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Meet Argireline, the neurotoxinlike cosmeceutical
Acetyl hexapeptide-8 (or -3), better known by its brand name, Argireline (Lubrizol; Wickliffe, Ohio), is a synthetic peptide gaining popularity in cosmeceutical products for its antiaging benefits. Argireline was developed by the company Lipotec in 2001. Media, beauty bloggers, and product claims have likened this product to a “Botox [or other neurotoxin] alternative,” or “Botox mimicker.”
Mechanism of action
Understanding how Argireline works requires a brief refresher on the mechanism of action of botulinum neurotoxin (BoNT). BoNT relaxes facial muscles and smooths expression lines by inhibiting acetylcholine release at the neuromuscular junction.1 More specifically, the various serotypes of BoNT are single-chain polypeptides that target members of the SNARE complex: SNAP-25, syntaxin, and Vamp. The proteins within the SNARE complex are involved in the docking and fusion of presynaptic vesicles to the presynaptic membrane, necessary steps for acetylcholine release into the neuromuscular junction and muscle contraction. By blocking the action of the SNARE complex proteins, BoNT inhibits release of acetylcholine in the neuromuscular junction and prevents muscle contraction.
Argireline is a synthetic peptide with the sequence Ac-EEMQRR-NH2.2 It is patterned after the N-terminal domain of SNAP-25, one of the members of the SNARE complex targeted by BoNT, and functions to interfere with the assembly of the SNARE complex. In this manner, Argireline would theoretically inhibit fusion of presynaptic vesicles and release of acetylcholine into the neuromuscular junction, thus impeding muscle movement. For this reason, it has been likened to topical Botox. Unlike Botox and other neurotoxins, Argireline was developed for topical application rather than injection.
Preclinical studies
In vitro work done 20 years ago demonstrated that Argireline can prevent assembly of the SNARE complex and inhibit neurotransmitter release with a potency similar to that of BoNT A (Botox).2
In 2013, Wang et al. evaluated the histologic effects of Argireline in aged mouse skin induced by D-galactose. For 6 weeks, Argireline was applied twice daily, and histological changes were assessed using hematoxylin and eosin (H&E) and picrosirius–polarization (PSP) stains. The researchers found elevated levels of type I collagen (P < .01) and reduced type III collagen (P < .05) with the Argireline treatment. These results demonstrated that Argireline could histologically enhance collagen in a manner consistent with skin rejuvenation.3
Clinical studies
In 2002, Blanes et al. assessed the antiwrinkle activity of Argireline by measuring skin topography from silicone implants in the lateral periorbital region of an oil/water (O/W) emulsion containing 10% of the acetyl-hexapeptide in 10 healthy women volunteers. The hexapeptide emulsion was applied twice daily in one lateral periorbital area, and the emulsion vehicle alone was applied twice daily on the contralateral side. Over 30 days of treatment, wrinkle depth was found to have decreased by 30%. The investigators also found that Argireline significantly hindered neurotransmitter release in vitro as robustly as BoNT A, though with notably lower efficacy. No toxicity or irritation was associated with this treatment.2 However, it should be noted that this small study conducted 2 decades ago evaluated only silicone implants with confocal microscopy to evaluate wrinkle depth. There was no subjective clinical assessment of dynamic facial wrinkles. As such, their study is an insufficient basis for drawing conclusions that Argireline is a BoNT mimic. Botox and other types of BoNT affect dynamic facial wrinkles mostly (i.e., wrinkles created by moving muscles of facial expression). This study primarily considers static wrinkles on periorbital skin. While static wrinkles may result from longstanding dynamic wrinkles, BoNT mainly targets dynamic wrinkles, again not comparing apples to apples.
At the same time that Wang et al. conducted their experiment on the skin of aged mice as noted above, they performed a multicenter clinical trial in 60 human subjects who received a randomized treatment of Argireline or placebo in a ratio of 3:1 to assess its safety and efficacy. For 4 weeks, the test product or placebo was applied to periorbital wrinkles twice daily. The researchers found the total antiwrinkle efficacy in the Argireline group to be 48.9% based on the subjective evaluation, compared with 0% in the placebo group. The objective evaluation indicated that all parameters of roughness were diminished in the Argireline group (P < .01), with no reduction observed in the placebo group (P < .05).4 There was a little more to appreciate from this study compared with the one reported by Blanes et al., insofar as subjective evaluations and objective evaluations with silica replicas were done. However, this study was not blinded, so the 48.9% wrinkle reduction in the Argireline group vs. 0% in the control group seems suspicious. Additionally, there was a greater focus on static rather than dynamic wrinkles.
