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Ulmus davidiana root extract
Ulmus davidiana, commonly known as yugeunpi, has a long history of use in Korea in treating burns, eczema, frostbite, difficulties in urination, inflammation, and psoriasis,1 and has also been used in China for some of these indications, including skin inflammation.2,3 Currently, there are several areas in which the bioactivity of U. davidiana are under investigation, with numerous potential applications in dermatology. This column focuses briefly on the evidence supporting the traditional uses of the plant and potential new applications.
Anti-inflammatory activity
Eom and colleagues studied the potential of a polysaccharide extract from the root bark of U. davidiana to serve as a suitable cosmetic ingredient for conferring moisturizing, anti-inflammatory, and photoprotective activity. In this 2006 investigation, the composition of the polysaccharide extract was found to be primarily rhamnose, galactose, and glucose. The root extract exhibited a similar humectant moisturizing effect as hyaluronic acid, the researchers reported. The U. davidiana root extract was also found to dose-dependently suppress prostaglandin E2. The inhibition of the release of interleukin-6 and IL-8 was also reported to be significant. The use of the U. davidiana extract also stimulated the recovery of human fibroblasts (two times that of positive control) exposed to UVA irradiation. The researchers suggested that their overall results point to the viability of U. davidiana root extract as a cosmetic agent ingredient to protect skin from UV exposure and the inflammation that follows.2
In 2013, Choi and colleagues found that a methanol extract of the stem and root barks of U. davidiana revealed anti-inflammatory properties, with activity attributed to two trihydroxy acids [then-new trihydroxy fatty acid, 9,12,13-trihydroxyoctadeca-10(Z),15(Z)-dienoic acid, and pinellic acid], both of which blocked prostaglandin D₂ production.4
That same year, Lyu and colleagues studied the antiallergic and anti-inflammatory effects of U. davidiana using a 1-fluoro-2,4-dinitrofluorobenzene (DNFB)–induced contact dermatitis mouse model. They found that treatment at a dose of 10 mg/mL successfully prevented skin lesions caused by consistent DNFB application. Further, the researchers observed that topically applied U. davidiana suppressed spongiosis and reduced total serum immunoglobulin and IgG2a levels. Overall, they concluded that the botanical treatment improved contact dermatitis in mice.1
In 2019, So and colleagues studied the chemical components of U. davidiana root bark (isolating a chromane derivative and 22 known substances) and reported data supporting the traditional use of the root bark for gastroenteric and inflammatory indications.3
Bakuchiol [(1E,3S)-3-ethenyl-3,7-dimethyl-1,6-octadien-1-yl]phenol, a prenylated phenolic monoterpene found in the seeds and leaves of various plants, including U. davidiana, is used for its anti-inflammatory properties in traditional Korean medicine.5 Choi and colleagues determined that bakuchiol exhibited robust anti-inflammatory activity in a study of U. davidiana constituents, at least partially accounting for the anti-inflammatory functions of the plant.5
Antifungal activity
In 2021, Alishir and colleagues conducted a phytochemical analysis of the root bark extract of U. davidiana, resulting in the isolation of 10 substances including the novel coumarin glycoside derivative ulmusakidian. Some of the compounds exhibited antifungal activity against Cryptococcus neoformans, though none demonstrated antifungal activity against Candida albicans.6
Wound dressing
Park and colleagues demonstrated in 2020 that superabsorbing hydrogel wound dressings composed of U. davidiana root bark powders, which exhibit gelling activity, performed effectively in speeding up wound closure and cutaneous regeneration in skin-wound mice models. These dressings also displayed thermal stability and superior mechanical properties to pullulan-only gel films. The researchers concluded that gel films composed of U. davidiana have potential to surpass the effectiveness of current products.7
Anti–hair loss activity
Early in 2022, Kwon and colleagues investigated the anti–hair loss mechanism of U. davidiana and determined that supercritical extraction-residues of U. davidiana significantly hinder the secretion of transforming growth factor–beta but dose dependently salvage insulinlike growth factor 1, and substantially decrease dihydrotestosterone synthesis. They concluded that these U. davidiana supercritical fluid extract residues have the potential to halt the loss of human hair.8
Photoprotective potential
Late in 2020, Her and colleagues reported on their development and analysis of a new distillate derived from a fermented mixture of nine anti-inflammatory herbs including U. davidiana. The investigators assessed the effects of the topically applied distillate on UVB-induced skin damage in Institute of Cancer Research mice, finding significant improvements in the dorsal skin photodamage. Application of the distillate also ameliorated collagen production impairment and diminished proinflammatory cytokine levels of tumor necrosis factor (TNF)–alpha and IL-1B. The researchers concluded that this anti-inflammatory herbal distillate, which includes U. davidiana, displays the potential to serve as a photoprotective agent.9
Antiaging activity
In 2011, Yang and colleagues set out to identify constituent substances of the root bark of U. davidiana that have the capacity to suppress cellular senescence in human fibroblasts and human umbilical vein endothelial cells. They isolated 22 compounds, of which epifriedelanol, ssioriside, and catechin-7-O-beta-D-glucopyranoside impeded adriamycin-induced cellular senescence in human dermal fibroblasts and friedelin, epifriedelanol, and catechin-7-O-beta-apiofuranoside in the umbilical vein endothelial cells. Epifriedelanol was the most potent of the substances, leading the researchers to conclude that this U. davidiana component can diminish cellular senescence in human primary cells and has the potential as an oral and/or topical antiaging agent.10
Also that year, in a study on the protective effects of U. davidiana on UVB-irradiated hairless mice, the authors claimed that an ethanol extract of U. davidiana significantly suppressed wrinkle development in mice chronically exposed to UVB.11 This study showed that U. davidiana extract exerts antioxidant activity as evidenced by a decrease in MMP-1 activity. It also demonstrated antielastase activity. The treated mice showed a decrease in wrinkles as compared with water-treated mice.11 Although this is just one study in mice, it may demonstrate a protective effect on elastic fibers on skin exposed to UVB light.
Late in 2020, Lee and colleagues reported on their study of the possible antiaging effects on the skin of (-)-phenolic compounds isolated from the root bark of U. davidiana. The function of collagenase MMP-1 was found to be inhibited by the isolate (-)-catechin, which also halted collagen degradation caused by TNF-alpha in normal human dermal fibroblasts. Further, the investigators demonstrated that the U. davidiana isolate (-)-catechin reduced the expression of proinflammatory cytokines such as IL-1B and IL-6. They concluded that the U. davidiana isolate exhibits the potential to combat intrinsic as well as extrinsic cutaneous aging.12
These findings are particularly intriguing. There is much overlap between intrinsic and extrinsic aging. If U. davidiana can keep collagen intact and inhibit cellular senescence, it may serve as an early intervention toward slowing or preventing skin aging.
Summary
Of greatest interest now, perhaps, is its potential to impede cellular senescence. Senescent cells release a multitude of inflammatory and other factors that hasten intrinsic aging. Blocking cellular senescence is an important approach to the prevention and treatment of skin aging.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur in Miami. She founded the division of cosmetic dermatology at the University of Miami in 1997. The third edition of her bestselling textbook, “Cosmetic Dermatology,” was published in 2022. Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Galderma, Johnson & Johnson, and Burt’s Bees. She is the CEO of Skin Type Solutions, a SaaS company used to generate skin care routines in the office and as an ecommerce solution. Write to her at [email protected].
References
1. Lyu J et al. J Pharmacopuncture. 2013 Jun;16(2):41-5.
2. Eom SY et al. J Cosmet Sci. 2006 Sep-Oct;57(5):355-67.
3. So HM et al. Bioorg Chem. 2019 Oct;91:103145.
4. Choi HG et al. Phytother Res. 2013 Sep;27(9):1376-80.
5. Choi SY et al. J Med Food. 2010 Aug;13(4):1019-23.
6. Alishir A et al. Bioorg Med Chem Lett. 2021 Mar 15;36:127828.
7. Park TH et al. Saudi Pharm J. 2020 Jul;28(7):791-802.
8. Kwon YE et al. Molecules. 2022 Feb 19;27(4):1419.
9. Her Y et al. Molecules. 2020 Dec 29;26(1):124.
10. Yang HH et al. Planta Med. 2011 Mar;77(5):441-9.
11. Kim YO et al. Korean Journal of Medicinal Crop Science. 2011;19(6):508-13.
12. Lee S et al. Antioxidants (Basel). 2020 Oct 13;9(10):981.
Ulmus davidiana, commonly known as yugeunpi, has a long history of use in Korea in treating burns, eczema, frostbite, difficulties in urination, inflammation, and psoriasis,1 and has also been used in China for some of these indications, including skin inflammation.2,3 Currently, there are several areas in which the bioactivity of U. davidiana are under investigation, with numerous potential applications in dermatology. This column focuses briefly on the evidence supporting the traditional uses of the plant and potential new applications.
Anti-inflammatory activity
Eom and colleagues studied the potential of a polysaccharide extract from the root bark of U. davidiana to serve as a suitable cosmetic ingredient for conferring moisturizing, anti-inflammatory, and photoprotective activity. In this 2006 investigation, the composition of the polysaccharide extract was found to be primarily rhamnose, galactose, and glucose. The root extract exhibited a similar humectant moisturizing effect as hyaluronic acid, the researchers reported. The U. davidiana root extract was also found to dose-dependently suppress prostaglandin E2. The inhibition of the release of interleukin-6 and IL-8 was also reported to be significant. The use of the U. davidiana extract also stimulated the recovery of human fibroblasts (two times that of positive control) exposed to UVA irradiation. The researchers suggested that their overall results point to the viability of U. davidiana root extract as a cosmetic agent ingredient to protect skin from UV exposure and the inflammation that follows.2
In 2013, Choi and colleagues found that a methanol extract of the stem and root barks of U. davidiana revealed anti-inflammatory properties, with activity attributed to two trihydroxy acids [then-new trihydroxy fatty acid, 9,12,13-trihydroxyoctadeca-10(Z),15(Z)-dienoic acid, and pinellic acid], both of which blocked prostaglandin D₂ production.4
That same year, Lyu and colleagues studied the antiallergic and anti-inflammatory effects of U. davidiana using a 1-fluoro-2,4-dinitrofluorobenzene (DNFB)–induced contact dermatitis mouse model. They found that treatment at a dose of 10 mg/mL successfully prevented skin lesions caused by consistent DNFB application. Further, the researchers observed that topically applied U. davidiana suppressed spongiosis and reduced total serum immunoglobulin and IgG2a levels. Overall, they concluded that the botanical treatment improved contact dermatitis in mice.1
In 2019, So and colleagues studied the chemical components of U. davidiana root bark (isolating a chromane derivative and 22 known substances) and reported data supporting the traditional use of the root bark for gastroenteric and inflammatory indications.3
Bakuchiol [(1E,3S)-3-ethenyl-3,7-dimethyl-1,6-octadien-1-yl]phenol, a prenylated phenolic monoterpene found in the seeds and leaves of various plants, including U. davidiana, is used for its anti-inflammatory properties in traditional Korean medicine.5 Choi and colleagues determined that bakuchiol exhibited robust anti-inflammatory activity in a study of U. davidiana constituents, at least partially accounting for the anti-inflammatory functions of the plant.5
Antifungal activity
In 2021, Alishir and colleagues conducted a phytochemical analysis of the root bark extract of U. davidiana, resulting in the isolation of 10 substances including the novel coumarin glycoside derivative ulmusakidian. Some of the compounds exhibited antifungal activity against Cryptococcus neoformans, though none demonstrated antifungal activity against Candida albicans.6
Wound dressing
Park and colleagues demonstrated in 2020 that superabsorbing hydrogel wound dressings composed of U. davidiana root bark powders, which exhibit gelling activity, performed effectively in speeding up wound closure and cutaneous regeneration in skin-wound mice models. These dressings also displayed thermal stability and superior mechanical properties to pullulan-only gel films. The researchers concluded that gel films composed of U. davidiana have potential to surpass the effectiveness of current products.7
Anti–hair loss activity
Early in 2022, Kwon and colleagues investigated the anti–hair loss mechanism of U. davidiana and determined that supercritical extraction-residues of U. davidiana significantly hinder the secretion of transforming growth factor–beta but dose dependently salvage insulinlike growth factor 1, and substantially decrease dihydrotestosterone synthesis. They concluded that these U. davidiana supercritical fluid extract residues have the potential to halt the loss of human hair.8
Photoprotective potential
Late in 2020, Her and colleagues reported on their development and analysis of a new distillate derived from a fermented mixture of nine anti-inflammatory herbs including U. davidiana. The investigators assessed the effects of the topically applied distillate on UVB-induced skin damage in Institute of Cancer Research mice, finding significant improvements in the dorsal skin photodamage. Application of the distillate also ameliorated collagen production impairment and diminished proinflammatory cytokine levels of tumor necrosis factor (TNF)–alpha and IL-1B. The researchers concluded that this anti-inflammatory herbal distillate, which includes U. davidiana, displays the potential to serve as a photoprotective agent.9
Antiaging activity
In 2011, Yang and colleagues set out to identify constituent substances of the root bark of U. davidiana that have the capacity to suppress cellular senescence in human fibroblasts and human umbilical vein endothelial cells. They isolated 22 compounds, of which epifriedelanol, ssioriside, and catechin-7-O-beta-D-glucopyranoside impeded adriamycin-induced cellular senescence in human dermal fibroblasts and friedelin, epifriedelanol, and catechin-7-O-beta-apiofuranoside in the umbilical vein endothelial cells. Epifriedelanol was the most potent of the substances, leading the researchers to conclude that this U. davidiana component can diminish cellular senescence in human primary cells and has the potential as an oral and/or topical antiaging agent.10
Also that year, in a study on the protective effects of U. davidiana on UVB-irradiated hairless mice, the authors claimed that an ethanol extract of U. davidiana significantly suppressed wrinkle development in mice chronically exposed to UVB.11 This study showed that U. davidiana extract exerts antioxidant activity as evidenced by a decrease in MMP-1 activity. It also demonstrated antielastase activity. The treated mice showed a decrease in wrinkles as compared with water-treated mice.11 Although this is just one study in mice, it may demonstrate a protective effect on elastic fibers on skin exposed to UVB light.
Late in 2020, Lee and colleagues reported on their study of the possible antiaging effects on the skin of (-)-phenolic compounds isolated from the root bark of U. davidiana. The function of collagenase MMP-1 was found to be inhibited by the isolate (-)-catechin, which also halted collagen degradation caused by TNF-alpha in normal human dermal fibroblasts. Further, the investigators demonstrated that the U. davidiana isolate (-)-catechin reduced the expression of proinflammatory cytokines such as IL-1B and IL-6. They concluded that the U. davidiana isolate exhibits the potential to combat intrinsic as well as extrinsic cutaneous aging.12
These findings are particularly intriguing. There is much overlap between intrinsic and extrinsic aging. If U. davidiana can keep collagen intact and inhibit cellular senescence, it may serve as an early intervention toward slowing or preventing skin aging.
Summary
Of greatest interest now, perhaps, is its potential to impede cellular senescence. Senescent cells release a multitude of inflammatory and other factors that hasten intrinsic aging. Blocking cellular senescence is an important approach to the prevention and treatment of skin aging.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur in Miami. She founded the division of cosmetic dermatology at the University of Miami in 1997. The third edition of her bestselling textbook, “Cosmetic Dermatology,” was published in 2022. Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Galderma, Johnson & Johnson, and Burt’s Bees. She is the CEO of Skin Type Solutions, a SaaS company used to generate skin care routines in the office and as an ecommerce solution. Write to her at [email protected].
References
1. Lyu J et al. J Pharmacopuncture. 2013 Jun;16(2):41-5.
2. Eom SY et al. J Cosmet Sci. 2006 Sep-Oct;57(5):355-67.
3. So HM et al. Bioorg Chem. 2019 Oct;91:103145.
4. Choi HG et al. Phytother Res. 2013 Sep;27(9):1376-80.
5. Choi SY et al. J Med Food. 2010 Aug;13(4):1019-23.
6. Alishir A et al. Bioorg Med Chem Lett. 2021 Mar 15;36:127828.
7. Park TH et al. Saudi Pharm J. 2020 Jul;28(7):791-802.
8. Kwon YE et al. Molecules. 2022 Feb 19;27(4):1419.
9. Her Y et al. Molecules. 2020 Dec 29;26(1):124.
10. Yang HH et al. Planta Med. 2011 Mar;77(5):441-9.
11. Kim YO et al. Korean Journal of Medicinal Crop Science. 2011;19(6):508-13.
12. Lee S et al. Antioxidants (Basel). 2020 Oct 13;9(10):981.
Ulmus davidiana, commonly known as yugeunpi, has a long history of use in Korea in treating burns, eczema, frostbite, difficulties in urination, inflammation, and psoriasis,1 and has also been used in China for some of these indications, including skin inflammation.2,3 Currently, there are several areas in which the bioactivity of U. davidiana are under investigation, with numerous potential applications in dermatology. This column focuses briefly on the evidence supporting the traditional uses of the plant and potential new applications.
