3,300 died during the monitoring period. The average age at death was 50, and almost two-thirds (65%, or 2,137) of those who died were men.

Investigators grouped excess deaths in BD patients into two categories – somatic and external.

Of those with BD who died from somatic or disease-related causes, alcohol caused the highest rate of death (29%). The second-leading cause was heart disease and stroke (27%), followed by cancer (22%), respiratory diseases (4%), and diabetes (2%).

Among the 595 patients with BD who died because of alcohol consumption, liver disease was the leading cause of death (48%). The second cause was accidental alcohol poisoning (28%), followed by alcohol dependence (10%).

The leading cause of death from external causes in BD patients was suicide (58%, or 740), nearly half of which (48%) were from an overdose with prescribed psychotropic medications.

Overall, 64%, or 2,104, of the deaths in BD patients from any cause were considered excess deaths, that is, the number of deaths above those expected for those without BD of comparable age and sex.

Most of the excess deaths from somatic illness were either from alcohol-related causes (40%) – a rate three times higher than that of the general population – CVD (26%), or cancer (10%).
 

High suicide rate

When the team examined excess deaths from external causes, they found that 61% (651) were attributable to suicide, a rate eight times higher than that of the general population.

“In terms of absolute numbers, somatic causes of death represented the majority of all deaths in BD, as also reported in previous research,” Dr. Paljärvi said.

“However, this finding reflects the fact that in many high-income countries most of the deaths are due to somatic causes; with CVD, cancers, and diseases of the nervous system as the leading causes of death in the older age groups,” he added.

Dr. Paljärvi advised that clinicians treating patients with BD balance therapeutic response with potentially serious long-term medication side effects, to prevent premature deaths.

A stronger emphasis on identifying and treating comorbid substance abuse is also warranted, he noted.

Dr. Paljärvi noted that the underlying causes of the excess somatic mortality in people with BD are not fully understood, but may result from the “complex interaction between various established risk factors, including tobacco use, alcohol abuse, physical inactivity, unhealthy diet, obesity, hypertension, etc.”

Regarding the generalizability of the findings, he said many previous studies have been based only on inpatient data and noted that the current study included individuals from various sources including inpatient and outpatient registries as well as social insurance registries.

“While the reported excess all-cause mortality rates are strikingly similar across populations globally, there is a paucity of more detailed cause-specific analyses of excess mortality in BD,” said Dr. Paljärvi, adding that these findings should be replicated in other countries, including the United States.
 

Chronic inflammation

Commenting on the findings, Benjamin Goldstein, MD, PhD, professor of psychiatry and pharmacology at the University of Toronto, noted that there are clear disparities in access to, and quality of care among, patients with BD and other serious mental illnesses.

“Taking heart disease as an example, disparities exist at virtually every point of contact, ranging from the point of preventive care to the time it takes to be assessed in the ER, to the likelihood of receiving cardiac catheterization, to the quality of postdischarge care,” said Dr. Goldstein.

He also noted that CVD occurs in patients with BD, on average, 10-15 years earlier than the general population. However, he added, “there is important evidence that when people with BD receive the same standard of care as those without BD their cardiovascular outcomes are similar.”

Dr. Goldstein also noted that inflammation, which is a driver of cardiovascular risk, is elevated among patients with BD, particularly during mania and depression.

“Given that the average person with BD has some degree of mood symptoms about 40% of the time, chronically elevated inflammation likely contributes in part to the excess risk of heart disease in bipolar disorder,” he said.

Dr. Goldstein’s team’s research focuses on microvessels. “We have found that microvessel function in both the heart and the brain, determined by MRI, is reduced among teens with BD,” he said.

His team has also found that endothelial function in fingertip microvessels, an indicator of future heart disease risk, varies according to mood states.

“Collectively, these findings suggest the microvascular problems may explain, in part, the extra risk of heart disease beyond traditional risk factors in BD,” he added.

The study was funded by a Wellcome Trust Senior Clinical Research Fellowship and by the Oxford Health Biomedical Research Centre. Dr. Paljärvi and Dr. Goldstein report no relevant financial relationships.

A version of this article appeared on Medscape.com.

Consuming a higher percentage of calories from added sugars is linked with a higher prevalence of kidney stones, new research suggests.

Though added sugars have been linked with multiple poor health outcomes, their link with kidney stones has been unclear.

Added sugars are sugars or caloric sweeteners added to foods or drinks during processing or preparation to add flavor or shelf life. They do not include natural sugars such as lactose in milk and fructose in fruits.

Researchers, led by Shan Yin, a urologist at Affiliated Hospital of North Sichuan Medical College, in Nanchong, China, compared the added-sugar intake by quartiles in the U.S. National Health and Nutrition Examination Survey 2007-2018.

A total of 28,303 adults were included in this study, with an average age of 48. Women who consumed less than 600 or more than 3,500 kcal or men who consumed less than 800 or more than 4,200 kcal were excluded.

Researchers adjusted for factors including age, race, education, income, physical activity, and marital, employment, and smoking status.

Compared with the first quartile of percentage added-sugar calorie intake, the population in the fourth quartile, with the highest added sugar intake, had a higher prevalence of kidney stones (odds ratio, 1.39; 95% confidence interval, 1.17-1.65).

Compared with the group with fewer than 5% of calories from added sugar, the group that consumed at least 25% of calories from added sugar had nearly twice the prevalence of kidney stones (OR, 1.88; 95% CI, 1.52-2.32).

Findings were published online in Frontiers in Nutrition.

“By identifying this association, policymakers and health professionals can emphasize the need for public health initiatives to reduce added sugar consumption and promote healthy dietary habits,” the authors write.
 

Added sugar in the U.S. diet

Sugar-sweetened beverages such as soft drinks and energy and sports drinks account for 34.4% of added sugars in the American diet. Previous studies have shown the relationship between consuming sugar-sweetened beverages and a higher risk of obesity, diabetes, and cardiovascular disease, diseases that often co-occur with kidney stones.

Researchers note that even though most added sugars in the United States come from sugar-sweetened beverages, it’s unclear whether the association between added sugars and kidney stones is caused by the beverages or other sources. For instance, fructose intake has been found to be independently associated with kidney stones.

How much is too much?

The recommended upper limit on added sugar is controversial and varies widely by health organization. The American Heart Association says daily average intake from added sugars should be no more than 150 kcal for adult males (about 9 teaspoons) and no more than 100 kcal for women (about 6 teaspoons). The Institute of Medicine allows up to 25% of calories to be consumed from added sugars. The 2020 Dietary Guidelines for Americans and World Health Organization set 10% of calories as the recommended upper limit.

Further investigating what causes kidney stones is critical as kidney stones are common worldwide, affecting about 1 in 10 people in the United States alone, and occurrence is increasing. Kidney stones have a high recurrence rate – about half of people who get them have a second episode within 10 years, the authors note.

The researchers acknowledge that because participants self-reported food intake, there is the potential for recall bias. Additionally, because of the cross-sectional design, the researchers were not able to determine whether sugar intake or kidney stone occurrence came first.

This work was supported by the Doctoral Fund Project of North Sichuan Medical College. The authors declare no relevant financial relationships.

Consuming a higher percentage of calories from added sugars is linked with a higher prevalence of kidney stones, new research suggests.

Though added sugars have been linked with multiple poor health outcomes, their link with kidney stones has been unclear.

Added sugars are sugars or caloric sweeteners added to foods or drinks during processing or preparation to add flavor or shelf life. They do not include natural sugars such as lactose in milk and fructose in fruits.

Researchers, led by Shan Yin, a urologist at Affiliated Hospital of North Sichuan Medical College, in Nanchong, China, compared the added-sugar intake by quartiles in the U.S. National Health and Nutrition Examination Survey 2007-2018.

A total of 28,303 adults were included in this study, with an average age of 48. Women who consumed less than 600 or more than 3,500 kcal or men who consumed less than 800 or more than 4,200 kcal were excluded.

Researchers adjusted for factors including age, race, education, income, physical activity, and marital, employment, and smoking status.

Compared with the first quartile of percentage added-sugar calorie intake, the population in the fourth quartile, with the highest added sugar intake, had a higher prevalence of kidney stones (odds ratio, 1.39; 95% confidence interval, 1.17-1.65).

Compared with the group with fewer than 5% of calories from added sugar, the group that consumed at least 25% of calories from added sugar had nearly twice the prevalence of kidney stones (OR, 1.88; 95% CI, 1.52-2.32).

Findings were published online in Frontiers in Nutrition.

“By identifying this association, policymakers and health professionals can emphasize the need for public health initiatives to reduce added sugar consumption and promote healthy dietary habits,” the authors write.
 

Added sugar in the U.S. diet

Sugar-sweetened beverages such as soft drinks and energy and sports drinks account for 34.4% of added sugars in the American diet. Previous studies have shown the relationship between consuming sugar-sweetened beverages and a higher risk of obesity, diabetes, and cardiovascular disease, diseases that often co-occur with kidney stones.

Researchers note that even though most added sugars in the United States come from sugar-sweetened beverages, it’s unclear whether the association between added sugars and kidney stones is caused by the beverages or other sources. For instance, fructose intake has been found to be independently associated with kidney stones.

How much is too much?

The recommended upper limit on added sugar is controversial and varies widely by health organization. The American Heart Association says daily average intake from added sugars should be no more than 150 kcal for adult males (about 9 teaspoons) and no more than 100 kcal for women (about 6 teaspoons). The Institute of Medicine allows up to 25% of calories to be consumed from added sugars. The 2020 Dietary Guidelines for Americans and World Health Organization set 10% of calories as the recommended upper limit.

Further investigating what causes kidney stones is critical as kidney stones are common worldwide, affecting about 1 in 10 people in the United States alone, and occurrence is increasing. Kidney stones have a high recurrence rate – about half of people who get them have a second episode within 10 years, the authors note.

The researchers acknowledge that because participants self-reported food intake, there is the potential for recall bias. Additionally, because of the cross-sectional design, the researchers were not able to determine whether sugar intake or kidney stone occurrence came first.

This work was supported by the Doctoral Fund Project of North Sichuan Medical College. The authors declare no relevant financial relationships.

Consuming a higher percentage of calories from added sugars is linked with a higher prevalence of kidney stones, new research suggests.

Though added sugars have been linked with multiple poor health outcomes, their link with kidney stones has been unclear.

Added sugars are sugars or caloric sweeteners added to foods or drinks during processing or preparation to add flavor or shelf life. They do not include natural sugars such as lactose in milk and fructose in fruits.

Researchers, led by Shan Yin, a urologist at Affiliated Hospital of North Sichuan Medical College, in Nanchong, China, compared the added-sugar intake by quartiles in the U.S. National Health and Nutrition Examination Survey 2007-2018.

A total of 28,303 adults were included in this study, with an average age of 48. Women who consumed less than 600 or more than 3,500 kcal or men who consumed less than 800 or more than 4,200 kcal were excluded.

Researchers adjusted for factors including age, race, education, income, physical activity, and marital, employment, and smoking status.

Compared with the first quartile of percentage added-sugar calorie intake, the population in the fourth quartile, with the highest added sugar intake, had a higher prevalence of kidney stones (odds ratio, 1.39; 95% confidence interval, 1.17-1.65).

Compared with the group with fewer than 5% of calories from added sugar, the group that consumed at least 25% of calories from added sugar had nearly twice the prevalence of kidney stones (OR, 1.88; 95% CI, 1.52-2.32).

Findings were published online in Frontiers in Nutrition.

“By identifying this association, policymakers and health professionals can emphasize the need for public health initiatives to reduce added sugar consumption and promote healthy dietary habits,” the authors write.
 

Added sugar in the U.S. diet

Sugar-sweetened beverages such as soft drinks and energy and sports drinks account for 34.4% of added sugars in the American diet. Previous studies have shown the relationship between consuming sugar-sweetened beverages and a higher risk of obesity, diabetes, and cardiovascular disease, diseases that often co-occur with kidney stones.

Researchers note that even though most added sugars in the United States come from sugar-sweetened beverages, it’s unclear whether the association between added sugars and kidney stones is caused by the beverages or other sources. For instance, fructose intake has been found to be independently associated with kidney stones.

How much is too much?

The recommended upper limit on added sugar is controversial and varies widely by health organization. The American Heart Association says daily average intake from added sugars should be no more than 150 kcal for adult males (about 9 teaspoons) and no more than 100 kcal for women (about 6 teaspoons). The Institute of Medicine allows up to 25% of calories to be consumed from added sugars. The 2020 Dietary Guidelines for Americans and World Health Organization set 10% of calories as the recommended upper limit.

Further investigating what causes kidney stones is critical as kidney stones are common worldwide, affecting about 1 in 10 people in the United States alone, and occurrence is increasing. Kidney stones have a high recurrence rate – about half of people who get them have a second episode within 10 years, the authors note.

The researchers acknowledge that because participants self-reported food intake, there is the potential for recall bias. Additionally, because of the cross-sectional design, the researchers were not able to determine whether sugar intake or kidney stone occurrence came first.

This work was supported by the Doctoral Fund Project of North Sichuan Medical College. The authors declare no relevant financial relationships.

TOPLINE:

A high parathyroid hormone (PTH) level was significantly associated with nonalcoholic fatty liver disease (NAFLD) and nonsignificantly associated with nonalcoholic steatohepatitis (NASH) in a meta-analysis.

METHODOLOGY:

• The researchers conducted a systematic review and meta-analysis of 12 case-control studies of patients with NAFLD/NASH and a comparison group without NAFLD/NASH.
• All studies had data on mean PTH levels in cases and controls.
• Pooled weighted mean difference (WMD) was calculated by combining WMDs of each study using a random-effects model.

TAKEAWAY:

• A meta-analysis of 10 studies with 1,051 patients with NAFLD and 1,510 controls revealed a significant association between high PTH level and NAFLD, with a pooled WMD of 5.479.
• A meta-analysis of four studies with 99 patients with NASH and 143 controls revealed a trend toward an association of high PTH level and NASH, with a pooled WMD of 11.995; statistical significance was not achieved owing to inadequate power.
• Both meta-analyses had high statistical heterogeneity (I² of 82.4% for NAFLD and 81.0% for NASH).

IN PRACTICE:

“These findings may have clinical implications as they may suggest that high PTH level could be another biochemical marker of presence of NAFLD and possibly NASH,” the researchers wrote.

SOURCE:

This study was led by Aunchalee Jaroenlapnopparat, MD, Mount Auburn Hospital/Beth Israel Lahey Health, Cambridge, Mass. It was published online in Diabetes & Metabolic Syndrome: Research & Reviews. The study had no funding.

LIMITATIONS:

This systematic review and meta-analysis included observational studies, which might not show a causal relationship owing to potential confounding effects. Both meta-analyses demonstrated high statistical heterogeneity, probably because of differences in study design, population, and quality among the included studies. The number of studies and participants in the NASH-related analysis were limited, which may have compromised the statistical power of the analysis.

DISCLOSURES:

The authors have no relevant conflicts of interest.

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

TOPLINE:

A high parathyroid hormone (PTH) level was significantly associated with nonalcoholic fatty liver disease (NAFLD) and nonsignificantly associated with nonalcoholic steatohepatitis (NASH) in a meta-analysis.

METHODOLOGY:

• The researchers conducted a systematic review and meta-analysis of 12 case-control studies of patients with NAFLD/NASH and a comparison group without NAFLD/NASH.
• All studies had data on mean PTH levels in cases and controls.
• Pooled weighted mean difference (WMD) was calculated by combining WMDs of each study using a random-effects model.

TAKEAWAY:

• A meta-analysis of 10 studies with 1,051 patients with NAFLD and 1,510 controls revealed a significant association between high PTH level and NAFLD, with a pooled WMD of 5.479.
• A meta-analysis of four studies with 99 patients with NASH and 143 controls revealed a trend toward an association of high PTH level and NASH, with a pooled WMD of 11.995; statistical significance was not achieved owing to inadequate power.
• Both meta-analyses had high statistical heterogeneity (I² of 82.4% for NAFLD and 81.0% for NASH).

IN PRACTICE:

“These findings may have clinical implications as they may suggest that high PTH level could be another biochemical marker of presence of NAFLD and possibly NASH,” the researchers wrote.

SOURCE:

This study was led by Aunchalee Jaroenlapnopparat, MD, Mount Auburn Hospital/Beth Israel Lahey Health, Cambridge, Mass. It was published online in Diabetes & Metabolic Syndrome: Research & Reviews. The study had no funding.

LIMITATIONS:

This systematic review and meta-analysis included observational studies, which might not show a causal relationship owing to potential confounding effects. Both meta-analyses demonstrated high statistical heterogeneity, probably because of differences in study design, population, and quality among the included studies. The number of studies and participants in the NASH-related analysis were limited, which may have compromised the statistical power of the analysis.

DISCLOSURES:

The authors have no relevant conflicts of interest.

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

TOPLINE:

A high parathyroid hormone (PTH) level was significantly associated with nonalcoholic fatty liver disease (NAFLD) and nonsignificantly associated with nonalcoholic steatohepatitis (NASH) in a meta-analysis.

METHODOLOGY:

• The researchers conducted a systematic review and meta-analysis of 12 case-control studies of patients with NAFLD/NASH and a comparison group without NAFLD/NASH.
• All studies had data on mean PTH levels in cases and controls.
• Pooled weighted mean difference (WMD) was calculated by combining WMDs of each study using a random-effects model.

TAKEAWAY:

• A meta-analysis of 10 studies with 1,051 patients with NAFLD and 1,510 controls revealed a significant association between high PTH level and NAFLD, with a pooled WMD of 5.479.
• A meta-analysis of four studies with 99 patients with NASH and 143 controls revealed a trend toward an association of high PTH level and NASH, with a pooled WMD of 11.995; statistical significance was not achieved owing to inadequate power.
• Both meta-analyses had high statistical heterogeneity (I² of 82.4% for NAFLD and 81.0% for NASH).

IN PRACTICE:

“These findings may have clinical implications as they may suggest that high PTH level could be another biochemical marker of presence of NAFLD and possibly NASH,” the researchers wrote.

SOURCE:

This study was led by Aunchalee Jaroenlapnopparat, MD, Mount Auburn Hospital/Beth Israel Lahey Health, Cambridge, Mass. It was published online in Diabetes & Metabolic Syndrome: Research & Reviews. The study had no funding.

LIMITATIONS:

This systematic review and meta-analysis included observational studies, which might not show a causal relationship owing to potential confounding effects. Both meta-analyses demonstrated high statistical heterogeneity, probably because of differences in study design, population, and quality among the included studies. The number of studies and participants in the NASH-related analysis were limited, which may have compromised the statistical power of the analysis.

DISCLOSURES:

The authors have no relevant conflicts of interest.

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

Medical students are taking more control over how and when they learn. It’s a practice propelled by the pandemic, but it started long before COVID shifted many traditional classrooms to virtual education.

New technologies, including online lectures and guided-lesson websites, along with alternative teaching methods, such as the flipped classroom model, in which med students complete before-class assignments and participate in group projects, are helping to train future physicians for their medical careers.

So though students may not be attending in-person lectures like they did in the past, proponents of online learning say the education students receive and the subsequent care they deliver remains the same.

The Association of American Medical Colleges’ most recent annual survey of 2nd-year medical students found that 25% “almost never” attended their in-person lectures in 2022. The figure has steadily improved since 2020 but mirrors what AAMC recorded in 2017.

“The pandemic may have exacerbated the trend, but it’s a long-standing issue,” said Katherine McOwen, senior director of educational and student affairs at AAMC. She said in an interview that she’s witnessed the pattern for 24 years in her work with medical schools.

“I know it sounds alarming that students aren’t attending lectures. But that doesn’t mean they’re not learning,” said Ahmed Ahmed, MD, MPP, MSc, a recent graduate of Harvard Medical School and now a resident at Brigham and Women’s Hospital, Boston.

Today’s generation of medical students grew up in the age of technology. They are comfortable in front of the screen, so it makes sense for them to learn certain aspects of medical sciences and public health in the same way, Dr. Ahmed told this news organization.

Dr. Ahmed said that at Harvard he participated in one or two case-based classes per week that followed a flipped classroom model, which allows students to study topics on their own before discussing in a lecture format as a group. “We had to come up with a diagnostic plan and walk through the case slide by slide,” he said. “It got us to think like a clinician.”

The flipped classroom allows students to study at their own pace using their preferred learning style, leading to more collaboration in the classroom and between students, according to a 2022 article on the “new standard in medical education” published in Trends in Anaesthesia & Critical Care.

Students use online education tools to complete pre-class assignments such as watching short videos, listening to podcasts, or reading journal articles. In-class time can then be used to cement and create connections through discussions, interactive exercises, group learning, and case studies, the article stated.