In 2017, Raikou et al. conducted a prospective, randomized controlled study to assess the effects of acetyl hexapeptide-3 (Argireline) and tripeptide-10 citrulline in 24 healthy female volunteers (aged 30-60 years) and determine if there was any synergistic action between the peptides. Subjects were randomized to receive a combination of the peptides, tripeptide-10 citrulline only, acetyl hexapeptide-3 only, or neither peptide for 60 days. The researchers found a significant reduction in transepidermal water loss (TEWL) in the Argireline group, compared with the placebo group.5 The result of this study makes me question if the decrease in depth of the wrinkles measured in the former studies is really just a measure of increased skin hydration from the Argireline, rather than a neurotoxic effect of Argireline.
Formulation and penetration: Can Argireline get through your skin?
One of the fundamental questions regarding Argireline is whether it can penetrate through the stratum corneum and find its target – the facial muscles – where it is intended to function. Argireline is a charged, hydrophilic, and large–molecular weight peptide, and each of these factors impairs penetration through the stratum corneum. Therefore, studies assessing penetration are particularly important.
In 2015, Kraeling et al. conducted an in vitro evaluation of the skin penetration of acetyl hexapeptide-8 in hairless guinea pig and human cadaver skin. An oil-in-water (O/W) emulsion containing 10% acetyl hexapeptide-8 was applied (2 mg/cm2) and penetration was quantified in skin layers via hydrophilic interaction liquid chromatography with tandem mass spectrometry. Most of the acetyl hexapeptide-8 was found to have been washed from human cadaver, as well as guinea pig, skin. Less than 1% of the peptide penetrated the guinea pig or human skin. Of this small amount that penetrated the skin, most stayed in the stratum corneum of guinea pigs (0.54%) and human cadavers (0.22%). The levels of acetyl hexapeptide-8 declined further with each layer of tape stripping removal. Epidermal levels of the peptide in tested skin were similar at 0.01%, and none of the peptide was found in the dermis.6 These results indicate negligible penetration by this highly touted peptide ingredient.
Some studies have shown that altering the formulation of acetyl hexapeptide-8 can enhance penetration. Hoppel et al. demonstrated that formulations of the peptide, especially in a water-oil-water (W/O/W emulsion [as compared with O/W and W/O emulsions] can increase penetration into the stratum corneum in porcine skin.7 Notably, this is still very superficial relative to the dermis and muscles. Irrespective of formulation, studies have shown that Argireline barely penetrates the stratum corneum, let alone the dermis. Therefore, I would give pause to attributing any clinical impact or benefit of Argireline to its neurotoxinlike effects measured in vitro.
Conclusion
Despite the growing popularity of this ingredient in cosmeceuticals and the praise it gets in media for acting as a topical neurotoxin, there are no rigorous clinical trials or data demonstrating its efficacy in suppressing dynamic facial wrinkles like BoNT does. Most importantly, without penetration into the stratum corneum and deeper layers of the skin, it seems unlikely that Argireline’s clinical benefit derives from a neurotoxiclike mechanism of action. It seems more likely that the Argireline-containing product enhances hydration or imparts some other quality to the skin surface. While there is certainly great appeal for a neurotoxinlike product without injections, I do not believe this ingredient will replace injections of BoNT in the foreseeable future, or at least until scientists can figure out how to enable these products to penetrate into the deeper layers of the skin.
Dr. Goldman is a dermatologist in private practice in Miami and specializes in cosmetic and general dermatology. She practices at Baumann Cosmetic & Research Institute and is also opening a general dermatology practice. Dr. Goldman has no relevant disclosures. Write to her at [email protected] or message her on Instagram @DrChloeGoldman.
References
1. Reddy BY et al. Exp Dermatol. 2012 Aug;21(8):569-75.
2. Blanes-Mira C et al. Int J Cosmet Sci. 2002 Oct;24(5):303-10.
3. Wang Y et al. J Cosmet Laser Ther. 2013 Aug;15(4):237-41.
4. Wang Y et al. J Cosmet Laser Ther. 2013;14(2):147-53.
5. Raikou V et al. J Cosmet Dermatol. 2017 Jun;16(2):271-8.
6. Kraeling ME et al. Cutan Ocul Toxicol. 2015 Mar;34(1):46-52.
7. Hoppel M et al. Eur J Pharm Sci. 2015 Feb 20;68:27-35.
Acetyl hexapeptide-8 (or -3), better known by its brand name, Argireline (Lubrizol; Wickliffe, Ohio), is a synthetic peptide gaining popularity in cosmeceutical products for its antiaging benefits. Argireline was developed by the company Lipotec in 2001. Media, beauty bloggers, and product claims have likened this product to a “Botox [or other neurotoxin] alternative,” or “Botox mimicker.”
Mechanism of action
Understanding how Argireline works requires a brief refresher on the mechanism of action of botulinum neurotoxin (BoNT). BoNT relaxes facial muscles and smooths expression lines by inhibiting acetylcholine release at the neuromuscular junction.1 More specifically, the various serotypes of BoNT are single-chain polypeptides that target members of the SNARE complex: SNAP-25, syntaxin, and Vamp. The proteins within the SNARE complex are involved in the docking and fusion of presynaptic vesicles to the presynaptic membrane, necessary steps for acetylcholine release into the neuromuscular junction and muscle contraction. By blocking the action of the SNARE complex proteins, BoNT inhibits release of acetylcholine in the neuromuscular junction and prevents muscle contraction.