Anti-inflammatory activity
Eom and colleagues studied the potential of a polysaccharide extract from the root bark of U. davidiana to serve as a suitable cosmetic ingredient for conferring moisturizing, anti-inflammatory, and photoprotective activity. In this 2006 investigation, the composition of the polysaccharide extract was found to be primarily rhamnose, galactose, and glucose. The root extract exhibited a similar humectant moisturizing effect as hyaluronic acid, the researchers reported. The U. davidiana root extract was also found to dose-dependently suppress prostaglandin E2. The inhibition of the release of interleukin-6 and IL-8 was also reported to be significant. The use of the U. davidiana extract also stimulated the recovery of human fibroblasts (two times that of positive control) exposed to UVA irradiation. The researchers suggested that their overall results point to the viability of U. davidiana root extract as a cosmetic agent ingredient to protect skin from UV exposure and the inflammation that follows.2
In 2013, Choi and colleagues found that a methanol extract of the stem and root barks of U. davidiana revealed anti-inflammatory properties, with activity attributed to two trihydroxy acids [then-new trihydroxy fatty acid, 9,12,13-trihydroxyoctadeca-10(Z),15(Z)-dienoic acid, and pinellic acid], both of which blocked prostaglandin D₂ production.4
That same year, Lyu and colleagues studied the antiallergic and anti-inflammatory effects of U. davidiana using a 1-fluoro-2,4-dinitrofluorobenzene (DNFB)–induced contact dermatitis mouse model. They found that treatment at a dose of 10 mg/mL successfully prevented skin lesions caused by consistent DNFB application. Further, the researchers observed that topically applied U. davidiana suppressed spongiosis and reduced total serum immunoglobulin and IgG2a levels. Overall, they concluded that the botanical treatment improved contact dermatitis in mice.1
In 2019, So and colleagues studied the chemical components of U. davidiana root bark (isolating a chromane derivative and 22 known substances) and reported data supporting the traditional use of the root bark for gastroenteric and inflammatory indications.3
Bakuchiol [(1E,3S)-3-ethenyl-3,7-dimethyl-1,6-octadien-1-yl]phenol, a prenylated phenolic monoterpene found in the seeds and leaves of various plants, including U. davidiana, is used for its anti-inflammatory properties in traditional Korean medicine.5 Choi and colleagues determined that bakuchiol exhibited robust anti-inflammatory activity in a study of U. davidiana constituents, at least partially accounting for the anti-inflammatory functions of the plant.5
Antifungal activity
In 2021, Alishir and colleagues conducted a phytochemical analysis of the root bark extract of U. davidiana, resulting in the isolation of 10 substances including the novel coumarin glycoside derivative ulmusakidian. Some of the compounds exhibited antifungal activity against Cryptococcus neoformans, though none demonstrated antifungal activity against Candida albicans.6
Wound dressing
Park and colleagues demonstrated in 2020 that superabsorbing hydrogel wound dressings composed of U. davidiana root bark powders, which exhibit gelling activity, performed effectively in speeding up wound closure and cutaneous regeneration in skin-wound mice models. These dressings also displayed thermal stability and superior mechanical properties to pullulan-only gel films. The researchers concluded that gel films composed of U. davidiana have potential to surpass the effectiveness of current products.7
Anti–hair loss activity
Early in 2022, Kwon and colleagues investigated the anti–hair loss mechanism of U. davidiana and determined that supercritical extraction-residues of U. davidiana significantly hinder the secretion of transforming growth factor–beta but dose dependently salvage insulinlike growth factor 1, and substantially decrease dihydrotestosterone synthesis. They concluded that these U. davidiana supercritical fluid extract residues have the potential to halt the loss of human hair.8
Photoprotective potential
Late in 2020, Her and colleagues reported on their development and analysis of a new distillate derived from a fermented mixture of nine anti-inflammatory herbs including U. davidiana. The investigators assessed the effects of the topically applied distillate on UVB-induced skin damage in Institute of Cancer Research mice, finding significant improvements in the dorsal skin photodamage. Application of the distillate also ameliorated collagen production impairment and diminished proinflammatory cytokine levels of tumor necrosis factor (TNF)–alpha and IL-1B. The researchers concluded that this anti-inflammatory herbal distillate, which includes U. davidiana, displays the potential to serve as a photoprotective agent.9
Antiaging activity
In 2011, Yang and colleagues set out to identify constituent substances of the root bark of U. davidiana that have the capacity to suppress cellular senescence in human fibroblasts and human umbilical vein endothelial cells. They isolated 22 compounds, of which epifriedelanol, ssioriside, and catechin-7-O-beta-D-glucopyranoside impeded adriamycin-induced cellular senescence in human dermal fibroblasts and friedelin, epifriedelanol, and catechin-7-O-beta-apiofuranoside in the umbilical vein endothelial cells. Epifriedelanol was the most potent of the substances, leading the researchers to conclude that this U. davidiana component can diminish cellular senescence in human primary cells and has the potential as an oral and/or topical antiaging agent.10
Also that year, in a study on the protective effects of U. davidiana on UVB-irradiated hairless mice, the authors claimed that an ethanol extract of U. davidiana significantly suppressed wrinkle development in mice chronically exposed to UVB.11 This study showed that U. davidiana extract exerts antioxidant activity as evidenced by a decrease in MMP-1 activity. It also demonstrated antielastase activity. The treated mice showed a decrease in wrinkles as compared with water-treated mice.11 Although this is just one study in mice, it may demonstrate a protective effect on elastic fibers on skin exposed to UVB light.
Late in 2020, Lee and colleagues reported on their study of the possible antiaging effects on the skin of (-)-phenolic compounds isolated from the root bark of U. davidiana. The function of collagenase MMP-1 was found to be inhibited by the isolate (-)-catechin, which also halted collagen degradation caused by TNF-alpha in normal human dermal fibroblasts. Further, the investigators demonstrated that the U. davidiana isolate (-)-catechin reduced the expression of proinflammatory cytokines such as IL-1B and IL-6. They concluded that the U. davidiana isolate exhibits the potential to combat intrinsic as well as extrinsic cutaneous aging.12
These findings are particularly intriguing. There is much overlap between intrinsic and extrinsic aging. If U. davidiana can keep collagen intact and inhibit cellular senescence, it may serve as an early intervention toward slowing or preventing skin aging.
Summary
Of greatest interest now, perhaps, is its potential to impede cellular senescence. Senescent cells release a multitude of inflammatory and other factors that hasten intrinsic aging. Blocking cellular senescence is an important approach to the prevention and treatment of skin aging.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur in Miami. She founded the division of cosmetic dermatology at the University of Miami in 1997. The third edition of her bestselling textbook, “Cosmetic Dermatology,” was published in 2022. Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Galderma, Johnson & Johnson, and Burt’s Bees. She is the CEO of Skin Type Solutions, a SaaS company used to generate skin care routines in the office and as an ecommerce solution. Write to her at [email protected].
References
1. Lyu J et al. J Pharmacopuncture. 2013 Jun;16(2):41-5.
2. Eom SY et al. J Cosmet Sci. 2006 Sep-Oct;57(5):355-67.
3. So HM et al. Bioorg Chem. 2019 Oct;91:103145.
4. Choi HG et al. Phytother Res. 2013 Sep;27(9):1376-80.
5. Choi SY et al. J Med Food. 2010 Aug;13(4):1019-23.
6. Alishir A et al. Bioorg Med Chem Lett. 2021 Mar 15;36:127828.
7. Park TH et al. Saudi Pharm J. 2020 Jul;28(7):791-802.
8. Kwon YE et al. Molecules. 2022 Feb 19;27(4):1419.
9. Her Y et al. Molecules. 2020 Dec 29;26(1):124.
10. Yang HH et al. Planta Med. 2011 Mar;77(5):441-9.
11. Kim YO et al. Korean Journal of Medicinal Crop Science. 2011;19(6):508-13.
12. Lee S et al. Antioxidants (Basel). 2020 Oct 13;9(10):981.
IBD and pregnancy: What to tell your patients
While many gastroenterologists may be comfortable with inflammatory bowel disease (IBD), most are not experts in women’s concerns about pregnancy. One study found that, although women with IBD may have concerns about the interplay of their disease and reproductive health, many have not had extensive conversations with their gastroenterologist about it. In fact, that same study found most women expect their gastroenterologist to initiate these conversations.
In this roundtable discussion, Uma Mahadevan, MD, professor of medicine and the director of the Colitis and Crohn’s Disease Center at the University of California, San Francisco; Marla C. Dubinsky, MD, professor of medicine at the Icahn School of Medicine at Mount Sinai, New York; and Sunanda V. Kane, MD, professor of medicine at Mayo Clinic in Rochester, Minn., share how they respond to these questions in their clinical practice.
What should a woman with IBD who is interested in having biological children in the future be thinking about now?
Dr. Mahadevan: Because active disease is associated with lower rates of conception and higher rates of pregnancy loss, women with IBD should first ensure they are in remission. I like to document endoscopic healing with a colonoscopy or sigmoidoscopy, but, if this has been done recently, a fecal calprotectin test can be helpful.
Women with IBD, particularly those with small bowel disease, are at risk for nutritional deficiencies, so prior to conception, I also check vitamin B-12, vitamin D, and iron, and repeat as needed. Zinc and folate can be considered. Those who are underweight should work with a nutritionist to ensure adequate caloric intake.
Dr. Dubinsky: I think it’s also important to stress the importance of taking their IBD medications because they can help patients achieve and maintain disease remission. Uncontrolled inflammation is a key risk factor for spontaneous abortion in the first trimester. Medication we would use in pregnancy is not putting them at risk for spontaneous abortion or congenital anomalies, which is what mothers to be are understandably most concerned about.
I am very honest and transparent with my patients: “About the only thing I need to take care of is you. If you are good, the baby is good.”
Dr. Kane: As Dr. Mahadevan mentioned, women with IBD are at higher risk for vitamin deficiencies so those need to be corrected before conception. If they smoke, they should stop before conceiving.
There is no increased risk of infertility unless there has been a history of abdominal surgery.
Also, if women are not actively planning on getting pregnant, that would be important to share because some gastroenterologists will avoid certain effective medications if pregnancy is a possibility.
If a woman has had surgery for her IBD, could that make it harder for her to get pregnant?
Dr. Kane: Yes, it can because scar tissue may develop within the pelvis. However, if surgery is indicated to manage a patient’s IBD, then talk to the surgeon about ways that they might be able to reduce the risk of scar tissue formation.
Dr. Dubinsky: One thing to note is that almost all the data of infertility risk and scarring are based on open surgical techniques that involve dissection of the rectum. On the other hand, we don’t yet have enough prospective data on the impact of the modern era of laparoscopic surgery to suggest whether it affects fertility. More data is needed because providers may be giving women old information that is no longer relevant in the modern era.
If a woman is experiencing IBD symptoms, should she attempt to conceive?
Dr. Kane: Gastrointestinal symptoms in patients with IBD could be from active disease but also other things, so it’s important to have a thorough check-up to assess if there is active disease or not. Active disease can (but does not always) lead to a more complicated pregnancy, and conception is not recommended while a patient has active IBD.
Dr. Dubinsky: Although some patients feel an urgency to conceive regardless of disease activity, we need to do our due diligence and explain that we need to focus on getting them into the deepest remission possible, including endoscopic findings, biomarkers, and symptoms.
The most important gift you can give your future moms is to optimize the therapy they’re on before they conceive.
Is it important for someone who’s working with a gastroenterologist and an obstetrician to also work with a maternal-fetal medicine (MFM) specialist?
Dr. Kane: Having a diagnosis of IBD makes a woman’s pregnancy “high risk” because just having the diagnosis is associated with a higher risk of prematurity and small for gestational age – but importantly, not birth defects. A woman whose IBD is in remission should still have a discussion with an MFM specialist, just so everyone is on the same page.
Dr. Dubinsky: I refer to care with MFM specialists as “tighter monitoring.” I tell my patients that MFM specialists have managed many complex pregnancies and feel confident around the safety of their medications, understand the impact of when the baby may be exposed to certain medications, and will focus on following them more closely.
What are the risks of IBD medications during pregnancy and while breastfeeding? Should women stop their medications during pregnancy and breastfeeding?
Dr. Dubinsky: Organogenesis occurs in the first 10 weeks, so any medicines that cross the placenta during that time are up for discussion and debate. Methotrexate and the newer small molecules, such as Janus kinase (JAK) inhibitors and S1P receptor modulators, do cross the placenta during the first trimester and need to be discontinued before conception, sometimes as early as 3 months before conception.
However, biologics are very large proteins and do not cross the placenta until closer to week 27. We are not advocating stopping biologics in advance of conception, or during pregnancy, or during breastfeeding. There is more risk to stopping than continuing.
Dr. Mahadevan: Methotrexate should be stopped at least 3 months prior to conception and should not be taken during pregnancy.
There are limited antibiotic safety data in pregnancy for the longer periods of time used in IBD. I generally prefer amoxicillin/clavulanic acid over ciprofloxacin or metronidazole, but short term (less than 2 weeks) use of any of those three are not contraindicated.
Mesalamine agents and thiopurine monotherapy can be continued through pregnancy and breastfeeding.
Biologic agents, such as anti–tumor necrosis factor, anti-interleukin 23, anti-integrin, and biosimilars, can be continued through pregnancy and during breastfeeding. Given limited exposure in the first trimester, there is no evidence of increased risk of birth defects. As Dr. Dubinsky pointed out, there is active transfer, particularly in the third trimester and minimal transfer in breast milk, but this has not been associated with harm.
Lastly, small molecules, such as the JAK inhibitors tofacitinib and upadacitinib, as well as ozanimod, have virtually no human safety data during pregnancy, and animal data show harm. The use of these agents in pregnancy is not recommended.
Dr. Kane: As Dr. Dubinsky stated, most of the medications our patients take are low risk to continue through pregnancy if the patients are in remission. Although a woman “in remission” on steroids is not really in remission and should not get pregnant until she is on something else.
As far as breastfeeding goes, that should be stopped if the patient is on methotrexate, cyclosporine, or certain antibiotics. If she is on more than 20 mg of prednisone this can pass to the infant, and a mother should not breastfeed.
Women should avoid fenugreek as a lactation aid, as that contains a compound that can promote bleeding. Lactation cookies are ok.
Otherwise, there are lots of potential benefits to breastfeeding, and I encourage it.
How is a flare treated if it occurs during pregnancy?
Dr. Dubinsky: A flare during pregnancy is treated the same as a flare outside of pregnancy. We want to use noninvasive ways to confirm it, but I think we don’t need to overly investigate in most of our women. If they’re already on a biologic, you may consider changing.
Some women may need corticosteroids. It’s not our favorite move, but there is an urgency to getting a flare under control during pregnancy because of possible complications.
Dr. Mahadevan: Some of this is contingent on when during pregnancy the flare occurs. A patient who has a flare at 38 weeks’ gestation will likely proceed with delivery and the flare will be dealt with separately. Someone at 8 weeks’ gestation is at high risk for pregnancy loss, so treatment should be quick and effective.
As does Dr. Dubinsky, I do try to avoid steroids if possible. For example, I would rather start an effective biologic right away than drag out steroids to see if they will respond.
Dr. Kane: I would add that, if a mother is losing weight, she might need to be hospitalized for additional nutritional support. If surgery is necessary, we usually try to time it for the second or third trimester.
What needs to be taken into consideration regarding mode of delivery? Also, if a woman has undergone prior surgeries, do they increase the risk of delivery complications?
For ulcerative colitis, mode of delivery is based on obstetric, not gastrointestinal, variables. For Crohn’s disease, if there is evidence of perianal disease, then a cesarean is appropriate.
If there is no history of perianal disease, then delivery is based on obstetric variables.
For a woman who has a J pouch, if possible, the surgeon who created it should be contacted to ask about the technical aspects of the pouch and how it lies in the pelvis.
What’s the risk of a postpartum flare if a woman’s IBD remains in clinical remission during pregnancy?
Dr. Mahadevan: There is no increased risk of postpartum flare if a woman continues her IBD medications after delivery. Many of the reports of flare are from stopping medications (mistakenly often) to breastfeed.
Dr. Kane: As Dr. Mahadevan said, the risk of a flare is usually because a woman stops taking her medications because she thinks that medication will be passed to the infant through breastfeeding, which in most cases is not true.
Otherwise, there is not an increased risk of a flare in a 12-month period. However, it is important to monitor for symptoms after delivery; the risk of a flare is not zero.
What symptoms should women watch out for after delivery that may indicate an uptick in disease activity?
Dr. Kane: The same symptoms as before they were pregnant. Diarrhea, abdominal pain, and rectal bleeding are not normal after delivery and should be considered signs of returning disease.
As a gastroenterologist, is there any additional advice you’d offer about conception, fertility, and pregnancy when treating women with IBD?
Dr. Mahadevan: Women with IBD should, when feasible, have a planned pregnancy when in documented remission and under the care of their gastroenterologists, obstetrician, and an MFM specialist. Life happens, and this is not always possible. That said, a woman with IBD has the same chance of getting pregnant as a woman of the same age without IBD, unless she has active disease or a history of pelvic surgery. Women with IBD in remission will generally have healthy pregnancies if they continue appropriate medications.
Dr. Kane: Agreed. The majority of women with IBD will have normal, healthy pregnancies. It is important for them to not stop their IBD therapy without talking to their gastroenterologist first. Well-intentioned but ignorant obstetricians or midwives may recommend stopping, but then panic when disease flares and the mother’s health is at risk. Active inflammation is the worst enemy to a pregnancy, not active therapy.
Dr. Dubinsky: One additional thing to consider is: How do we help women with IBD who have delivered meet the needs of their family and continue to stay on their meds and be in good inflammatory control?
For example, we can give the biologic in the hospital after they’ve had a cesarean or a vaginal delivery and before they leave. We know that that is safe, giving that to them before they leave the hospital is a huge value added.
Another thing is possibly changing their infusions to home infusions. That would be helpful for the moms as well.
Dr. Mahadevan reports being a consultant for AbbVie, Janssen, Pfizer, Gilead, Bristol-Myers Squibb, Takeda, Protagonist, Prometheus, and Boehringer Ingelheim. Dr. Dubinsky is a consultant for AbbVie, Arena, Bristol-Myers Squibb, Janssen, Eli Lilly, Takeda, and Prometheus BioSciences. She is a shareholder and CEO of a publicly traded company, Trellis Health. Dr. Kane is a consultant for Bristol-Myers Squibb, Boehringer Ingelheim, Gilead, Janssen, Takeda, Seres Therapeutics, TechLab, United Healthcare, Predicta-Med, and InveniAI, and is the editor for the IBD section of UptoDate.
While many gastroenterologists may be comfortable with inflammatory bowel disease (IBD), most are not experts in women’s concerns about pregnancy. One study found that, although women with IBD may have concerns about the interplay of their disease and reproductive health, many have not had extensive conversations with their gastroenterologist about it. In fact, that same study found most women expect their gastroenterologist to initiate these conversations.
In this roundtable discussion, Uma Mahadevan, MD, professor of medicine and the director of the Colitis and Crohn’s Disease Center at the University of California, San Francisco; Marla C. Dubinsky, MD, professor of medicine at the Icahn School of Medicine at Mount Sinai, New York; and Sunanda V. Kane, MD, professor of medicine at Mayo Clinic in Rochester, Minn., share how they respond to these questions in their clinical practice.
What should a woman with IBD who is interested in having biological children in the future be thinking about now?
Dr. Mahadevan: Because active disease is associated with lower rates of conception and higher rates of pregnancy loss, women with IBD should first ensure they are in remission. I like to document endoscopic healing with a colonoscopy or sigmoidoscopy, but, if this has been done recently, a fecal calprotectin test can be helpful.
Women with IBD, particularly those with small bowel disease, are at risk for nutritional deficiencies, so prior to conception, I also check vitamin B-12, vitamin D, and iron, and repeat as needed. Zinc and folate can be considered. Those who are underweight should work with a nutritionist to ensure adequate caloric intake.