Benefits of the flipped classroom include student satisfaction, learner motivation, and faculty interest in learning new teaching methods, according to the article: “Students are performing at least as well as those who attended traditional lectures, while some studies in select health care settings show increased retention in flipped classroom settings.”

Another study on the flipped classroom, published in 2018 in BMC Medical Education found that the teaching method was superior to traditional classrooms for health professions education. Researchers focused specifically on flipped classrooms that provided prerecorded videos to students.

Molly Cooke, MD, director of education for global health sciences at the University of California, San Francisco, School of Medicine, said that the school no longer requires attendance at lectures. “Personally, my position is that medical students are very busy people and make, by and large, rational decisions about how to spend their time. As learning and retention from 50-minute lectures has been shown for decades to be poor, I think it’s perfectly reasonable to watch lectures on their own time.”

Dr. Ahmed agrees. “By our standards, the old model is archaic. It’s passive, and instead we should be encouraging lifelong, self-directed learning.”

To that end, Dr. Ahmed and his fellow students also relied heavily during medical school on secondary educational sources such as Boards and Beyond and Sketchy. “There’s an entire community of medical school students across the country using them,” Dr. Ahmed explained. “You can learn what you need in a tenth of the time of lectures.”

Today lectures only provide a portion of the information delivered to students, Dr. McGowen said. “They also learn in small groups, in problem-solving sessions, and in clinical experiences, all of which make up the meat of their education.”

The purpose of medical school is to prepare students for residency, she added. “Medical school education is very different from other types of education. Students are examined in a variety of ways before they move on to residency and ultimately, practice.”

For example, every student must pass the three-part United States Medical Licensing Examination. Students complete the first two parts in medical school and the third part during residency. “The tests represent a combination of everything students have learned, from lectures, clinical time, and in self-directed learning,” Dr. McGowen said.

Post pandemic, the tools and styles of learning in medical education have changed, and they are likely to continue to evolve along with students and technology, according to the 2022 article on the flipped classroom. “The future of medical education will continue to move in ways that embrace digital technology, as this is what digital native learners are increasingly expecting for their health care education,” states the article.

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

Medical students are taking more control over how and when they learn. It’s a practice propelled by the pandemic, but it started long before COVID shifted many traditional classrooms to virtual education.

New technologies, including online lectures and guided-lesson websites, along with alternative teaching methods, such as the flipped classroom model, in which med students complete before-class assignments and participate in group projects, are helping to train future physicians for their medical careers.

So though students may not be attending in-person lectures like they did in the past, proponents of online learning say the education students receive and the subsequent care they deliver remains the same.

The Association of American Medical Colleges’ most recent annual survey of 2nd-year medical students found that 25% “almost never” attended their in-person lectures in 2022. The figure has steadily improved since 2020 but mirrors what AAMC recorded in 2017.

“The pandemic may have exacerbated the trend, but it’s a long-standing issue,” said Katherine McOwen, senior director of educational and student affairs at AAMC. She said in an interview that she’s witnessed the pattern for 24 years in her work with medical schools.

“I know it sounds alarming that students aren’t attending lectures. But that doesn’t mean they’re not learning,” said Ahmed Ahmed, MD, MPP, MSc, a recent graduate of Harvard Medical School and now a resident at Brigham and Women’s Hospital, Boston.

Today’s generation of medical students grew up in the age of technology. They are comfortable in front of the screen, so it makes sense for them to learn certain aspects of medical sciences and public health in the same way, Dr. Ahmed told this news organization.

Dr. Ahmed said that at Harvard he participated in one or two case-based classes per week that followed a flipped classroom model, which allows students to study topics on their own before discussing in a lecture format as a group. “We had to come up with a diagnostic plan and walk through the case slide by slide,” he said. “It got us to think like a clinician.”

The flipped classroom allows students to study at their own pace using their preferred learning style, leading to more collaboration in the classroom and between students, according to a 2022 article on the “new standard in medical education” published in Trends in Anaesthesia & Critical Care.

Students use online education tools to complete pre-class assignments such as watching short videos, listening to podcasts, or reading journal articles. In-class time can then be used to cement and create connections through discussions, interactive exercises, group learning, and case studies, the article stated.

Benefits of the flipped classroom include student satisfaction, learner motivation, and faculty interest in learning new teaching methods, according to the article: “Students are performing at least as well as those who attended traditional lectures, while some studies in select health care settings show increased retention in flipped classroom settings.”

Another study on the flipped classroom, published in 2018 in BMC Medical Education found that the teaching method was superior to traditional classrooms for health professions education. Researchers focused specifically on flipped classrooms that provided prerecorded videos to students.

Molly Cooke, MD, director of education for global health sciences at the University of California, San Francisco, School of Medicine, said that the school no longer requires attendance at lectures. “Personally, my position is that medical students are very busy people and make, by and large, rational decisions about how to spend their time. As learning and retention from 50-minute lectures has been shown for decades to be poor, I think it’s perfectly reasonable to watch lectures on their own time.”

Dr. Ahmed agrees. “By our standards, the old model is archaic. It’s passive, and instead we should be encouraging lifelong, self-directed learning.”

To that end, Dr. Ahmed and his fellow students also relied heavily during medical school on secondary educational sources such as Boards and Beyond and Sketchy. “There’s an entire community of medical school students across the country using them,” Dr. Ahmed explained. “You can learn what you need in a tenth of the time of lectures.”

Today lectures only provide a portion of the information delivered to students, Dr. McGowen said. “They also learn in small groups, in problem-solving sessions, and in clinical experiences, all of which make up the meat of their education.”

The purpose of medical school is to prepare students for residency, she added. “Medical school education is very different from other types of education. Students are examined in a variety of ways before they move on to residency and ultimately, practice.”

For example, every student must pass the three-part United States Medical Licensing Examination. Students complete the first two parts in medical school and the third part during residency. “The tests represent a combination of everything students have learned, from lectures, clinical time, and in self-directed learning,” Dr. McGowen said.

Post pandemic, the tools and styles of learning in medical education have changed, and they are likely to continue to evolve along with students and technology, according to the 2022 article on the flipped classroom. “The future of medical education will continue to move in ways that embrace digital technology, as this is what digital native learners are increasingly expecting for their health care education,” states the article.

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

Medical students are taking more control over how and when they learn. It’s a practice propelled by the pandemic, but it started long before COVID shifted many traditional classrooms to virtual education.

New technologies, including online lectures and guided-lesson websites, along with alternative teaching methods, such as the flipped classroom model, in which med students complete before-class assignments and participate in group projects, are helping to train future physicians for their medical careers.

So though students may not be attending in-person lectures like they did in the past, proponents of online learning say the education students receive and the subsequent care they deliver remains the same.

The Association of American Medical Colleges’ most recent annual survey of 2nd-year medical students found that 25% “almost never” attended their in-person lectures in 2022. The figure has steadily improved since 2020 but mirrors what AAMC recorded in 2017.

“The pandemic may have exacerbated the trend, but it’s a long-standing issue,” said Katherine McOwen, senior director of educational and student affairs at AAMC. She said in an interview that she’s witnessed the pattern for 24 years in her work with medical schools.

“I know it sounds alarming that students aren’t attending lectures. But that doesn’t mean they’re not learning,” said Ahmed Ahmed, MD, MPP, MSc, a recent graduate of Harvard Medical School and now a resident at Brigham and Women’s Hospital, Boston.

Today’s generation of medical students grew up in the age of technology. They are comfortable in front of the screen, so it makes sense for them to learn certain aspects of medical sciences and public health in the same way, Dr. Ahmed told this news organization.

Dr. Ahmed said that at Harvard he participated in one or two case-based classes per week that followed a flipped classroom model, which allows students to study topics on their own before discussing in a lecture format as a group. “We had to come up with a diagnostic plan and walk through the case slide by slide,” he said. “It got us to think like a clinician.”

The flipped classroom allows students to study at their own pace using their preferred learning style, leading to more collaboration in the classroom and between students, according to a 2022 article on the “new standard in medical education” published in Trends in Anaesthesia & Critical Care.

Students use online education tools to complete pre-class assignments such as watching short videos, listening to podcasts, or reading journal articles. In-class time can then be used to cement and create connections through discussions, interactive exercises, group learning, and case studies, the article stated.

Benefits of the flipped classroom include student satisfaction, learner motivation, and faculty interest in learning new teaching methods, according to the article: “Students are performing at least as well as those who attended traditional lectures, while some studies in select health care settings show increased retention in flipped classroom settings.”

Another study on the flipped classroom, published in 2018 in BMC Medical Education found that the teaching method was superior to traditional classrooms for health professions education. Researchers focused specifically on flipped classrooms that provided prerecorded videos to students.

Molly Cooke, MD, director of education for global health sciences at the University of California, San Francisco, School of Medicine, said that the school no longer requires attendance at lectures. “Personally, my position is that medical students are very busy people and make, by and large, rational decisions about how to spend their time. As learning and retention from 50-minute lectures has been shown for decades to be poor, I think it’s perfectly reasonable to watch lectures on their own time.”

Dr. Ahmed agrees. “By our standards, the old model is archaic. It’s passive, and instead we should be encouraging lifelong, self-directed learning.”

To that end, Dr. Ahmed and his fellow students also relied heavily during medical school on secondary educational sources such as Boards and Beyond and Sketchy. “There’s an entire community of medical school students across the country using them,” Dr. Ahmed explained. “You can learn what you need in a tenth of the time of lectures.”

Today lectures only provide a portion of the information delivered to students, Dr. McGowen said. “They also learn in small groups, in problem-solving sessions, and in clinical experiences, all of which make up the meat of their education.”

The purpose of medical school is to prepare students for residency, she added. “Medical school education is very different from other types of education. Students are examined in a variety of ways before they move on to residency and ultimately, practice.”

For example, every student must pass the three-part United States Medical Licensing Examination. Students complete the first two parts in medical school and the third part during residency. “The tests represent a combination of everything students have learned, from lectures, clinical time, and in self-directed learning,” Dr. McGowen said.

Post pandemic, the tools and styles of learning in medical education have changed, and they are likely to continue to evolve along with students and technology, according to the 2022 article on the flipped classroom. “The future of medical education will continue to move in ways that embrace digital technology, as this is what digital native learners are increasingly expecting for their health care education,” states the article.

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

To the Editor:

Micrographic surgery and dermatologic oncology (MSDO) is a highly competitive subspecialty fellowship in dermatology. Prospective applicants often depend on the Internet to obtain pertinent information about fellowship programs to navigate the application process. An up-to-date and comprehensive fellowship website has the potential to be advantageous for both applicants and programs—applicants can more readily identify programs that align with their goals and values, and programs can effectively attract compatible applicants. These advantages are increasingly relevant with the virtual application process that has become essential considering the COVID-19 pandemic. At the height of the COVID-19 pandemic in 2020, we sought to evaluate the comprehensiveness of the content of Accreditation Council for Graduate Medical Education (ACGME) MSDO fellowship program websites to identify possible areas for improvement.

We obtained a list of all ACGME MSDO fellowships from the ACGME website (https://www.acgme.org/) and verified it against the list of MSDO programs in FREIDA, the American Medical Association residency and fellowship database (https://freida.ama-assn.org/). All programs without a website were excluded from further analysis. All data collection from currently accessible fellowship websites and evaluation occurred in April 2020.

The remaining MSDO fellowship program websites were evaluated using 25 criteria distributed among 5 domains: education/research, clinical training, program information, application process, and incentives. These criteria were determined based on earlier studies that similarly evaluated the website content of fellowship programs with inclusion of information that was considered valuable in the appraisal of fellowship programs.^1,2 Criteria were further refined by direct consideration of relevance and importance to MSDO fellowship applicants (eg, inclusion of case volume, exclusion of call schedule).

Each criterion was independently assessed by 2 investigators (J.Y.C. and S.J.E.S.). A third investigator (J.R.P.) then independently evaluated those 2 assessments for agreement. Where disagreement was discovered, the third evaluator (J.R.P.) provided a final appraisal. Cohen’s kappa (κ) was conducted to evaluate for concordance between the 2 primary website evaluators. We found there to be substantial agreement between the reviewers within the education/research (κ [SD]=0.772 [0.077]), clinical training (κ [SD]=0.740 [0.051]), application process (κ [SD]=0.726 [0.103]), and incentives domains (κ [SD]=0.730 [0.110]). There was moderate agreement (κ [SD]=0.603 [0.128]) between the reviewers within the program information domain.

We identified 77 active MSDO fellowship programs. Sixty of those 77 programs (77.9%) had a dedicated fellowship website that was readily accessible. Most programs that had a dedicated fellowship website had a core or affiliated residency program (49/60 [81.7%]).

Websites that we evaluated fulfilled a mean (SD) of 9.37 (4.17) of the 25 identified criteria. Only 13 of 60 (21.7%) websites fulfilled more than 50% of evaluated criteria.

There was no statistical difference in the number of criteria fulfilled based on whether the fellowship program had a core or affiliated residency program.

Upon reviewing website accessibility directly from FREIDA, only 5 of 60 programs (8.3%) provided applicants with a link directly to their fellowship page (Table). Most programs (41 [68.3%]) provided a link to the dermatology department website, not to the specific fellowship program page, thus requiring a multistep process to find the fellowship-specific page. The remaining programs had an inaccessible (4 [6.7%]) or absent (10 [16.7%]) link on FREIDA, though a fellowship website could be identified by an Internet search of the program name.

The domain most fulfilled was program information with an average of 51.1% of programs satisfying the criteria, whereas the incentives domain was least fulfilled with an average of only 20.8% of programs satisfying the criteria. Across the various criteria, websites more often included a description of the program (58 [96.6%]), mentioned accreditation (53 [88.3%]), and provided case descriptions (48 [80.0%]). They less often reported information regarding a fellow’s call responsibility (3 [5%]); evaluation criteria (5 [8.3%]); and rotation schedule or options (6 [10.0%]).

The highest number of criteria fulfilled by a single program was 19 (76%). The lowest number of criteria met was 2 (8%). These findings suggest a large variation in comprehensiveness across fellowship websites.

Our research suggests that many current MSDO fellowship programs have room to maximize the information provided to applicants through their websites, which is particularly relevant following the COVID-19 pandemic, as the value of providing comprehensive and transparent information through an online platform is greater than ever. Given the ongoing desire to limit travel, virtual methods for navigating the application process have been readily used, including online videoconferencing for interviews and virtual program visits. This scenario has placed applicants in a challenging situation—their ability to directly evaluate their compatibility with a given program has been limited.³

Earlier studies that analyzed rheumatology fellowship recruitment during the COVID-19 pandemic found that programs may have more difficulty highlighting the strengths of their institution (eg, clinical facilities, professional opportunities, educational environment).⁴ An updated and comprehensive fellowship website was recommended⁴ as a key part in facing these new challenges. On the other hand, given the large number of applicants each year for fellowship positions in any given program, we acknowledge the potential benefit programs may obtain from limiting electronic information that is readily accessible to all applicants, as doing so may encourage applicants to communicate directly with a program and allow programs to identify candidates who are more interested.

In light of the movement to a more virtual-friendly and technology-driven fellowship application process, we identified 25 content areas that fellowships may want to include on their websites so that potential applicants can be well informed about the program before submitting an application and scheduling an interview. Efforts to improve accessibility and maximize the content of these websites may help programs attract compatible candidates, improve transparency, and guide applicants throughout the application process.

To the Editor:

Micrographic surgery and dermatologic oncology (MSDO) is a highly competitive subspecialty fellowship in dermatology. Prospective applicants often depend on the Internet to obtain pertinent information about fellowship programs to navigate the application process. An up-to-date and comprehensive fellowship website has the potential to be advantageous for both applicants and programs—applicants can more readily identify programs that align with their goals and values, and programs can effectively attract compatible applicants. These advantages are increasingly relevant with the virtual application process that has become essential considering the COVID-19 pandemic. At the height of the COVID-19 pandemic in 2020, we sought to evaluate the comprehensiveness of the content of Accreditation Council for Graduate Medical Education (ACGME) MSDO fellowship program websites to identify possible areas for improvement.

We obtained a list of all ACGME MSDO fellowships from the ACGME website (https://www.acgme.org/) and verified it against the list of MSDO programs in FREIDA, the American Medical Association residency and fellowship database (https://freida.ama-assn.org/). All programs without a website were excluded from further analysis. All data collection from currently accessible fellowship websites and evaluation occurred in April 2020.

The remaining MSDO fellowship program websites were evaluated using 25 criteria distributed among 5 domains: education/research, clinical training, program information, application process, and incentives. These criteria were determined based on earlier studies that similarly evaluated the website content of fellowship programs with inclusion of information that was considered valuable in the appraisal of fellowship programs.^1,2 Criteria were further refined by direct consideration of relevance and importance to MSDO fellowship applicants (eg, inclusion of case volume, exclusion of call schedule).

Each criterion was independently assessed by 2 investigators (J.Y.C. and S.J.E.S.). A third investigator (J.R.P.) then independently evaluated those 2 assessments for agreement. Where disagreement was discovered, the third evaluator (J.R.P.) provided a final appraisal. Cohen’s kappa (κ) was conducted to evaluate for concordance between the 2 primary website evaluators. We found there to be substantial agreement between the reviewers within the education/research (κ [SD]=0.772 [0.077]), clinical training (κ [SD]=0.740 [0.051]), application process (κ [SD]=0.726 [0.103]), and incentives domains (κ [SD]=0.730 [0.110]). There was moderate agreement (κ [SD]=0.603 [0.128]) between the reviewers within the program information domain.

We identified 77 active MSDO fellowship programs. Sixty of those 77 programs (77.9%) had a dedicated fellowship website that was readily accessible. Most programs that had a dedicated fellowship website had a core or affiliated residency program (49/60 [81.7%]).

Websites that we evaluated fulfilled a mean (SD) of 9.37 (4.17) of the 25 identified criteria. Only 13 of 60 (21.7%) websites fulfilled more than 50% of evaluated criteria.

There was no statistical difference in the number of criteria fulfilled based on whether the fellowship program had a core or affiliated residency program.

Upon reviewing website accessibility directly from FREIDA, only 5 of 60 programs (8.3%) provided applicants with a link directly to their fellowship page (Table). Most programs (41 [68.3%]) provided a link to the dermatology department website, not to the specific fellowship program page, thus requiring a multistep process to find the fellowship-specific page. The remaining programs had an inaccessible (4 [6.7%]) or absent (10 [16.7%]) link on FREIDA, though a fellowship website could be identified by an Internet search of the program name.

The domain most fulfilled was program information with an average of 51.1% of programs satisfying the criteria, whereas the incentives domain was least fulfilled with an average of only 20.8% of programs satisfying the criteria. Across the various criteria, websites more often included a description of the program (58 [96.6%]), mentioned accreditation (53 [88.3%]), and provided case descriptions (48 [80.0%]). They less often reported information regarding a fellow’s call responsibility (3 [5%]); evaluation criteria (5 [8.3%]); and rotation schedule or options (6 [10.0%]).

The highest number of criteria fulfilled by a single program was 19 (76%). The lowest number of criteria met was 2 (8%). These findings suggest a large variation in comprehensiveness across fellowship websites.

Our research suggests that many current MSDO fellowship programs have room to maximize the information provided to applicants through their websites, which is particularly relevant following the COVID-19 pandemic, as the value of providing comprehensive and transparent information through an online platform is greater than ever. Given the ongoing desire to limit travel, virtual methods for navigating the application process have been readily used, including online videoconferencing for interviews and virtual program visits. This scenario has placed applicants in a challenging situation—their ability to directly evaluate their compatibility with a given program has been limited.³

Earlier studies that analyzed rheumatology fellowship recruitment during the COVID-19 pandemic found that programs may have more difficulty highlighting the strengths of their institution (eg, clinical facilities, professional opportunities, educational environment).⁴ An updated and comprehensive fellowship website was recommended⁴ as a key part in facing these new challenges. On the other hand, given the large number of applicants each year for fellowship positions in any given program, we acknowledge the potential benefit programs may obtain from limiting electronic information that is readily accessible to all applicants, as doing so may encourage applicants to communicate directly with a program and allow programs to identify candidates who are more interested.

In light of the movement to a more virtual-friendly and technology-driven fellowship application process, we identified 25 content areas that fellowships may want to include on their websites so that potential applicants can be well informed about the program before submitting an application and scheduling an interview. Efforts to improve accessibility and maximize the content of these websites may help programs attract compatible candidates, improve transparency, and guide applicants throughout the application process.

To the Editor:

Micrographic surgery and dermatologic oncology (MSDO) is a highly competitive subspecialty fellowship in dermatology. Prospective applicants often depend on the Internet to obtain pertinent information about fellowship programs to navigate the application process. An up-to-date and comprehensive fellowship website has the potential to be advantageous for both applicants and programs—applicants can more readily identify programs that align with their goals and values, and programs can effectively attract compatible applicants. These advantages are increasingly relevant with the virtual application process that has become essential considering the COVID-19 pandemic. At the height of the COVID-19 pandemic in 2020, we sought to evaluate the comprehensiveness of the content of Accreditation Council for Graduate Medical Education (ACGME) MSDO fellowship program websites to identify possible areas for improvement.