Argireline is a synthetic peptide with the sequence Ac-EEMQRR-NH2.2 It is patterned after the N-terminal domain of SNAP-25, one of the members of the SNARE complex targeted by BoNT, and functions to interfere with the assembly of the SNARE complex. In this manner, Argireline would theoretically inhibit fusion of presynaptic vesicles and release of acetylcholine into the neuromuscular junction, thus impeding muscle movement. For this reason, it has been likened to topical Botox. Unlike Botox and other neurotoxins, Argireline was developed for topical application rather than injection.
Preclinical studies
In vitro work done 20 years ago demonstrated that Argireline can prevent assembly of the SNARE complex and inhibit neurotransmitter release with a potency similar to that of BoNT A (Botox).2
In 2013, Wang et al. evaluated the histologic effects of Argireline in aged mouse skin induced by D-galactose. For 6 weeks, Argireline was applied twice daily, and histological changes were assessed using hematoxylin and eosin (H&E) and picrosirius–polarization (PSP) stains. The researchers found elevated levels of type I collagen (P < .01) and reduced type III collagen (P < .05) with the Argireline treatment. These results demonstrated that Argireline could histologically enhance collagen in a manner consistent with skin rejuvenation.3
Clinical studies
In 2002, Blanes et al. assessed the antiwrinkle activity of Argireline by measuring skin topography from silicone implants in the lateral periorbital region of an oil/water (O/W) emulsion containing 10% of the acetyl-hexapeptide in 10 healthy women volunteers. The hexapeptide emulsion was applied twice daily in one lateral periorbital area, and the emulsion vehicle alone was applied twice daily on the contralateral side. Over 30 days of treatment, wrinkle depth was found to have decreased by 30%. The investigators also found that Argireline significantly hindered neurotransmitter release in vitro as robustly as BoNT A, though with notably lower efficacy. No toxicity or irritation was associated with this treatment.2 However, it should be noted that this small study conducted 2 decades ago evaluated only silicone implants with confocal microscopy to evaluate wrinkle depth. There was no subjective clinical assessment of dynamic facial wrinkles. As such, their study is an insufficient basis for drawing conclusions that Argireline is a BoNT mimic. Botox and other types of BoNT affect dynamic facial wrinkles mostly (i.e., wrinkles created by moving muscles of facial expression). This study primarily considers static wrinkles on periorbital skin. While static wrinkles may result from longstanding dynamic wrinkles, BoNT mainly targets dynamic wrinkles, again not comparing apples to apples.
At the same time that Wang et al. conducted their experiment on the skin of aged mice as noted above, they performed a multicenter clinical trial in 60 human subjects who received a randomized treatment of Argireline or placebo in a ratio of 3:1 to assess its safety and efficacy. For 4 weeks, the test product or placebo was applied to periorbital wrinkles twice daily. The researchers found the total antiwrinkle efficacy in the Argireline group to be 48.9% based on the subjective evaluation, compared with 0% in the placebo group. The objective evaluation indicated that all parameters of roughness were diminished in the Argireline group (P < .01), with no reduction observed in the placebo group (P < .05).4 There was a little more to appreciate from this study compared with the one reported by Blanes et al., insofar as subjective evaluations and objective evaluations with silica replicas were done. However, this study was not blinded, so the 48.9% wrinkle reduction in the Argireline group vs. 0% in the control group seems suspicious. Additionally, there was a greater focus on static rather than dynamic wrinkles.
In 2017, Raikou et al. conducted a prospective, randomized controlled study to assess the effects of acetyl hexapeptide-3 (Argireline) and tripeptide-10 citrulline in 24 healthy female volunteers (aged 30-60 years) and determine if there was any synergistic action between the peptides. Subjects were randomized to receive a combination of the peptides, tripeptide-10 citrulline only, acetyl hexapeptide-3 only, or neither peptide for 60 days. The researchers found a significant reduction in transepidermal water loss (TEWL) in the Argireline group, compared with the placebo group.5 The result of this study makes me question if the decrease in depth of the wrinkles measured in the former studies is really just a measure of increased skin hydration from the Argireline, rather than a neurotoxic effect of Argireline.
Formulation and penetration: Can Argireline get through your skin?
One of the fundamental questions regarding Argireline is whether it can penetrate through the stratum corneum and find its target – the facial muscles – where it is intended to function. Argireline is a charged, hydrophilic, and large–molecular weight peptide, and each of these factors impairs penetration through the stratum corneum. Therefore, studies assessing penetration are particularly important.