Dr. Dubinsky: I think it’s also important to stress the importance of taking their IBD medications because they can help patients achieve and maintain disease remission. Uncontrolled inflammation is a key risk factor for spontaneous abortion in the first trimester. Medication we would use in pregnancy is not putting them at risk for spontaneous abortion or congenital anomalies, which is what mothers to be are understandably most concerned about.
I am very honest and transparent with my patients: “About the only thing I need to take care of is you. If you are good, the baby is good.”
Dr. Kane: As Dr. Mahadevan mentioned, women with IBD are at higher risk for vitamin deficiencies so those need to be corrected before conception. If they smoke, they should stop before conceiving.
There is no increased risk of infertility unless there has been a history of abdominal surgery.
Also, if women are not actively planning on getting pregnant, that would be important to share because some gastroenterologists will avoid certain effective medications if pregnancy is a possibility.
If a woman has had surgery for her IBD, could that make it harder for her to get pregnant?
Dr. Kane: Yes, it can because scar tissue may develop within the pelvis. However, if surgery is indicated to manage a patient’s IBD, then talk to the surgeon about ways that they might be able to reduce the risk of scar tissue formation.
Dr. Dubinsky: One thing to note is that almost all the data of infertility risk and scarring are based on open surgical techniques that involve dissection of the rectum. On the other hand, we don’t yet have enough prospective data on the impact of the modern era of laparoscopic surgery to suggest whether it affects fertility. More data is needed because providers may be giving women old information that is no longer relevant in the modern era.
If a woman is experiencing IBD symptoms, should she attempt to conceive?
Dr. Kane: Gastrointestinal symptoms in patients with IBD could be from active disease but also other things, so it’s important to have a thorough check-up to assess if there is active disease or not. Active disease can (but does not always) lead to a more complicated pregnancy, and conception is not recommended while a patient has active IBD.
Dr. Dubinsky: Although some patients feel an urgency to conceive regardless of disease activity, we need to do our due diligence and explain that we need to focus on getting them into the deepest remission possible, including endoscopic findings, biomarkers, and symptoms.
The most important gift you can give your future moms is to optimize the therapy they’re on before they conceive.
Is it important for someone who’s working with a gastroenterologist and an obstetrician to also work with a maternal-fetal medicine (MFM) specialist?
Dr. Kane: Having a diagnosis of IBD makes a woman’s pregnancy “high risk” because just having the diagnosis is associated with a higher risk of prematurity and small for gestational age – but importantly, not birth defects. A woman whose IBD is in remission should still have a discussion with an MFM specialist, just so everyone is on the same page.
Dr. Dubinsky: I refer to care with MFM specialists as “tighter monitoring.” I tell my patients that MFM specialists have managed many complex pregnancies and feel confident around the safety of their medications, understand the impact of when the baby may be exposed to certain medications, and will focus on following them more closely.
What are the risks of IBD medications during pregnancy and while breastfeeding? Should women stop their medications during pregnancy and breastfeeding?
Dr. Dubinsky: Organogenesis occurs in the first 10 weeks, so any medicines that cross the placenta during that time are up for discussion and debate. Methotrexate and the newer small molecules, such as Janus kinase (JAK) inhibitors and S1P receptor modulators, do cross the placenta during the first trimester and need to be discontinued before conception, sometimes as early as 3 months before conception.
However, biologics are very large proteins and do not cross the placenta until closer to week 27. We are not advocating stopping biologics in advance of conception, or during pregnancy, or during breastfeeding. There is more risk to stopping than continuing.
Dr. Mahadevan: Methotrexate should be stopped at least 3 months prior to conception and should not be taken during pregnancy.
There are limited antibiotic safety data in pregnancy for the longer periods of time used in IBD. I generally prefer amoxicillin/clavulanic acid over ciprofloxacin or metronidazole, but short term (less than 2 weeks) use of any of those three are not contraindicated.
Mesalamine agents and thiopurine monotherapy can be continued through pregnancy and breastfeeding.
Biologic agents, such as anti–tumor necrosis factor, anti-interleukin 23, anti-integrin, and biosimilars, can be continued through pregnancy and during breastfeeding. Given limited exposure in the first trimester, there is no evidence of increased risk of birth defects. As Dr. Dubinsky pointed out, there is active transfer, particularly in the third trimester and minimal transfer in breast milk, but this has not been associated with harm.
Lastly, small molecules, such as the JAK inhibitors tofacitinib and upadacitinib, as well as ozanimod, have virtually no human safety data during pregnancy, and animal data show harm. The use of these agents in pregnancy is not recommended.
Dr. Kane: As Dr. Dubinsky stated, most of the medications our patients take are low risk to continue through pregnancy if the patients are in remission. Although a woman “in remission” on steroids is not really in remission and should not get pregnant until she is on something else.
As far as breastfeeding goes, that should be stopped if the patient is on methotrexate, cyclosporine, or certain antibiotics. If she is on more than 20 mg of prednisone this can pass to the infant, and a mother should not breastfeed.
Women should avoid fenugreek as a lactation aid, as that contains a compound that can promote bleeding. Lactation cookies are ok.
Otherwise, there are lots of potential benefits to breastfeeding, and I encourage it.
How is a flare treated if it occurs during pregnancy?
Dr. Dubinsky: A flare during pregnancy is treated the same as a flare outside of pregnancy. We want to use noninvasive ways to confirm it, but I think we don’t need to overly investigate in most of our women. If they’re already on a biologic, you may consider changing.
Some women may need corticosteroids. It’s not our favorite move, but there is an urgency to getting a flare under control during pregnancy because of possible complications.
Dr. Mahadevan: Some of this is contingent on when during pregnancy the flare occurs. A patient who has a flare at 38 weeks’ gestation will likely proceed with delivery and the flare will be dealt with separately. Someone at 8 weeks’ gestation is at high risk for pregnancy loss, so treatment should be quick and effective.
As does Dr. Dubinsky, I do try to avoid steroids if possible. For example, I would rather start an effective biologic right away than drag out steroids to see if they will respond.
Dr. Kane: I would add that, if a mother is losing weight, she might need to be hospitalized for additional nutritional support. If surgery is necessary, we usually try to time it for the second or third trimester.
What needs to be taken into consideration regarding mode of delivery? Also, if a woman has undergone prior surgeries, do they increase the risk of delivery complications?
For ulcerative colitis, mode of delivery is based on obstetric, not gastrointestinal, variables. For Crohn’s disease, if there is evidence of perianal disease, then a cesarean is appropriate.
If there is no history of perianal disease, then delivery is based on obstetric variables.
For a woman who has a J pouch, if possible, the surgeon who created it should be contacted to ask about the technical aspects of the pouch and how it lies in the pelvis.
What’s the risk of a postpartum flare if a woman’s IBD remains in clinical remission during pregnancy?
Dr. Mahadevan: There is no increased risk of postpartum flare if a woman continues her IBD medications after delivery. Many of the reports of flare are from stopping medications (mistakenly often) to breastfeed.
Dr. Kane: As Dr. Mahadevan said, the risk of a flare is usually because a woman stops taking her medications because she thinks that medication will be passed to the infant through breastfeeding, which in most cases is not true.
Otherwise, there is not an increased risk of a flare in a 12-month period. However, it is important to monitor for symptoms after delivery; the risk of a flare is not zero.
What symptoms should women watch out for after delivery that may indicate an uptick in disease activity?
Dr. Kane: The same symptoms as before they were pregnant. Diarrhea, abdominal pain, and rectal bleeding are not normal after delivery and should be considered signs of returning disease.
As a gastroenterologist, is there any additional advice you’d offer about conception, fertility, and pregnancy when treating women with IBD?
Dr. Mahadevan: Women with IBD should, when feasible, have a planned pregnancy when in documented remission and under the care of their gastroenterologists, obstetrician, and an MFM specialist. Life happens, and this is not always possible. That said, a woman with IBD has the same chance of getting pregnant as a woman of the same age without IBD, unless she has active disease or a history of pelvic surgery. Women with IBD in remission will generally have healthy pregnancies if they continue appropriate medications.
Dr. Kane: Agreed. The majority of women with IBD will have normal, healthy pregnancies. It is important for them to not stop their IBD therapy without talking to their gastroenterologist first. Well-intentioned but ignorant obstetricians or midwives may recommend stopping, but then panic when disease flares and the mother’s health is at risk. Active inflammation is the worst enemy to a pregnancy, not active therapy.
Dr. Dubinsky: One additional thing to consider is: How do we help women with IBD who have delivered meet the needs of their family and continue to stay on their meds and be in good inflammatory control?
For example, we can give the biologic in the hospital after they’ve had a cesarean or a vaginal delivery and before they leave. We know that that is safe, giving that to them before they leave the hospital is a huge value added.
Another thing is possibly changing their infusions to home infusions. That would be helpful for the moms as well.
Dr. Mahadevan reports being a consultant for AbbVie, Janssen, Pfizer, Gilead, Bristol-Myers Squibb, Takeda, Protagonist, Prometheus, and Boehringer Ingelheim. Dr. Dubinsky is a consultant for AbbVie, Arena, Bristol-Myers Squibb, Janssen, Eli Lilly, Takeda, and Prometheus BioSciences. She is a shareholder and CEO of a publicly traded company, Trellis Health. Dr. Kane is a consultant for Bristol-Myers Squibb, Boehringer Ingelheim, Gilead, Janssen, Takeda, Seres Therapeutics, TechLab, United Healthcare, Predicta-Med, and InveniAI, and is the editor for the IBD section of UptoDate.
While many gastroenterologists may be comfortable with inflammatory bowel disease (IBD), most are not experts in women’s concerns about pregnancy. One study found that, although women with IBD may have concerns about the interplay of their disease and reproductive health, many have not had extensive conversations with their gastroenterologist about it. In fact, that same study found most women expect their gastroenterologist to initiate these conversations.
In this roundtable discussion, Uma Mahadevan, MD, professor of medicine and the director of the Colitis and Crohn’s Disease Center at the University of California, San Francisco; Marla C. Dubinsky, MD, professor of medicine at the Icahn School of Medicine at Mount Sinai, New York; and Sunanda V. Kane, MD, professor of medicine at Mayo Clinic in Rochester, Minn., share how they respond to these questions in their clinical practice.
What should a woman with IBD who is interested in having biological children in the future be thinking about now?
Dr. Mahadevan: Because active disease is associated with lower rates of conception and higher rates of pregnancy loss, women with IBD should first ensure they are in remission. I like to document endoscopic healing with a colonoscopy or sigmoidoscopy, but, if this has been done recently, a fecal calprotectin test can be helpful.
Women with IBD, particularly those with small bowel disease, are at risk for nutritional deficiencies, so prior to conception, I also check vitamin B-12, vitamin D, and iron, and repeat as needed. Zinc and folate can be considered. Those who are underweight should work with a nutritionist to ensure adequate caloric intake.
Dr. Dubinsky: I think it’s also important to stress the importance of taking their IBD medications because they can help patients achieve and maintain disease remission. Uncontrolled inflammation is a key risk factor for spontaneous abortion in the first trimester. Medication we would use in pregnancy is not putting them at risk for spontaneous abortion or congenital anomalies, which is what mothers to be are understandably most concerned about.
I am very honest and transparent with my patients: “About the only thing I need to take care of is you. If you are good, the baby is good.”
Dr. Kane: As Dr. Mahadevan mentioned, women with IBD are at higher risk for vitamin deficiencies so those need to be corrected before conception. If they smoke, they should stop before conceiving.
There is no increased risk of infertility unless there has been a history of abdominal surgery.
Also, if women are not actively planning on getting pregnant, that would be important to share because some gastroenterologists will avoid certain effective medications if pregnancy is a possibility.
If a woman has had surgery for her IBD, could that make it harder for her to get pregnant?
Dr. Kane: Yes, it can because scar tissue may develop within the pelvis. However, if surgery is indicated to manage a patient’s IBD, then talk to the surgeon about ways that they might be able to reduce the risk of scar tissue formation.
Dr. Dubinsky: One thing to note is that almost all the data of infertility risk and scarring are based on open surgical techniques that involve dissection of the rectum. On the other hand, we don’t yet have enough prospective data on the impact of the modern era of laparoscopic surgery to suggest whether it affects fertility. More data is needed because providers may be giving women old information that is no longer relevant in the modern era.
If a woman is experiencing IBD symptoms, should she attempt to conceive?
Dr. Kane: Gastrointestinal symptoms in patients with IBD could be from active disease but also other things, so it’s important to have a thorough check-up to assess if there is active disease or not. Active disease can (but does not always) lead to a more complicated pregnancy, and conception is not recommended while a patient has active IBD.
Dr. Dubinsky: Although some patients feel an urgency to conceive regardless of disease activity, we need to do our due diligence and explain that we need to focus on getting them into the deepest remission possible, including endoscopic findings, biomarkers, and symptoms.
The most important gift you can give your future moms is to optimize the therapy they’re on before they conceive.
Is it important for someone who’s working with a gastroenterologist and an obstetrician to also work with a maternal-fetal medicine (MFM) specialist?
Dr. Kane: Having a diagnosis of IBD makes a woman’s pregnancy “high risk” because just having the diagnosis is associated with a higher risk of prematurity and small for gestational age – but importantly, not birth defects. A woman whose IBD is in remission should still have a discussion with an MFM specialist, just so everyone is on the same page.
Dr. Dubinsky: I refer to care with MFM specialists as “tighter monitoring.” I tell my patients that MFM specialists have managed many complex pregnancies and feel confident around the safety of their medications, understand the impact of when the baby may be exposed to certain medications, and will focus on following them more closely.
What are the risks of IBD medications during pregnancy and while breastfeeding? Should women stop their medications during pregnancy and breastfeeding?
Dr. Dubinsky: Organogenesis occurs in the first 10 weeks, so any medicines that cross the placenta during that time are up for discussion and debate. Methotrexate and the newer small molecules, such as Janus kinase (JAK) inhibitors and S1P receptor modulators, do cross the placenta during the first trimester and need to be discontinued before conception, sometimes as early as 3 months before conception.
However, biologics are very large proteins and do not cross the placenta until closer to week 27. We are not advocating stopping biologics in advance of conception, or during pregnancy, or during breastfeeding. There is more risk to stopping than continuing.
Dr. Mahadevan: Methotrexate should be stopped at least 3 months prior to conception and should not be taken during pregnancy.
There are limited antibiotic safety data in pregnancy for the longer periods of time used in IBD. I generally prefer amoxicillin/clavulanic acid over ciprofloxacin or metronidazole, but short term (less than 2 weeks) use of any of those three are not contraindicated.
Mesalamine agents and thiopurine monotherapy can be continued through pregnancy and breastfeeding.
Biologic agents, such as anti–tumor necrosis factor, anti-interleukin 23, anti-integrin, and biosimilars, can be continued through pregnancy and during breastfeeding. Given limited exposure in the first trimester, there is no evidence of increased risk of birth defects. As Dr. Dubinsky pointed out, there is active transfer, particularly in the third trimester and minimal transfer in breast milk, but this has not been associated with harm.
Lastly, small molecules, such as the JAK inhibitors tofacitinib and upadacitinib, as well as ozanimod, have virtually no human safety data during pregnancy, and animal data show harm. The use of these agents in pregnancy is not recommended.
Dr. Kane: As Dr. Dubinsky stated, most of the medications our patients take are low risk to continue through pregnancy if the patients are in remission. Although a woman “in remission” on steroids is not really in remission and should not get pregnant until she is on something else.
As far as breastfeeding goes, that should be stopped if the patient is on methotrexate, cyclosporine, or certain antibiotics. If she is on more than 20 mg of prednisone this can pass to the infant, and a mother should not breastfeed.
Women should avoid fenugreek as a lactation aid, as that contains a compound that can promote bleeding. Lactation cookies are ok.
Otherwise, there are lots of potential benefits to breastfeeding, and I encourage it.
How is a flare treated if it occurs during pregnancy?
Dr. Dubinsky: A flare during pregnancy is treated the same as a flare outside of pregnancy. We want to use noninvasive ways to confirm it, but I think we don’t need to overly investigate in most of our women. If they’re already on a biologic, you may consider changing.
Some women may need corticosteroids. It’s not our favorite move, but there is an urgency to getting a flare under control during pregnancy because of possible complications.
Dr. Mahadevan: Some of this is contingent on when during pregnancy the flare occurs. A patient who has a flare at 38 weeks’ gestation will likely proceed with delivery and the flare will be dealt with separately. Someone at 8 weeks’ gestation is at high risk for pregnancy loss, so treatment should be quick and effective.
As does Dr. Dubinsky, I do try to avoid steroids if possible. For example, I would rather start an effective biologic right away than drag out steroids to see if they will respond.
Dr. Kane: I would add that, if a mother is losing weight, she might need to be hospitalized for additional nutritional support. If surgery is necessary, we usually try to time it for the second or third trimester.
What needs to be taken into consideration regarding mode of delivery? Also, if a woman has undergone prior surgeries, do they increase the risk of delivery complications?
For ulcerative colitis, mode of delivery is based on obstetric, not gastrointestinal, variables. For Crohn’s disease, if there is evidence of perianal disease, then a cesarean is appropriate.
If there is no history of perianal disease, then delivery is based on obstetric variables.
For a woman who has a J pouch, if possible, the surgeon who created it should be contacted to ask about the technical aspects of the pouch and how it lies in the pelvis.
What’s the risk of a postpartum flare if a woman’s IBD remains in clinical remission during pregnancy?
Dr. Mahadevan: There is no increased risk of postpartum flare if a woman continues her IBD medications after delivery. Many of the reports of flare are from stopping medications (mistakenly often) to breastfeed.
Dr. Kane: As Dr. Mahadevan said, the risk of a flare is usually because a woman stops taking her medications because she thinks that medication will be passed to the infant through breastfeeding, which in most cases is not true.
Otherwise, there is not an increased risk of a flare in a 12-month period. However, it is important to monitor for symptoms after delivery; the risk of a flare is not zero.
What symptoms should women watch out for after delivery that may indicate an uptick in disease activity?
Dr. Kane: The same symptoms as before they were pregnant. Diarrhea, abdominal pain, and rectal bleeding are not normal after delivery and should be considered signs of returning disease.
As a gastroenterologist, is there any additional advice you’d offer about conception, fertility, and pregnancy when treating women with IBD?
Dr. Mahadevan: Women with IBD should, when feasible, have a planned pregnancy when in documented remission and under the care of their gastroenterologists, obstetrician, and an MFM specialist. Life happens, and this is not always possible. That said, a woman with IBD has the same chance of getting pregnant as a woman of the same age without IBD, unless she has active disease or a history of pelvic surgery. Women with IBD in remission will generally have healthy pregnancies if they continue appropriate medications.