We obtained a list of all ACGME MSDO fellowships from the ACGME website (https://www.acgme.org/) and verified it against the list of MSDO programs in FREIDA, the American Medical Association residency and fellowship database (https://freida.ama-assn.org/). All programs without a website were excluded from further analysis. All data collection from currently accessible fellowship websites and evaluation occurred in April 2020.

The remaining MSDO fellowship program websites were evaluated using 25 criteria distributed among 5 domains: education/research, clinical training, program information, application process, and incentives. These criteria were determined based on earlier studies that similarly evaluated the website content of fellowship programs with inclusion of information that was considered valuable in the appraisal of fellowship programs.^1,2 Criteria were further refined by direct consideration of relevance and importance to MSDO fellowship applicants (eg, inclusion of case volume, exclusion of call schedule).

Each criterion was independently assessed by 2 investigators (J.Y.C. and S.J.E.S.). A third investigator (J.R.P.) then independently evaluated those 2 assessments for agreement. Where disagreement was discovered, the third evaluator (J.R.P.) provided a final appraisal. Cohen’s kappa (κ) was conducted to evaluate for concordance between the 2 primary website evaluators. We found there to be substantial agreement between the reviewers within the education/research (κ [SD]=0.772 [0.077]), clinical training (κ [SD]=0.740 [0.051]), application process (κ [SD]=0.726 [0.103]), and incentives domains (κ [SD]=0.730 [0.110]). There was moderate agreement (κ [SD]=0.603 [0.128]) between the reviewers within the program information domain.

We identified 77 active MSDO fellowship programs. Sixty of those 77 programs (77.9%) had a dedicated fellowship website that was readily accessible. Most programs that had a dedicated fellowship website had a core or affiliated residency program (49/60 [81.7%]).

Websites that we evaluated fulfilled a mean (SD) of 9.37 (4.17) of the 25 identified criteria. Only 13 of 60 (21.7%) websites fulfilled more than 50% of evaluated criteria.

There was no statistical difference in the number of criteria fulfilled based on whether the fellowship program had a core or affiliated residency program.

Upon reviewing website accessibility directly from FREIDA, only 5 of 60 programs (8.3%) provided applicants with a link directly to their fellowship page (Table). Most programs (41 [68.3%]) provided a link to the dermatology department website, not to the specific fellowship program page, thus requiring a multistep process to find the fellowship-specific page. The remaining programs had an inaccessible (4 [6.7%]) or absent (10 [16.7%]) link on FREIDA, though a fellowship website could be identified by an Internet search of the program name.

The domain most fulfilled was program information with an average of 51.1% of programs satisfying the criteria, whereas the incentives domain was least fulfilled with an average of only 20.8% of programs satisfying the criteria. Across the various criteria, websites more often included a description of the program (58 [96.6%]), mentioned accreditation (53 [88.3%]), and provided case descriptions (48 [80.0%]). They less often reported information regarding a fellow’s call responsibility (3 [5%]); evaluation criteria (5 [8.3%]); and rotation schedule or options (6 [10.0%]).

The highest number of criteria fulfilled by a single program was 19 (76%). The lowest number of criteria met was 2 (8%). These findings suggest a large variation in comprehensiveness across fellowship websites.

Our research suggests that many current MSDO fellowship programs have room to maximize the information provided to applicants through their websites, which is particularly relevant following the COVID-19 pandemic, as the value of providing comprehensive and transparent information through an online platform is greater than ever. Given the ongoing desire to limit travel, virtual methods for navigating the application process have been readily used, including online videoconferencing for interviews and virtual program visits. This scenario has placed applicants in a challenging situation—their ability to directly evaluate their compatibility with a given program has been limited.³

Earlier studies that analyzed rheumatology fellowship recruitment during the COVID-19 pandemic found that programs may have more difficulty highlighting the strengths of their institution (eg, clinical facilities, professional opportunities, educational environment).⁴ An updated and comprehensive fellowship website was recommended⁴ as a key part in facing these new challenges. On the other hand, given the large number of applicants each year for fellowship positions in any given program, we acknowledge the potential benefit programs may obtain from limiting electronic information that is readily accessible to all applicants, as doing so may encourage applicants to communicate directly with a program and allow programs to identify candidates who are more interested.

In light of the movement to a more virtual-friendly and technology-driven fellowship application process, we identified 25 content areas that fellowships may want to include on their websites so that potential applicants can be well informed about the program before submitting an application and scheduling an interview. Efforts to improve accessibility and maximize the content of these websites may help programs attract compatible candidates, improve transparency, and guide applicants throughout the application process.

TOPLINE:

A dramatic increase in cancer diagnoses following Medicaid expansion in Ohio suggests that expanding the program improves access to cancer care.

METHODOLOGY:

• To assess the impact of Medicaid expansion on cancer diagnosis, investigators compared the volume of patients with newly diagnosed cancer in Ohio, which expanded its Medicaid coverage in 2014, with that of Georgia, which did not.
• State cancer registries were queried from 2010 to 2017 to identify adults younger than 64 years with incident female breast cancer, cervical cancer, or colorectal cancer (CRC).

TAKEAWAY:

• In Ohio, researchers found a substantial increase in diagnoses for all three cancers among Medicaid patients after expansion. The increase ranged from 42% for breast cancer to 77% for CRC.
• In Georgia, fewer Medicaid patients were diagnosed with breast cancer in the postexpansion period. There were also smaller increases in the number of patients diagnosed with cervical cancer (6%) and CRC (13%), compared with the postexpansion increases seen in Ohio.
• The risk of being diagnosed with late-stage breast cancer fell 7% among Medicaid patients in Ohio after expansion.
• The risk of being diagnosed with late-stage CRC fell 6% among Medicaid patients in George and Ohio. The Georgia results are potentially attributable to increases in state and local screening programs, especially in rural areas.

IN PRACTICE:

“These starkly different patterns in changes in the number of diagnosed [breast cancer], [cervical cancer], and CRC cases among patients on Medicaid in Ohio versus Georgia in the postexpansion period suggest that expanding insurance coverage might have effectively improved access to care,” the authors wrote.

SOURCE:

The study, led by Kirsten Eom, PhD, of the MetroHealth Population Health Research Institute, Cleveland, was published online in Cancer.

LIMITATIONS:

• Medicaid status was determined at diagnosis; past studies have associated being enrolled in Medicaid at the time of cancer diagnosis, rather than before, with late‐stage disease.
• The team could not assess the effectiveness of state and local cancer screening programs in preventing late-stage cancer.

DISCLOSURES:

• The study was funded by the Ohio Department of Health and the Georgia Department of Public Health.
• One researcher reported a grant from Celgene.

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

TOPLINE:

A dramatic increase in cancer diagnoses following Medicaid expansion in Ohio suggests that expanding the program improves access to cancer care.

METHODOLOGY:

• To assess the impact of Medicaid expansion on cancer diagnosis, investigators compared the volume of patients with newly diagnosed cancer in Ohio, which expanded its Medicaid coverage in 2014, with that of Georgia, which did not.
• State cancer registries were queried from 2010 to 2017 to identify adults younger than 64 years with incident female breast cancer, cervical cancer, or colorectal cancer (CRC).

TAKEAWAY:

• In Ohio, researchers found a substantial increase in diagnoses for all three cancers among Medicaid patients after expansion. The increase ranged from 42% for breast cancer to 77% for CRC.
• In Georgia, fewer Medicaid patients were diagnosed with breast cancer in the postexpansion period. There were also smaller increases in the number of patients diagnosed with cervical cancer (6%) and CRC (13%), compared with the postexpansion increases seen in Ohio.
• The risk of being diagnosed with late-stage breast cancer fell 7% among Medicaid patients in Ohio after expansion.
• The risk of being diagnosed with late-stage CRC fell 6% among Medicaid patients in George and Ohio. The Georgia results are potentially attributable to increases in state and local screening programs, especially in rural areas.

IN PRACTICE:

“These starkly different patterns in changes in the number of diagnosed [breast cancer], [cervical cancer], and CRC cases among patients on Medicaid in Ohio versus Georgia in the postexpansion period suggest that expanding insurance coverage might have effectively improved access to care,” the authors wrote.

SOURCE:

The study, led by Kirsten Eom, PhD, of the MetroHealth Population Health Research Institute, Cleveland, was published online in Cancer.

LIMITATIONS:

• Medicaid status was determined at diagnosis; past studies have associated being enrolled in Medicaid at the time of cancer diagnosis, rather than before, with late‐stage disease.
• The team could not assess the effectiveness of state and local cancer screening programs in preventing late-stage cancer.

DISCLOSURES:

• The study was funded by the Ohio Department of Health and the Georgia Department of Public Health.
• One researcher reported a grant from Celgene.

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

TOPLINE:

A dramatic increase in cancer diagnoses following Medicaid expansion in Ohio suggests that expanding the program improves access to cancer care.

METHODOLOGY:

• To assess the impact of Medicaid expansion on cancer diagnosis, investigators compared the volume of patients with newly diagnosed cancer in Ohio, which expanded its Medicaid coverage in 2014, with that of Georgia, which did not.
• State cancer registries were queried from 2010 to 2017 to identify adults younger than 64 years with incident female breast cancer, cervical cancer, or colorectal cancer (CRC).

TAKEAWAY:

• In Ohio, researchers found a substantial increase in diagnoses for all three cancers among Medicaid patients after expansion. The increase ranged from 42% for breast cancer to 77% for CRC.
• In Georgia, fewer Medicaid patients were diagnosed with breast cancer in the postexpansion period. There were also smaller increases in the number of patients diagnosed with cervical cancer (6%) and CRC (13%), compared with the postexpansion increases seen in Ohio.
• The risk of being diagnosed with late-stage breast cancer fell 7% among Medicaid patients in Ohio after expansion.
• The risk of being diagnosed with late-stage CRC fell 6% among Medicaid patients in George and Ohio. The Georgia results are potentially attributable to increases in state and local screening programs, especially in rural areas.

IN PRACTICE:

“These starkly different patterns in changes in the number of diagnosed [breast cancer], [cervical cancer], and CRC cases among patients on Medicaid in Ohio versus Georgia in the postexpansion period suggest that expanding insurance coverage might have effectively improved access to care,” the authors wrote.

SOURCE:

The study, led by Kirsten Eom, PhD, of the MetroHealth Population Health Research Institute, Cleveland, was published online in Cancer.

LIMITATIONS:

• Medicaid status was determined at diagnosis; past studies have associated being enrolled in Medicaid at the time of cancer diagnosis, rather than before, with late‐stage disease.
• The team could not assess the effectiveness of state and local cancer screening programs in preventing late-stage cancer.

DISCLOSURES:

• The study was funded by the Ohio Department of Health and the Georgia Department of Public Health.
• One researcher reported a grant from Celgene.

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

The Cleveland Clinic is once again the No. 1 hospital for cardiology and heart surgery, according to U.S. News & World Report’s latest rankings.
 

In the magazine’s 2023-2024 list, Cedars-Sinai Medical Center, Los Angeles, takes over the No. 2 spot from Mayo Clinic, Rochester, Minn., which dropped to No. 3. Cedars-Sinai held the No. 3 on the 2022-2023 rankings.

Mount Sinai Hospital in New York City holds the No. 4 spot in 2023-2024, up from No. 6; NYU Langone Hospitals, New York, continue to hold the No. 5 spot.

New York–Presbyterian Hospital–Columbia and Cornell in New York City is No. 6, down from No. 4 i.

Northwestern Medicine-Northwestern Memorial Hospital in Chicago takes over the No. 7 spot (up from No. 8), while Massachusetts General Hospital in Boston holds the No. 8 (down from No. 7).

Stanford (Calif.) Health Care–Stanford Hospital holds the No. 9 spot, the same as 2, and Lenox Hill Hospital at Northwell Health in New York is No. 10 on the list.

U.S. News evaluated 779 hospitals and ranked the top 50 that care for patients with challenging heart and vascular cases, including heart transplants; implantation of cardiac devices, such as pacemakers and defibrillators; major chest procedures and patients with cardiovascular disease and other complex conditions, such as endocarditis; and heart failure and circulatory issues.

“Consumers want useful resources to help them assess which hospital can best meet their specific care needs,” Ben Harder, chief of health analysis and managing editor at U.S. News, said in a statement.

“The 2023-2024 Best Hospitals rankings offer patients and the physicians with whom they consult a data-driven source for comparing performance in outcomes, patient satisfaction, and other metrics that matter to them,” Mr. Harder said.
 

Best hospitals overall honor roll

In 2023-2024, as in prior years, U.S. News also recognized Honor Roll hospitals that have excelled across multiple areas of care. However, in 2023-2024, for the first time, there is no ordinal ranking of hospitals making honor roll.

In a letter to hospital leaders, U.S. News explained that the major change in format came after months of deliberation, feedback from health care organizations and professionals, and an analysis of how consumers navigate their website.

Ordinal ranking of hospitals that make the honor roll “obscures the fact that all of the Honor Roll hospitals have attained the highest standard of care in the nation,” the letter reads.

With the new format, honor roll hospitals are listed in alphabetical order. In 2023-2024, there are 22.

• Barnes-Jewish Hospital, St. Louis
• Brigham and Women’s Hospital, Boston
• Cedars-Sinai Medical Center, Los Angeles
• Cleveland Clinic
• Hospitals of the University of Pennsylvania–Penn Medicine, Philadelphia
• Houston Methodist Hospital
• Johns Hopkins Hospital, Baltimore
• Massachusetts General Hospital, Boston
• Mayo Clinic, Rochester, Minn.
• Mount Sinai Hospital, New York
• New York–Presbyterian Hospital–Columbia and Cornell
• North Shore University Hospital at Northwell Health, Manhasset, N.Y.
• Northwestern Memorial Hospital, Chicago
• NYU Langone Hospitals, New York
• Rush University Medical Center, Chicago
• Stanford (Calif.) Health Care–Stanford Hospital
• UC San Diego Health–La Jolla (Calif.) and Hillcrest Hospitals
• UCLA Medical Center, Los Angeles
• UCSF Health–UCSF Medical Center, San Francisco
• University of Michigan Health, Ann Arbor
• UT Southwestern Medical Center, Dallas
• Vanderbilt University Medical Center, Nashville, Tenn.

According to U.S. News, to keep pace with consumers’ needs and the ever-evolving landscape of health care, “several refinements” are reflected in the latest best hospitals rankings.

These include the introduction of outpatient outcomes in key specialty rankings and surgical ratings, the expanded inclusion of other outpatient data, an increased weight on objective quality measures, and a reduced weight on expert opinion.

In addition, hospital profiles on the U.S. News website feature refined health equity measures, including a new measure of racial disparities in outcomes.

The full report for best hospitals, best specialty hospitals, and methodology is available online.

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

The Cleveland Clinic is once again the No. 1 hospital for cardiology and heart surgery, according to U.S. News & World Report’s latest rankings.
 

In the magazine’s 2023-2024 list, Cedars-Sinai Medical Center, Los Angeles, takes over the No. 2 spot from Mayo Clinic, Rochester, Minn., which dropped to No. 3. Cedars-Sinai held the No. 3 on the 2022-2023 rankings.

Mount Sinai Hospital in New York City holds the No. 4 spot in 2023-2024, up from No. 6; NYU Langone Hospitals, New York, continue to hold the No. 5 spot.

New York–Presbyterian Hospital–Columbia and Cornell in New York City is No. 6, down from No. 4 i.

Northwestern Medicine-Northwestern Memorial Hospital in Chicago takes over the No. 7 spot (up from No. 8), while Massachusetts General Hospital in Boston holds the No. 8 (down from No. 7).

Stanford (Calif.) Health Care–Stanford Hospital holds the No. 9 spot, the same as 2, and Lenox Hill Hospital at Northwell Health in New York is No. 10 on the list.

U.S. News evaluated 779 hospitals and ranked the top 50 that care for patients with challenging heart and vascular cases, including heart transplants; implantation of cardiac devices, such as pacemakers and defibrillators; major chest procedures and patients with cardiovascular disease and other complex conditions, such as endocarditis; and heart failure and circulatory issues.

“Consumers want useful resources to help them assess which hospital can best meet their specific care needs,” Ben Harder, chief of health analysis and managing editor at U.S. News, said in a statement.

“The 2023-2024 Best Hospitals rankings offer patients and the physicians with whom they consult a data-driven source for comparing performance in outcomes, patient satisfaction, and other metrics that matter to them,” Mr. Harder said.
 

Best hospitals overall honor roll

In 2023-2024, as in prior years, U.S. News also recognized Honor Roll hospitals that have excelled across multiple areas of care. However, in 2023-2024, for the first time, there is no ordinal ranking of hospitals making honor roll.

In a letter to hospital leaders, U.S. News explained that the major change in format came after months of deliberation, feedback from health care organizations and professionals, and an analysis of how consumers navigate their website.

Ordinal ranking of hospitals that make the honor roll “obscures the fact that all of the Honor Roll hospitals have attained the highest standard of care in the nation,” the letter reads.

With the new format, honor roll hospitals are listed in alphabetical order. In 2023-2024, there are 22.

• Barnes-Jewish Hospital, St. Louis
• Brigham and Women’s Hospital, Boston
• Cedars-Sinai Medical Center, Los Angeles
• Cleveland Clinic
• Hospitals of the University of Pennsylvania–Penn Medicine, Philadelphia
• Houston Methodist Hospital
• Johns Hopkins Hospital, Baltimore
• Massachusetts General Hospital, Boston
• Mayo Clinic, Rochester, Minn.
• Mount Sinai Hospital, New York
• New York–Presbyterian Hospital–Columbia and Cornell
• North Shore University Hospital at Northwell Health, Manhasset, N.Y.
• Northwestern Memorial Hospital, Chicago
• NYU Langone Hospitals, New York
• Rush University Medical Center, Chicago
• Stanford (Calif.) Health Care–Stanford Hospital
• UC San Diego Health–La Jolla (Calif.) and Hillcrest Hospitals
• UCLA Medical Center, Los Angeles
• UCSF Health–UCSF Medical Center, San Francisco
• University of Michigan Health, Ann Arbor
• UT Southwestern Medical Center, Dallas
• Vanderbilt University Medical Center, Nashville, Tenn.

According to U.S. News, to keep pace with consumers’ needs and the ever-evolving landscape of health care, “several refinements” are reflected in the latest best hospitals rankings.

These include the introduction of outpatient outcomes in key specialty rankings and surgical ratings, the expanded inclusion of other outpatient data, an increased weight on objective quality measures, and a reduced weight on expert opinion.

In addition, hospital profiles on the U.S. News website feature refined health equity measures, including a new measure of racial disparities in outcomes.

The full report for best hospitals, best specialty hospitals, and methodology is available online.

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

The Cleveland Clinic is once again the No. 1 hospital for cardiology and heart surgery, according to U.S. News & World Report’s latest rankings.
 

In the magazine’s 2023-2024 list, Cedars-Sinai Medical Center, Los Angeles, takes over the No. 2 spot from Mayo Clinic, Rochester, Minn., which dropped to No. 3. Cedars-Sinai held the No. 3 on the 2022-2023 rankings.

Mount Sinai Hospital in New York City holds the No. 4 spot in 2023-2024, up from No. 6; NYU Langone Hospitals, New York, continue to hold the No. 5 spot.

New York–Presbyterian Hospital–Columbia and Cornell in New York City is No. 6, down from No. 4 i.

Northwestern Medicine-Northwestern Memorial Hospital in Chicago takes over the No. 7 spot (up from No. 8), while Massachusetts General Hospital in Boston holds the No. 8 (down from No. 7).

Stanford (Calif.) Health Care–Stanford Hospital holds the No. 9 spot, the same as 2, and Lenox Hill Hospital at Northwell Health in New York is No. 10 on the list.

U.S. News evaluated 779 hospitals and ranked the top 50 that care for patients with challenging heart and vascular cases, including heart transplants; implantation of cardiac devices, such as pacemakers and defibrillators; major chest procedures and patients with cardiovascular disease and other complex conditions, such as endocarditis; and heart failure and circulatory issues.

“Consumers want useful resources to help them assess which hospital can best meet their specific care needs,” Ben Harder, chief of health analysis and managing editor at U.S. News, said in a statement.

“The 2023-2024 Best Hospitals rankings offer patients and the physicians with whom they consult a data-driven source for comparing performance in outcomes, patient satisfaction, and other metrics that matter to them,” Mr. Harder said.
 