In 2015, Kraeling et al. conducted an in vitro evaluation of the skin penetration of acetyl hexapeptide-8 in hairless guinea pig and human cadaver skin. An oil-in-water (O/W) emulsion containing 10% acetyl hexapeptide-8 was applied (2 mg/cm2) and penetration was quantified in skin layers via hydrophilic interaction liquid chromatography with tandem mass spectrometry. Most of the acetyl hexapeptide-8 was found to have been washed from human cadaver, as well as guinea pig, skin. Less than 1% of the peptide penetrated the guinea pig or human skin. Of this small amount that penetrated the skin, most stayed in the stratum corneum of guinea pigs (0.54%) and human cadavers (0.22%). The levels of acetyl hexapeptide-8 declined further with each layer of tape stripping removal. Epidermal levels of the peptide in tested skin were similar at 0.01%, and none of the peptide was found in the dermis.6 These results indicate negligible penetration by this highly touted peptide ingredient.
Some studies have shown that altering the formulation of acetyl hexapeptide-8 can enhance penetration. Hoppel et al. demonstrated that formulations of the peptide, especially in a water-oil-water (W/O/W emulsion [as compared with O/W and W/O emulsions] can increase penetration into the stratum corneum in porcine skin.7 Notably, this is still very superficial relative to the dermis and muscles. Irrespective of formulation, studies have shown that Argireline barely penetrates the stratum corneum, let alone the dermis. Therefore, I would give pause to attributing any clinical impact or benefit of Argireline to its neurotoxinlike effects measured in vitro.
Conclusion
Despite the growing popularity of this ingredient in cosmeceuticals and the praise it gets in media for acting as a topical neurotoxin, there are no rigorous clinical trials or data demonstrating its efficacy in suppressing dynamic facial wrinkles like BoNT does. Most importantly, without penetration into the stratum corneum and deeper layers of the skin, it seems unlikely that Argireline’s clinical benefit derives from a neurotoxiclike mechanism of action. It seems more likely that the Argireline-containing product enhances hydration or imparts some other quality to the skin surface. While there is certainly great appeal for a neurotoxinlike product without injections, I do not believe this ingredient will replace injections of BoNT in the foreseeable future, or at least until scientists can figure out how to enable these products to penetrate into the deeper layers of the skin.
Dr. Goldman is a dermatologist in private practice in Miami and specializes in cosmetic and general dermatology. She practices at Baumann Cosmetic & Research Institute and is also opening a general dermatology practice. Dr. Goldman has no relevant disclosures. Write to her at [email protected] or message her on Instagram @DrChloeGoldman.
References
1. Reddy BY et al. Exp Dermatol. 2012 Aug;21(8):569-75.
2. Blanes-Mira C et al. Int J Cosmet Sci. 2002 Oct;24(5):303-10.
3. Wang Y et al. J Cosmet Laser Ther. 2013 Aug;15(4):237-41.
4. Wang Y et al. J Cosmet Laser Ther. 2013;14(2):147-53.
5. Raikou V et al. J Cosmet Dermatol. 2017 Jun;16(2):271-8.
6. Kraeling ME et al. Cutan Ocul Toxicol. 2015 Mar;34(1):46-52.
7. Hoppel M et al. Eur J Pharm Sci. 2015 Feb 20;68:27-35.
Acetyl hexapeptide-8 (or -3), better known by its brand name, Argireline (Lubrizol; Wickliffe, Ohio), is a synthetic peptide gaining popularity in cosmeceutical products for its antiaging benefits. Argireline was developed by the company Lipotec in 2001. Media, beauty bloggers, and product claims have likened this product to a “Botox [or other neurotoxin] alternative,” or “Botox mimicker.”
Mechanism of action
Understanding how Argireline works requires a brief refresher on the mechanism of action of botulinum neurotoxin (BoNT). BoNT relaxes facial muscles and smooths expression lines by inhibiting acetylcholine release at the neuromuscular junction.1 More specifically, the various serotypes of BoNT are single-chain polypeptides that target members of the SNARE complex: SNAP-25, syntaxin, and Vamp. The proteins within the SNARE complex are involved in the docking and fusion of presynaptic vesicles to the presynaptic membrane, necessary steps for acetylcholine release into the neuromuscular junction and muscle contraction. By blocking the action of the SNARE complex proteins, BoNT inhibits release of acetylcholine in the neuromuscular junction and prevents muscle contraction.
Argireline is a synthetic peptide with the sequence Ac-EEMQRR-NH2.2 It is patterned after the N-terminal domain of SNAP-25, one of the members of the SNARE complex targeted by BoNT, and functions to interfere with the assembly of the SNARE complex. In this manner, Argireline would theoretically inhibit fusion of presynaptic vesicles and release of acetylcholine into the neuromuscular junction, thus impeding muscle movement. For this reason, it has been likened to topical Botox. Unlike Botox and other neurotoxins, Argireline was developed for topical application rather than injection.