Dr. Kane: Agreed. The majority of women with IBD will have normal, healthy pregnancies. It is important for them to not stop their IBD therapy without talking to their gastroenterologist first. Well-intentioned but ignorant obstetricians or midwives may recommend stopping, but then panic when disease flares and the mother’s health is at risk. Active inflammation is the worst enemy to a pregnancy, not active therapy.
Dr. Dubinsky: One additional thing to consider is: How do we help women with IBD who have delivered meet the needs of their family and continue to stay on their meds and be in good inflammatory control?
For example, we can give the biologic in the hospital after they’ve had a cesarean or a vaginal delivery and before they leave. We know that that is safe, giving that to them before they leave the hospital is a huge value added.
Another thing is possibly changing their infusions to home infusions. That would be helpful for the moms as well.
Dr. Mahadevan reports being a consultant for AbbVie, Janssen, Pfizer, Gilead, Bristol-Myers Squibb, Takeda, Protagonist, Prometheus, and Boehringer Ingelheim. Dr. Dubinsky is a consultant for AbbVie, Arena, Bristol-Myers Squibb, Janssen, Eli Lilly, Takeda, and Prometheus BioSciences. She is a shareholder and CEO of a publicly traded company, Trellis Health. Dr. Kane is a consultant for Bristol-Myers Squibb, Boehringer Ingelheim, Gilead, Janssen, Takeda, Seres Therapeutics, TechLab, United Healthcare, Predicta-Med, and InveniAI, and is the editor for the IBD section of UptoDate.
Starting a podcast
In my last column, I discussed . At this writing (November 2022), more than 600 million blogs are online, compared with about 2 million podcasts, and relatively few of them are run by physicians. With podcasts, you have a better chance of standing out in a crowded online world.
Starting a podcast is not difficult, but there are several steps you need to go through before launching one.
As with blogging, start by outlining a long-range plan. Your general topic will probably be your specialty, but you will need to narrow your focus to a few specific subjects, such as the problems you see most often, or a subspecialty that you concentrate on. You can always expand your topic later, as you get more popular. Choose a name for your podcast, and purchase a domain name that accurately describes it.
You will also need to choose a hosting service. Numerous inexpensive hosting platforms are available, and a simple Google search will find them for you. Many of them provide free learning materials, helpful creative tools, and customer support to get you through the confusing technical aspects. They can also help you choose a music introduction (to add a bit of polish), and help you piece together your audio segments. Buzzsprout, RSS.com, and Podbean get good reviews on many sites. (As always, I have no financial interest in any company or service mentioned herein.)
Hosting services can assist you in creating a template – a framework that you can reuse each time you record an episode – containing your intro and exit music, tracks for your conversations, etc. This will make your podcasts instantly recognizable each time your listeners tune in.
Many podcasting experts recommend recruiting a co-host. This can be an associate within your practice, a friend who practices elsewhere, or perhaps a resident in an academic setting. You will be able to spread the workload of creating, editing, and promoting. Plus, it is much easier to generate interesting content when two people are having a conversation, rather than one person lecturing from a prepared script. You might also consider having multiple co-hosts, either to expand episodes into group discussions, or to take turns working with you in covering different subjects.
How long you make your podcast is entirely up to you. Some consultants recommend specific time frames, such as 5 minutes (because that’s an average attention span), or 28 minutes (because that’s the average driving commute time). There are short podcasts and long ones; whatever works for you is fine, as long as you don’t drift off the topic. Furthermore, no one says they must all be the same length; when you are finished talking, you are done. And no one says you must stick with one subject throughout. Combining several short segments might hold more listeners’ interest and will make it easier to share small clips on social media.
Content guidelines are similar to those for blogs. Give people content that will be of interest or benefit to them. Talk about subjects – medical and otherwise – that are relevant to your practice or are prominent in the news.
As with blogs, try to avoid polarizing political discussions, and while it’s fine to discuss treatments and procedures that you offer, aggressive solicitation tends to make viewers look elsewhere. Keep any medical advice in general terms; don’t portray any specific patients as examples.
When your podcast is ready, your hosting platform will show you how to submit it to iTunes, and how to submit your podcast RSS feed to other podcast directories. As you upload new episodes, your host will automatically update your RSS feed, so that any directory you are listed on will receive the new episode.
Once you are uploaded, you can use your host’s social sharing tools to spread the word. As with blogs, use social media, such as your practice’s Facebook page, to push podcast updates into patients’ feeds and track relevant Twitter hashtags to find online communities that might be interested in your subject matter. You should also find your episode embed code (which your host will have) and place it in a prominent place on your website so patients can listen directly from there.
Transcriptions are another excellent promotional tool. Search engines will “read” your podcasts and list them in searches. Some podcast hosts will do transcribing for a fee, but there are independent transcription services as well.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
In my last column, I discussed . At this writing (November 2022), more than 600 million blogs are online, compared with about 2 million podcasts, and relatively few of them are run by physicians. With podcasts, you have a better chance of standing out in a crowded online world.
Starting a podcast is not difficult, but there are several steps you need to go through before launching one.
As with blogging, start by outlining a long-range plan. Your general topic will probably be your specialty, but you will need to narrow your focus to a few specific subjects, such as the problems you see most often, or a subspecialty that you concentrate on. You can always expand your topic later, as you get more popular. Choose a name for your podcast, and purchase a domain name that accurately describes it.
You will also need to choose a hosting service. Numerous inexpensive hosting platforms are available, and a simple Google search will find them for you. Many of them provide free learning materials, helpful creative tools, and customer support to get you through the confusing technical aspects. They can also help you choose a music introduction (to add a bit of polish), and help you piece together your audio segments. Buzzsprout, RSS.com, and Podbean get good reviews on many sites. (As always, I have no financial interest in any company or service mentioned herein.)
Hosting services can assist you in creating a template – a framework that you can reuse each time you record an episode – containing your intro and exit music, tracks for your conversations, etc. This will make your podcasts instantly recognizable each time your listeners tune in.
Many podcasting experts recommend recruiting a co-host. This can be an associate within your practice, a friend who practices elsewhere, or perhaps a resident in an academic setting. You will be able to spread the workload of creating, editing, and promoting. Plus, it is much easier to generate interesting content when two people are having a conversation, rather than one person lecturing from a prepared script. You might also consider having multiple co-hosts, either to expand episodes into group discussions, or to take turns working with you in covering different subjects.
How long you make your podcast is entirely up to you. Some consultants recommend specific time frames, such as 5 minutes (because that’s an average attention span), or 28 minutes (because that’s the average driving commute time). There are short podcasts and long ones; whatever works for you is fine, as long as you don’t drift off the topic. Furthermore, no one says they must all be the same length; when you are finished talking, you are done. And no one says you must stick with one subject throughout. Combining several short segments might hold more listeners’ interest and will make it easier to share small clips on social media.
Content guidelines are similar to those for blogs. Give people content that will be of interest or benefit to them. Talk about subjects – medical and otherwise – that are relevant to your practice or are prominent in the news.
As with blogs, try to avoid polarizing political discussions, and while it’s fine to discuss treatments and procedures that you offer, aggressive solicitation tends to make viewers look elsewhere. Keep any medical advice in general terms; don’t portray any specific patients as examples.
When your podcast is ready, your hosting platform will show you how to submit it to iTunes, and how to submit your podcast RSS feed to other podcast directories. As you upload new episodes, your host will automatically update your RSS feed, so that any directory you are listed on will receive the new episode.
Once you are uploaded, you can use your host’s social sharing tools to spread the word. As with blogs, use social media, such as your practice’s Facebook page, to push podcast updates into patients’ feeds and track relevant Twitter hashtags to find online communities that might be interested in your subject matter. You should also find your episode embed code (which your host will have) and place it in a prominent place on your website so patients can listen directly from there.
Transcriptions are another excellent promotional tool. Search engines will “read” your podcasts and list them in searches. Some podcast hosts will do transcribing for a fee, but there are independent transcription services as well.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
In my last column, I discussed . At this writing (November 2022), more than 600 million blogs are online, compared with about 2 million podcasts, and relatively few of them are run by physicians. With podcasts, you have a better chance of standing out in a crowded online world.
Starting a podcast is not difficult, but there are several steps you need to go through before launching one.
As with blogging, start by outlining a long-range plan. Your general topic will probably be your specialty, but you will need to narrow your focus to a few specific subjects, such as the problems you see most often, or a subspecialty that you concentrate on. You can always expand your topic later, as you get more popular. Choose a name for your podcast, and purchase a domain name that accurately describes it.
You will also need to choose a hosting service. Numerous inexpensive hosting platforms are available, and a simple Google search will find them for you. Many of them provide free learning materials, helpful creative tools, and customer support to get you through the confusing technical aspects. They can also help you choose a music introduction (to add a bit of polish), and help you piece together your audio segments. Buzzsprout, RSS.com, and Podbean get good reviews on many sites. (As always, I have no financial interest in any company or service mentioned herein.)
Hosting services can assist you in creating a template – a framework that you can reuse each time you record an episode – containing your intro and exit music, tracks for your conversations, etc. This will make your podcasts instantly recognizable each time your listeners tune in.
Many podcasting experts recommend recruiting a co-host. This can be an associate within your practice, a friend who practices elsewhere, or perhaps a resident in an academic setting. You will be able to spread the workload of creating, editing, and promoting. Plus, it is much easier to generate interesting content when two people are having a conversation, rather than one person lecturing from a prepared script. You might also consider having multiple co-hosts, either to expand episodes into group discussions, or to take turns working with you in covering different subjects.
How long you make your podcast is entirely up to you. Some consultants recommend specific time frames, such as 5 minutes (because that’s an average attention span), or 28 minutes (because that’s the average driving commute time). There are short podcasts and long ones; whatever works for you is fine, as long as you don’t drift off the topic. Furthermore, no one says they must all be the same length; when you are finished talking, you are done. And no one says you must stick with one subject throughout. Combining several short segments might hold more listeners’ interest and will make it easier to share small clips on social media.
Content guidelines are similar to those for blogs. Give people content that will be of interest or benefit to them. Talk about subjects – medical and otherwise – that are relevant to your practice or are prominent in the news.
As with blogs, try to avoid polarizing political discussions, and while it’s fine to discuss treatments and procedures that you offer, aggressive solicitation tends to make viewers look elsewhere. Keep any medical advice in general terms; don’t portray any specific patients as examples.
When your podcast is ready, your hosting platform will show you how to submit it to iTunes, and how to submit your podcast RSS feed to other podcast directories. As you upload new episodes, your host will automatically update your RSS feed, so that any directory you are listed on will receive the new episode.
Once you are uploaded, you can use your host’s social sharing tools to spread the word. As with blogs, use social media, such as your practice’s Facebook page, to push podcast updates into patients’ feeds and track relevant Twitter hashtags to find online communities that might be interested in your subject matter. You should also find your episode embed code (which your host will have) and place it in a prominent place on your website so patients can listen directly from there.
Transcriptions are another excellent promotional tool. Search engines will “read” your podcasts and list them in searches. Some podcast hosts will do transcribing for a fee, but there are independent transcription services as well.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
Love them or hate them, masks in schools work
This transcript has been edited for clarity.
Welcome to Impact Factor, your weekly dose of commentary on a new medical study. I’m Dr. F. Perry Wilson of the Yale School of Medicine.
On March 26, 2022, Hawaii became the last state in the United States to lift its indoor mask mandate. By the time the current school year started, there were essentially no public school mask mandates either.
Whether you viewed the mask as an emblem of stalwart defiance against a rampaging virus, or a scarlet letter emblematic of the overreaches of public policy, you probably aren’t seeing them much anymore.
And yet, the debate about masks still rages. Who was right, who was wrong? Who trusted science, and what does the science even say? If we brought our country into marriage counseling, would we be told it is time to move on? To look forward, not backward? To plan for our bright future together?
Perhaps. But this question isn’t really moot just because masks have largely disappeared in the United States. Variants may emerge that lead to more infection waves – and other pandemics may occur in the future. And so I think it is important to discuss a study that, with quite rigorous analysis, attempts to answer the following question: Did masking in schools lower students’ and teachers’ risk of COVID?
We are talking about this study, appearing in the New England Journal of Medicine. The short version goes like this.
Researchers had access to two important sources of data. One – an accounting of all the teachers and students (more than 300,000 of them) in 79 public, noncharter school districts in Eastern Massachusetts who tested positive for COVID every week. Two – the date that each of those school districts lifted their mask mandates or (in the case of two districts) didn’t.
Right away, I’m sure you’re thinking of potential issues. Districts that kept masks even when the statewide ban was lifted are likely quite a bit different from districts that dropped masks right away. You’re right, of course – hold on to that thought; we’ll get there.
But first – the big question – would districts that kept their masks on longer do better when it comes to the rate of COVID infection?
When everyone was masking, COVID case rates were pretty similar. Statewide mandates are lifted in late February – and most school districts remove their mandates within a few weeks – the black line are the two districts (Boston and Chelsea) where mask mandates remained in place.
Prior to the mask mandate lifting, you see very similar COVID rates in districts that would eventually remove the mandate and those that would not, with a bit of noise around the initial Omicron wave which saw just a huge amount of people get infected.
And then, after the mandate was lifted, separation. Districts that held on to masks longer had lower rates of COVID infection.
In all, over the 15-weeks of the study, there were roughly 12,000 extra cases of COVID in the mask-free school districts, which corresponds to about 35% of the total COVID burden during that time. And, yes, kids do well with COVID – on average. But 12,000 extra cases is enough to translate into a significant number of important clinical outcomes – think hospitalizations and post-COVID syndromes. And of course, maybe most importantly, missed school days. Positive kids were not allowed in class no matter what district they were in.
Okay – I promised we’d address confounders. This was not a cluster-randomized trial, where some school districts had their mandates removed based on the vicissitudes of a virtual coin flip, as much as many of us would have been interested to see that. The decision to remove masks was up to the various school boards – and they had a lot of pressure on them from many different directions. But all we need to worry about is whether any of those things that pressure a school board to keep masks on would ALSO lead to fewer COVID cases. That’s how confounders work, and how you can get false results in a study like this.
And yes – districts that kept the masks on longer were different than those who took them right off. But check out how they were different.
The districts that kept masks on longer had more low-income students. More Black and Latino students. More students per classroom. These are all risk factors that increase the risk of COVID infection. In other words, the confounding here goes in the opposite direction of the results. If anything, these factors should make you more certain that masking works.
The authors also adjusted for other factors – the community transmission of COVID-19, vaccination rates, school district sizes, and so on. No major change in the results.
One concern I addressed to Dr. Ellie Murray, the biostatistician on the study – could districts that removed masks simply have been testing more to compensate, leading to increased capturing of cases?
If anything, the schools that kept masks on were testing more than the schools that took them off – again that would tend to imply that the results are even stronger than what was reported.
Is this a perfect study? Of course not – it’s one study, it’s from one state. And the relatively large effects from keeping masks on for one or 2 weeks require us to really embrace the concept of exponential growth of infections, but, if COVID has taught us anything, it is that small changes in initial conditions can have pretty big effects.
My daughter, who goes to a public school here in Connecticut, unmasked, was home with COVID this past week. She’s fine. But you know what? She missed a week of school. I worked from home to be with her – though I didn’t test positive. And that is a real cost to both of us that I think we need to consider when we consider the value of masks. Yes, they’re annoying – but if they keep kids in school, might they be worth it? Perhaps not for now, as cases aren’t surging. But in the future, be it a particularly concerning variant, or a whole new pandemic, we should not discount the simple, cheap, and apparently beneficial act of wearing masks to decrease transmission.
Dr. Perry Wilson is an associate professor of medicine and director of the Clinical and Translational Research Accelerator at Yale University, New Haven, Conn. He disclosed no relevant conflicts of interest.
A version of this article first appeared on Medscape.com.
This transcript has been edited for clarity.
Welcome to Impact Factor, your weekly dose of commentary on a new medical study. I’m Dr. F. Perry Wilson of the Yale School of Medicine.
On March 26, 2022, Hawaii became the last state in the United States to lift its indoor mask mandate. By the time the current school year started, there were essentially no public school mask mandates either.
Whether you viewed the mask as an emblem of stalwart defiance against a rampaging virus, or a scarlet letter emblematic of the overreaches of public policy, you probably aren’t seeing them much anymore.
And yet, the debate about masks still rages. Who was right, who was wrong? Who trusted science, and what does the science even say? If we brought our country into marriage counseling, would we be told it is time to move on? To look forward, not backward? To plan for our bright future together?
Perhaps. But this question isn’t really moot just because masks have largely disappeared in the United States. Variants may emerge that lead to more infection waves – and other pandemics may occur in the future. And so I think it is important to discuss a study that, with quite rigorous analysis, attempts to answer the following question: Did masking in schools lower students’ and teachers’ risk of COVID?
We are talking about this study, appearing in the New England Journal of Medicine. The short version goes like this.
Researchers had access to two important sources of data. One – an accounting of all the teachers and students (more than 300,000 of them) in 79 public, noncharter school districts in Eastern Massachusetts who tested positive for COVID every week. Two – the date that each of those school districts lifted their mask mandates or (in the case of two districts) didn’t.
Right away, I’m sure you’re thinking of potential issues. Districts that kept masks even when the statewide ban was lifted are likely quite a bit different from districts that dropped masks right away. You’re right, of course – hold on to that thought; we’ll get there.
But first – the big question – would districts that kept their masks on longer do better when it comes to the rate of COVID infection?
When everyone was masking, COVID case rates were pretty similar. Statewide mandates are lifted in late February – and most school districts remove their mandates within a few weeks – the black line are the two districts (Boston and Chelsea) where mask mandates remained in place.
Prior to the mask mandate lifting, you see very similar COVID rates in districts that would eventually remove the mandate and those that would not, with a bit of noise around the initial Omicron wave which saw just a huge amount of people get infected.
And then, after the mandate was lifted, separation. Districts that held on to masks longer had lower rates of COVID infection.
In all, over the 15-weeks of the study, there were roughly 12,000 extra cases of COVID in the mask-free school districts, which corresponds to about 35% of the total COVID burden during that time. And, yes, kids do well with COVID – on average. But 12,000 extra cases is enough to translate into a significant number of important clinical outcomes – think hospitalizations and post-COVID syndromes. And of course, maybe most importantly, missed school days. Positive kids were not allowed in class no matter what district they were in.