Best hospitals overall honor roll

In 2023-2024, as in prior years, U.S. News also recognized Honor Roll hospitals that have excelled across multiple areas of care. However, in 2023-2024, for the first time, there is no ordinal ranking of hospitals making honor roll.

In a letter to hospital leaders, U.S. News explained that the major change in format came after months of deliberation, feedback from health care organizations and professionals, and an analysis of how consumers navigate their website.

Ordinal ranking of hospitals that make the honor roll “obscures the fact that all of the Honor Roll hospitals have attained the highest standard of care in the nation,” the letter reads.

With the new format, honor roll hospitals are listed in alphabetical order. In 2023-2024, there are 22.

• Barnes-Jewish Hospital, St. Louis
• Brigham and Women’s Hospital, Boston
• Cedars-Sinai Medical Center, Los Angeles
• Cleveland Clinic
• Hospitals of the University of Pennsylvania–Penn Medicine, Philadelphia
• Houston Methodist Hospital
• Johns Hopkins Hospital, Baltimore
• Massachusetts General Hospital, Boston
• Mayo Clinic, Rochester, Minn.
• Mount Sinai Hospital, New York
• New York–Presbyterian Hospital–Columbia and Cornell
• North Shore University Hospital at Northwell Health, Manhasset, N.Y.
• Northwestern Memorial Hospital, Chicago
• NYU Langone Hospitals, New York
• Rush University Medical Center, Chicago
• Stanford (Calif.) Health Care–Stanford Hospital
• UC San Diego Health–La Jolla (Calif.) and Hillcrest Hospitals
• UCLA Medical Center, Los Angeles
• UCSF Health–UCSF Medical Center, San Francisco
• University of Michigan Health, Ann Arbor
• UT Southwestern Medical Center, Dallas
• Vanderbilt University Medical Center, Nashville, Tenn.

According to U.S. News, to keep pace with consumers’ needs and the ever-evolving landscape of health care, “several refinements” are reflected in the latest best hospitals rankings.

These include the introduction of outpatient outcomes in key specialty rankings and surgical ratings, the expanded inclusion of other outpatient data, an increased weight on objective quality measures, and a reduced weight on expert opinion.

In addition, hospital profiles on the U.S. News website feature refined health equity measures, including a new measure of racial disparities in outcomes.

The full report for best hospitals, best specialty hospitals, and methodology is available online.

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

Atopic dermatitis (AD) is a common inflammatory skin disease that may severely decrease quality of life (QOL) and lead to psychiatric comorbidities.^1-3 Prior studies have indicated that AD causes a substantial economic burden, and disease severity has been proportionally linked to medical costs.^4,5 Results of a multicenter cost-of-illness study from Germany estimated that a relapse of AD costs approximately €123 (US $136). The authors calculated the average annual cost of AD per patient to be €1425 (US $1580), whereas it is €956 (US $1060) in moderate disease and €2068 (US $2293) in severe disease (direct and indirect medical costs included).⁶ An observational cohort study from the Netherlands found that total direct cost per patient-year (PPY) was €4401 (US $4879) for patients with controlled AD vs €6993 (US $7756) for patients with uncontrolled AD.⁷

In a retrospective survey-based study, it was estimated that the annual cost of AD in Canada was approximately CAD $1.4 billion. The cost per patient varied from CAD $282 to CAD $1242 depending on disease severity.⁸ In another retrospective cohort study from the Netherlands, the average direct medical cost per patient with AD seeing a general practitioner was US $71 during follow-up in primary care. If the patient needed specialist consultation, the cost increased to an average of US $186.⁹

We aimed to assess the direct and indirect medical costs in adult patients with moderate to severe AD who attended a tertiary health care center in Finland. In addition, we evaluated the impact of AD on QOL in this patient cohort.

Methods

Study Design—Patients with AD who were treated at the Department of Dermatology and Allergology, Helsinki University Hospital, Finland, between February 2018 and December 2019 were randomly selected to participate in our survey study. All participants provided written informed consent. In Finland, patients with mild AD generally are treated in primary health care centers, and only patients with moderate to severe AD are referred to specialists and tertiary care centers. Patients were excluded if they were younger than 18 years, had AD confined to the hands, or reported the presence of other concomitant skin diseases that were being treated with topical or systemic therapies. The protocol for the study was approved by the local ethics committee of the University of Helsinki.

Questionnaire and Analysis of Disease Severity—The survey included the medical history, signs of atopy, former treatment(s) for AD, skin infections, visits to dermatologists or general practitioners, questions on mental health and hospitalization, and absence from work due to AD in the last 12 months. Disease severity was evaluated using the patient-oriented Rajka & Langeland eczema severity score and Patient Oriented Eczema Measure (POEM).^10,11 The impact on QOL was evaluated by the Dermatology Life Quality Index (DLQI).¹²

Medication Costs—The cost of prescription drugs was based on data from the Finnish national electronic prescription center. In Finland, all prescriptions are made electronically in the database. We analyzed all topical medications (eg, topical corticosteroids [TCSs], topical calcineurin inhibitors [TCIs], and emollients) and systemic medicaments (eg, antibiotics, antihistamines, cyclosporine, methotrexate, and corticosteroids) prescribed for the treatment of AD. In Finland, dupilumab was introduced for the treatment of severe AD in early 2019, and patients receiving dupilumab were excluded from the study. Over-the-counter medications were not included. The costs for laboratory testing were estimations based on the standard monitoring protocols of the Helsinki University Hospital. All costs were based on the Finnish price level standard for the year 2019.

Inpatient/Outpatient Visits and Sick Leave Due to AD—The number of inpatient and outpatient visits due to AD in the last 12 months was evaluated. Outpatient specialist consultations or nurse appointments at Helsinki University Hospital were verified from electronic patient records. In addition, inpatient treatment and phototherapy sessions were calculated from the database.

We assessed the number of sick leave days from work or educational activities during the last year. All costs of transportation for doctors’ appointments, laboratory monitoring, and phototherapy treatments were summed together to estimate the total transportation cost. Visits to nurse and inpatient visits were not included in the total transportation cost because patients often were hospitalized directly after consultation visits, and nurse appointments often were combined with inpatient and outpatient visits. To calculate the total transportation cost, we used a rate of €0.43 per kilometer measured from the patients’ home addresses, which was the official compensation rate of the Finnish Tax Administration for 2019.¹³

Statistical Analysis—Statistical analyses were performed using SPSS Statistics 25 (IBM). Descriptive analyses were used to describe baseline characteristics and to evaluate the mean costs of AD. The patients were divided into 2 groups according to POEM: (1) controlled AD (patients with clear skin or only mild AD; POEM score 0–7) and (2) uncontrolled AD (patients with moderate to very severe AD; POEM score 8–28). The Mann-Whitney U statistic was used to evaluate differences between the study groups.

Results

Patient Characteristics—One hundred sixty-seven patients answered the survey, of which 69 (41.3%) were males and 98 (58.7%) were females. There were 16 patients with controlled AD and 148 patients with uncontrolled AD. Three patients did not answer to POEM and were excluded. The baseline characteristics are presented in Table 1 and include self-reported symptoms related to atopy.

The most-used topical treatments were TCSs (n=155; 92.8%) and emollients (n=166; 99.4%). One hundred sixteen (69.5%) patients had used TCIs. The median amount of TCSs used was 300 g/y vs 30 g/y for TCIs (range, 0-5160 g/y) and 1200 g/y for emollients.

Fifteen (9.0%) patients had been hospitalized for AD in the last year. The mean (SD) length of hospitalization was 6.5 (2.8) days. Thirty-four (20.4%) patients received UVB phototherapy. Thirty-four (20.4%) patients were treated with at least 1 antibiotic course for secondary AD infection. Thirty-six (21.6%) patients needed at least 1 oral corticosteroid course for the treatment of an AD flare.

Fifteen (9.0%) patients reported a diagnosed psychiatric illness, and 17 (10.2%) patients were using prescription drugs for psychiatric illness. Forty-nine (29.3%) patients reported anxiety or depression often or very often, 54 (32.3%) patients reported sometimes, 33 (19.8%) patients reported rarely, and only 30 (18.0%) patients reported none.

Medication Costs—Mean medication cost PPY was €457.40 (US $507.34)(Figure 1 and Table 2). On average, one patient spent €87.50 (US $97.05) for TCSs, €121.90 (US $135.21) for emollients, and €225.10 (US $249.68) for TCIs. The average cost PPY for antibiotics was €6.10 (US $6.77). Other systemic treatments, including (US $18.65). Seventeen patients (10.2%) were on methotrexate therapy for AD in the last year, and 1 patient also used cyclosporine. The costs for laboratory monitoring in these patients were included in the direct cost calculations. The mean cost PPY of laboratory monitoring in the whole study cohort was €6.60 (US $7.32). In patients with systemic immunosuppressive therapy, the mean cost PPY for laboratory monitoring was €65.00 (US $72.09). Five patients had been tested for contact dermatitis; the costs of patch tests or other diagnostic tests were not included.

Visits to Health Care Providers—In the last year, patients had an average of 1.83 dermatologist consultations in the tertiary center (Table 2). In addition, the mean number of visits to private dermatologists was 0.61 and 1.42 visits to general practitioners. The mean cost of physician visits was €302.70 (US $335.75) in the tertiary center, €66.60 (US $73.87) in the private sector, and €141.90 (US $157.39) in primary health care. In total, the average cost of doctors’ appointments PPY was €506.30 (US $561.57). The mean estimated distance traveled per visit was 9.5 km.

The mean cost PPY of inpatient treatments was €329.90 (US $365.92) and €239.00 (US $265.09) for UV phototherapy. Only 4 patients had visited a nurse in the last year, with an average cost PPY of €2.50 (US $2.78).

In total, the cost PPY for health care provider visits was €1084.20, which included specialist consultations in a tertiary center and private sector, visits in primary health care, inpatient treatments, UV phototherapy sessions, nurse appointments in a tertiary center, and laboratory monitoring. The average transportation cost PPY was €34.00 (US $37.71). The mean number of visits to health care providers was 8.3 per year. Altogether, the direct cost PPY in the study cohort was €1580.60 (US $1752.39)(Table 2 and Figure 2).

Comparison of Medical Costs in Controlled vs Uncontrolled AD—In the controlled AD group (POEM score <8), the mean medication cost PPY was €567.15 (US $629.13), and the mean total direct cost PPY was €2040.46 (US $2263.24). In the uncontrolled AD group (POEM score ≥8), the mean medication cost PPY was €449.55 (US $498.63), and the mean total direct cost PPY was €1539.39 (US $1707.36)(Table 2). The comparisons of the study groups—controlled vs uncontrolled AD—showed no significant differences regarding medication costs PPY (P=.305, Mann-Whitney U statistic) and total direct costs PPY (P=.361, Mann-Whitney U statistic)(Figure 3). Thus, the distribution of medical costs was similar across all categories of the POEM score.

AD Severity and QOL—The mean (SD) POEM score in the study cohort was 17.9 (6.9). Sixteen (9.6%) patients had clear to almost clear skin or mild AD (POEM score 0–7). Forty-two (25.1%) patients had moderate AD (POEM score 8–16). Most of the patients (106; 63.5%) had severe or very severe AD (POEM score 17–28). According to the Rajka & Langeland score, 5 (3.0%) patients had mild disease (score 34), 81 (48.5%) patients had moderate disease (score 5–7), and 81 (48.5%) patients had severe disease (score 8–9). Eighty-one (48.5%) patients answered that AD affects their lives greatly, and 58 (34.7%) patients answered that it affects their lives extremely. Twenty-five (15.0%) patients answered that AD affects their everyday life to some extent, and only 2 (1.2%) patients answered that AD had little or no effect.

The mean (SD) DLQI was 13 (7.2). Based on the DLQI, 31 (18.6%) patients answered that AD had no effect or only a small effect on QOL (DLQI 0–5). In 36 (21.6%) patients, AD had a moderate effect on QOL (DLQI 6–10). The QOL impact was large (DLQI 11–20) and very large (DLQI 21–30) in 67 (40.1%) and 33 (19.8%) patients, respectively.

There was no significant difference in the impact of disease severity (POEM score) on the decrease of QOL (severe or very severe disease; P=.305, Mann-Whitney U statistic).

Absence From Work or Studies—At the study inclusion, 12 (7.2%) patients were not working or studying. Of the remaining 155 patients, 73 (47.1%) reported absence from work or educational activities due to AD in the last 12 months. The mean (SD) length of absence was 11.6 (10.2) days.

Comment

In this survey-based study of Finnish patients with moderate to severe AD, we observed that AD creates a substantial economic burden¹⁴ and negative impact on everyday life and QOL. According to DLQI, AD had a large or very large effect on most of the patients’ (59.9%) lives, and 90.2% of the included patients had self-reported moderate to very severe symptoms (POEM score 8–28). Our observations can partly be explained by characteristics of the Finnish health care system, in which patients with moderate to severe AD mainly are referred to specialist consultation. In the investigated cohort, many patients had used antibiotics (20.4%) and/or oral corticosteroids (21.6%) in the last year for the treatment of AD, which might indicate inadequate treatment of AD in the Finnish health care system.

Motivating patients to remain compliant is one of the main challenges in AD therapy.¹⁵ Fear of adverse effects from TCSs is common among patients and may cause poor treatment adherence.¹⁶ In a prospective study from the United Kingdom, the use of emollients in moderate to severe AD was considerably lower than AD guidelines recommend—approximately 10 g/d on average in adult patients. The median use of TCSs was between 35 and 38 g/mo.¹⁷ In our Finnish patient cohort, the amount of topical treatments was even lower, with a median use of emollients of 3.3 g/d and median use of TCSs of 25 g/mo. In another study from Denmark (N=322), 31% of patients with AD did not redeem their topical prescription medicaments, indicating poor adherence to topical treatment.¹⁸

It has been demonstrated that most of the patients’ habituation (tachyphylaxis) to TCSs is due to poor adherence instead of physiologic changes in tissue corticosteroid receptors.^19,20 Treatment adherence may be increased by scheduling early follow-up visits and providing adequate therapeutic patient education,²¹ which requires major efforts by the health care system and a financial investment.

Inadequate treatment will lead to more frequent disease flares and subsequently increase the medical costs for the patients and the health care system.²² In our Finnish patient cohort, a large part of direct treatment costs was due to inpatient treatment (Figure 2) even though only a small proportion of patients had been hospitalized. The patients were frequently young and otherwise in good general health, and they did not necessarily need continuous inpatient treatment and monitoring. In Finland, it will be necessary to develop more cost-effective treatment regimens for patients with AD with severe and frequent flares. Many patients would benefit from subsequent and regular sessions of topical treatment in an outpatient setting. In addition, the prevention of flares in moderate to severe AD will decrease medical costs.²³

The mean medication cost PPY was €457.40 (US $507.34), and mean total direct cost PPY was €1579.90 (US $1752.40), which indicates that AD causes a major economic burden to Finnish patients and to the Finnish health care system (Figures 1 and 2).²⁴ We did not observe significant differences between controlled and uncontrolled AD medical costs in our patient cohort (Figure 3), which may have been due to the relatively small sample size of only 16 patients in the controlled AD group. All patients attending the tertiary care hospital had moderate to severe AD, so it is likely that the patients with lower POEM scores had better-controlled disease. The POEM score estimates the grade of AD in the last 7 days, but based on the relapsing course of the disease, the grading score may differ substantially during the year in the same patient depending on the timing.^25,26

Topical calcineurin inhibitors comprised almost half of the medication costs (Figure 1), which may be caused by their higher prices compared with TCSs in Finland. In the beginning of 2019, a 50% less expensive biosimilar of tacrolimus ointment 0.1% was introduced to the Finnish market, which might decrease future treatment costs of TCIs. However, availability problems in both topical tacrolimus products were seen throughout 2019, which also may have affected the results in our study cohort. The median use of TCIs was unexpectedly low (only 30 g/y), which may be explained by different application habits. The use of large TCI amounts in some patients may have elevated mean costs.²⁷

In the Finnish public health care system, 40% of the cost for prescription medication and emollients is reimbursed after an initial deductible of €50. Emollients are reimbursed up to an amount of 1500 g/mo. Therefore, patients mostly acquired emollients as prescription medicine and not over-the-counter. Nonprescription medicaments were not included in our study, so the actual costs of topical treatment may have been higher.²⁸

In our cohort, 61.7% of the patients reported food allergies, and 70.1% reported allergic conjunctivitis. However, the study included only questionnaire-based data, and many of these patients probably had symptoms not associated with IgE-mediated allergies. The high prevalence indicates a substantial concomitant burden of more than skin symptoms in patients with AD.²⁹ Nine percent of patients reported a diagnosed psychiatric disorder, and 29.3% had self-reported anxiety or depression often or very often in the last year. Based on these findings, there may be high percentages of undiagnosed psychiatric comorbidities such as depression and anxiety disorders in patients with moderate to severe AD in Finland.³⁰ An important limitation of our study was that the patient data were based on a voluntary and anonymous survey and that depression and anxiety were addressed solely by a single question. In addition, the response rate cannot be analyzed correctly, and the demographics of the survey responders likely will differ substantially from all patients with AD at the university hospital.

Atopic dermatitis had a substantial effect on QOL in our patient cohort. Inadequate treatment of AD is known to negatively affect patient QOL and may lead to hospitalization or frequent oral corticosteroid courses.^31,32 In most cases, structured patient education and early follow-up visits may improve patient adherence to treatment and should be considered as an integral part of AD treatment.³³ In the investigated Finnish tertiary care hospital, a structured patient education system unfortunately was still lacking, though it has been proven effective elsewhere.³⁴ In addition, patient-centred educational programs are recommended in European guidelines for the treatment of AD.³⁵

Medical costs of AD may increase in the future as new treatments with higher direct costs, such as dupilumab, are introduced. Eichenfeld et al³⁶ analyzed electronic health plan claims in patients with AD with newly introduced systemic therapies and phototherapies after the availability of dupilumab in the United States (March 2017). Mean annualized total cost in all patients was $20,722; the highest in the dupilumab group with $36,505. Compared to our data, the total costs are much higher, but these are likely to rise in Finland in the future if a substantial amount (eg, 1%–5%) of patients will be on advanced therapies, including dupilumab. If advanced therapies will be introduced more broadly in Finland (eg, in the treatment of moderate AD [10%–20% of patients]), they will represent a major direct cost to the health care system. Zimmermann et al³⁷ showed in a cost-utility analysis that dupilumab improves health outcomes but with additional direct costs, and it is likely more cost-effective in patients with severe AD. Conversely, more efficient treatments may improve severe AD, reduce the need for hospitalization and recurrent doctors’ appointments as well as absence from work, and improve patient QOL,³⁸ consequently decreasing indirect medical costs and disease burden. Ariëns et al³⁹ showed in a recent registry-based study that dupilumab treatment induces a notable rise in work productivity and reduction of associated costs in patients with difficult-to-treat AD.

Conclusion

We aimed to analyze the economic burden of AD in Finland before the introduction of dupilumab. It will be interesting to see what the introduction of dupilumab and other novel systemic therapies have on total economic burden and medical costs. Most patients with AD in Finland can achieve disease control with topical treatments, but it is important to efficiently manage the patients who require additional supportive measures and specialist consultations, which may be challenging in the primary health care system because of the relapsing and remitting nature of the disease.

Atopic dermatitis (AD) is a common inflammatory skin disease that may severely decrease quality of life (QOL) and lead to psychiatric comorbidities.^1-3 Prior studies have indicated that AD causes a substantial economic burden, and disease severity has been proportionally linked to medical costs.^4,5 Results of a multicenter cost-of-illness study from Germany estimated that a relapse of AD costs approximately €123 (US $136). The authors calculated the average annual cost of AD per patient to be €1425 (US $1580), whereas it is €956 (US $1060) in moderate disease and €2068 (US $2293) in severe disease (direct and indirect medical costs included).⁶ An observational cohort study from the Netherlands found that total direct cost per patient-year (PPY) was €4401 (US $4879) for patients with controlled AD vs €6993 (US $7756) for patients with uncontrolled AD.⁷

In a retrospective survey-based study, it was estimated that the annual cost of AD in Canada was approximately CAD $1.4 billion. The cost per patient varied from CAD $282 to CAD $1242 depending on disease severity.⁸ In another retrospective cohort study from the Netherlands, the average direct medical cost per patient with AD seeing a general practitioner was US $71 during follow-up in primary care. If the patient needed specialist consultation, the cost increased to an average of US $186.⁹

We aimed to assess the direct and indirect medical costs in adult patients with moderate to severe AD who attended a tertiary health care center in Finland. In addition, we evaluated the impact of AD on QOL in this patient cohort.