Preclinical studies
In vitro work done 20 years ago demonstrated that Argireline can prevent assembly of the SNARE complex and inhibit neurotransmitter release with a potency similar to that of BoNT A (Botox).2
In 2013, Wang et al. evaluated the histologic effects of Argireline in aged mouse skin induced by D-galactose. For 6 weeks, Argireline was applied twice daily, and histological changes were assessed using hematoxylin and eosin (H&E) and picrosirius–polarization (PSP) stains. The researchers found elevated levels of type I collagen (P < .01) and reduced type III collagen (P < .05) with the Argireline treatment. These results demonstrated that Argireline could histologically enhance collagen in a manner consistent with skin rejuvenation.3
Clinical studies
In 2002, Blanes et al. assessed the antiwrinkle activity of Argireline by measuring skin topography from silicone implants in the lateral periorbital region of an oil/water (O/W) emulsion containing 10% of the acetyl-hexapeptide in 10 healthy women volunteers. The hexapeptide emulsion was applied twice daily in one lateral periorbital area, and the emulsion vehicle alone was applied twice daily on the contralateral side. Over 30 days of treatment, wrinkle depth was found to have decreased by 30%. The investigators also found that Argireline significantly hindered neurotransmitter release in vitro as robustly as BoNT A, though with notably lower efficacy. No toxicity or irritation was associated with this treatment.2 However, it should be noted that this small study conducted 2 decades ago evaluated only silicone implants with confocal microscopy to evaluate wrinkle depth. There was no subjective clinical assessment of dynamic facial wrinkles. As such, their study is an insufficient basis for drawing conclusions that Argireline is a BoNT mimic. Botox and other types of BoNT affect dynamic facial wrinkles mostly (i.e., wrinkles created by moving muscles of facial expression). This study primarily considers static wrinkles on periorbital skin. While static wrinkles may result from longstanding dynamic wrinkles, BoNT mainly targets dynamic wrinkles, again not comparing apples to apples.
At the same time that Wang et al. conducted their experiment on the skin of aged mice as noted above, they performed a multicenter clinical trial in 60 human subjects who received a randomized treatment of Argireline or placebo in a ratio of 3:1 to assess its safety and efficacy. For 4 weeks, the test product or placebo was applied to periorbital wrinkles twice daily. The researchers found the total antiwrinkle efficacy in the Argireline group to be 48.9% based on the subjective evaluation, compared with 0% in the placebo group. The objective evaluation indicated that all parameters of roughness were diminished in the Argireline group (P < .01), with no reduction observed in the placebo group (P < .05).4 There was a little more to appreciate from this study compared with the one reported by Blanes et al., insofar as subjective evaluations and objective evaluations with silica replicas were done. However, this study was not blinded, so the 48.9% wrinkle reduction in the Argireline group vs. 0% in the control group seems suspicious. Additionally, there was a greater focus on static rather than dynamic wrinkles.
In 2017, Raikou et al. conducted a prospective, randomized controlled study to assess the effects of acetyl hexapeptide-3 (Argireline) and tripeptide-10 citrulline in 24 healthy female volunteers (aged 30-60 years) and determine if there was any synergistic action between the peptides. Subjects were randomized to receive a combination of the peptides, tripeptide-10 citrulline only, acetyl hexapeptide-3 only, or neither peptide for 60 days. The researchers found a significant reduction in transepidermal water loss (TEWL) in the Argireline group, compared with the placebo group.5 The result of this study makes me question if the decrease in depth of the wrinkles measured in the former studies is really just a measure of increased skin hydration from the Argireline, rather than a neurotoxic effect of Argireline.
Formulation and penetration: Can Argireline get through your skin?
One of the fundamental questions regarding Argireline is whether it can penetrate through the stratum corneum and find its target – the facial muscles – where it is intended to function. Argireline is a charged, hydrophilic, and large–molecular weight peptide, and each of these factors impairs penetration through the stratum corneum. Therefore, studies assessing penetration are particularly important.
In 2015, Kraeling et al. conducted an in vitro evaluation of the skin penetration of acetyl hexapeptide-8 in hairless guinea pig and human cadaver skin. An oil-in-water (O/W) emulsion containing 10% acetyl hexapeptide-8 was applied (2 mg/cm2) and penetration was quantified in skin layers via hydrophilic interaction liquid chromatography with tandem mass spectrometry. Most of the acetyl hexapeptide-8 was found to have been washed from human cadaver, as well as guinea pig, skin. Less than 1% of the peptide penetrated the guinea pig or human skin. Of this small amount that penetrated the skin, most stayed in the stratum corneum of guinea pigs (0.54%) and human cadavers (0.22%). The levels of acetyl hexapeptide-8 declined further with each layer of tape stripping removal. Epidermal levels of the peptide in tested skin were similar at 0.01%, and none of the peptide was found in the dermis.6 These results indicate negligible penetration by this highly touted peptide ingredient.