Okay – I promised we’d address confounders. This was not a cluster-randomized trial, where some school districts had their mandates removed based on the vicissitudes of a virtual coin flip, as much as many of us would have been interested to see that. The decision to remove masks was up to the various school boards – and they had a lot of pressure on them from many different directions. But all we need to worry about is whether any of those things that pressure a school board to keep masks on would ALSO lead to fewer COVID cases. That’s how confounders work, and how you can get false results in a study like this.
And yes – districts that kept the masks on longer were different than those who took them right off. But check out how they were different.
The districts that kept masks on longer had more low-income students. More Black and Latino students. More students per classroom. These are all risk factors that increase the risk of COVID infection. In other words, the confounding here goes in the opposite direction of the results. If anything, these factors should make you more certain that masking works.
The authors also adjusted for other factors – the community transmission of COVID-19, vaccination rates, school district sizes, and so on. No major change in the results.
One concern I addressed to Dr. Ellie Murray, the biostatistician on the study – could districts that removed masks simply have been testing more to compensate, leading to increased capturing of cases?
If anything, the schools that kept masks on were testing more than the schools that took them off – again that would tend to imply that the results are even stronger than what was reported.
Is this a perfect study? Of course not – it’s one study, it’s from one state. And the relatively large effects from keeping masks on for one or 2 weeks require us to really embrace the concept of exponential growth of infections, but, if COVID has taught us anything, it is that small changes in initial conditions can have pretty big effects.
My daughter, who goes to a public school here in Connecticut, unmasked, was home with COVID this past week. She’s fine. But you know what? She missed a week of school. I worked from home to be with her – though I didn’t test positive. And that is a real cost to both of us that I think we need to consider when we consider the value of masks. Yes, they’re annoying – but if they keep kids in school, might they be worth it? Perhaps not for now, as cases aren’t surging. But in the future, be it a particularly concerning variant, or a whole new pandemic, we should not discount the simple, cheap, and apparently beneficial act of wearing masks to decrease transmission.
Dr. Perry Wilson is an associate professor of medicine and director of the Clinical and Translational Research Accelerator at Yale University, New Haven, Conn. He disclosed no relevant conflicts of interest.
A version of this article first appeared on Medscape.com.
This transcript has been edited for clarity.
Welcome to Impact Factor, your weekly dose of commentary on a new medical study. I’m Dr. F. Perry Wilson of the Yale School of Medicine.
On March 26, 2022, Hawaii became the last state in the United States to lift its indoor mask mandate. By the time the current school year started, there were essentially no public school mask mandates either.
Whether you viewed the mask as an emblem of stalwart defiance against a rampaging virus, or a scarlet letter emblematic of the overreaches of public policy, you probably aren’t seeing them much anymore.
And yet, the debate about masks still rages. Who was right, who was wrong? Who trusted science, and what does the science even say? If we brought our country into marriage counseling, would we be told it is time to move on? To look forward, not backward? To plan for our bright future together?
Perhaps. But this question isn’t really moot just because masks have largely disappeared in the United States. Variants may emerge that lead to more infection waves – and other pandemics may occur in the future. And so I think it is important to discuss a study that, with quite rigorous analysis, attempts to answer the following question: Did masking in schools lower students’ and teachers’ risk of COVID?
We are talking about this study, appearing in the New England Journal of Medicine. The short version goes like this.
Researchers had access to two important sources of data. One – an accounting of all the teachers and students (more than 300,000 of them) in 79 public, noncharter school districts in Eastern Massachusetts who tested positive for COVID every week. Two – the date that each of those school districts lifted their mask mandates or (in the case of two districts) didn’t.
Right away, I’m sure you’re thinking of potential issues. Districts that kept masks even when the statewide ban was lifted are likely quite a bit different from districts that dropped masks right away. You’re right, of course – hold on to that thought; we’ll get there.
But first – the big question – would districts that kept their masks on longer do better when it comes to the rate of COVID infection?
When everyone was masking, COVID case rates were pretty similar. Statewide mandates are lifted in late February – and most school districts remove their mandates within a few weeks – the black line are the two districts (Boston and Chelsea) where mask mandates remained in place.
Prior to the mask mandate lifting, you see very similar COVID rates in districts that would eventually remove the mandate and those that would not, with a bit of noise around the initial Omicron wave which saw just a huge amount of people get infected.
And then, after the mandate was lifted, separation. Districts that held on to masks longer had lower rates of COVID infection.
In all, over the 15-weeks of the study, there were roughly 12,000 extra cases of COVID in the mask-free school districts, which corresponds to about 35% of the total COVID burden during that time. And, yes, kids do well with COVID – on average. But 12,000 extra cases is enough to translate into a significant number of important clinical outcomes – think hospitalizations and post-COVID syndromes. And of course, maybe most importantly, missed school days. Positive kids were not allowed in class no matter what district they were in.
Okay – I promised we’d address confounders. This was not a cluster-randomized trial, where some school districts had their mandates removed based on the vicissitudes of a virtual coin flip, as much as many of us would have been interested to see that. The decision to remove masks was up to the various school boards – and they had a lot of pressure on them from many different directions. But all we need to worry about is whether any of those things that pressure a school board to keep masks on would ALSO lead to fewer COVID cases. That’s how confounders work, and how you can get false results in a study like this.
And yes – districts that kept the masks on longer were different than those who took them right off. But check out how they were different.
The districts that kept masks on longer had more low-income students. More Black and Latino students. More students per classroom. These are all risk factors that increase the risk of COVID infection. In other words, the confounding here goes in the opposite direction of the results. If anything, these factors should make you more certain that masking works.
The authors also adjusted for other factors – the community transmission of COVID-19, vaccination rates, school district sizes, and so on. No major change in the results.
One concern I addressed to Dr. Ellie Murray, the biostatistician on the study – could districts that removed masks simply have been testing more to compensate, leading to increased capturing of cases?
If anything, the schools that kept masks on were testing more than the schools that took them off – again that would tend to imply that the results are even stronger than what was reported.
Is this a perfect study? Of course not – it’s one study, it’s from one state. And the relatively large effects from keeping masks on for one or 2 weeks require us to really embrace the concept of exponential growth of infections, but, if COVID has taught us anything, it is that small changes in initial conditions can have pretty big effects.
My daughter, who goes to a public school here in Connecticut, unmasked, was home with COVID this past week. She’s fine. But you know what? She missed a week of school. I worked from home to be with her – though I didn’t test positive. And that is a real cost to both of us that I think we need to consider when we consider the value of masks. Yes, they’re annoying – but if they keep kids in school, might they be worth it? Perhaps not for now, as cases aren’t surging. But in the future, be it a particularly concerning variant, or a whole new pandemic, we should not discount the simple, cheap, and apparently beneficial act of wearing masks to decrease transmission.
Dr. Perry Wilson is an associate professor of medicine and director of the Clinical and Translational Research Accelerator at Yale University, New Haven, Conn. He disclosed no relevant conflicts of interest.
A version of this article first appeared on Medscape.com.
The body of evidence for Paxlovid therapy
Dear Colleagues,
We have a mismatch. The evidence supporting treatment for Paxlovid is compelling for people aged 60 or over, but the older patients in the United States are much less likely to be treated. Not only was there a randomized, placebo-controlled trial of high-risk patients which showed 89% reduction of hospitalizations and deaths (median age, 45), but there have been multiple real-world effectiveness studies subsequently published that have partitioned the benefit for age 65 or older, such as the ones from Israel and Hong Kong (age 60+). Overall, the real-world effectiveness in the first month after treatment is at least as good, if not better, than in the high-risk randomized trial.
We’re doing the current survey to find out, but the most likely reasons include (1) lack of confidence of benefit; (2) medication interactions; and (3) concerns over rebound.
Let me address each of these briefly. The lack of confidence in benefit stems from the fact that the initial high-risk trial was in unvaccinated individuals. That concern can now be put aside because all of the several real-world studies confirming the protective benefit against hospitalizations and deaths are in people who have been vaccinated, and a significant proportion received booster shots.
The potential medication interactions due to the ritonavir component of the Paxlovid drug combination, attributable to its cytochrome P450 3A4 inhibition, have been unduly emphasized. There are many drug-interaction checkers for Paxlovid, but this one from the University of Liverpool is user friendly, color- and icon-coded, and shows that the vast majority of interactions can be sidestepped by discontinuing the medication of concern for the length of the Paxlovid treatment, 5 days. The simple chart is provided in my recent substack newsletter.
As far as rebound, this problem has unfortunately been exaggerated because of lack of prospective systematic studies and appreciation that a positive test of clinical symptom rebound can occur without Paxlovid. There are soon to be multiple reports that the incidence of Paxlovid rebound is fairly low, in the range of 10%. That concern should not be a reason to withhold treatment.
Now the plot thickens. A new preprint report from the Veterans Health Administration, the largest health care system in the United States, looks at 90-day outcomes of about 9,000 Paxlovid-treated patients and approximately 47,000 controls. Not only was there a 26% reduction in long COVID, but of the breakdown of 12 organs/systems and symptoms, 10 of 12 were significantly reduced with Paxlovid, including pulmonary embolism, deep vein thrombosis, and neurocognitive impairment. There was also a 48% reduction in death and a 30% reduction in hospitalizations after the first 30 days. I have reviewed all of these data and put them in context in a recent newsletter. A key point is that the magnitude of benefit was unaffected by vaccination or booster status, or prior COVID infections, or unvaccinated status. Also, it was the same for men and women, as well as for age > 70 and age < 60. These findings all emphasize a new reason to be using Paxlovid therapy, and if replicated, Paxlovid may even be indicated for younger patients (who are at low risk for hospitalizations and deaths but at increased risk for long COVID).
In summary, for older patients, we should be thinking of why we should be using Paxlovid rather than the reason not to treat. We’ll be interested in the survey results to understand the mismatch better, and we look forward to your ideas and feedback to make better use of this treatment for the people who need it the most.
Sincerely yours, Eric J. Topol, MD
Dr. Topol reports no conflicts of interest with Pfizer; he receives no honoraria or speaker fees, does not serve in an advisory role, and has no financial association with the company.
A version of this article first appeared on Medscape.com.
Dear Colleagues,
We have a mismatch. The evidence supporting treatment for Paxlovid is compelling for people aged 60 or over, but the older patients in the United States are much less likely to be treated. Not only was there a randomized, placebo-controlled trial of high-risk patients which showed 89% reduction of hospitalizations and deaths (median age, 45), but there have been multiple real-world effectiveness studies subsequently published that have partitioned the benefit for age 65 or older, such as the ones from Israel and Hong Kong (age 60+). Overall, the real-world effectiveness in the first month after treatment is at least as good, if not better, than in the high-risk randomized trial.
We’re doing the current survey to find out, but the most likely reasons include (1) lack of confidence of benefit; (2) medication interactions; and (3) concerns over rebound.
Let me address each of these briefly. The lack of confidence in benefit stems from the fact that the initial high-risk trial was in unvaccinated individuals. That concern can now be put aside because all of the several real-world studies confirming the protective benefit against hospitalizations and deaths are in people who have been vaccinated, and a significant proportion received booster shots.
The potential medication interactions due to the ritonavir component of the Paxlovid drug combination, attributable to its cytochrome P450 3A4 inhibition, have been unduly emphasized. There are many drug-interaction checkers for Paxlovid, but this one from the University of Liverpool is user friendly, color- and icon-coded, and shows that the vast majority of interactions can be sidestepped by discontinuing the medication of concern for the length of the Paxlovid treatment, 5 days. The simple chart is provided in my recent substack newsletter.
As far as rebound, this problem has unfortunately been exaggerated because of lack of prospective systematic studies and appreciation that a positive test of clinical symptom rebound can occur without Paxlovid. There are soon to be multiple reports that the incidence of Paxlovid rebound is fairly low, in the range of 10%. That concern should not be a reason to withhold treatment.
Now the plot thickens. A new preprint report from the Veterans Health Administration, the largest health care system in the United States, looks at 90-day outcomes of about 9,000 Paxlovid-treated patients and approximately 47,000 controls. Not only was there a 26% reduction in long COVID, but of the breakdown of 12 organs/systems and symptoms, 10 of 12 were significantly reduced with Paxlovid, including pulmonary embolism, deep vein thrombosis, and neurocognitive impairment. There was also a 48% reduction in death and a 30% reduction in hospitalizations after the first 30 days. I have reviewed all of these data and put them in context in a recent newsletter. A key point is that the magnitude of benefit was unaffected by vaccination or booster status, or prior COVID infections, or unvaccinated status. Also, it was the same for men and women, as well as for age > 70 and age < 60. These findings all emphasize a new reason to be using Paxlovid therapy, and if replicated, Paxlovid may even be indicated for younger patients (who are at low risk for hospitalizations and deaths but at increased risk for long COVID).
In summary, for older patients, we should be thinking of why we should be using Paxlovid rather than the reason not to treat. We’ll be interested in the survey results to understand the mismatch better, and we look forward to your ideas and feedback to make better use of this treatment for the people who need it the most.
Sincerely yours, Eric J. Topol, MD
Dr. Topol reports no conflicts of interest with Pfizer; he receives no honoraria or speaker fees, does not serve in an advisory role, and has no financial association with the company.
A version of this article first appeared on Medscape.com.
Dear Colleagues,
We have a mismatch. The evidence supporting treatment for Paxlovid is compelling for people aged 60 or over, but the older patients in the United States are much less likely to be treated. Not only was there a randomized, placebo-controlled trial of high-risk patients which showed 89% reduction of hospitalizations and deaths (median age, 45), but there have been multiple real-world effectiveness studies subsequently published that have partitioned the benefit for age 65 or older, such as the ones from Israel and Hong Kong (age 60+). Overall, the real-world effectiveness in the first month after treatment is at least as good, if not better, than in the high-risk randomized trial.
We’re doing the current survey to find out, but the most likely reasons include (1) lack of confidence of benefit; (2) medication interactions; and (3) concerns over rebound.
Let me address each of these briefly. The lack of confidence in benefit stems from the fact that the initial high-risk trial was in unvaccinated individuals. That concern can now be put aside because all of the several real-world studies confirming the protective benefit against hospitalizations and deaths are in people who have been vaccinated, and a significant proportion received booster shots.
The potential medication interactions due to the ritonavir component of the Paxlovid drug combination, attributable to its cytochrome P450 3A4 inhibition, have been unduly emphasized. There are many drug-interaction checkers for Paxlovid, but this one from the University of Liverpool is user friendly, color- and icon-coded, and shows that the vast majority of interactions can be sidestepped by discontinuing the medication of concern for the length of the Paxlovid treatment, 5 days. The simple chart is provided in my recent substack newsletter.
As far as rebound, this problem has unfortunately been exaggerated because of lack of prospective systematic studies and appreciation that a positive test of clinical symptom rebound can occur without Paxlovid. There are soon to be multiple reports that the incidence of Paxlovid rebound is fairly low, in the range of 10%. That concern should not be a reason to withhold treatment.
Now the plot thickens. A new preprint report from the Veterans Health Administration, the largest health care system in the United States, looks at 90-day outcomes of about 9,000 Paxlovid-treated patients and approximately 47,000 controls. Not only was there a 26% reduction in long COVID, but of the breakdown of 12 organs/systems and symptoms, 10 of 12 were significantly reduced with Paxlovid, including pulmonary embolism, deep vein thrombosis, and neurocognitive impairment. There was also a 48% reduction in death and a 30% reduction in hospitalizations after the first 30 days. I have reviewed all of these data and put them in context in a recent newsletter. A key point is that the magnitude of benefit was unaffected by vaccination or booster status, or prior COVID infections, or unvaccinated status. Also, it was the same for men and women, as well as for age > 70 and age < 60. These findings all emphasize a new reason to be using Paxlovid therapy, and if replicated, Paxlovid may even be indicated for younger patients (who are at low risk for hospitalizations and deaths but at increased risk for long COVID).
In summary, for older patients, we should be thinking of why we should be using Paxlovid rather than the reason not to treat. We’ll be interested in the survey results to understand the mismatch better, and we look forward to your ideas and feedback to make better use of this treatment for the people who need it the most.
Sincerely yours, Eric J. Topol, MD
Dr. Topol reports no conflicts of interest with Pfizer; he receives no honoraria or speaker fees, does not serve in an advisory role, and has no financial association with the company.
A version of this article first appeared on Medscape.com.
Which exercise is best for bone health?
An 18-year-old woman with Crohn’s disease (diagnosed 3 years ago) came to my office for advice regarding management of osteoporosis. Her bone density was low for her age, and she had three low-impact fractures of her long bones in the preceding 4 years.
Loss of weight after the onset of Crohn’s disease, subsequent loss of periods, inflammation associated with her underlying diagnosis, and early treatment with glucocorticoids (known to have deleterious effects on bone) were believed to have caused osteoporosis in this young woman.
A few months previously, she was switched to a medication that doesn’t impair bone health and glucocorticoids were discontinued; her weight began to improve, and her Crohn’s disease was now in remission. Her menses had resumed about 3 months before her visit to my clinic after a prolonged period without periods. She was on calcium and vitamin D supplements, with normal levels of vitamin D.
Many factors determine bone health including (but not limited to) genetics, nutritional status, exercise activity (with mechanical loading of bones), macro- and micronutrient intake, hormonal status, chronic inflammation and other disease states, and medication use.
Exercise certainly has beneficial effects on bone. Bone-loading activities increase bone formation through the activation of certain cells in bone called osteocytes, which serve as mechanosensors and sense bone loading. Osteocytes make a hormone called sclerostin, which typically inhibits bone formation. When osteocytes sense bone-loading activities, sclerostin secretion reduces, allowing for increased bone formation.
Consistent with this, investigators in Canada have demonstrated greater increases in bone density and strength in schoolchildren who engage in moderate to vigorous physical activity, particularly bone-loading exercise, during the school day, compared with those who don’t (J Bone Miner Res. 2007 Mar;22[3]:434-46; J Bone Miner Res. 2017 Jul;32[7]:1525-36). In females, normal levels of estrogen seem necessary for osteocytes to bring about these effects after bone-loading activities. This is probably one of several reasons why athletes who lose their periods (indicative of low estrogen levels) and develop low bone density with an increased risk for fracture even when they are still at a normal weight (J Clin Endocrinol Metab. 2018 Jun 1;103[6]:2392-402; Med Sci Sports Exerc. 2015 Aug;47[8]:1577-86).
One concern around prescribing bone-loading activity or exercise to persons with osteoporosis is whether it would increase the risk for fracture from the impact on fragile bone. The extent of bone loading safe for fragile bone can be difficult to determine. Furthermore, excessive exercise may worsen bone health by causing weight loss or loss of periods in women. Very careful monitoring may be necessary to ensure that energy balance is maintained. Therefore, the nature and volume of exercise should be discussed with one’s doctor or physical therapist as well as a dietitian (if the patient is seeing one).