Methods

Study Design—Patients with AD who were treated at the Department of Dermatology and Allergology, Helsinki University Hospital, Finland, between February 2018 and December 2019 were randomly selected to participate in our survey study. All participants provided written informed consent. In Finland, patients with mild AD generally are treated in primary health care centers, and only patients with moderate to severe AD are referred to specialists and tertiary care centers. Patients were excluded if they were younger than 18 years, had AD confined to the hands, or reported the presence of other concomitant skin diseases that were being treated with topical or systemic therapies. The protocol for the study was approved by the local ethics committee of the University of Helsinki.

Questionnaire and Analysis of Disease Severity—The survey included the medical history, signs of atopy, former treatment(s) for AD, skin infections, visits to dermatologists or general practitioners, questions on mental health and hospitalization, and absence from work due to AD in the last 12 months. Disease severity was evaluated using the patient-oriented Rajka & Langeland eczema severity score and Patient Oriented Eczema Measure (POEM).^10,11 The impact on QOL was evaluated by the Dermatology Life Quality Index (DLQI).¹²

Medication Costs—The cost of prescription drugs was based on data from the Finnish national electronic prescription center. In Finland, all prescriptions are made electronically in the database. We analyzed all topical medications (eg, topical corticosteroids [TCSs], topical calcineurin inhibitors [TCIs], and emollients) and systemic medicaments (eg, antibiotics, antihistamines, cyclosporine, methotrexate, and corticosteroids) prescribed for the treatment of AD. In Finland, dupilumab was introduced for the treatment of severe AD in early 2019, and patients receiving dupilumab were excluded from the study. Over-the-counter medications were not included. The costs for laboratory testing were estimations based on the standard monitoring protocols of the Helsinki University Hospital. All costs were based on the Finnish price level standard for the year 2019.

Inpatient/Outpatient Visits and Sick Leave Due to AD—The number of inpatient and outpatient visits due to AD in the last 12 months was evaluated. Outpatient specialist consultations or nurse appointments at Helsinki University Hospital were verified from electronic patient records. In addition, inpatient treatment and phototherapy sessions were calculated from the database.

We assessed the number of sick leave days from work or educational activities during the last year. All costs of transportation for doctors’ appointments, laboratory monitoring, and phototherapy treatments were summed together to estimate the total transportation cost. Visits to nurse and inpatient visits were not included in the total transportation cost because patients often were hospitalized directly after consultation visits, and nurse appointments often were combined with inpatient and outpatient visits. To calculate the total transportation cost, we used a rate of €0.43 per kilometer measured from the patients’ home addresses, which was the official compensation rate of the Finnish Tax Administration for 2019.¹³

Statistical Analysis—Statistical analyses were performed using SPSS Statistics 25 (IBM). Descriptive analyses were used to describe baseline characteristics and to evaluate the mean costs of AD. The patients were divided into 2 groups according to POEM: (1) controlled AD (patients with clear skin or only mild AD; POEM score 0–7) and (2) uncontrolled AD (patients with moderate to very severe AD; POEM score 8–28). The Mann-Whitney U statistic was used to evaluate differences between the study groups.

Results

Patient Characteristics—One hundred sixty-seven patients answered the survey, of which 69 (41.3%) were males and 98 (58.7%) were females. There were 16 patients with controlled AD and 148 patients with uncontrolled AD. Three patients did not answer to POEM and were excluded. The baseline characteristics are presented in Table 1 and include self-reported symptoms related to atopy.

The most-used topical treatments were TCSs (n=155; 92.8%) and emollients (n=166; 99.4%). One hundred sixteen (69.5%) patients had used TCIs. The median amount of TCSs used was 300 g/y vs 30 g/y for TCIs (range, 0-5160 g/y) and 1200 g/y for emollients.

Fifteen (9.0%) patients had been hospitalized for AD in the last year. The mean (SD) length of hospitalization was 6.5 (2.8) days. Thirty-four (20.4%) patients received UVB phototherapy. Thirty-four (20.4%) patients were treated with at least 1 antibiotic course for secondary AD infection. Thirty-six (21.6%) patients needed at least 1 oral corticosteroid course for the treatment of an AD flare.

Fifteen (9.0%) patients reported a diagnosed psychiatric illness, and 17 (10.2%) patients were using prescription drugs for psychiatric illness. Forty-nine (29.3%) patients reported anxiety or depression often or very often, 54 (32.3%) patients reported sometimes, 33 (19.8%) patients reported rarely, and only 30 (18.0%) patients reported none.

Medication Costs—Mean medication cost PPY was €457.40 (US $507.34)(Figure 1 and Table 2). On average, one patient spent €87.50 (US $97.05) for TCSs, €121.90 (US $135.21) for emollients, and €225.10 (US $249.68) for TCIs. The average cost PPY for antibiotics was €6.10 (US $6.77). Other systemic treatments, including (US $18.65). Seventeen patients (10.2%) were on methotrexate therapy for AD in the last year, and 1 patient also used cyclosporine. The costs for laboratory monitoring in these patients were included in the direct cost calculations. The mean cost PPY of laboratory monitoring in the whole study cohort was €6.60 (US $7.32). In patients with systemic immunosuppressive therapy, the mean cost PPY for laboratory monitoring was €65.00 (US $72.09). Five patients had been tested for contact dermatitis; the costs of patch tests or other diagnostic tests were not included.

Visits to Health Care Providers—In the last year, patients had an average of 1.83 dermatologist consultations in the tertiary center (Table 2). In addition, the mean number of visits to private dermatologists was 0.61 and 1.42 visits to general practitioners. The mean cost of physician visits was €302.70 (US $335.75) in the tertiary center, €66.60 (US $73.87) in the private sector, and €141.90 (US $157.39) in primary health care. In total, the average cost of doctors’ appointments PPY was €506.30 (US $561.57). The mean estimated distance traveled per visit was 9.5 km.

The mean cost PPY of inpatient treatments was €329.90 (US $365.92) and €239.00 (US $265.09) for UV phototherapy. Only 4 patients had visited a nurse in the last year, with an average cost PPY of €2.50 (US $2.78).

In total, the cost PPY for health care provider visits was €1084.20, which included specialist consultations in a tertiary center and private sector, visits in primary health care, inpatient treatments, UV phototherapy sessions, nurse appointments in a tertiary center, and laboratory monitoring. The average transportation cost PPY was €34.00 (US $37.71). The mean number of visits to health care providers was 8.3 per year. Altogether, the direct cost PPY in the study cohort was €1580.60 (US $1752.39)(Table 2 and Figure 2).

Comparison of Medical Costs in Controlled vs Uncontrolled AD—In the controlled AD group (POEM score <8), the mean medication cost PPY was €567.15 (US $629.13), and the mean total direct cost PPY was €2040.46 (US $2263.24). In the uncontrolled AD group (POEM score ≥8), the mean medication cost PPY was €449.55 (US $498.63), and the mean total direct cost PPY was €1539.39 (US $1707.36)(Table 2). The comparisons of the study groups—controlled vs uncontrolled AD—showed no significant differences regarding medication costs PPY (P=.305, Mann-Whitney U statistic) and total direct costs PPY (P=.361, Mann-Whitney U statistic)(Figure 3). Thus, the distribution of medical costs was similar across all categories of the POEM score.

AD Severity and QOL—The mean (SD) POEM score in the study cohort was 17.9 (6.9). Sixteen (9.6%) patients had clear to almost clear skin or mild AD (POEM score 0–7). Forty-two (25.1%) patients had moderate AD (POEM score 8–16). Most of the patients (106; 63.5%) had severe or very severe AD (POEM score 17–28). According to the Rajka & Langeland score, 5 (3.0%) patients had mild disease (score 34), 81 (48.5%) patients had moderate disease (score 5–7), and 81 (48.5%) patients had severe disease (score 8–9). Eighty-one (48.5%) patients answered that AD affects their lives greatly, and 58 (34.7%) patients answered that it affects their lives extremely. Twenty-five (15.0%) patients answered that AD affects their everyday life to some extent, and only 2 (1.2%) patients answered that AD had little or no effect.

The mean (SD) DLQI was 13 (7.2). Based on the DLQI, 31 (18.6%) patients answered that AD had no effect or only a small effect on QOL (DLQI 0–5). In 36 (21.6%) patients, AD had a moderate effect on QOL (DLQI 6–10). The QOL impact was large (DLQI 11–20) and very large (DLQI 21–30) in 67 (40.1%) and 33 (19.8%) patients, respectively.

There was no significant difference in the impact of disease severity (POEM score) on the decrease of QOL (severe or very severe disease; P=.305, Mann-Whitney U statistic).

Absence From Work or Studies—At the study inclusion, 12 (7.2%) patients were not working or studying. Of the remaining 155 patients, 73 (47.1%) reported absence from work or educational activities due to AD in the last 12 months. The mean (SD) length of absence was 11.6 (10.2) days.

Comment

In this survey-based study of Finnish patients with moderate to severe AD, we observed that AD creates a substantial economic burden¹⁴ and negative impact on everyday life and QOL. According to DLQI, AD had a large or very large effect on most of the patients’ (59.9%) lives, and 90.2% of the included patients had self-reported moderate to very severe symptoms (POEM score 8–28). Our observations can partly be explained by characteristics of the Finnish health care system, in which patients with moderate to severe AD mainly are referred to specialist consultation. In the investigated cohort, many patients had used antibiotics (20.4%) and/or oral corticosteroids (21.6%) in the last year for the treatment of AD, which might indicate inadequate treatment of AD in the Finnish health care system.

Motivating patients to remain compliant is one of the main challenges in AD therapy.¹⁵ Fear of adverse effects from TCSs is common among patients and may cause poor treatment adherence.¹⁶ In a prospective study from the United Kingdom, the use of emollients in moderate to severe AD was considerably lower than AD guidelines recommend—approximately 10 g/d on average in adult patients. The median use of TCSs was between 35 and 38 g/mo.¹⁷ In our Finnish patient cohort, the amount of topical treatments was even lower, with a median use of emollients of 3.3 g/d and median use of TCSs of 25 g/mo. In another study from Denmark (N=322), 31% of patients with AD did not redeem their topical prescription medicaments, indicating poor adherence to topical treatment.¹⁸

It has been demonstrated that most of the patients’ habituation (tachyphylaxis) to TCSs is due to poor adherence instead of physiologic changes in tissue corticosteroid receptors.^19,20 Treatment adherence may be increased by scheduling early follow-up visits and providing adequate therapeutic patient education,²¹ which requires major efforts by the health care system and a financial investment.

Inadequate treatment will lead to more frequent disease flares and subsequently increase the medical costs for the patients and the health care system.²² In our Finnish patient cohort, a large part of direct treatment costs was due to inpatient treatment (Figure 2) even though only a small proportion of patients had been hospitalized. The patients were frequently young and otherwise in good general health, and they did not necessarily need continuous inpatient treatment and monitoring. In Finland, it will be necessary to develop more cost-effective treatment regimens for patients with AD with severe and frequent flares. Many patients would benefit from subsequent and regular sessions of topical treatment in an outpatient setting. In addition, the prevention of flares in moderate to severe AD will decrease medical costs.²³

The mean medication cost PPY was €457.40 (US $507.34), and mean total direct cost PPY was €1579.90 (US $1752.40), which indicates that AD causes a major economic burden to Finnish patients and to the Finnish health care system (Figures 1 and 2).²⁴ We did not observe significant differences between controlled and uncontrolled AD medical costs in our patient cohort (Figure 3), which may have been due to the relatively small sample size of only 16 patients in the controlled AD group. All patients attending the tertiary care hospital had moderate to severe AD, so it is likely that the patients with lower POEM scores had better-controlled disease. The POEM score estimates the grade of AD in the last 7 days, but based on the relapsing course of the disease, the grading score may differ substantially during the year in the same patient depending on the timing.^25,26

Topical calcineurin inhibitors comprised almost half of the medication costs (Figure 1), which may be caused by their higher prices compared with TCSs in Finland. In the beginning of 2019, a 50% less expensive biosimilar of tacrolimus ointment 0.1% was introduced to the Finnish market, which might decrease future treatment costs of TCIs. However, availability problems in both topical tacrolimus products were seen throughout 2019, which also may have affected the results in our study cohort. The median use of TCIs was unexpectedly low (only 30 g/y), which may be explained by different application habits. The use of large TCI amounts in some patients may have elevated mean costs.²⁷

In the Finnish public health care system, 40% of the cost for prescription medication and emollients is reimbursed after an initial deductible of €50. Emollients are reimbursed up to an amount of 1500 g/mo. Therefore, patients mostly acquired emollients as prescription medicine and not over-the-counter. Nonprescription medicaments were not included in our study, so the actual costs of topical treatment may have been higher.²⁸

In our cohort, 61.7% of the patients reported food allergies, and 70.1% reported allergic conjunctivitis. However, the study included only questionnaire-based data, and many of these patients probably had symptoms not associated with IgE-mediated allergies. The high prevalence indicates a substantial concomitant burden of more than skin symptoms in patients with AD.²⁹ Nine percent of patients reported a diagnosed psychiatric disorder, and 29.3% had self-reported anxiety or depression often or very often in the last year. Based on these findings, there may be high percentages of undiagnosed psychiatric comorbidities such as depression and anxiety disorders in patients with moderate to severe AD in Finland.³⁰ An important limitation of our study was that the patient data were based on a voluntary and anonymous survey and that depression and anxiety were addressed solely by a single question. In addition, the response rate cannot be analyzed correctly, and the demographics of the survey responders likely will differ substantially from all patients with AD at the university hospital.

Atopic dermatitis had a substantial effect on QOL in our patient cohort. Inadequate treatment of AD is known to negatively affect patient QOL and may lead to hospitalization or frequent oral corticosteroid courses.^31,32 In most cases, structured patient education and early follow-up visits may improve patient adherence to treatment and should be considered as an integral part of AD treatment.³³ In the investigated Finnish tertiary care hospital, a structured patient education system unfortunately was still lacking, though it has been proven effective elsewhere.³⁴ In addition, patient-centred educational programs are recommended in European guidelines for the treatment of AD.³⁵

Medical costs of AD may increase in the future as new treatments with higher direct costs, such as dupilumab, are introduced. Eichenfeld et al³⁶ analyzed electronic health plan claims in patients with AD with newly introduced systemic therapies and phototherapies after the availability of dupilumab in the United States (March 2017). Mean annualized total cost in all patients was $20,722; the highest in the dupilumab group with $36,505. Compared to our data, the total costs are much higher, but these are likely to rise in Finland in the future if a substantial amount (eg, 1%–5%) of patients will be on advanced therapies, including dupilumab. If advanced therapies will be introduced more broadly in Finland (eg, in the treatment of moderate AD [10%–20% of patients]), they will represent a major direct cost to the health care system. Zimmermann et al³⁷ showed in a cost-utility analysis that dupilumab improves health outcomes but with additional direct costs, and it is likely more cost-effective in patients with severe AD. Conversely, more efficient treatments may improve severe AD, reduce the need for hospitalization and recurrent doctors’ appointments as well as absence from work, and improve patient QOL,³⁸ consequently decreasing indirect medical costs and disease burden. Ariëns et al³⁹ showed in a recent registry-based study that dupilumab treatment induces a notable rise in work productivity and reduction of associated costs in patients with difficult-to-treat AD.

Conclusion

We aimed to analyze the economic burden of AD in Finland before the introduction of dupilumab. It will be interesting to see what the introduction of dupilumab and other novel systemic therapies have on total economic burden and medical costs. Most patients with AD in Finland can achieve disease control with topical treatments, but it is important to efficiently manage the patients who require additional supportive measures and specialist consultations, which may be challenging in the primary health care system because of the relapsing and remitting nature of the disease.

Atopic dermatitis (AD) is a common inflammatory skin disease that may severely decrease quality of life (QOL) and lead to psychiatric comorbidities.^1-3 Prior studies have indicated that AD causes a substantial economic burden, and disease severity has been proportionally linked to medical costs.^4,5 Results of a multicenter cost-of-illness study from Germany estimated that a relapse of AD costs approximately €123 (US $136). The authors calculated the average annual cost of AD per patient to be €1425 (US $1580), whereas it is €956 (US $1060) in moderate disease and €2068 (US $2293) in severe disease (direct and indirect medical costs included).⁶ An observational cohort study from the Netherlands found that total direct cost per patient-year (PPY) was €4401 (US $4879) for patients with controlled AD vs €6993 (US $7756) for patients with uncontrolled AD.⁷

In a retrospective survey-based study, it was estimated that the annual cost of AD in Canada was approximately CAD $1.4 billion. The cost per patient varied from CAD $282 to CAD $1242 depending on disease severity.⁸ In another retrospective cohort study from the Netherlands, the average direct medical cost per patient with AD seeing a general practitioner was US $71 during follow-up in primary care. If the patient needed specialist consultation, the cost increased to an average of US $186.⁹

We aimed to assess the direct and indirect medical costs in adult patients with moderate to severe AD who attended a tertiary health care center in Finland. In addition, we evaluated the impact of AD on QOL in this patient cohort.

Methods

Study Design—Patients with AD who were treated at the Department of Dermatology and Allergology, Helsinki University Hospital, Finland, between February 2018 and December 2019 were randomly selected to participate in our survey study. All participants provided written informed consent. In Finland, patients with mild AD generally are treated in primary health care centers, and only patients with moderate to severe AD are referred to specialists and tertiary care centers. Patients were excluded if they were younger than 18 years, had AD confined to the hands, or reported the presence of other concomitant skin diseases that were being treated with topical or systemic therapies. The protocol for the study was approved by the local ethics committee of the University of Helsinki.

Questionnaire and Analysis of Disease Severity—The survey included the medical history, signs of atopy, former treatment(s) for AD, skin infections, visits to dermatologists or general practitioners, questions on mental health and hospitalization, and absence from work due to AD in the last 12 months. Disease severity was evaluated using the patient-oriented Rajka & Langeland eczema severity score and Patient Oriented Eczema Measure (POEM).^10,11 The impact on QOL was evaluated by the Dermatology Life Quality Index (DLQI).¹²

Medication Costs—The cost of prescription drugs was based on data from the Finnish national electronic prescription center. In Finland, all prescriptions are made electronically in the database. We analyzed all topical medications (eg, topical corticosteroids [TCSs], topical calcineurin inhibitors [TCIs], and emollients) and systemic medicaments (eg, antibiotics, antihistamines, cyclosporine, methotrexate, and corticosteroids) prescribed for the treatment of AD. In Finland, dupilumab was introduced for the treatment of severe AD in early 2019, and patients receiving dupilumab were excluded from the study. Over-the-counter medications were not included. The costs for laboratory testing were estimations based on the standard monitoring protocols of the Helsinki University Hospital. All costs were based on the Finnish price level standard for the year 2019.

Inpatient/Outpatient Visits and Sick Leave Due to AD—The number of inpatient and outpatient visits due to AD in the last 12 months was evaluated. Outpatient specialist consultations or nurse appointments at Helsinki University Hospital were verified from electronic patient records. In addition, inpatient treatment and phototherapy sessions were calculated from the database.

We assessed the number of sick leave days from work or educational activities during the last year. All costs of transportation for doctors’ appointments, laboratory monitoring, and phototherapy treatments were summed together to estimate the total transportation cost. Visits to nurse and inpatient visits were not included in the total transportation cost because patients often were hospitalized directly after consultation visits, and nurse appointments often were combined with inpatient and outpatient visits. To calculate the total transportation cost, we used a rate of €0.43 per kilometer measured from the patients’ home addresses, which was the official compensation rate of the Finnish Tax Administration for 2019.¹³

Statistical Analysis—Statistical analyses were performed using SPSS Statistics 25 (IBM). Descriptive analyses were used to describe baseline characteristics and to evaluate the mean costs of AD. The patients were divided into 2 groups according to POEM: (1) controlled AD (patients with clear skin or only mild AD; POEM score 0–7) and (2) uncontrolled AD (patients with moderate to very severe AD; POEM score 8–28). The Mann-Whitney U statistic was used to evaluate differences between the study groups.

Results

Patient Characteristics—One hundred sixty-seven patients answered the survey, of which 69 (41.3%) were males and 98 (58.7%) were females. There were 16 patients with controlled AD and 148 patients with uncontrolled AD. Three patients did not answer to POEM and were excluded. The baseline characteristics are presented in Table 1 and include self-reported symptoms related to atopy.

The most-used topical treatments were TCSs (n=155; 92.8%) and emollients (n=166; 99.4%). One hundred sixteen (69.5%) patients had used TCIs. The median amount of TCSs used was 300 g/y vs 30 g/y for TCIs (range, 0-5160 g/y) and 1200 g/y for emollients.

Fifteen (9.0%) patients had been hospitalized for AD in the last year. The mean (SD) length of hospitalization was 6.5 (2.8) days. Thirty-four (20.4%) patients received UVB phototherapy. Thirty-four (20.4%) patients were treated with at least 1 antibiotic course for secondary AD infection. Thirty-six (21.6%) patients needed at least 1 oral corticosteroid course for the treatment of an AD flare.