Some studies have shown that altering the formulation of acetyl hexapeptide-8 can enhance penetration. Hoppel et al. demonstrated that formulations of the peptide, especially in a water-oil-water (W/O/W emulsion [as compared with O/W and W/O emulsions] can increase penetration into the stratum corneum in porcine skin.7 Notably, this is still very superficial relative to the dermis and muscles. Irrespective of formulation, studies have shown that Argireline barely penetrates the stratum corneum, let alone the dermis. Therefore, I would give pause to attributing any clinical impact or benefit of Argireline to its neurotoxinlike effects measured in vitro.
Conclusion
Despite the growing popularity of this ingredient in cosmeceuticals and the praise it gets in media for acting as a topical neurotoxin, there are no rigorous clinical trials or data demonstrating its efficacy in suppressing dynamic facial wrinkles like BoNT does. Most importantly, without penetration into the stratum corneum and deeper layers of the skin, it seems unlikely that Argireline’s clinical benefit derives from a neurotoxiclike mechanism of action. It seems more likely that the Argireline-containing product enhances hydration or imparts some other quality to the skin surface. While there is certainly great appeal for a neurotoxinlike product without injections, I do not believe this ingredient will replace injections of BoNT in the foreseeable future, or at least until scientists can figure out how to enable these products to penetrate into the deeper layers of the skin.
Dr. Goldman is a dermatologist in private practice in Miami and specializes in cosmetic and general dermatology. She practices at Baumann Cosmetic & Research Institute and is also opening a general dermatology practice. Dr. Goldman has no relevant disclosures. Write to her at [email protected] or message her on Instagram @DrChloeGoldman.
References
1. Reddy BY et al. Exp Dermatol. 2012 Aug;21(8):569-75.
2. Blanes-Mira C et al. Int J Cosmet Sci. 2002 Oct;24(5):303-10.
3. Wang Y et al. J Cosmet Laser Ther. 2013 Aug;15(4):237-41.
4. Wang Y et al. J Cosmet Laser Ther. 2013;14(2):147-53.
5. Raikou V et al. J Cosmet Dermatol. 2017 Jun;16(2):271-8.
6. Kraeling ME et al. Cutan Ocul Toxicol. 2015 Mar;34(1):46-52.
7. Hoppel M et al. Eur J Pharm Sci. 2015 Feb 20;68:27-35.
Our role in preventing postpartum depression
Tragic, embarrassing, criminal ... Choose your own adjective. The maternal mortality rate in this country is the worst of any developed nation in the world. And the numbers are getting worse with an increase of 14% over the previous year. One-third of these deaths occur weeks or months after the delivery.
In a recent issue of Harvard Public Health, researchers at the T.H. Chan School of Public Health discuss some of the possible remedies for what they describe as a crisis. While some of the solutions they list will require major restructuring of how we deliver health care to mothers, others could take advantage of our current systems by employing a slight shift in emphasis. And here is where those of us on the frontline of care delivery can make a difference.
The researchers point out that “More than 90% of maternal deaths could be prevented if women had access to quality care.” They also observe that most mothers have a single postpartum check with the ob.gyn. facility that delivered the baby and then are often left to navigate the health system because transfer to their primary care and/or mental health professional is haphazard or lacking in follow-up.
As I read through the article it struck me that as pediatricians we could and should be playing a larger role in this critical postpartum period when so many women seem to be falling through the cracks in our health care nonsystem. This is not a great “Ah-ha” moment for which I deserve any credit. In 2010 the American Academy of Pediatrics recommended that mothers be screened for depression at the 1-, 2-, and 4-month visits using either a validated 10-question screening instrument or a more direct 2-question tool (Pediatrics 2010;126[5]:1032-9). However, a periodic survey of AAP members 3 years later revealed that less than a third of the respondents were screening regularly for postpartum depression. In 2019 the academy reemphasized the important role that pediatric primary care givers can play in the detection and early management of the condition.
The reasons for the disappointing response include the list of usual suspects of inadequate training, workload demands, reimbursement, liability concerns, and the difficulty in finding and establishing effective referral networks. Unfortunately, these factors continue to exist, and many cases have multiplied in the wake of the pandemic.
In some states, educational outreach, funding, and changes in the reimbursement structure have resulted in improved outcomes. Not all of us are fortunate enough to live in a state that has made postpartum depression detection and management a priority. However, simply making it our own professional priority can save lives, ease suffering, and improve postpartum outcomes. Here I am talking about first caring and then inquiring about a mother’s mental health. Asking how much sleep she is getting. And then spending the time to give personalized advice on feeding and sleep schedules. Even, if this means ignoring half of the topics on the recommended health maintenance. It doesn’t take but a few minutes to convince yourself that the baby is healthy, and you know that 90% of them are.
However, a new mother who is sleep deprived and already has one foot on the spiral staircase down into postpartum depression represents an emergency. And, you should have the skills to turn it around. But, you have to care about the problem and make it your own priority – high enough on the list to make a follow-up appointment or call in a week instead of waiting a month or 2 until the next visit.