In patients with osteoporosis, high-impact activities such as jumping; repetitive impact activities such as running or jogging; and bending and twisting activities such as touching one’s toes, golf, tennis, and bowling aren’t recommended because they increase the risk for fracture. Even yoga poses should be discussed, because some may increase the risk for compression fractures of the vertebrae in the spine.
Strength and resistance training are generally believed to be good for bones. Strength training involves activities that build muscle strength and mass. Resistance training builds muscle strength, mass, and endurance by making muscles work against some form of resistance. Such activities include weight training with free weights or weight machines, use of resistance bands, and use of one’s own body to strengthen major muscle groups (such as through push-ups, squats, lunges, and gluteus maximus extension).
Some amount of weight-bearing aerobic training is also recommended, including walking, low-impact aerobics, the elliptical, and stair-climbing. Non–weight-bearing activities, such as swimming and cycling, typically don’t contribute to improving bone density.
In older individuals with osteoporosis, agility exercises are particularly useful to reduce the fall risk (J Am Geriatr Soc. 2004 May;52[5]:657-65; CMAJ. 2002 Oct 29;167[9]:997-1004). These can be structured to improve hand-eye coordination, foot-eye coordination, static and dynamic balance, and reaction time. Agility exercises with resistance training help improve bone density in older women.
An optimal exercise regimen includes a combination of strength and resistance training; weight-bearing aerobic training; and exercises that build flexibility, stability, and balance. A doctor, physical therapist, or trainer with expertise in the right combination of exercises should be consulted to ensure optimal effects on bone and general health.
In those at risk for overexercising to the point that they start to lose weight or lose their periods, and certainly in all women with disordered eating patterns, a dietitian should be part of the decision team to ensure that energy balance is maintained. In this group, particularly in very-low-weight women with eating disorders, exercise activity is often limited until they reach a healthier weight, and ideally after their menses resume.
For my patient with Crohn’s disease, I recommended that she see a physical therapist and a dietitian for guidance about a graded increase in exercise activity and an exercise regimen that would work best for her. I assess her bone density annually using dual-energy x-ray absorptiometry. Her bone density has gradually improved with the combination of weight gain, resumption of menses, medications for Crohn’s disease that do not affect bone deleteriously, remission of Crohn’s disease, and her exercise regimen.
Dr. Misra is chief of the division of pediatric endocrinology at Mass General Hospital for Children and professor in the department of pediatrics at Harvard Medical School, both in Boston. She reported conflicts of interest with AbbVie, Sanofi, and Ipsen.
A version of this article first appeared on Medscape.com.
An 18-year-old woman with Crohn’s disease (diagnosed 3 years ago) came to my office for advice regarding management of osteoporosis. Her bone density was low for her age, and she had three low-impact fractures of her long bones in the preceding 4 years.
Loss of weight after the onset of Crohn’s disease, subsequent loss of periods, inflammation associated with her underlying diagnosis, and early treatment with glucocorticoids (known to have deleterious effects on bone) were believed to have caused osteoporosis in this young woman.
A few months previously, she was switched to a medication that doesn’t impair bone health and glucocorticoids were discontinued; her weight began to improve, and her Crohn’s disease was now in remission. Her menses had resumed about 3 months before her visit to my clinic after a prolonged period without periods. She was on calcium and vitamin D supplements, with normal levels of vitamin D.
Many factors determine bone health including (but not limited to) genetics, nutritional status, exercise activity (with mechanical loading of bones), macro- and micronutrient intake, hormonal status, chronic inflammation and other disease states, and medication use.
Exercise certainly has beneficial effects on bone. Bone-loading activities increase bone formation through the activation of certain cells in bone called osteocytes, which serve as mechanosensors and sense bone loading. Osteocytes make a hormone called sclerostin, which typically inhibits bone formation. When osteocytes sense bone-loading activities, sclerostin secretion reduces, allowing for increased bone formation.
Consistent with this, investigators in Canada have demonstrated greater increases in bone density and strength in schoolchildren who engage in moderate to vigorous physical activity, particularly bone-loading exercise, during the school day, compared with those who don’t (J Bone Miner Res. 2007 Mar;22[3]:434-46; J Bone Miner Res. 2017 Jul;32[7]:1525-36). In females, normal levels of estrogen seem necessary for osteocytes to bring about these effects after bone-loading activities. This is probably one of several reasons why athletes who lose their periods (indicative of low estrogen levels) and develop low bone density with an increased risk for fracture even when they are still at a normal weight (J Clin Endocrinol Metab. 2018 Jun 1;103[6]:2392-402; Med Sci Sports Exerc. 2015 Aug;47[8]:1577-86).
One concern around prescribing bone-loading activity or exercise to persons with osteoporosis is whether it would increase the risk for fracture from the impact on fragile bone. The extent of bone loading safe for fragile bone can be difficult to determine. Furthermore, excessive exercise may worsen bone health by causing weight loss or loss of periods in women. Very careful monitoring may be necessary to ensure that energy balance is maintained. Therefore, the nature and volume of exercise should be discussed with one’s doctor or physical therapist as well as a dietitian (if the patient is seeing one).
In patients with osteoporosis, high-impact activities such as jumping; repetitive impact activities such as running or jogging; and bending and twisting activities such as touching one’s toes, golf, tennis, and bowling aren’t recommended because they increase the risk for fracture. Even yoga poses should be discussed, because some may increase the risk for compression fractures of the vertebrae in the spine.
Strength and resistance training are generally believed to be good for bones. Strength training involves activities that build muscle strength and mass. Resistance training builds muscle strength, mass, and endurance by making muscles work against some form of resistance. Such activities include weight training with free weights or weight machines, use of resistance bands, and use of one’s own body to strengthen major muscle groups (such as through push-ups, squats, lunges, and gluteus maximus extension).
Some amount of weight-bearing aerobic training is also recommended, including walking, low-impact aerobics, the elliptical, and stair-climbing. Non–weight-bearing activities, such as swimming and cycling, typically don’t contribute to improving bone density.
In older individuals with osteoporosis, agility exercises are particularly useful to reduce the fall risk (J Am Geriatr Soc. 2004 May;52[5]:657-65; CMAJ. 2002 Oct 29;167[9]:997-1004). These can be structured to improve hand-eye coordination, foot-eye coordination, static and dynamic balance, and reaction time. Agility exercises with resistance training help improve bone density in older women.
An optimal exercise regimen includes a combination of strength and resistance training; weight-bearing aerobic training; and exercises that build flexibility, stability, and balance. A doctor, physical therapist, or trainer with expertise in the right combination of exercises should be consulted to ensure optimal effects on bone and general health.
In those at risk for overexercising to the point that they start to lose weight or lose their periods, and certainly in all women with disordered eating patterns, a dietitian should be part of the decision team to ensure that energy balance is maintained. In this group, particularly in very-low-weight women with eating disorders, exercise activity is often limited until they reach a healthier weight, and ideally after their menses resume.
For my patient with Crohn’s disease, I recommended that she see a physical therapist and a dietitian for guidance about a graded increase in exercise activity and an exercise regimen that would work best for her. I assess her bone density annually using dual-energy x-ray absorptiometry. Her bone density has gradually improved with the combination of weight gain, resumption of menses, medications for Crohn’s disease that do not affect bone deleteriously, remission of Crohn’s disease, and her exercise regimen.
Dr. Misra is chief of the division of pediatric endocrinology at Mass General Hospital for Children and professor in the department of pediatrics at Harvard Medical School, both in Boston. She reported conflicts of interest with AbbVie, Sanofi, and Ipsen.
A version of this article first appeared on Medscape.com.
An 18-year-old woman with Crohn’s disease (diagnosed 3 years ago) came to my office for advice regarding management of osteoporosis. Her bone density was low for her age, and she had three low-impact fractures of her long bones in the preceding 4 years.
Loss of weight after the onset of Crohn’s disease, subsequent loss of periods, inflammation associated with her underlying diagnosis, and early treatment with glucocorticoids (known to have deleterious effects on bone) were believed to have caused osteoporosis in this young woman.
A few months previously, she was switched to a medication that doesn’t impair bone health and glucocorticoids were discontinued; her weight began to improve, and her Crohn’s disease was now in remission. Her menses had resumed about 3 months before her visit to my clinic after a prolonged period without periods. She was on calcium and vitamin D supplements, with normal levels of vitamin D.
Many factors determine bone health including (but not limited to) genetics, nutritional status, exercise activity (with mechanical loading of bones), macro- and micronutrient intake, hormonal status, chronic inflammation and other disease states, and medication use.
Exercise certainly has beneficial effects on bone. Bone-loading activities increase bone formation through the activation of certain cells in bone called osteocytes, which serve as mechanosensors and sense bone loading. Osteocytes make a hormone called sclerostin, which typically inhibits bone formation. When osteocytes sense bone-loading activities, sclerostin secretion reduces, allowing for increased bone formation.
Consistent with this, investigators in Canada have demonstrated greater increases in bone density and strength in schoolchildren who engage in moderate to vigorous physical activity, particularly bone-loading exercise, during the school day, compared with those who don’t (J Bone Miner Res. 2007 Mar;22[3]:434-46; J Bone Miner Res. 2017 Jul;32[7]:1525-36). In females, normal levels of estrogen seem necessary for osteocytes to bring about these effects after bone-loading activities. This is probably one of several reasons why athletes who lose their periods (indicative of low estrogen levels) and develop low bone density with an increased risk for fracture even when they are still at a normal weight (J Clin Endocrinol Metab. 2018 Jun 1;103[6]:2392-402; Med Sci Sports Exerc. 2015 Aug;47[8]:1577-86).
One concern around prescribing bone-loading activity or exercise to persons with osteoporosis is whether it would increase the risk for fracture from the impact on fragile bone. The extent of bone loading safe for fragile bone can be difficult to determine. Furthermore, excessive exercise may worsen bone health by causing weight loss or loss of periods in women. Very careful monitoring may be necessary to ensure that energy balance is maintained. Therefore, the nature and volume of exercise should be discussed with one’s doctor or physical therapist as well as a dietitian (if the patient is seeing one).
In patients with osteoporosis, high-impact activities such as jumping; repetitive impact activities such as running or jogging; and bending and twisting activities such as touching one’s toes, golf, tennis, and bowling aren’t recommended because they increase the risk for fracture. Even yoga poses should be discussed, because some may increase the risk for compression fractures of the vertebrae in the spine.
Strength and resistance training are generally believed to be good for bones. Strength training involves activities that build muscle strength and mass. Resistance training builds muscle strength, mass, and endurance by making muscles work against some form of resistance. Such activities include weight training with free weights or weight machines, use of resistance bands, and use of one’s own body to strengthen major muscle groups (such as through push-ups, squats, lunges, and gluteus maximus extension).
Some amount of weight-bearing aerobic training is also recommended, including walking, low-impact aerobics, the elliptical, and stair-climbing. Non–weight-bearing activities, such as swimming and cycling, typically don’t contribute to improving bone density.
In older individuals with osteoporosis, agility exercises are particularly useful to reduce the fall risk (J Am Geriatr Soc. 2004 May;52[5]:657-65; CMAJ. 2002 Oct 29;167[9]:997-1004). These can be structured to improve hand-eye coordination, foot-eye coordination, static and dynamic balance, and reaction time. Agility exercises with resistance training help improve bone density in older women.
An optimal exercise regimen includes a combination of strength and resistance training; weight-bearing aerobic training; and exercises that build flexibility, stability, and balance. A doctor, physical therapist, or trainer with expertise in the right combination of exercises should be consulted to ensure optimal effects on bone and general health.
In those at risk for overexercising to the point that they start to lose weight or lose their periods, and certainly in all women with disordered eating patterns, a dietitian should be part of the decision team to ensure that energy balance is maintained. In this group, particularly in very-low-weight women with eating disorders, exercise activity is often limited until they reach a healthier weight, and ideally after their menses resume.
For my patient with Crohn’s disease, I recommended that she see a physical therapist and a dietitian for guidance about a graded increase in exercise activity and an exercise regimen that would work best for her. I assess her bone density annually using dual-energy x-ray absorptiometry. Her bone density has gradually improved with the combination of weight gain, resumption of menses, medications for Crohn’s disease that do not affect bone deleteriously, remission of Crohn’s disease, and her exercise regimen.
Dr. Misra is chief of the division of pediatric endocrinology at Mass General Hospital for Children and professor in the department of pediatrics at Harvard Medical School, both in Boston. She reported conflicts of interest with AbbVie, Sanofi, and Ipsen.
A version of this article first appeared on Medscape.com.
A new ultrabrief screening scale for pediatric OCD
Obsessive-compulsive disorder (OCD) affects 1-2% of the population. The disorder is characterized by recurrent intrusive unwanted thoughts (obsessions) that cause significant distress and anxiety, and behavioral or mental rituals (compulsions) that are performed to reduce distress stemming from obsessions. OCD may onset at any time in life, but most commonly begins in childhood or in early adulthood.
Cognitive behavioral therapy (CBT) with exposure and response prevention is an empirically based and highly effective treatment for OCD. However, most youth with OCD do not receive any treatment, which is related to a shortage of mental health care providers with expertise in assessment and treatment of the disorder, and misdiagnosis of the disorder is all too prevalent.
Aside from the subjective emotional toll associated with OCD, individuals living with this disorder frequently experience interpersonal, academic, and vocational impairments. Nevertheless, OCD is often overlooked or misdiagnosed. This may be more pronounced in youth with OCD, particularly in primary health care settings and large nonspecialized medical institutions. In fact, research indicates that pediatric OCD is often underrecognized even among mental health professionals. This situation is not new, and in fact the National Institute for Health and Care Excellence (NICE) in the United Kingdom stated that there is an urgent need to develop brief reliable screeners for OCD nearly 20 years ago.
Although there were several attempts to develop brief screening scales for adults and youth with OCD, none of them were found to be suitable for use as rapid screening tools in nonspecialized settings. One of the primary reasons is that OCD is associated with different “themes” or dimensions. For example, a child with OCD may engage in cleaning rituals because the context (or dimension) of their obsessions is contamination concerns. Another child with OCD, who may suffer from similar overall symptom severity, may primarily engage in checking rituals which are related with obsessions associated with fear of being responsible for harm. Therefore, one child with OCD may score very high on items assessing one dimension (e.g., contamination concerns), but very low on another dimension (e.g., harm obsessions).
This results in a known challenge in the assessment and psychometrics of self-report (as opposed to clinician administered) measures of OCD. Secondly, development of such measures requires very large carefully screened samples of individuals with OCD, with other disorders, and those without a known psychological disorder – which may be more challenging than requiring adult participants.
To accomplish this, we harmonized data from several sites that included three samples of carefully screened youths with OCD, with other disorders, and without known disorders who completed multiple self-report questionnaires, including the 21-item Obsessive-Compulsive Inventory – Child Version (OCI-CV).
Utilizing psychometric analyses including factor analyses, invariance analyses, and item response theory methodologies, we were able to develop an ultrabrief measure extracted from the OCI-CV: the 5-item Obsessive-Compulsive Inventory – Child Version (OCI-CV-5). This very brief self-report measure was found to have very good psychometric properties including a sensitive and specific clinical cutoff score. Youth who score at or above the cutoff score are nearly 21 times more likely to meet criteria for OCD.
This measure corresponds to a need to rapidly screen for OCD in children in nonspecialized settings, including community mental health clinics, primary care settings, and pediatric treatment facilities. However, it is important to note it is not a diagnostic measure. The measure is intended to identify youth who should be referred to a mental health care professional to conduct a diagnostic interview.
Dr. Abramovitch is a clinical psychologist and neuropsychologist based in Austin, Tex., and an associate professor at Texas State University. Dr. Abramowitz is professor and director of clinical training in the Anxiety and Stress Lab at University of North Carolina at Chapel Hill. Dr. McKay is professor of psychology at Fordham University, Bronx, N.Y.
Obsessive-compulsive disorder (OCD) affects 1-2% of the population. The disorder is characterized by recurrent intrusive unwanted thoughts (obsessions) that cause significant distress and anxiety, and behavioral or mental rituals (compulsions) that are performed to reduce distress stemming from obsessions. OCD may onset at any time in life, but most commonly begins in childhood or in early adulthood.
Cognitive behavioral therapy (CBT) with exposure and response prevention is an empirically based and highly effective treatment for OCD. However, most youth with OCD do not receive any treatment, which is related to a shortage of mental health care providers with expertise in assessment and treatment of the disorder, and misdiagnosis of the disorder is all too prevalent.
Aside from the subjective emotional toll associated with OCD, individuals living with this disorder frequently experience interpersonal, academic, and vocational impairments. Nevertheless, OCD is often overlooked or misdiagnosed. This may be more pronounced in youth with OCD, particularly in primary health care settings and large nonspecialized medical institutions. In fact, research indicates that pediatric OCD is often underrecognized even among mental health professionals. This situation is not new, and in fact the National Institute for Health and Care Excellence (NICE) in the United Kingdom stated that there is an urgent need to develop brief reliable screeners for OCD nearly 20 years ago.
Although there were several attempts to develop brief screening scales for adults and youth with OCD, none of them were found to be suitable for use as rapid screening tools in nonspecialized settings. One of the primary reasons is that OCD is associated with different “themes” or dimensions. For example, a child with OCD may engage in cleaning rituals because the context (or dimension) of their obsessions is contamination concerns. Another child with OCD, who may suffer from similar overall symptom severity, may primarily engage in checking rituals which are related with obsessions associated with fear of being responsible for harm. Therefore, one child with OCD may score very high on items assessing one dimension (e.g., contamination concerns), but very low on another dimension (e.g., harm obsessions).
This results in a known challenge in the assessment and psychometrics of self-report (as opposed to clinician administered) measures of OCD. Secondly, development of such measures requires very large carefully screened samples of individuals with OCD, with other disorders, and those without a known psychological disorder – which may be more challenging than requiring adult participants.
To accomplish this, we harmonized data from several sites that included three samples of carefully screened youths with OCD, with other disorders, and without known disorders who completed multiple self-report questionnaires, including the 21-item Obsessive-Compulsive Inventory – Child Version (OCI-CV).
Utilizing psychometric analyses including factor analyses, invariance analyses, and item response theory methodologies, we were able to develop an ultrabrief measure extracted from the OCI-CV: the 5-item Obsessive-Compulsive Inventory – Child Version (OCI-CV-5). This very brief self-report measure was found to have very good psychometric properties including a sensitive and specific clinical cutoff score. Youth who score at or above the cutoff score are nearly 21 times more likely to meet criteria for OCD.