Fifteen (9.0%) patients reported a diagnosed psychiatric illness, and 17 (10.2%) patients were using prescription drugs for psychiatric illness. Forty-nine (29.3%) patients reported anxiety or depression often or very often, 54 (32.3%) patients reported sometimes, 33 (19.8%) patients reported rarely, and only 30 (18.0%) patients reported none.

Medication Costs—Mean medication cost PPY was €457.40 (US $507.34)(Figure 1 and Table 2). On average, one patient spent €87.50 (US $97.05) for TCSs, €121.90 (US $135.21) for emollients, and €225.10 (US $249.68) for TCIs. The average cost PPY for antibiotics was €6.10 (US $6.77). Other systemic treatments, including (US $18.65). Seventeen patients (10.2%) were on methotrexate therapy for AD in the last year, and 1 patient also used cyclosporine. The costs for laboratory monitoring in these patients were included in the direct cost calculations. The mean cost PPY of laboratory monitoring in the whole study cohort was €6.60 (US $7.32). In patients with systemic immunosuppressive therapy, the mean cost PPY for laboratory monitoring was €65.00 (US $72.09). Five patients had been tested for contact dermatitis; the costs of patch tests or other diagnostic tests were not included.

Visits to Health Care Providers—In the last year, patients had an average of 1.83 dermatologist consultations in the tertiary center (Table 2). In addition, the mean number of visits to private dermatologists was 0.61 and 1.42 visits to general practitioners. The mean cost of physician visits was €302.70 (US $335.75) in the tertiary center, €66.60 (US $73.87) in the private sector, and €141.90 (US $157.39) in primary health care. In total, the average cost of doctors’ appointments PPY was €506.30 (US $561.57). The mean estimated distance traveled per visit was 9.5 km.

The mean cost PPY of inpatient treatments was €329.90 (US $365.92) and €239.00 (US $265.09) for UV phototherapy. Only 4 patients had visited a nurse in the last year, with an average cost PPY of €2.50 (US $2.78).

In total, the cost PPY for health care provider visits was €1084.20, which included specialist consultations in a tertiary center and private sector, visits in primary health care, inpatient treatments, UV phototherapy sessions, nurse appointments in a tertiary center, and laboratory monitoring. The average transportation cost PPY was €34.00 (US $37.71). The mean number of visits to health care providers was 8.3 per year. Altogether, the direct cost PPY in the study cohort was €1580.60 (US $1752.39)(Table 2 and Figure 2).

Comparison of Medical Costs in Controlled vs Uncontrolled AD—In the controlled AD group (POEM score <8), the mean medication cost PPY was €567.15 (US $629.13), and the mean total direct cost PPY was €2040.46 (US $2263.24). In the uncontrolled AD group (POEM score ≥8), the mean medication cost PPY was €449.55 (US $498.63), and the mean total direct cost PPY was €1539.39 (US $1707.36)(Table 2). The comparisons of the study groups—controlled vs uncontrolled AD—showed no significant differences regarding medication costs PPY (P=.305, Mann-Whitney U statistic) and total direct costs PPY (P=.361, Mann-Whitney U statistic)(Figure 3). Thus, the distribution of medical costs was similar across all categories of the POEM score.

AD Severity and QOL—The mean (SD) POEM score in the study cohort was 17.9 (6.9). Sixteen (9.6%) patients had clear to almost clear skin or mild AD (POEM score 0–7). Forty-two (25.1%) patients had moderate AD (POEM score 8–16). Most of the patients (106; 63.5%) had severe or very severe AD (POEM score 17–28). According to the Rajka & Langeland score, 5 (3.0%) patients had mild disease (score 34), 81 (48.5%) patients had moderate disease (score 5–7), and 81 (48.5%) patients had severe disease (score 8–9). Eighty-one (48.5%) patients answered that AD affects their lives greatly, and 58 (34.7%) patients answered that it affects their lives extremely. Twenty-five (15.0%) patients answered that AD affects their everyday life to some extent, and only 2 (1.2%) patients answered that AD had little or no effect.

The mean (SD) DLQI was 13 (7.2). Based on the DLQI, 31 (18.6%) patients answered that AD had no effect or only a small effect on QOL (DLQI 0–5). In 36 (21.6%) patients, AD had a moderate effect on QOL (DLQI 6–10). The QOL impact was large (DLQI 11–20) and very large (DLQI 21–30) in 67 (40.1%) and 33 (19.8%) patients, respectively.

There was no significant difference in the impact of disease severity (POEM score) on the decrease of QOL (severe or very severe disease; P=.305, Mann-Whitney U statistic).

Absence From Work or Studies—At the study inclusion, 12 (7.2%) patients were not working or studying. Of the remaining 155 patients, 73 (47.1%) reported absence from work or educational activities due to AD in the last 12 months. The mean (SD) length of absence was 11.6 (10.2) days.

Comment

In this survey-based study of Finnish patients with moderate to severe AD, we observed that AD creates a substantial economic burden¹⁴ and negative impact on everyday life and QOL. According to DLQI, AD had a large or very large effect on most of the patients’ (59.9%) lives, and 90.2% of the included patients had self-reported moderate to very severe symptoms (POEM score 8–28). Our observations can partly be explained by characteristics of the Finnish health care system, in which patients with moderate to severe AD mainly are referred to specialist consultation. In the investigated cohort, many patients had used antibiotics (20.4%) and/or oral corticosteroids (21.6%) in the last year for the treatment of AD, which might indicate inadequate treatment of AD in the Finnish health care system.

Motivating patients to remain compliant is one of the main challenges in AD therapy.¹⁵ Fear of adverse effects from TCSs is common among patients and may cause poor treatment adherence.¹⁶ In a prospective study from the United Kingdom, the use of emollients in moderate to severe AD was considerably lower than AD guidelines recommend—approximately 10 g/d on average in adult patients. The median use of TCSs was between 35 and 38 g/mo.¹⁷ In our Finnish patient cohort, the amount of topical treatments was even lower, with a median use of emollients of 3.3 g/d and median use of TCSs of 25 g/mo. In another study from Denmark (N=322), 31% of patients with AD did not redeem their topical prescription medicaments, indicating poor adherence to topical treatment.¹⁸

It has been demonstrated that most of the patients’ habituation (tachyphylaxis) to TCSs is due to poor adherence instead of physiologic changes in tissue corticosteroid receptors.^19,20 Treatment adherence may be increased by scheduling early follow-up visits and providing adequate therapeutic patient education,²¹ which requires major efforts by the health care system and a financial investment.

Inadequate treatment will lead to more frequent disease flares and subsequently increase the medical costs for the patients and the health care system.²² In our Finnish patient cohort, a large part of direct treatment costs was due to inpatient treatment (Figure 2) even though only a small proportion of patients had been hospitalized. The patients were frequently young and otherwise in good general health, and they did not necessarily need continuous inpatient treatment and monitoring. In Finland, it will be necessary to develop more cost-effective treatment regimens for patients with AD with severe and frequent flares. Many patients would benefit from subsequent and regular sessions of topical treatment in an outpatient setting. In addition, the prevention of flares in moderate to severe AD will decrease medical costs.²³

The mean medication cost PPY was €457.40 (US $507.34), and mean total direct cost PPY was €1579.90 (US $1752.40), which indicates that AD causes a major economic burden to Finnish patients and to the Finnish health care system (Figures 1 and 2).²⁴ We did not observe significant differences between controlled and uncontrolled AD medical costs in our patient cohort (Figure 3), which may have been due to the relatively small sample size of only 16 patients in the controlled AD group. All patients attending the tertiary care hospital had moderate to severe AD, so it is likely that the patients with lower POEM scores had better-controlled disease. The POEM score estimates the grade of AD in the last 7 days, but based on the relapsing course of the disease, the grading score may differ substantially during the year in the same patient depending on the timing.^25,26

Topical calcineurin inhibitors comprised almost half of the medication costs (Figure 1), which may be caused by their higher prices compared with TCSs in Finland. In the beginning of 2019, a 50% less expensive biosimilar of tacrolimus ointment 0.1% was introduced to the Finnish market, which might decrease future treatment costs of TCIs. However, availability problems in both topical tacrolimus products were seen throughout 2019, which also may have affected the results in our study cohort. The median use of TCIs was unexpectedly low (only 30 g/y), which may be explained by different application habits. The use of large TCI amounts in some patients may have elevated mean costs.²⁷

In the Finnish public health care system, 40% of the cost for prescription medication and emollients is reimbursed after an initial deductible of €50. Emollients are reimbursed up to an amount of 1500 g/mo. Therefore, patients mostly acquired emollients as prescription medicine and not over-the-counter. Nonprescription medicaments were not included in our study, so the actual costs of topical treatment may have been higher.²⁸

In our cohort, 61.7% of the patients reported food allergies, and 70.1% reported allergic conjunctivitis. However, the study included only questionnaire-based data, and many of these patients probably had symptoms not associated with IgE-mediated allergies. The high prevalence indicates a substantial concomitant burden of more than skin symptoms in patients with AD.²⁹ Nine percent of patients reported a diagnosed psychiatric disorder, and 29.3% had self-reported anxiety or depression often or very often in the last year. Based on these findings, there may be high percentages of undiagnosed psychiatric comorbidities such as depression and anxiety disorders in patients with moderate to severe AD in Finland.³⁰ An important limitation of our study was that the patient data were based on a voluntary and anonymous survey and that depression and anxiety were addressed solely by a single question. In addition, the response rate cannot be analyzed correctly, and the demographics of the survey responders likely will differ substantially from all patients with AD at the university hospital.

Atopic dermatitis had a substantial effect on QOL in our patient cohort. Inadequate treatment of AD is known to negatively affect patient QOL and may lead to hospitalization or frequent oral corticosteroid courses.^31,32 In most cases, structured patient education and early follow-up visits may improve patient adherence to treatment and should be considered as an integral part of AD treatment.³³ In the investigated Finnish tertiary care hospital, a structured patient education system unfortunately was still lacking, though it has been proven effective elsewhere.³⁴ In addition, patient-centred educational programs are recommended in European guidelines for the treatment of AD.³⁵

Medical costs of AD may increase in the future as new treatments with higher direct costs, such as dupilumab, are introduced. Eichenfeld et al³⁶ analyzed electronic health plan claims in patients with AD with newly introduced systemic therapies and phototherapies after the availability of dupilumab in the United States (March 2017). Mean annualized total cost in all patients was $20,722; the highest in the dupilumab group with $36,505. Compared to our data, the total costs are much higher, but these are likely to rise in Finland in the future if a substantial amount (eg, 1%–5%) of patients will be on advanced therapies, including dupilumab. If advanced therapies will be introduced more broadly in Finland (eg, in the treatment of moderate AD [10%–20% of patients]), they will represent a major direct cost to the health care system. Zimmermann et al³⁷ showed in a cost-utility analysis that dupilumab improves health outcomes but with additional direct costs, and it is likely more cost-effective in patients with severe AD. Conversely, more efficient treatments may improve severe AD, reduce the need for hospitalization and recurrent doctors’ appointments as well as absence from work, and improve patient QOL,³⁸ consequently decreasing indirect medical costs and disease burden. Ariëns et al³⁹ showed in a recent registry-based study that dupilumab treatment induces a notable rise in work productivity and reduction of associated costs in patients with difficult-to-treat AD.

Conclusion

We aimed to analyze the economic burden of AD in Finland before the introduction of dupilumab. It will be interesting to see what the introduction of dupilumab and other novel systemic therapies have on total economic burden and medical costs. Most patients with AD in Finland can achieve disease control with topical treatments, but it is important to efficiently manage the patients who require additional supportive measures and specialist consultations, which may be challenging in the primary health care system because of the relapsing and remitting nature of the disease.

New imaging tools along with adaptations to existing technologies have been emerging in recent years, with the potential to improve hair diagnostics and treatment monitoring. We provide an overview of 4 noninvasive hair imaging technologies: global photography, trichoscopy, reflectance confocal microscopy (RCM), and optical coherence tomography (OCT). For each instrument, we discuss current and future applications in clinical practice and research along with advantages and disadvantages.

Global Photography

Global photography allows for the analysis of hair growth, volume, distribution, and density through serial standardized photographs.¹ Global photography was first introduced for hair growth studies in 1987 and soon after was used for hair and scalp assessments in finasteride clinical trials.²

Hair Assessment—Washed, dried, and combed hair, without hair product, are required for accurate imaging; wet conditions increase reflection and promote hair clumping, thus revealing more scalp and depicting the patient as having less hair.¹ Headshots are taken from short distances and use stereotactic positioning devices to create 4 global views: vertex, midline, frontal, and temporal.³ Stereotactic positioning involves fixing the patient’s chin and forehead as well as mounting the camera and flash device to ensure proper magnification. These adjustments ensure lighting remains consistent throughout consecutive study visits.⁴ Various grading scales are available for use in hair growth clinical studies to increase objectivity in the analysis of serial global photographs. A blinded evaluator should assess the before and after photographs to limit experimenter bias. Global photography often is combined with quantitative software analysis for improved detection of hair changes.¹

Advancements—Growing interest in improving global photography has resulted in various application-based, artificial intelligence (AI)–mediated tools to simplify photograph collection and analysis. For instance, new hair analysis software utilizes AI algorithms to account for facial features in determining the optimal angle for capturing global photographs (Figure 1), which simplifies the generation of global photography images through smartphone applications and obviates the need for additional stereotactic positioning equipment.^5,6

Limitations—Clinicians should be aware of global photography’s requirements for consistency in lighting, camera settings, film, and image processing, which can limit the accuracy of hair assessment over time if not replicated correctly.^7,8 Emerging global photography software has helped to overcome some of these limitations.

Global photography is less precise when a patient’s hair loss is less than 50%, as it is difficult to discern subtle hair changes. Thus, global photography provides limited utility in assessing minimal to moderate hair loss.⁹ Currently, global photography largely functions as an adjunct tool for other hair analysis methods rather than as a stand-alone tool.

Trichoscopy

Trichoscopy (also known as dermoscopy of the hair and scalp) may be performed with a manual dermoscope (with 10× magnification) or a digital videodermatoscope (up to 1000× magnification).^10-12 Unlike global photography, trichoscopy provides a detailed structural analysis of hair shafts, follicular openings, and perifollicular and interfollicular areas.¹³ Kinoshita-Ise and Sachdeva¹³ provided an in-depth, updated review of trichoscopy terminology with their definitions and associated conditions (with prevalence), which should be referenced when performing trichoscopic examination.

Hair Assessment—Trichoscopic assessment begins with inspection of follicular openings (also referred to as “dots”), which vary in color depending on the material filling them—degrading keratinocytes, keratin, sebaceous debris, melanin, or fractured hairs.¹³ The structure of hair shafts also is examined, showing broken hairs, short vellus hairs, and comma hairs, among others. Perifollicular areas are examined for scale, erythema, blue-gray dots, and whitish halos. Interfollicular areas are examined for pigment pattern as well as vascularization, which often presents in a looping configuration under dermoscopy. A combination of dot colorization, hair shaft structure, and perifollicular and interfollicular findings inform diagnostic algorithms of hair and scalp conditions. For example, central centrifugal cicatricial alopecia, the most common alopecia seen in Black women, has been associated with a combination of honeycomb pigment pattern, perifollicular whitish halo, pinpoint white dots, white patches, and perifollicular erythema.¹³

Advantages—Perhaps the most useful feature of trichoscopy is its ability to translate visualized features into simple diagnostic algorithms. For instance, if the clinician has diagnosed the patient with noncicatricial alopecia, they would next focus on dot colors. With black dots, the next step would be to determine whether the hairs are tapered or coiled, and so on. This systematic approach enables the clinician to narrow possible diagnoses.² An additional advantage of trichoscopy is that it examines large surface areas noninvasively as compared to hair-pull tests and scalp biopsy.^14,15 Trichoscopy allows temporal comparisons of the same area for disease and treatment monitoring with more diagnostic detail than global photography.¹⁶ Trichoscopy also is useful in selecting biopsy locations by discerning and avoiding areas of scar tissue.¹⁷

Limitations—Diagnosis via the trichoscopy algorithm is limiting because it is not comprehensive of all hair and scalp disease.¹⁸ Additionally, many pathologies exhibit overlapping follicular and interfollicular patterning. For example, almost all subtypes of scarring alopecia present with hair loss and scarred follicles once they have progressed to advanced stages. Further studies should identify more specific patterns of hair and scalp pathologies, which could then be incorporated into a diagnostic algorithm.¹³

Advancements—The advent of hair analysis software has expanded the role of videodermoscopy by rapidly quantifying hair growth parameters such as hair count, follicular density, and follicular diameter, as well as interfollicular distances (Figure 2).^14,17 Vellus and terminal hairs are differentiated according to their thickness and length.¹⁷ Moreover, the software can analyze the same area of the scalp over time by either virtual tattoos, semipermanent markings, or precise location measurements, increasing intra- and interclass correlation. The rate of hair growth, hair shedding, and parameters of anagen and telogen hairs can be studied by a method termed phototrichogram whereby a transitional area of hair loss and normal hair growth is identified and trimmed to less than 1 mm from the skin surface.¹⁹ A baseline photograph is taken using videodermoscopy. After approximately 3 days, the identical region is photographed and compared with the initial image to observe changes in the hair. Software programs can distinguish the growing hair as anagen and nongrowing hair as telogen, calculating the anagen-to-telogen ratio as well as hair growth rate, which are essential measurements in hair research and clinical studies. Software programs have replaced laborious and time-consuming manual hair counts and have rapidly grown in popularity in evaluating patterned hair loss.

Reflectance Confocal Microscopy

Reflectance confocal microscopy is a noninvasive imaging tool that visualizes skin and its appendages at near-histologic resolution (lateral resolution of 0.5–1 μm). It produces grayscale horizontal images that can be taken at levels ranging from the stratum corneum to the superficial papillary dermis, corresponding to a depth of approximately 100 to 150 µm. Thus, a hair follicle can be imaged starting from the follicular ostia down to the reachable papillary dermis (Figure 3).²⁰ Image contrast is provided by differences in the size and refractive indices of cellular organelles.^21,22 There are 2 commercially available RCM devices: VivaScope 1500 and VivaScope 3000 (Caliber Imaging & Diagnostics, Inc).

VivaScope 1500, a wide-probe microscope, requires the attachment of a plastic window to the desired imaging area. The plastic window is lined with medical adhesive tape to prevent movement during imaging. The adhesive tape can pull on hair upon removal, which is not ideal for patients with existing hair loss. Additionally, the image quality of VivaSope 1500 is best in flat areas and areas where hair is shaved.^20,23,24 Despite these disadvantages, VivaScope 1500 has successfully shown utility in research studies, which suggests that these obstacles can be overcome by experienced users. The handheld VivaScope 3000 is ergonomically designed and suitable for curved surfaces such as the scalp, with the advantage of not requiring any adhesive. However, the images acquired from the VivaScope 3000 cover a smaller surface area.

Structures Visualized—Structures distinguished with RCM include keratinocytes, melanocytes, inflammatory cells, hair follicles, hair shafts, adnexal infundibular epithelium, blood vessels, fibroblasts, and collagen.²³ Real-time visualization of blood flow also can be seen.

Applications of RCM—Reflectance confocal microscopy has been used to study scalp discoid lupus, lichen planopilaris, frontal fibrosing alopecia, folliculitis decalvans, chemotherapy-induced alopecia (CIA), alopecia areata, and androgenetic alopecia. Diagnostic RCM criteria for such alopecias have been developed based on their correspondence to histopathology. An RCM study of classic lichen planopilaris and frontal fibrosing alopecia identified features of epidermal disarray, infundibular hyperkeratosis, inflammatory cells, pigment incontinence, perifollicular fibrosis, bandlike scarring, melanophages in the dermis, dilated blood vessels, basal layer vacuolar degeneration, and necrotic keratinocytes.²⁵ Pigment incontinence in the superficial epidermis, perifollicular lichenoid inflammation, and hyperkeratosis were characteristic RCM features of early-stage lichen planopilaris, while perifollicular fibrosis and dilated blood vessels were characteristic RCM features of late-stage disease. The ability of RCM features to distinguish different stages of lichen planopilaris shows its potential in treating early disease and preventing irreversible hair loss.