Unfortunately, even with your best efforts there are some families who need services beyond the scope of your practice. Making the necessary referrals can be frustrating and time consuming but not dropping ball until it lands in the appropriate place may save a life.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].
Tragic, embarrassing, criminal ... Choose your own adjective. The maternal mortality rate in this country is the worst of any developed nation in the world. And the numbers are getting worse with an increase of 14% over the previous year. One-third of these deaths occur weeks or months after the delivery.
In a recent issue of Harvard Public Health, researchers at the T.H. Chan School of Public Health discuss some of the possible remedies for what they describe as a crisis. While some of the solutions they list will require major restructuring of how we deliver health care to mothers, others could take advantage of our current systems by employing a slight shift in emphasis. And here is where those of us on the frontline of care delivery can make a difference.
The researchers point out that “More than 90% of maternal deaths could be prevented if women had access to quality care.” They also observe that most mothers have a single postpartum check with the ob.gyn. facility that delivered the baby and then are often left to navigate the health system because transfer to their primary care and/or mental health professional is haphazard or lacking in follow-up.
As I read through the article it struck me that as pediatricians we could and should be playing a larger role in this critical postpartum period when so many women seem to be falling through the cracks in our health care nonsystem. This is not a great “Ah-ha” moment for which I deserve any credit. In 2010 the American Academy of Pediatrics recommended that mothers be screened for depression at the 1-, 2-, and 4-month visits using either a validated 10-question screening instrument or a more direct 2-question tool (Pediatrics 2010;126[5]:1032-9). However, a periodic survey of AAP members 3 years later revealed that less than a third of the respondents were screening regularly for postpartum depression. In 2019 the academy reemphasized the important role that pediatric primary care givers can play in the detection and early management of the condition.
The reasons for the disappointing response include the list of usual suspects of inadequate training, workload demands, reimbursement, liability concerns, and the difficulty in finding and establishing effective referral networks. Unfortunately, these factors continue to exist, and many cases have multiplied in the wake of the pandemic.
In some states, educational outreach, funding, and changes in the reimbursement structure have resulted in improved outcomes. Not all of us are fortunate enough to live in a state that has made postpartum depression detection and management a priority. However, simply making it our own professional priority can save lives, ease suffering, and improve postpartum outcomes. Here I am talking about first caring and then inquiring about a mother’s mental health. Asking how much sleep she is getting. And then spending the time to give personalized advice on feeding and sleep schedules. Even, if this means ignoring half of the topics on the recommended health maintenance. It doesn’t take but a few minutes to convince yourself that the baby is healthy, and you know that 90% of them are.
However, a new mother who is sleep deprived and already has one foot on the spiral staircase down into postpartum depression represents an emergency. And, you should have the skills to turn it around. But, you have to care about the problem and make it your own priority – high enough on the list to make a follow-up appointment or call in a week instead of waiting a month or 2 until the next visit.
Unfortunately, even with your best efforts there are some families who need services beyond the scope of your practice. Making the necessary referrals can be frustrating and time consuming but not dropping ball until it lands in the appropriate place may save a life.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].
Tragic, embarrassing, criminal ... Choose your own adjective. The maternal mortality rate in this country is the worst of any developed nation in the world. And the numbers are getting worse with an increase of 14% over the previous year. One-third of these deaths occur weeks or months after the delivery.
In a recent issue of Harvard Public Health, researchers at the T.H. Chan School of Public Health discuss some of the possible remedies for what they describe as a crisis. While some of the solutions they list will require major restructuring of how we deliver health care to mothers, others could take advantage of our current systems by employing a slight shift in emphasis. And here is where those of us on the frontline of care delivery can make a difference.
The researchers point out that “More than 90% of maternal deaths could be prevented if women had access to quality care.” They also observe that most mothers have a single postpartum check with the ob.gyn. facility that delivered the baby and then are often left to navigate the health system because transfer to their primary care and/or mental health professional is haphazard or lacking in follow-up.
As I read through the article it struck me that as pediatricians we could and should be playing a larger role in this critical postpartum period when so many women seem to be falling through the cracks in our health care nonsystem. This is not a great “Ah-ha” moment for which I deserve any credit. In 2010 the American Academy of Pediatrics recommended that mothers be screened for depression at the 1-, 2-, and 4-month visits using either a validated 10-question screening instrument or a more direct 2-question tool (Pediatrics 2010;126[5]:1032-9). However, a periodic survey of AAP members 3 years later revealed that less than a third of the respondents were screening regularly for postpartum depression. In 2019 the academy reemphasized the important role that pediatric primary care givers can play in the detection and early management of the condition.
The reasons for the disappointing response include the list of usual suspects of inadequate training, workload demands, reimbursement, liability concerns, and the difficulty in finding and establishing effective referral networks. Unfortunately, these factors continue to exist, and many cases have multiplied in the wake of the pandemic.