This measure corresponds to a need to rapidly screen for OCD in children in nonspecialized settings, including community mental health clinics, primary care settings, and pediatric treatment facilities. However, it is important to note it is not a diagnostic measure. The measure is intended to identify youth who should be referred to a mental health care professional to conduct a diagnostic interview.
Dr. Abramovitch is a clinical psychologist and neuropsychologist based in Austin, Tex., and an associate professor at Texas State University. Dr. Abramowitz is professor and director of clinical training in the Anxiety and Stress Lab at University of North Carolina at Chapel Hill. Dr. McKay is professor of psychology at Fordham University, Bronx, N.Y.
Obsessive-compulsive disorder (OCD) affects 1-2% of the population. The disorder is characterized by recurrent intrusive unwanted thoughts (obsessions) that cause significant distress and anxiety, and behavioral or mental rituals (compulsions) that are performed to reduce distress stemming from obsessions. OCD may onset at any time in life, but most commonly begins in childhood or in early adulthood.
Cognitive behavioral therapy (CBT) with exposure and response prevention is an empirically based and highly effective treatment for OCD. However, most youth with OCD do not receive any treatment, which is related to a shortage of mental health care providers with expertise in assessment and treatment of the disorder, and misdiagnosis of the disorder is all too prevalent.
Aside from the subjective emotional toll associated with OCD, individuals living with this disorder frequently experience interpersonal, academic, and vocational impairments. Nevertheless, OCD is often overlooked or misdiagnosed. This may be more pronounced in youth with OCD, particularly in primary health care settings and large nonspecialized medical institutions. In fact, research indicates that pediatric OCD is often underrecognized even among mental health professionals. This situation is not new, and in fact the National Institute for Health and Care Excellence (NICE) in the United Kingdom stated that there is an urgent need to develop brief reliable screeners for OCD nearly 20 years ago.
Although there were several attempts to develop brief screening scales for adults and youth with OCD, none of them were found to be suitable for use as rapid screening tools in nonspecialized settings. One of the primary reasons is that OCD is associated with different “themes” or dimensions. For example, a child with OCD may engage in cleaning rituals because the context (or dimension) of their obsessions is contamination concerns. Another child with OCD, who may suffer from similar overall symptom severity, may primarily engage in checking rituals which are related with obsessions associated with fear of being responsible for harm. Therefore, one child with OCD may score very high on items assessing one dimension (e.g., contamination concerns), but very low on another dimension (e.g., harm obsessions).
This results in a known challenge in the assessment and psychometrics of self-report (as opposed to clinician administered) measures of OCD. Secondly, development of such measures requires very large carefully screened samples of individuals with OCD, with other disorders, and those without a known psychological disorder – which may be more challenging than requiring adult participants.
To accomplish this, we harmonized data from several sites that included three samples of carefully screened youths with OCD, with other disorders, and without known disorders who completed multiple self-report questionnaires, including the 21-item Obsessive-Compulsive Inventory – Child Version (OCI-CV).
Utilizing psychometric analyses including factor analyses, invariance analyses, and item response theory methodologies, we were able to develop an ultrabrief measure extracted from the OCI-CV: the 5-item Obsessive-Compulsive Inventory – Child Version (OCI-CV-5). This very brief self-report measure was found to have very good psychometric properties including a sensitive and specific clinical cutoff score. Youth who score at or above the cutoff score are nearly 21 times more likely to meet criteria for OCD.
This measure corresponds to a need to rapidly screen for OCD in children in nonspecialized settings, including community mental health clinics, primary care settings, and pediatric treatment facilities. However, it is important to note it is not a diagnostic measure. The measure is intended to identify youth who should be referred to a mental health care professional to conduct a diagnostic interview.
Dr. Abramovitch is a clinical psychologist and neuropsychologist based in Austin, Tex., and an associate professor at Texas State University. Dr. Abramowitz is professor and director of clinical training in the Anxiety and Stress Lab at University of North Carolina at Chapel Hill. Dr. McKay is professor of psychology at Fordham University, Bronx, N.Y.
An adolescent male presents with an eroded bump on the temple
The correct answer is (D), molluscum contagiosum. Upon surgical excision, the pathology indicated the lesion was consistent with molluscum contagiosum.
Molluscum contagiosum is a benign skin disorder caused by a pox virus and is frequently seen in children. This disease is transmitted primarily through direct skin contact with an infected individual.1 Contaminated fomites have been suggested as another source of infection.2 The typical lesion appears dome-shaped, round, and pinkish-purple in color.1 The incubation period ranges from 2 weeks to 6 months and is typically self-limited in immunocompetent hosts; however, in immunocompromised persons, molluscum contagiosum lesions may present atypically such that they are larger in size and/or resemble malignancies, such as basal cell carcinoma or keratoacanthoma (for single lesions), or other infectious diseases, such as cryptococcosis and histoplasmosis (for more numerous lesions).3,4 A giant atypical molluscum contagiosum is rarely seen in healthy individuals.
What’s on the differential?
The recent episode of bleeding raises concern for other neoplastic processes of the skin including squamous cell carcinoma or basal cell carcinoma as well as cutaneous metastatic rhabdoid tumor, given the patient’s history.
Eruptive keratoacanthomas are also reported in patients taking nivolumab, an anti-PD-1 immunotherapy, which the patient has received for treatment of his recurrent metastatic rhabdoid tumor.5 More common entities such as a pyogenic granuloma or verruca are also included on the differential. The initial presentation of the lesion, however, is more consistent with the pearly umbilicated papules associated with molluscum contagiosum.
Comments from Dr. Eichenfield
This is a very hard diagnosis to make with the clinical findings and history.
Molluscum contagiosum infections are common, but with this patient’s medical history, biopsy and excision with pathologic examination was an appropriate approach to make a certain diagnosis.
Ms. Moyal is a research associate in the division of pediatric and adolescent dermatology at the University of California, San Diego, and Rady Children’s Hospital, San Diego. Dr. Eichenfield is vice chair of the department of dermatology and professor of dermatology and pediatrics at the University of California, San Diego, and Rady Children’s Hospital, San Diego.
References
1. Brown J et al. Int J Dermatol. 2006 Feb;45(2):93-9.
2. Hanson D and Diven DG. Dermatol Online J. 2003 Mar;9(2).
3. Badri T and Gandhi GR. Molluscum contagiosum. 2022. In: StatPearls [Internet]. Treasure Island, Fla.: StatPearls Publishing.
4. Schwartz JJ and Myskowski PL. J Am Acad Dermatol. 1992 Oct 1;27(4):583-8.
5. Antonov NK et al. JAAD Case Rep. 2019 Apr 5;5(4):342-5.
The correct answer is (D), molluscum contagiosum. Upon surgical excision, the pathology indicated the lesion was consistent with molluscum contagiosum.
Molluscum contagiosum is a benign skin disorder caused by a pox virus and is frequently seen in children. This disease is transmitted primarily through direct skin contact with an infected individual.1 Contaminated fomites have been suggested as another source of infection.2 The typical lesion appears dome-shaped, round, and pinkish-purple in color.1 The incubation period ranges from 2 weeks to 6 months and is typically self-limited in immunocompetent hosts; however, in immunocompromised persons, molluscum contagiosum lesions may present atypically such that they are larger in size and/or resemble malignancies, such as basal cell carcinoma or keratoacanthoma (for single lesions), or other infectious diseases, such as cryptococcosis and histoplasmosis (for more numerous lesions).3,4 A giant atypical molluscum contagiosum is rarely seen in healthy individuals.
What’s on the differential?
The recent episode of bleeding raises concern for other neoplastic processes of the skin including squamous cell carcinoma or basal cell carcinoma as well as cutaneous metastatic rhabdoid tumor, given the patient’s history.
Eruptive keratoacanthomas are also reported in patients taking nivolumab, an anti-PD-1 immunotherapy, which the patient has received for treatment of his recurrent metastatic rhabdoid tumor.5 More common entities such as a pyogenic granuloma or verruca are also included on the differential. The initial presentation of the lesion, however, is more consistent with the pearly umbilicated papules associated with molluscum contagiosum.
Comments from Dr. Eichenfield
This is a very hard diagnosis to make with the clinical findings and history.
Molluscum contagiosum infections are common, but with this patient’s medical history, biopsy and excision with pathologic examination was an appropriate approach to make a certain diagnosis.
Ms. Moyal is a research associate in the division of pediatric and adolescent dermatology at the University of California, San Diego, and Rady Children’s Hospital, San Diego. Dr. Eichenfield is vice chair of the department of dermatology and professor of dermatology and pediatrics at the University of California, San Diego, and Rady Children’s Hospital, San Diego.
References
1. Brown J et al. Int J Dermatol. 2006 Feb;45(2):93-9.
2. Hanson D and Diven DG. Dermatol Online J. 2003 Mar;9(2).
3. Badri T and Gandhi GR. Molluscum contagiosum. 2022. In: StatPearls [Internet]. Treasure Island, Fla.: StatPearls Publishing.
4. Schwartz JJ and Myskowski PL. J Am Acad Dermatol. 1992 Oct 1;27(4):583-8.
5. Antonov NK et al. JAAD Case Rep. 2019 Apr 5;5(4):342-5.
The correct answer is (D), molluscum contagiosum. Upon surgical excision, the pathology indicated the lesion was consistent with molluscum contagiosum.
Molluscum contagiosum is a benign skin disorder caused by a pox virus and is frequently seen in children. This disease is transmitted primarily through direct skin contact with an infected individual.1 Contaminated fomites have been suggested as another source of infection.2 The typical lesion appears dome-shaped, round, and pinkish-purple in color.1 The incubation period ranges from 2 weeks to 6 months and is typically self-limited in immunocompetent hosts; however, in immunocompromised persons, molluscum contagiosum lesions may present atypically such that they are larger in size and/or resemble malignancies, such as basal cell carcinoma or keratoacanthoma (for single lesions), or other infectious diseases, such as cryptococcosis and histoplasmosis (for more numerous lesions).3,4 A giant atypical molluscum contagiosum is rarely seen in healthy individuals.
What’s on the differential?
The recent episode of bleeding raises concern for other neoplastic processes of the skin including squamous cell carcinoma or basal cell carcinoma as well as cutaneous metastatic rhabdoid tumor, given the patient’s history.
Eruptive keratoacanthomas are also reported in patients taking nivolumab, an anti-PD-1 immunotherapy, which the patient has received for treatment of his recurrent metastatic rhabdoid tumor.5 More common entities such as a pyogenic granuloma or verruca are also included on the differential. The initial presentation of the lesion, however, is more consistent with the pearly umbilicated papules associated with molluscum contagiosum.
Comments from Dr. Eichenfield
This is a very hard diagnosis to make with the clinical findings and history.
Molluscum contagiosum infections are common, but with this patient’s medical history, biopsy and excision with pathologic examination was an appropriate approach to make a certain diagnosis.
Ms. Moyal is a research associate in the division of pediatric and adolescent dermatology at the University of California, San Diego, and Rady Children’s Hospital, San Diego. Dr. Eichenfield is vice chair of the department of dermatology and professor of dermatology and pediatrics at the University of California, San Diego, and Rady Children’s Hospital, San Diego.
References
1. Brown J et al. Int J Dermatol. 2006 Feb;45(2):93-9.
2. Hanson D and Diven DG. Dermatol Online J. 2003 Mar;9(2).
3. Badri T and Gandhi GR. Molluscum contagiosum. 2022. In: StatPearls [Internet]. Treasure Island, Fla.: StatPearls Publishing.
4. Schwartz JJ and Myskowski PL. J Am Acad Dermatol. 1992 Oct 1;27(4):583-8.
5. Antonov NK et al. JAAD Case Rep. 2019 Apr 5;5(4):342-5.
Will Congress step up to save primary care?
Primary care and family physicians operate on the front lines of health care, working tirelessly to serve patients and their families. However, many primary care practices are operating on tight margins and cannot sustain additional financial hits. As we continue to navigate a pandemic that has altered our health care landscape, we traveled to Capitol Hill to urge Congress to act on two critical issues: Medicare payment reform and streamlining administrative burden for physicians.
The current Medicare system for compensating physicians jeopardizes access to primary care. Family physicians, along with other primary care clinicians, are facing significant cuts in payments and rising inflation that threaten our ability to care for patients.
Each of us has experienced the effects of this pincer in devastating ways – from the independent clinicians who have been forced to sell their practices to hospitals or large health systems, to the physicians who are retiring early, leaving their practices, or even closing them because they can’t afford to keep their doors open.
Practices also struggle to cover the rising costs of staff wages, leasing space, and purchasing supplies and equipment, leaving little room for innovation or investments to transition into new payment models. Meanwhile, hospitals, skilled nursing facilities, ambulatory surgery centers, and other Medicare providers receive annual payment increases to account for rising costs.
Insufficient Medicare payments also challenge practices that serve many publicly insured patients. If practices cannot cover their expenses, they may be forced to turn away new Medicare and Medicaid patients – something that goes against the core tenets of our health care system.
Fortunately, we have some solutions. We’re asking Congress to pass the Supporting Medicare Providers Act of 2022, which calls for a 4.42% positive adjustment to the Medicare Physician Fee Schedule (MPFS) conversion factor for 2023 to offset the statutory reduction triggered by budget neutrality rules.
We also are calling on lawmakers to end the statutory freeze on annual updates to the MPFS and enact a positive annual update to the conversion factor based on the Medicare Economic Index. This critical relief would stave off the most immediate cuts while giving us more time to work with Congress on comprehensive reforms to the Medicare physician payment system.
As many practices struggle to operate, burnout among primary care physicians has also increased, with research showing that 66% of primary care physicians reported frequent burnout symptoms in 2021. Streamlining prior authorizations – a cumbersome process that requires physicians to obtain preapproval for treatments or tests before providing care to patients, and can risk patients’ access to timely care – is one way to reduce burden and alleviate burnout.
According to the American Medical Association, 82% of physicians report that prior authorization can lead to patients abandoning care, and 93% believe that prior authorization delays access to necessary care.
All of us have had patients whose care has been affected by these delays, including difficulty in getting necessary medications filled or having medical procedures postponed. Moreover, primary care physicians and their staff spend hours each week completing paperwork and communicating with insurers to ensure that their patients can access the treatments and services they need.
That is why we’re urging the Senate to pass the Improving Seniors’ Timely Access to Care Act, which would streamline the prior authorization process in the Medicare Advantage program.
As family physicians, we are in a unique position to help improve our patients’ health and their quality of life. But we can’t do this alone. We need the support of policy makers to make patient health and primary care a national priority.
Dr. Iroku-Malize is a family physician in Long Island, New York, and President of the American Academy of Family Physicians. Dr. Ransone is a family physician in Deltaville, Va., and board chair, immediate past president of the AAFP. Dr. Furr is a family physician in Jackson, Ala., and President-elect of the AAFP. They reported no conflicts of interest.
A version of this article first appeared on Medscape.com.
Primary care and family physicians operate on the front lines of health care, working tirelessly to serve patients and their families. However, many primary care practices are operating on tight margins and cannot sustain additional financial hits. As we continue to navigate a pandemic that has altered our health care landscape, we traveled to Capitol Hill to urge Congress to act on two critical issues: Medicare payment reform and streamlining administrative burden for physicians.
The current Medicare system for compensating physicians jeopardizes access to primary care. Family physicians, along with other primary care clinicians, are facing significant cuts in payments and rising inflation that threaten our ability to care for patients.
Each of us has experienced the effects of this pincer in devastating ways – from the independent clinicians who have been forced to sell their practices to hospitals or large health systems, to the physicians who are retiring early, leaving their practices, or even closing them because they can’t afford to keep their doors open.
Practices also struggle to cover the rising costs of staff wages, leasing space, and purchasing supplies and equipment, leaving little room for innovation or investments to transition into new payment models. Meanwhile, hospitals, skilled nursing facilities, ambulatory surgery centers, and other Medicare providers receive annual payment increases to account for rising costs.
Insufficient Medicare payments also challenge practices that serve many publicly insured patients. If practices cannot cover their expenses, they may be forced to turn away new Medicare and Medicaid patients – something that goes against the core tenets of our health care system.
Fortunately, we have some solutions. We’re asking Congress to pass the Supporting Medicare Providers Act of 2022, which calls for a 4.42% positive adjustment to the Medicare Physician Fee Schedule (MPFS) conversion factor for 2023 to offset the statutory reduction triggered by budget neutrality rules.
We also are calling on lawmakers to end the statutory freeze on annual updates to the MPFS and enact a positive annual update to the conversion factor based on the Medicare Economic Index. This critical relief would stave off the most immediate cuts while giving us more time to work with Congress on comprehensive reforms to the Medicare physician payment system.
As many practices struggle to operate, burnout among primary care physicians has also increased, with research showing that 66% of primary care physicians reported frequent burnout symptoms in 2021. Streamlining prior authorizations – a cumbersome process that requires physicians to obtain preapproval for treatments or tests before providing care to patients, and can risk patients’ access to timely care – is one way to reduce burden and alleviate burnout.
According to the American Medical Association, 82% of physicians report that prior authorization can lead to patients abandoning care, and 93% believe that prior authorization delays access to necessary care.
All of us have had patients whose care has been affected by these delays, including difficulty in getting necessary medications filled or having medical procedures postponed. Moreover, primary care physicians and their staff spend hours each week completing paperwork and communicating with insurers to ensure that their patients can access the treatments and services they need.
That is why we’re urging the Senate to pass the Improving Seniors’ Timely Access to Care Act, which would streamline the prior authorization process in the Medicare Advantage program.
As family physicians, we are in a unique position to help improve our patients’ health and their quality of life. But we can’t do this alone. We need the support of policy makers to make patient health and primary care a national priority.
Dr. Iroku-Malize is a family physician in Long Island, New York, and President of the American Academy of Family Physicians. Dr. Ransone is a family physician in Deltaville, Va., and board chair, immediate past president of the AAFP. Dr. Furr is a family physician in Jackson, Ala., and President-elect of the AAFP. They reported no conflicts of interest.
A version of this article first appeared on Medscape.com.
Primary care and family physicians operate on the front lines of health care, working tirelessly to serve patients and their families. However, many primary care practices are operating on tight margins and cannot sustain additional financial hits. As we continue to navigate a pandemic that has altered our health care landscape, we traveled to Capitol Hill to urge Congress to act on two critical issues: Medicare payment reform and streamlining administrative burden for physicians.