Differentiating between scarring and nonscarring alopecia also is possible through RCM. The presence of periadnexal, epidermal, and dermal inflammatory cells, in addition to periadnexal sclerosis, are defining RCM features of scarring alopecia.²⁶ These features are absent in nonscarring alopecias. Reflectance confocal microscopy additionally has been shown to be useful in the treatment monitoring of lichen planopilaris and discoid lupus erythematosus.²⁰ Independent reviewers, blinded to the patients’ identities, were able to characterize and follow features of these scarring alopecias by RCM. The assessed RCM features were comparable to those observed by histopathologic evaluation: epidermal disarray, spongiosis, exocytosis of inflammatory cells in the epidermis, interface dermatitis, peri- and intra-adnexal infiltration of inflammatory cells, dilated vessels in the dermis, dermal infiltration of inflammatory cells and melanophages, and dermal sclerosis. A reduction in inflammatory cells across multiple skin layers and at the level of the adnexal epithelium correlated with clinical response to treatment. Reflectance confocal microscopy also was able to detect recurrence of inflammation in cases where treatment had been interrupted before clinical signs of disease recurrence were evident. The authors thus concluded that RCM’s sensitivity can guide timing of treatment and avoid delays in starting or restarting treatment.²⁰

Reflectance confocal microscopy also has served as a learning tool for new subclinical understandings of alopecia. In a study of CIA, the disease was found to be a dynamic process that could be categorized into 4 distinct phases distinguishable by combined confocal and dermoscopic features. This study also identified a new feature observable on RCM images—a CIA dot—defined as a dilated follicular infundibulum containing mashed, malted, nonhomogeneous material and normal or fragmented hair. This dot is thought to represent the initial microscopic sign of direct toxicity of chemotherapy on the hair follicle. Chemotherapy-induced alopecia dots persist throughout chemotherapy and subsequently disappear after chemotherapy ends.²⁷

Limitations and Advantages—Currently, subtypes of cicatricial alopecias cannot be characterized on RCM because inflammatory cell types are not distinguished from each other (eg, eosinophils vs neutrophils). Another limitation of RCM is the loss of resolution below the superficial papillary dermis (a depth of approximately 150 µm); thus, deeper structures, such as the hair bulb, cannot be visualized.

Unlike global photography and trichoscopy, which are low-cost methods, RCM is much more costly, ranging upwards of several thousand dollars, and it may require additional technical support fees, making it less accessible for clinical practice. However, RCM imaging continues to be recommended as an intermediate step between trichoscopy and histology for the diagnosis and management of hair disease.²⁶ If a biopsy is required, RCM can aid in the selection of a biopsy site, as areas with active inflammation are more informative than atrophic and fibrosed areas.²³ The role of RCM in trichoscopy can be expanded by designing a more cost-effective and ergonomically suited scope for hair and scalp assessment.

Optical Coherence Tomography

Optical coherence tomography is a noninvasive handheld device that emits low-power infrared light to visualize the skin and adnexal structures. Optical coherence tomography relies on the principle of interferometry to detect phase differences in optical backscattering at varying tissue depths.^28,29 It allows visualization up to 2 mm, which is 2 to 5 times deeper than RCM.³⁶ Unlike RCM, which has cellular resolution, OCT has an axial resolution of 3 to 15 μm, which allows only for the detection of structural boundaries.³⁰ There are various OCT modalities that differ in lateral and axial resolutions and maximum depth. Commercial software is available that measures changes in vascular density by depth, epidermal thickness, skin surface texture, and optical attenuation—the latter being an indirect measurement of collagen density and skin hydration.

Structures Visualized—Hair follicles can be well distinguished on OCT images, and as such, OCT is recognized as a diagnostic tool in trichology (Figure 4).³¹ Follicular openings, interfollicular collagen, and outlines of the hair shafts are visible; however, detailed components of the follicular unit cannot be visualized by OCT. Keratin hyperrefractivity identifies the hair shaft. Additionally, the hair matrix is denoted by a slightly granular texture in the dermis. Dynamic OCT produces colorized images that visualize blood flow within vessels.

Applications of OCT—Optical coherence tomography is utilized in investigative trichology because it provides highly reproducible measurements of hair shaft diameters, cross-sectional surface areas, and form factor, which is a surrogate parameter for hair shape. The cross-section of hair shafts provides insight into local metabolism and perifollicular inflammation. Cross-sections of hair shafts in areas of alopecia areata were found to be smaller than cross-sections in the unaffected scalp within the same individual.³² Follicular density can be manually quantified on OCT images, but there also is promise for automated quantification. A recent study by Urban et al³³ described training a convolutional neural network to automatically count hair as well as hair-bearing and non–hair-bearing follicles in OCT scans. These investigators also were able to color-code hair according to height, resulting in the creation of a “height” map.

Optical coherence tomography has furthered our understanding of the pathophysiology of cicatricial and nonscarring alopecias. Vazquez-Herrera et al³⁴ assessed the inflammatory and cicatricial stages of frontal fibrosing alopecia by OCT imaging. Inflammatory hairlines, which are seen in the early stages of frontal fibrosing alopecia, exhibited a thickened dermis, irregular distribution of collagen, and increased vascularity in both the superficial and deep dermal layers compared to cicatricial and healthy scalp. Conversely, late-stage cicatricial areas exhibited a thin dermis and collagen that appeared in a hyperreflective, concentric, onion-shaped pattern around remnant follicular openings. Vascular flow was reduced in the superficial dermis of a cicatricial scalp but increased in the deep dermal layers compared with a healthy scalp. The attenuation coefficients of these disease stages also were assessed. The attenuation coefficient of the inflammatory hairline was higher compared with normal skin, likely as a reflection of inflammatory infiltrate and edema, whereas the attenuation coefficient of cicatricial scalp was lower compared with normal skin, likely reflecting the reduced water content of atrophic skin.³⁴ This differentiation of early- and late-stage cicatricial alopecias has implications for early treatment and improved prognosis. Additionally, there is potential for OCT to assist in the differentiation of alopecia subtypes, as it can measure the epidermal thickness and follicular density and was previously used to compare scarring and nonscarring alopecia.³⁵

Advantages and Limitations—Similar to RCM, OCT may be cost prohibitive for some clinicians. In addition, OCT cannot visualize the follicular unit in cellular detail. However, the extent of OCT’s capabilities may not be fully realized. Dynamic OCT is a new angiographic type of OCT that shows potential in monitoring early subclinical responses to novel alopecia therapies, such as platelet-rich plasminogen, which is hypothesized to stimulate hair growth through angiogenesis. Additionally, OCT may improve outcomes of hair transplantation procedures by allowing for visualization of the subcutaneous angle of hair follicles. Blind extraction of hair follicles in follicular unit extraction procedures can result in inadvertent transection and damage to the hair follicle; OCT could help identify good candidates for follicular unit extraction, such as patients with hair follicles in parallel arrangement, who are predicted to have better results.³⁶

Conclusion

The field of trichology will continue to evolve with the emergence of noninvasive imaging technologies that diagnose hair disease in early stages and enable treatment monitoring with quantification of hair parameters. As discussed in this review, global photography, trichoscopy, RCM, and OCT have furthered our understanding of alopecia pathophysiology and provided objective methods of treatment evaluation. The capabilities of these tools will continue to expand with advancements in add-on software and AI algorithms.

New imaging tools along with adaptations to existing technologies have been emerging in recent years, with the potential to improve hair diagnostics and treatment monitoring. We provide an overview of 4 noninvasive hair imaging technologies: global photography, trichoscopy, reflectance confocal microscopy (RCM), and optical coherence tomography (OCT). For each instrument, we discuss current and future applications in clinical practice and research along with advantages and disadvantages.

Global Photography

Global photography allows for the analysis of hair growth, volume, distribution, and density through serial standardized photographs.¹ Global photography was first introduced for hair growth studies in 1987 and soon after was used for hair and scalp assessments in finasteride clinical trials.²

Hair Assessment—Washed, dried, and combed hair, without hair product, are required for accurate imaging; wet conditions increase reflection and promote hair clumping, thus revealing more scalp and depicting the patient as having less hair.¹ Headshots are taken from short distances and use stereotactic positioning devices to create 4 global views: vertex, midline, frontal, and temporal.³ Stereotactic positioning involves fixing the patient’s chin and forehead as well as mounting the camera and flash device to ensure proper magnification. These adjustments ensure lighting remains consistent throughout consecutive study visits.⁴ Various grading scales are available for use in hair growth clinical studies to increase objectivity in the analysis of serial global photographs. A blinded evaluator should assess the before and after photographs to limit experimenter bias. Global photography often is combined with quantitative software analysis for improved detection of hair changes.¹

Advancements—Growing interest in improving global photography has resulted in various application-based, artificial intelligence (AI)–mediated tools to simplify photograph collection and analysis. For instance, new hair analysis software utilizes AI algorithms to account for facial features in determining the optimal angle for capturing global photographs (Figure 1), which simplifies the generation of global photography images through smartphone applications and obviates the need for additional stereotactic positioning equipment.^5,6

Limitations—Clinicians should be aware of global photography’s requirements for consistency in lighting, camera settings, film, and image processing, which can limit the accuracy of hair assessment over time if not replicated correctly.^7,8 Emerging global photography software has helped to overcome some of these limitations.

Global photography is less precise when a patient’s hair loss is less than 50%, as it is difficult to discern subtle hair changes. Thus, global photography provides limited utility in assessing minimal to moderate hair loss.⁹ Currently, global photography largely functions as an adjunct tool for other hair analysis methods rather than as a stand-alone tool.

Trichoscopy

Trichoscopy (also known as dermoscopy of the hair and scalp) may be performed with a manual dermoscope (with 10× magnification) or a digital videodermatoscope (up to 1000× magnification).^10-12 Unlike global photography, trichoscopy provides a detailed structural analysis of hair shafts, follicular openings, and perifollicular and interfollicular areas.¹³ Kinoshita-Ise and Sachdeva¹³ provided an in-depth, updated review of trichoscopy terminology with their definitions and associated conditions (with prevalence), which should be referenced when performing trichoscopic examination.

Hair Assessment—Trichoscopic assessment begins with inspection of follicular openings (also referred to as “dots”), which vary in color depending on the material filling them—degrading keratinocytes, keratin, sebaceous debris, melanin, or fractured hairs.¹³ The structure of hair shafts also is examined, showing broken hairs, short vellus hairs, and comma hairs, among others. Perifollicular areas are examined for scale, erythema, blue-gray dots, and whitish halos. Interfollicular areas are examined for pigment pattern as well as vascularization, which often presents in a looping configuration under dermoscopy. A combination of dot colorization, hair shaft structure, and perifollicular and interfollicular findings inform diagnostic algorithms of hair and scalp conditions. For example, central centrifugal cicatricial alopecia, the most common alopecia seen in Black women, has been associated with a combination of honeycomb pigment pattern, perifollicular whitish halo, pinpoint white dots, white patches, and perifollicular erythema.¹³

Advantages—Perhaps the most useful feature of trichoscopy is its ability to translate visualized features into simple diagnostic algorithms. For instance, if the clinician has diagnosed the patient with noncicatricial alopecia, they would next focus on dot colors. With black dots, the next step would be to determine whether the hairs are tapered or coiled, and so on. This systematic approach enables the clinician to narrow possible diagnoses.² An additional advantage of trichoscopy is that it examines large surface areas noninvasively as compared to hair-pull tests and scalp biopsy.^14,15 Trichoscopy allows temporal comparisons of the same area for disease and treatment monitoring with more diagnostic detail than global photography.¹⁶ Trichoscopy also is useful in selecting biopsy locations by discerning and avoiding areas of scar tissue.¹⁷

Limitations—Diagnosis via the trichoscopy algorithm is limiting because it is not comprehensive of all hair and scalp disease.¹⁸ Additionally, many pathologies exhibit overlapping follicular and interfollicular patterning. For example, almost all subtypes of scarring alopecia present with hair loss and scarred follicles once they have progressed to advanced stages. Further studies should identify more specific patterns of hair and scalp pathologies, which could then be incorporated into a diagnostic algorithm.¹³

Advancements—The advent of hair analysis software has expanded the role of videodermoscopy by rapidly quantifying hair growth parameters such as hair count, follicular density, and follicular diameter, as well as interfollicular distances (Figure 2).^14,17 Vellus and terminal hairs are differentiated according to their thickness and length.¹⁷ Moreover, the software can analyze the same area of the scalp over time by either virtual tattoos, semipermanent markings, or precise location measurements, increasing intra- and interclass correlation. The rate of hair growth, hair shedding, and parameters of anagen and telogen hairs can be studied by a method termed phototrichogram whereby a transitional area of hair loss and normal hair growth is identified and trimmed to less than 1 mm from the skin surface.¹⁹ A baseline photograph is taken using videodermoscopy. After approximately 3 days, the identical region is photographed and compared with the initial image to observe changes in the hair. Software programs can distinguish the growing hair as anagen and nongrowing hair as telogen, calculating the anagen-to-telogen ratio as well as hair growth rate, which are essential measurements in hair research and clinical studies. Software programs have replaced laborious and time-consuming manual hair counts and have rapidly grown in popularity in evaluating patterned hair loss.

Reflectance Confocal Microscopy

Reflectance confocal microscopy is a noninvasive imaging tool that visualizes skin and its appendages at near-histologic resolution (lateral resolution of 0.5–1 μm). It produces grayscale horizontal images that can be taken at levels ranging from the stratum corneum to the superficial papillary dermis, corresponding to a depth of approximately 100 to 150 µm. Thus, a hair follicle can be imaged starting from the follicular ostia down to the reachable papillary dermis (Figure 3).²⁰ Image contrast is provided by differences in the size and refractive indices of cellular organelles.^21,22 There are 2 commercially available RCM devices: VivaScope 1500 and VivaScope 3000 (Caliber Imaging & Diagnostics, Inc).

VivaScope 1500, a wide-probe microscope, requires the attachment of a plastic window to the desired imaging area. The plastic window is lined with medical adhesive tape to prevent movement during imaging. The adhesive tape can pull on hair upon removal, which is not ideal for patients with existing hair loss. Additionally, the image quality of VivaSope 1500 is best in flat areas and areas where hair is shaved.^20,23,24 Despite these disadvantages, VivaScope 1500 has successfully shown utility in research studies, which suggests that these obstacles can be overcome by experienced users. The handheld VivaScope 3000 is ergonomically designed and suitable for curved surfaces such as the scalp, with the advantage of not requiring any adhesive. However, the images acquired from the VivaScope 3000 cover a smaller surface area.

Structures Visualized—Structures distinguished with RCM include keratinocytes, melanocytes, inflammatory cells, hair follicles, hair shafts, adnexal infundibular epithelium, blood vessels, fibroblasts, and collagen.²³ Real-time visualization of blood flow also can be seen.

Applications of RCM—Reflectance confocal microscopy has been used to study scalp discoid lupus, lichen planopilaris, frontal fibrosing alopecia, folliculitis decalvans, chemotherapy-induced alopecia (CIA), alopecia areata, and androgenetic alopecia. Diagnostic RCM criteria for such alopecias have been developed based on their correspondence to histopathology. An RCM study of classic lichen planopilaris and frontal fibrosing alopecia identified features of epidermal disarray, infundibular hyperkeratosis, inflammatory cells, pigment incontinence, perifollicular fibrosis, bandlike scarring, melanophages in the dermis, dilated blood vessels, basal layer vacuolar degeneration, and necrotic keratinocytes.²⁵ Pigment incontinence in the superficial epidermis, perifollicular lichenoid inflammation, and hyperkeratosis were characteristic RCM features of early-stage lichen planopilaris, while perifollicular fibrosis and dilated blood vessels were characteristic RCM features of late-stage disease. The ability of RCM features to distinguish different stages of lichen planopilaris shows its potential in treating early disease and preventing irreversible hair loss.

Differentiating between scarring and nonscarring alopecia also is possible through RCM. The presence of periadnexal, epidermal, and dermal inflammatory cells, in addition to periadnexal sclerosis, are defining RCM features of scarring alopecia.²⁶ These features are absent in nonscarring alopecias. Reflectance confocal microscopy additionally has been shown to be useful in the treatment monitoring of lichen planopilaris and discoid lupus erythematosus.²⁰ Independent reviewers, blinded to the patients’ identities, were able to characterize and follow features of these scarring alopecias by RCM. The assessed RCM features were comparable to those observed by histopathologic evaluation: epidermal disarray, spongiosis, exocytosis of inflammatory cells in the epidermis, interface dermatitis, peri- and intra-adnexal infiltration of inflammatory cells, dilated vessels in the dermis, dermal infiltration of inflammatory cells and melanophages, and dermal sclerosis. A reduction in inflammatory cells across multiple skin layers and at the level of the adnexal epithelium correlated with clinical response to treatment. Reflectance confocal microscopy also was able to detect recurrence of inflammation in cases where treatment had been interrupted before clinical signs of disease recurrence were evident. The authors thus concluded that RCM’s sensitivity can guide timing of treatment and avoid delays in starting or restarting treatment.²⁰

Reflectance confocal microscopy also has served as a learning tool for new subclinical understandings of alopecia. In a study of CIA, the disease was found to be a dynamic process that could be categorized into 4 distinct phases distinguishable by combined confocal and dermoscopic features. This study also identified a new feature observable on RCM images—a CIA dot—defined as a dilated follicular infundibulum containing mashed, malted, nonhomogeneous material and normal or fragmented hair. This dot is thought to represent the initial microscopic sign of direct toxicity of chemotherapy on the hair follicle. Chemotherapy-induced alopecia dots persist throughout chemotherapy and subsequently disappear after chemotherapy ends.²⁷

Limitations and Advantages—Currently, subtypes of cicatricial alopecias cannot be characterized on RCM because inflammatory cell types are not distinguished from each other (eg, eosinophils vs neutrophils). Another limitation of RCM is the loss of resolution below the superficial papillary dermis (a depth of approximately 150 µm); thus, deeper structures, such as the hair bulb, cannot be visualized.

Unlike global photography and trichoscopy, which are low-cost methods, RCM is much more costly, ranging upwards of several thousand dollars, and it may require additional technical support fees, making it less accessible for clinical practice. However, RCM imaging continues to be recommended as an intermediate step between trichoscopy and histology for the diagnosis and management of hair disease.²⁶ If a biopsy is required, RCM can aid in the selection of a biopsy site, as areas with active inflammation are more informative than atrophic and fibrosed areas.²³ The role of RCM in trichoscopy can be expanded by designing a more cost-effective and ergonomically suited scope for hair and scalp assessment.

Optical Coherence Tomography

Optical coherence tomography is a noninvasive handheld device that emits low-power infrared light to visualize the skin and adnexal structures. Optical coherence tomography relies on the principle of interferometry to detect phase differences in optical backscattering at varying tissue depths.^28,29 It allows visualization up to 2 mm, which is 2 to 5 times deeper than RCM.³⁶ Unlike RCM, which has cellular resolution, OCT has an axial resolution of 3 to 15 μm, which allows only for the detection of structural boundaries.³⁰ There are various OCT modalities that differ in lateral and axial resolutions and maximum depth. Commercial software is available that measures changes in vascular density by depth, epidermal thickness, skin surface texture, and optical attenuation—the latter being an indirect measurement of collagen density and skin hydration.

Structures Visualized—Hair follicles can be well distinguished on OCT images, and as such, OCT is recognized as a diagnostic tool in trichology (Figure 4).³¹ Follicular openings, interfollicular collagen, and outlines of the hair shafts are visible; however, detailed components of the follicular unit cannot be visualized by OCT. Keratin hyperrefractivity identifies the hair shaft. Additionally, the hair matrix is denoted by a slightly granular texture in the dermis. Dynamic OCT produces colorized images that visualize blood flow within vessels.

Applications of OCT—Optical coherence tomography is utilized in investigative trichology because it provides highly reproducible measurements of hair shaft diameters, cross-sectional surface areas, and form factor, which is a surrogate parameter for hair shape. The cross-section of hair shafts provides insight into local metabolism and perifollicular inflammation. Cross-sections of hair shafts in areas of alopecia areata were found to be smaller than cross-sections in the unaffected scalp within the same individual.³² Follicular density can be manually quantified on OCT images, but there also is promise for automated quantification. A recent study by Urban et al³³ described training a convolutional neural network to automatically count hair as well as hair-bearing and non–hair-bearing follicles in OCT scans. These investigators also were able to color-code hair according to height, resulting in the creation of a “height” map.