The current Medicare system for compensating physicians jeopardizes access to primary care. Family physicians, along with other primary care clinicians, are facing significant cuts in payments and rising inflation that threaten our ability to care for patients.
Each of us has experienced the effects of this pincer in devastating ways – from the independent clinicians who have been forced to sell their practices to hospitals or large health systems, to the physicians who are retiring early, leaving their practices, or even closing them because they can’t afford to keep their doors open.
Practices also struggle to cover the rising costs of staff wages, leasing space, and purchasing supplies and equipment, leaving little room for innovation or investments to transition into new payment models. Meanwhile, hospitals, skilled nursing facilities, ambulatory surgery centers, and other Medicare providers receive annual payment increases to account for rising costs.
Insufficient Medicare payments also challenge practices that serve many publicly insured patients. If practices cannot cover their expenses, they may be forced to turn away new Medicare and Medicaid patients – something that goes against the core tenets of our health care system.
Fortunately, we have some solutions. We’re asking Congress to pass the Supporting Medicare Providers Act of 2022, which calls for a 4.42% positive adjustment to the Medicare Physician Fee Schedule (MPFS) conversion factor for 2023 to offset the statutory reduction triggered by budget neutrality rules.
We also are calling on lawmakers to end the statutory freeze on annual updates to the MPFS and enact a positive annual update to the conversion factor based on the Medicare Economic Index. This critical relief would stave off the most immediate cuts while giving us more time to work with Congress on comprehensive reforms to the Medicare physician payment system.
As many practices struggle to operate, burnout among primary care physicians has also increased, with research showing that 66% of primary care physicians reported frequent burnout symptoms in 2021. Streamlining prior authorizations – a cumbersome process that requires physicians to obtain preapproval for treatments or tests before providing care to patients, and can risk patients’ access to timely care – is one way to reduce burden and alleviate burnout.
According to the American Medical Association, 82% of physicians report that prior authorization can lead to patients abandoning care, and 93% believe that prior authorization delays access to necessary care.
All of us have had patients whose care has been affected by these delays, including difficulty in getting necessary medications filled or having medical procedures postponed. Moreover, primary care physicians and their staff spend hours each week completing paperwork and communicating with insurers to ensure that their patients can access the treatments and services they need.
That is why we’re urging the Senate to pass the Improving Seniors’ Timely Access to Care Act, which would streamline the prior authorization process in the Medicare Advantage program.
As family physicians, we are in a unique position to help improve our patients’ health and their quality of life. But we can’t do this alone. We need the support of policy makers to make patient health and primary care a national priority.
Dr. Iroku-Malize is a family physician in Long Island, New York, and President of the American Academy of Family Physicians. Dr. Ransone is a family physician in Deltaville, Va., and board chair, immediate past president of the AAFP. Dr. Furr is a family physician in Jackson, Ala., and President-elect of the AAFP. They reported no conflicts of interest.
A version of this article first appeared on Medscape.com.
More children should be getting flu vaccines
Cold and flu season came early in 2022.
On Nov. 4, 2022, the Centers for Disease Control and Prevention issued a Health Alert Network Health Advisory about early, elevated respiratory disease incidence caused by multiple viruses other than SARS-CoV-2.
Interseasonal spread of respiratory syncytial virus has continued in 2022, with RSV-associated hospitalizations increasing in the late spring and continuing throughout the summer and into the fall. In October, some regions of the country were seeing RSV activity near the peak seasonal levels typically observed in December and January.
Cases of severe respiratory infection in children who tested positive for rhinovirus or enterovirus spiked in August; further testing confirmed the presence of EV-D68 in some children. Rhinovirus and enterovirus continue to circulate and are isolated in hospitalized children with respiratory illness.
In some parts of the country, influenza cases have rapidly increased ahead of what we normally anticipate. According to preliminary estimates from the CDC, between Oct. 1 and Oct. 22, 880,000 people were sickened with flu, 420,000 people visited a health care provider for flu illness, and 6,900 people were hospitalized for flu. The cumulative hospitalization rate is higher than observed at this time of year in every previous flu season since 2010-2011. Hospitalization rates are highest in children aged 0-4 years and adults 65 years and older.
Of course, this report came as no surprise to pediatric health care providers. Many children’s hospitals had been operating at or over capacity for weeks. While a systematic assessment of the surge on children’s hospitals has not been published, anecdotally, hospitals from around the country have described record emergency department visits and inpatient census numbers. Some have set up tents or other temporary facilities to see ambulatory patients and have canceled elective surgeries because of a lack of beds.
There is no quick or easy solution to stem the tide of RSV-related or enterovirus/rhinovirus admissions, but many flu-related hospitalizations are vaccine preventable. Unfortunately, too few children are receiving influenza vaccine. As of the week ending Oct. 15, only about 22.1% of eligible children had been immunized. The American Academy of Pediatrics and the CDC recommend that all children are vaccinated, preferably by the end of October so they have time to develop immunity before influenza starts circulating. As it stands now, the majority of the nation’s children are facing a flu season without the benefits of vaccine.
There is still time to take steps to prevent this flu season from becoming one of the worst in recent memory. A strong provider recommendation for influenza vaccine is consistently associated with higher rates of vaccine acceptance. We need to recommend influenza vaccine to all eligible patients at every visit and in every setting. It will help if we can say it like we mean it. Some of us are tired of debating the merits of COVID-19 vaccine with families and may be leery of additional debates about flu. Some of us may just be tired, as many practices have already expanded office hours to care for the influx of kids with respiratory illness. On the heels of two atypical flu seasons, a few of us may be quietly complacent about the importance of flu vaccines for children.
Anyone in need of a little motivation should check out a paper recently published in Clinical Infectious Diseases that reinforces the value of flu vaccine, even in a year when there is a poor match between the vaccine and circulating viruses.
The 2019-2020 flu season was a bad flu season for children. Two antigenically drifted influenza viruses predominated and cases of influenza soared, resulting in the largest influenza epidemic in children in the United States since 1992. Pediatric Intensive Care Influenza Study investigators used a test-negative design to estimate the effectiveness of influenza vaccine in preventing critical and life-threatening influenza in children during that season. The good news: vaccination reduced the risk of critical influenza by 78% against H1N1pdm09 viruses that were well-matched to vaccine and by 47% against mismatched viruses. Vaccination was estimated to be 75% protective against antigenically drifted B-Victoria viruses. Overall vaccine effectiveness against critical illness from any influenza virus was 63% (95% confidence interval, 38%-78%).
While it might be tempting to attribute suboptimal immunization rates to vaccine hesitancy, ready availability remains an issue for some families. We need to eliminate barriers to access. While the AAP continues to emphasize immunization in the medical home, especially for the youngest infants, the 2022 policy statement suggests that vaccinating children in schools, pharmacies, and other nontraditional settings could improve immunization rates. To the extent feasible, we need to work with partners to support community-based initiatives and promote these to families who struggle to make it into the office.
Improving access is just one potential way to reduce health disparities related to influenza and influenza vaccination. Over 10 influenza seasons, higher rates of influenza-associated hospitalizations and intensive care unit admissions were observed in Black, Hispanic, and American Indian/Alaska Native people. These disparities were highest in children aged younger than 4 years and influenza-associated in-hospital deaths were three- to fourfold higher in Black, Hispanic, and Asian/Pacific Islander children, compared with White children. The reason for the disparities isn’t completely clear but increasing immunization rates may be part of the solution. During the 2020-2021 influenza season, flu immunization rates in Black children (51.6%) were lower than those seen in White (57.4%) and Hispanic children (58.9%).
The AAP’s Recommendations for Prevention and Control of Influenza in Children, 2022–2023, highlight a variety of evidence-based strategies to increase influenza immunization rates. These may provide a little inspiration for clinicians looking to try a new approach. If you wish to share your experience with increasing influenza immunization rates in your practice setting, please email me at [email protected].
Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Norton Children’s Hospital, also in Louisville. She is a member of the AAP’s Committee on Infectious Diseases and one of the lead authors of the AAP’s Recommendations for Prevention and Control of Influenza in Children, 2022–2023. The opinions expressed in this article are her own. Dr. Bryant discloses that she has served as an investigator on clinical trials funded by Pfizer, Enanta, and Gilead.
Cold and flu season came early in 2022.
On Nov. 4, 2022, the Centers for Disease Control and Prevention issued a Health Alert Network Health Advisory about early, elevated respiratory disease incidence caused by multiple viruses other than SARS-CoV-2.
Interseasonal spread of respiratory syncytial virus has continued in 2022, with RSV-associated hospitalizations increasing in the late spring and continuing throughout the summer and into the fall. In October, some regions of the country were seeing RSV activity near the peak seasonal levels typically observed in December and January.
Cases of severe respiratory infection in children who tested positive for rhinovirus or enterovirus spiked in August; further testing confirmed the presence of EV-D68 in some children. Rhinovirus and enterovirus continue to circulate and are isolated in hospitalized children with respiratory illness.
In some parts of the country, influenza cases have rapidly increased ahead of what we normally anticipate. According to preliminary estimates from the CDC, between Oct. 1 and Oct. 22, 880,000 people were sickened with flu, 420,000 people visited a health care provider for flu illness, and 6,900 people were hospitalized for flu. The cumulative hospitalization rate is higher than observed at this time of year in every previous flu season since 2010-2011. Hospitalization rates are highest in children aged 0-4 years and adults 65 years and older.
Of course, this report came as no surprise to pediatric health care providers. Many children’s hospitals had been operating at or over capacity for weeks. While a systematic assessment of the surge on children’s hospitals has not been published, anecdotally, hospitals from around the country have described record emergency department visits and inpatient census numbers. Some have set up tents or other temporary facilities to see ambulatory patients and have canceled elective surgeries because of a lack of beds.
There is no quick or easy solution to stem the tide of RSV-related or enterovirus/rhinovirus admissions, but many flu-related hospitalizations are vaccine preventable. Unfortunately, too few children are receiving influenza vaccine. As of the week ending Oct. 15, only about 22.1% of eligible children had been immunized. The American Academy of Pediatrics and the CDC recommend that all children are vaccinated, preferably by the end of October so they have time to develop immunity before influenza starts circulating. As it stands now, the majority of the nation’s children are facing a flu season without the benefits of vaccine.
There is still time to take steps to prevent this flu season from becoming one of the worst in recent memory. A strong provider recommendation for influenza vaccine is consistently associated with higher rates of vaccine acceptance. We need to recommend influenza vaccine to all eligible patients at every visit and in every setting. It will help if we can say it like we mean it. Some of us are tired of debating the merits of COVID-19 vaccine with families and may be leery of additional debates about flu. Some of us may just be tired, as many practices have already expanded office hours to care for the influx of kids with respiratory illness. On the heels of two atypical flu seasons, a few of us may be quietly complacent about the importance of flu vaccines for children.
Anyone in need of a little motivation should check out a paper recently published in Clinical Infectious Diseases that reinforces the value of flu vaccine, even in a year when there is a poor match between the vaccine and circulating viruses.
The 2019-2020 flu season was a bad flu season for children. Two antigenically drifted influenza viruses predominated and cases of influenza soared, resulting in the largest influenza epidemic in children in the United States since 1992. Pediatric Intensive Care Influenza Study investigators used a test-negative design to estimate the effectiveness of influenza vaccine in preventing critical and life-threatening influenza in children during that season. The good news: vaccination reduced the risk of critical influenza by 78% against H1N1pdm09 viruses that were well-matched to vaccine and by 47% against mismatched viruses. Vaccination was estimated to be 75% protective against antigenically drifted B-Victoria viruses. Overall vaccine effectiveness against critical illness from any influenza virus was 63% (95% confidence interval, 38%-78%).
While it might be tempting to attribute suboptimal immunization rates to vaccine hesitancy, ready availability remains an issue for some families. We need to eliminate barriers to access. While the AAP continues to emphasize immunization in the medical home, especially for the youngest infants, the 2022 policy statement suggests that vaccinating children in schools, pharmacies, and other nontraditional settings could improve immunization rates. To the extent feasible, we need to work with partners to support community-based initiatives and promote these to families who struggle to make it into the office.
Improving access is just one potential way to reduce health disparities related to influenza and influenza vaccination. Over 10 influenza seasons, higher rates of influenza-associated hospitalizations and intensive care unit admissions were observed in Black, Hispanic, and American Indian/Alaska Native people. These disparities were highest in children aged younger than 4 years and influenza-associated in-hospital deaths were three- to fourfold higher in Black, Hispanic, and Asian/Pacific Islander children, compared with White children. The reason for the disparities isn’t completely clear but increasing immunization rates may be part of the solution. During the 2020-2021 influenza season, flu immunization rates in Black children (51.6%) were lower than those seen in White (57.4%) and Hispanic children (58.9%).
The AAP’s Recommendations for Prevention and Control of Influenza in Children, 2022–2023, highlight a variety of evidence-based strategies to increase influenza immunization rates. These may provide a little inspiration for clinicians looking to try a new approach. If you wish to share your experience with increasing influenza immunization rates in your practice setting, please email me at [email protected].
Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Norton Children’s Hospital, also in Louisville. She is a member of the AAP’s Committee on Infectious Diseases and one of the lead authors of the AAP’s Recommendations for Prevention and Control of Influenza in Children, 2022–2023. The opinions expressed in this article are her own. Dr. Bryant discloses that she has served as an investigator on clinical trials funded by Pfizer, Enanta, and Gilead.
Cold and flu season came early in 2022.
On Nov. 4, 2022, the Centers for Disease Control and Prevention issued a Health Alert Network Health Advisory about early, elevated respiratory disease incidence caused by multiple viruses other than SARS-CoV-2.
Interseasonal spread of respiratory syncytial virus has continued in 2022, with RSV-associated hospitalizations increasing in the late spring and continuing throughout the summer and into the fall. In October, some regions of the country were seeing RSV activity near the peak seasonal levels typically observed in December and January.
Cases of severe respiratory infection in children who tested positive for rhinovirus or enterovirus spiked in August; further testing confirmed the presence of EV-D68 in some children. Rhinovirus and enterovirus continue to circulate and are isolated in hospitalized children with respiratory illness.
In some parts of the country, influenza cases have rapidly increased ahead of what we normally anticipate. According to preliminary estimates from the CDC, between Oct. 1 and Oct. 22, 880,000 people were sickened with flu, 420,000 people visited a health care provider for flu illness, and 6,900 people were hospitalized for flu. The cumulative hospitalization rate is higher than observed at this time of year in every previous flu season since 2010-2011. Hospitalization rates are highest in children aged 0-4 years and adults 65 years and older.
Of course, this report came as no surprise to pediatric health care providers. Many children’s hospitals had been operating at or over capacity for weeks. While a systematic assessment of the surge on children’s hospitals has not been published, anecdotally, hospitals from around the country have described record emergency department visits and inpatient census numbers. Some have set up tents or other temporary facilities to see ambulatory patients and have canceled elective surgeries because of a lack of beds.
There is no quick or easy solution to stem the tide of RSV-related or enterovirus/rhinovirus admissions, but many flu-related hospitalizations are vaccine preventable. Unfortunately, too few children are receiving influenza vaccine. As of the week ending Oct. 15, only about 22.1% of eligible children had been immunized. The American Academy of Pediatrics and the CDC recommend that all children are vaccinated, preferably by the end of October so they have time to develop immunity before influenza starts circulating. As it stands now, the majority of the nation’s children are facing a flu season without the benefits of vaccine.
There is still time to take steps to prevent this flu season from becoming one of the worst in recent memory. A strong provider recommendation for influenza vaccine is consistently associated with higher rates of vaccine acceptance. We need to recommend influenza vaccine to all eligible patients at every visit and in every setting. It will help if we can say it like we mean it. Some of us are tired of debating the merits of COVID-19 vaccine with families and may be leery of additional debates about flu. Some of us may just be tired, as many practices have already expanded office hours to care for the influx of kids with respiratory illness. On the heels of two atypical flu seasons, a few of us may be quietly complacent about the importance of flu vaccines for children.
Anyone in need of a little motivation should check out a paper recently published in Clinical Infectious Diseases that reinforces the value of flu vaccine, even in a year when there is a poor match between the vaccine and circulating viruses.
The 2019-2020 flu season was a bad flu season for children. Two antigenically drifted influenza viruses predominated and cases of influenza soared, resulting in the largest influenza epidemic in children in the United States since 1992. Pediatric Intensive Care Influenza Study investigators used a test-negative design to estimate the effectiveness of influenza vaccine in preventing critical and life-threatening influenza in children during that season. The good news: vaccination reduced the risk of critical influenza by 78% against H1N1pdm09 viruses that were well-matched to vaccine and by 47% against mismatched viruses. Vaccination was estimated to be 75% protective against antigenically drifted B-Victoria viruses. Overall vaccine effectiveness against critical illness from any influenza virus was 63% (95% confidence interval, 38%-78%).
While it might be tempting to attribute suboptimal immunization rates to vaccine hesitancy, ready availability remains an issue for some families. We need to eliminate barriers to access. While the AAP continues to emphasize immunization in the medical home, especially for the youngest infants, the 2022 policy statement suggests that vaccinating children in schools, pharmacies, and other nontraditional settings could improve immunization rates. To the extent feasible, we need to work with partners to support community-based initiatives and promote these to families who struggle to make it into the office.
Improving access is just one potential way to reduce health disparities related to influenza and influenza vaccination. Over 10 influenza seasons, higher rates of influenza-associated hospitalizations and intensive care unit admissions were observed in Black, Hispanic, and American Indian/Alaska Native people. These disparities were highest in children aged younger than 4 years and influenza-associated in-hospital deaths were three- to fourfold higher in Black, Hispanic, and Asian/Pacific Islander children, compared with White children. The reason for the disparities isn’t completely clear but increasing immunization rates may be part of the solution. During the 2020-2021 influenza season, flu immunization rates in Black children (51.6%) were lower than those seen in White (57.4%) and Hispanic children (58.9%).
The AAP’s Recommendations for Prevention and Control of Influenza in Children, 2022–2023, highlight a variety of evidence-based strategies to increase influenza immunization rates. These may provide a little inspiration for clinicians looking to try a new approach. If you wish to share your experience with increasing influenza immunization rates in your practice setting, please email me at [email protected].
Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Norton Children’s Hospital, also in Louisville. She is a member of the AAP’s Committee on Infectious Diseases and one of the lead authors of the AAP’s Recommendations for Prevention and Control of Influenza in Children, 2022–2023. The opinions expressed in this article are her own. Dr. Bryant discloses that she has served as an investigator on clinical trials funded by Pfizer, Enanta, and Gilead.