Optical coherence tomography has furthered our understanding of the pathophysiology of cicatricial and nonscarring alopecias. Vazquez-Herrera et al³⁴ assessed the inflammatory and cicatricial stages of frontal fibrosing alopecia by OCT imaging. Inflammatory hairlines, which are seen in the early stages of frontal fibrosing alopecia, exhibited a thickened dermis, irregular distribution of collagen, and increased vascularity in both the superficial and deep dermal layers compared to cicatricial and healthy scalp. Conversely, late-stage cicatricial areas exhibited a thin dermis and collagen that appeared in a hyperreflective, concentric, onion-shaped pattern around remnant follicular openings. Vascular flow was reduced in the superficial dermis of a cicatricial scalp but increased in the deep dermal layers compared with a healthy scalp. The attenuation coefficients of these disease stages also were assessed. The attenuation coefficient of the inflammatory hairline was higher compared with normal skin, likely as a reflection of inflammatory infiltrate and edema, whereas the attenuation coefficient of cicatricial scalp was lower compared with normal skin, likely reflecting the reduced water content of atrophic skin.³⁴ This differentiation of early- and late-stage cicatricial alopecias has implications for early treatment and improved prognosis. Additionally, there is potential for OCT to assist in the differentiation of alopecia subtypes, as it can measure the epidermal thickness and follicular density and was previously used to compare scarring and nonscarring alopecia.³⁵

Advantages and Limitations—Similar to RCM, OCT may be cost prohibitive for some clinicians. In addition, OCT cannot visualize the follicular unit in cellular detail. However, the extent of OCT’s capabilities may not be fully realized. Dynamic OCT is a new angiographic type of OCT that shows potential in monitoring early subclinical responses to novel alopecia therapies, such as platelet-rich plasminogen, which is hypothesized to stimulate hair growth through angiogenesis. Additionally, OCT may improve outcomes of hair transplantation procedures by allowing for visualization of the subcutaneous angle of hair follicles. Blind extraction of hair follicles in follicular unit extraction procedures can result in inadvertent transection and damage to the hair follicle; OCT could help identify good candidates for follicular unit extraction, such as patients with hair follicles in parallel arrangement, who are predicted to have better results.³⁶

Conclusion

The field of trichology will continue to evolve with the emergence of noninvasive imaging technologies that diagnose hair disease in early stages and enable treatment monitoring with quantification of hair parameters. As discussed in this review, global photography, trichoscopy, RCM, and OCT have furthered our understanding of alopecia pathophysiology and provided objective methods of treatment evaluation. The capabilities of these tools will continue to expand with advancements in add-on software and AI algorithms.

New imaging tools along with adaptations to existing technologies have been emerging in recent years, with the potential to improve hair diagnostics and treatment monitoring. We provide an overview of 4 noninvasive hair imaging technologies: global photography, trichoscopy, reflectance confocal microscopy (RCM), and optical coherence tomography (OCT). For each instrument, we discuss current and future applications in clinical practice and research along with advantages and disadvantages.

Global Photography

Global photography allows for the analysis of hair growth, volume, distribution, and density through serial standardized photographs.¹ Global photography was first introduced for hair growth studies in 1987 and soon after was used for hair and scalp assessments in finasteride clinical trials.²

Hair Assessment—Washed, dried, and combed hair, without hair product, are required for accurate imaging; wet conditions increase reflection and promote hair clumping, thus revealing more scalp and depicting the patient as having less hair.¹ Headshots are taken from short distances and use stereotactic positioning devices to create 4 global views: vertex, midline, frontal, and temporal.³ Stereotactic positioning involves fixing the patient’s chin and forehead as well as mounting the camera and flash device to ensure proper magnification. These adjustments ensure lighting remains consistent throughout consecutive study visits.⁴ Various grading scales are available for use in hair growth clinical studies to increase objectivity in the analysis of serial global photographs. A blinded evaluator should assess the before and after photographs to limit experimenter bias. Global photography often is combined with quantitative software analysis for improved detection of hair changes.¹

Advancements—Growing interest in improving global photography has resulted in various application-based, artificial intelligence (AI)–mediated tools to simplify photograph collection and analysis. For instance, new hair analysis software utilizes AI algorithms to account for facial features in determining the optimal angle for capturing global photographs (Figure 1), which simplifies the generation of global photography images through smartphone applications and obviates the need for additional stereotactic positioning equipment.^5,6

Limitations—Clinicians should be aware of global photography’s requirements for consistency in lighting, camera settings, film, and image processing, which can limit the accuracy of hair assessment over time if not replicated correctly.^7,8 Emerging global photography software has helped to overcome some of these limitations.

Global photography is less precise when a patient’s hair loss is less than 50%, as it is difficult to discern subtle hair changes. Thus, global photography provides limited utility in assessing minimal to moderate hair loss.⁹ Currently, global photography largely functions as an adjunct tool for other hair analysis methods rather than as a stand-alone tool.

Trichoscopy

Trichoscopy (also known as dermoscopy of the hair and scalp) may be performed with a manual dermoscope (with 10× magnification) or a digital videodermatoscope (up to 1000× magnification).^10-12 Unlike global photography, trichoscopy provides a detailed structural analysis of hair shafts, follicular openings, and perifollicular and interfollicular areas.¹³ Kinoshita-Ise and Sachdeva¹³ provided an in-depth, updated review of trichoscopy terminology with their definitions and associated conditions (with prevalence), which should be referenced when performing trichoscopic examination.

Hair Assessment—Trichoscopic assessment begins with inspection of follicular openings (also referred to as “dots”), which vary in color depending on the material filling them—degrading keratinocytes, keratin, sebaceous debris, melanin, or fractured hairs.¹³ The structure of hair shafts also is examined, showing broken hairs, short vellus hairs, and comma hairs, among others. Perifollicular areas are examined for scale, erythema, blue-gray dots, and whitish halos. Interfollicular areas are examined for pigment pattern as well as vascularization, which often presents in a looping configuration under dermoscopy. A combination of dot colorization, hair shaft structure, and perifollicular and interfollicular findings inform diagnostic algorithms of hair and scalp conditions. For example, central centrifugal cicatricial alopecia, the most common alopecia seen in Black women, has been associated with a combination of honeycomb pigment pattern, perifollicular whitish halo, pinpoint white dots, white patches, and perifollicular erythema.¹³

Advantages—Perhaps the most useful feature of trichoscopy is its ability to translate visualized features into simple diagnostic algorithms. For instance, if the clinician has diagnosed the patient with noncicatricial alopecia, they would next focus on dot colors. With black dots, the next step would be to determine whether the hairs are tapered or coiled, and so on. This systematic approach enables the clinician to narrow possible diagnoses.² An additional advantage of trichoscopy is that it examines large surface areas noninvasively as compared to hair-pull tests and scalp biopsy.^14,15 Trichoscopy allows temporal comparisons of the same area for disease and treatment monitoring with more diagnostic detail than global photography.¹⁶ Trichoscopy also is useful in selecting biopsy locations by discerning and avoiding areas of scar tissue.¹⁷

Limitations—Diagnosis via the trichoscopy algorithm is limiting because it is not comprehensive of all hair and scalp disease.¹⁸ Additionally, many pathologies exhibit overlapping follicular and interfollicular patterning. For example, almost all subtypes of scarring alopecia present with hair loss and scarred follicles once they have progressed to advanced stages. Further studies should identify more specific patterns of hair and scalp pathologies, which could then be incorporated into a diagnostic algorithm.¹³

Advancements—The advent of hair analysis software has expanded the role of videodermoscopy by rapidly quantifying hair growth parameters such as hair count, follicular density, and follicular diameter, as well as interfollicular distances (Figure 2).^14,17 Vellus and terminal hairs are differentiated according to their thickness and length.¹⁷ Moreover, the software can analyze the same area of the scalp over time by either virtual tattoos, semipermanent markings, or precise location measurements, increasing intra- and interclass correlation. The rate of hair growth, hair shedding, and parameters of anagen and telogen hairs can be studied by a method termed phototrichogram whereby a transitional area of hair loss and normal hair growth is identified and trimmed to less than 1 mm from the skin surface.¹⁹ A baseline photograph is taken using videodermoscopy. After approximately 3 days, the identical region is photographed and compared with the initial image to observe changes in the hair. Software programs can distinguish the growing hair as anagen and nongrowing hair as telogen, calculating the anagen-to-telogen ratio as well as hair growth rate, which are essential measurements in hair research and clinical studies. Software programs have replaced laborious and time-consuming manual hair counts and have rapidly grown in popularity in evaluating patterned hair loss.

Reflectance Confocal Microscopy

Reflectance confocal microscopy is a noninvasive imaging tool that visualizes skin and its appendages at near-histologic resolution (lateral resolution of 0.5–1 μm). It produces grayscale horizontal images that can be taken at levels ranging from the stratum corneum to the superficial papillary dermis, corresponding to a depth of approximately 100 to 150 µm. Thus, a hair follicle can be imaged starting from the follicular ostia down to the reachable papillary dermis (Figure 3).²⁰ Image contrast is provided by differences in the size and refractive indices of cellular organelles.^21,22 There are 2 commercially available RCM devices: VivaScope 1500 and VivaScope 3000 (Caliber Imaging & Diagnostics, Inc).

VivaScope 1500, a wide-probe microscope, requires the attachment of a plastic window to the desired imaging area. The plastic window is lined with medical adhesive tape to prevent movement during imaging. The adhesive tape can pull on hair upon removal, which is not ideal for patients with existing hair loss. Additionally, the image quality of VivaSope 1500 is best in flat areas and areas where hair is shaved.^20,23,24 Despite these disadvantages, VivaScope 1500 has successfully shown utility in research studies, which suggests that these obstacles can be overcome by experienced users. The handheld VivaScope 3000 is ergonomically designed and suitable for curved surfaces such as the scalp, with the advantage of not requiring any adhesive. However, the images acquired from the VivaScope 3000 cover a smaller surface area.

Structures Visualized—Structures distinguished with RCM include keratinocytes, melanocytes, inflammatory cells, hair follicles, hair shafts, adnexal infundibular epithelium, blood vessels, fibroblasts, and collagen.²³ Real-time visualization of blood flow also can be seen.

Applications of RCM—Reflectance confocal microscopy has been used to study scalp discoid lupus, lichen planopilaris, frontal fibrosing alopecia, folliculitis decalvans, chemotherapy-induced alopecia (CIA), alopecia areata, and androgenetic alopecia. Diagnostic RCM criteria for such alopecias have been developed based on their correspondence to histopathology. An RCM study of classic lichen planopilaris and frontal fibrosing alopecia identified features of epidermal disarray, infundibular hyperkeratosis, inflammatory cells, pigment incontinence, perifollicular fibrosis, bandlike scarring, melanophages in the dermis, dilated blood vessels, basal layer vacuolar degeneration, and necrotic keratinocytes.²⁵ Pigment incontinence in the superficial epidermis, perifollicular lichenoid inflammation, and hyperkeratosis were characteristic RCM features of early-stage lichen planopilaris, while perifollicular fibrosis and dilated blood vessels were characteristic RCM features of late-stage disease. The ability of RCM features to distinguish different stages of lichen planopilaris shows its potential in treating early disease and preventing irreversible hair loss.

Differentiating between scarring and nonscarring alopecia also is possible through RCM. The presence of periadnexal, epidermal, and dermal inflammatory cells, in addition to periadnexal sclerosis, are defining RCM features of scarring alopecia.²⁶ These features are absent in nonscarring alopecias. Reflectance confocal microscopy additionally has been shown to be useful in the treatment monitoring of lichen planopilaris and discoid lupus erythematosus.²⁰ Independent reviewers, blinded to the patients’ identities, were able to characterize and follow features of these scarring alopecias by RCM. The assessed RCM features were comparable to those observed by histopathologic evaluation: epidermal disarray, spongiosis, exocytosis of inflammatory cells in the epidermis, interface dermatitis, peri- and intra-adnexal infiltration of inflammatory cells, dilated vessels in the dermis, dermal infiltration of inflammatory cells and melanophages, and dermal sclerosis. A reduction in inflammatory cells across multiple skin layers and at the level of the adnexal epithelium correlated with clinical response to treatment. Reflectance confocal microscopy also was able to detect recurrence of inflammation in cases where treatment had been interrupted before clinical signs of disease recurrence were evident. The authors thus concluded that RCM’s sensitivity can guide timing of treatment and avoid delays in starting or restarting treatment.²⁰

Reflectance confocal microscopy also has served as a learning tool for new subclinical understandings of alopecia. In a study of CIA, the disease was found to be a dynamic process that could be categorized into 4 distinct phases distinguishable by combined confocal and dermoscopic features. This study also identified a new feature observable on RCM images—a CIA dot—defined as a dilated follicular infundibulum containing mashed, malted, nonhomogeneous material and normal or fragmented hair. This dot is thought to represent the initial microscopic sign of direct toxicity of chemotherapy on the hair follicle. Chemotherapy-induced alopecia dots persist throughout chemotherapy and subsequently disappear after chemotherapy ends.²⁷

Limitations and Advantages—Currently, subtypes of cicatricial alopecias cannot be characterized on RCM because inflammatory cell types are not distinguished from each other (eg, eosinophils vs neutrophils). Another limitation of RCM is the loss of resolution below the superficial papillary dermis (a depth of approximately 150 µm); thus, deeper structures, such as the hair bulb, cannot be visualized.

Unlike global photography and trichoscopy, which are low-cost methods, RCM is much more costly, ranging upwards of several thousand dollars, and it may require additional technical support fees, making it less accessible for clinical practice. However, RCM imaging continues to be recommended as an intermediate step between trichoscopy and histology for the diagnosis and management of hair disease.²⁶ If a biopsy is required, RCM can aid in the selection of a biopsy site, as areas with active inflammation are more informative than atrophic and fibrosed areas.²³ The role of RCM in trichoscopy can be expanded by designing a more cost-effective and ergonomically suited scope for hair and scalp assessment.

Optical Coherence Tomography

Optical coherence tomography is a noninvasive handheld device that emits low-power infrared light to visualize the skin and adnexal structures. Optical coherence tomography relies on the principle of interferometry to detect phase differences in optical backscattering at varying tissue depths.^28,29 It allows visualization up to 2 mm, which is 2 to 5 times deeper than RCM.³⁶ Unlike RCM, which has cellular resolution, OCT has an axial resolution of 3 to 15 μm, which allows only for the detection of structural boundaries.³⁰ There are various OCT modalities that differ in lateral and axial resolutions and maximum depth. Commercial software is available that measures changes in vascular density by depth, epidermal thickness, skin surface texture, and optical attenuation—the latter being an indirect measurement of collagen density and skin hydration.

Structures Visualized—Hair follicles can be well distinguished on OCT images, and as such, OCT is recognized as a diagnostic tool in trichology (Figure 4).³¹ Follicular openings, interfollicular collagen, and outlines of the hair shafts are visible; however, detailed components of the follicular unit cannot be visualized by OCT. Keratin hyperrefractivity identifies the hair shaft. Additionally, the hair matrix is denoted by a slightly granular texture in the dermis. Dynamic OCT produces colorized images that visualize blood flow within vessels.

Applications of OCT—Optical coherence tomography is utilized in investigative trichology because it provides highly reproducible measurements of hair shaft diameters, cross-sectional surface areas, and form factor, which is a surrogate parameter for hair shape. The cross-section of hair shafts provides insight into local metabolism and perifollicular inflammation. Cross-sections of hair shafts in areas of alopecia areata were found to be smaller than cross-sections in the unaffected scalp within the same individual.³² Follicular density can be manually quantified on OCT images, but there also is promise for automated quantification. A recent study by Urban et al³³ described training a convolutional neural network to automatically count hair as well as hair-bearing and non–hair-bearing follicles in OCT scans. These investigators also were able to color-code hair according to height, resulting in the creation of a “height” map.

Optical coherence tomography has furthered our understanding of the pathophysiology of cicatricial and nonscarring alopecias. Vazquez-Herrera et al³⁴ assessed the inflammatory and cicatricial stages of frontal fibrosing alopecia by OCT imaging. Inflammatory hairlines, which are seen in the early stages of frontal fibrosing alopecia, exhibited a thickened dermis, irregular distribution of collagen, and increased vascularity in both the superficial and deep dermal layers compared to cicatricial and healthy scalp. Conversely, late-stage cicatricial areas exhibited a thin dermis and collagen that appeared in a hyperreflective, concentric, onion-shaped pattern around remnant follicular openings. Vascular flow was reduced in the superficial dermis of a cicatricial scalp but increased in the deep dermal layers compared with a healthy scalp. The attenuation coefficients of these disease stages also were assessed. The attenuation coefficient of the inflammatory hairline was higher compared with normal skin, likely as a reflection of inflammatory infiltrate and edema, whereas the attenuation coefficient of cicatricial scalp was lower compared with normal skin, likely reflecting the reduced water content of atrophic skin.³⁴ This differentiation of early- and late-stage cicatricial alopecias has implications for early treatment and improved prognosis. Additionally, there is potential for OCT to assist in the differentiation of alopecia subtypes, as it can measure the epidermal thickness and follicular density and was previously used to compare scarring and nonscarring alopecia.³⁵

Advantages and Limitations—Similar to RCM, OCT may be cost prohibitive for some clinicians. In addition, OCT cannot visualize the follicular unit in cellular detail. However, the extent of OCT’s capabilities may not be fully realized. Dynamic OCT is a new angiographic type of OCT that shows potential in monitoring early subclinical responses to novel alopecia therapies, such as platelet-rich plasminogen, which is hypothesized to stimulate hair growth through angiogenesis. Additionally, OCT may improve outcomes of hair transplantation procedures by allowing for visualization of the subcutaneous angle of hair follicles. Blind extraction of hair follicles in follicular unit extraction procedures can result in inadvertent transection and damage to the hair follicle; OCT could help identify good candidates for follicular unit extraction, such as patients with hair follicles in parallel arrangement, who are predicted to have better results.³⁶

Conclusion

The field of trichology will continue to evolve with the emergence of noninvasive imaging technologies that diagnose hair disease in early stages and enable treatment monitoring with quantification of hair parameters. As discussed in this review, global photography, trichoscopy, RCM, and OCT have furthered our understanding of alopecia pathophysiology and provided objective methods of treatment evaluation. The capabilities of these tools will continue to expand with advancements in add-on software and AI algorithms.

This transcript has been edited for clarity.

When you stub your toe or get a paper cut on your finger, you feel the pain in that part of your body. It feels like the pain is coming from that place. But, of course, that’s not really what is happening. Pain doesn’t really happen in your toe or your finger. It happens in your brain.

It’s a game of telephone, really. The afferent nerve fiber detects the noxious stimulus, passing that signal to the second-order neuron in the dorsal root ganglia of the spinal cord, which runs it up to the thalamus to be passed to the third-order neuron which brings it to the cortex for localization and conscious perception. It’s not even a very good game of telephone. It takes about 100 ms for a pain signal to get from the hand to the brain – longer from the feet, given the greater distance. You see your foot hit the corner of the coffee table and have just enough time to think: “Oh no!” before the pain hits.

Wikimedia Commons

Dr. F. Perry Wilson

The New England Journal of Medicine

Dr. F. Perry Wilson

The New England Journal of Medicine

Dr. Wilson is an associate professor of medicine and public health and director of Yale’s Clinical and Translational Research Accelerator, New Haven, Conn. He disclosed no relevant financial relationships.

A version of this article appeared on Medscape.com.

This transcript has been edited for clarity.

When you stub your toe or get a paper cut on your finger, you feel the pain in that part of your body. It feels like the pain is coming from that place. But, of course, that’s not really what is happening. Pain doesn’t really happen in your toe or your finger. It happens in your brain.

It’s a game of telephone, really. The afferent nerve fiber detects the noxious stimulus, passing that signal to the second-order neuron in the dorsal root ganglia of the spinal cord, which runs it up to the thalamus to be passed to the third-order neuron which brings it to the cortex for localization and conscious perception. It’s not even a very good game of telephone. It takes about 100 ms for a pain signal to get from the hand to the brain – longer from the feet, given the greater distance. You see your foot hit the corner of the coffee table and have just enough time to think: “Oh no!” before the pain hits.

Wikimedia Commons

Dr. F. Perry Wilson

The New England Journal of Medicine

Dr. F. Perry Wilson

The New England Journal of Medicine

Dr. Wilson is an associate professor of medicine and public health and director of Yale’s Clinical and Translational Research Accelerator, New Haven, Conn. He disclosed no relevant financial relationships.

A version of this article appeared on Medscape.com.

This transcript has been edited for clarity.

When you stub your toe or get a paper cut on your finger, you feel the pain in that part of your body. It feels like the pain is coming from that place. But, of course, that’s not really what is happening. Pain doesn’t really happen in your toe or your finger. It happens in your brain.

It’s a game of telephone, really. The afferent nerve fiber detects the noxious stimulus, passing that signal to the second-order neuron in the dorsal root ganglia of the spinal cord, which runs it up to the thalamus to be passed to the third-order neuron which brings it to the cortex for localization and conscious perception. It’s not even a very good game of telephone. It takes about 100 ms for a pain signal to get from the hand to the brain – longer from the feet, given the greater distance. You see your foot hit the corner of the coffee table and have just enough time to think: “Oh no!” before the pain hits.

Wikimedia Commons

Dr. F. Perry Wilson

The New England Journal of Medicine

Dr. F. Perry Wilson

The New England Journal of Medicine

Dr. Wilson is an associate professor of medicine and public health and director of Yale’s Clinical and Translational Research Accelerator, New Haven, Conn. He disclosed no relevant financial relationships.

A version of this article appeared on Medscape.com.