In some states, educational outreach, funding, and changes in the reimbursement structure have resulted in improved outcomes. Not all of us are fortunate enough to live in a state that has made postpartum depression detection and management a priority. However, simply making it our own professional priority can save lives, ease suffering, and improve postpartum outcomes. Here I am talking about first caring and then inquiring about a mother’s mental health. Asking how much sleep she is getting. And then spending the time to give personalized advice on feeding and sleep schedules. Even, if this means ignoring half of the topics on the recommended health maintenance. It doesn’t take but a few minutes to convince yourself that the baby is healthy, and you know that 90% of them are.
However, a new mother who is sleep deprived and already has one foot on the spiral staircase down into postpartum depression represents an emergency. And, you should have the skills to turn it around. But, you have to care about the problem and make it your own priority – high enough on the list to make a follow-up appointment or call in a week instead of waiting a month or 2 until the next visit.
Unfortunately, even with your best efforts there are some families who need services beyond the scope of your practice. Making the necessary referrals can be frustrating and time consuming but not dropping ball until it lands in the appropriate place may save a life.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].
Commentary: Reversal of Roe v. Wade affects adolescents
The Supreme Court decision to strike down the 50-year ruling on Roe v. Wade, which allowed legal abortion, will affect all patients and families seeking care in pediatric and adolescent medicine clinics. Regardless of how you view abortion, the reality is your adolescent female patients and their parents will seek your counsel.
The overturning of Roe has resulted in much confusion for both patients and providers. The overall effect of this decision in Wisconsin is yet to be known but currently we have had to create road maps to direct adolescent patients who experience an unplanned pregnancy and wish to abort. Unfortunately, these road maps include only resources out of state or online. Providing adolescents confidential care may be challenged as the teens may need to disclose the unplanned pregnancy to an adult to access resources.
Providers remain unsettled regarding their risk of assisting an adolescent who discloses an unplanned pregnancy. Recently, many questions arose regarding dispensing Plan B and the risk to prescribers. Communication was needed to assure providers that Plan B is contraception and at this time contraception remains legal in our state.
Daily I educate adolescent females on the risks of unplanned pregnancy and what the Supreme Court decision will mean to them if they become pregnant. Unfortunately, many teens do not understand the ruling and how this decision affects them personally. Education is needed today more than ever regarding pregnancy prevention.
The recent AAP policy statement reaffirms its position that the rights of adolescents to seek confidential care when considering abortion must be protected.1 It further reaffirms access to safe and legal abortion is a core tenant of sexual and reproductive health care.
A recent article published in AAP News by Elise D. Berlan, MD, “AAP’s teen reproductive health policies reaffirm right to comprehensive care,” further advises on the role of the pediatric provider.2 Pediatric providers should continue offering option counseling for pregnant adolescents, be prepared to provide accurate information regarding these options with awareness that some options such as the IUD may no longer be available, remain supportive of the decision they choose, and encourage discussion with a family member to support their decisions. It is imperative that we familiarize ourselves with the abortion policies in our states, advocate to prevent government interference with the patient-doctor relationship, and recognize the impact restrictive abortion has regarding marginalized individuals, she stated. Finally we must recognize our own bias regarding option counseling and refer appropriately to another professional if we are unable to confidently offer guidance.
Ms. Thew is the medical director of the department of adolescent medicine at Children’s Wisconsin in Milwaukee.
References
1. AAP Committee on Adolescence. Pediatrics. 2022. doi: 10.1542/peds.2022-058780.
2. Berlan ED. AAP’s teen reproductive health policies reaffirm right to comprehensive care. 2022. AAP News.
The Supreme Court decision to strike down the 50-year ruling on Roe v. Wade, which allowed legal abortion, will affect all patients and families seeking care in pediatric and adolescent medicine clinics. Regardless of how you view abortion, the reality is your adolescent female patients and their parents will seek your counsel.
The overturning of Roe has resulted in much confusion for both patients and providers. The overall effect of this decision in Wisconsin is yet to be known but currently we have had to create road maps to direct adolescent patients who experience an unplanned pregnancy and wish to abort. Unfortunately, these road maps include only resources out of state or online. Providing adolescents confidential care may be challenged as the teens may need to disclose the unplanned pregnancy to an adult to access resources.
Providers remain unsettled regarding their risk of assisting an adolescent who discloses an unplanned pregnancy. Recently, many questions arose regarding dispensing Plan B and the risk to prescribers. Communication was needed to assure providers that Plan B is contraception and at this time contraception remains legal in our state.
Daily I educate adolescent females on the risks of unplanned pregnancy and what the Supreme Court decision will mean to them if they become pregnant. Unfortunately, many teens do not understand the ruling and how this decision affects them personally. Education is needed today more than ever regarding pregnancy prevention.
The recent AAP policy statement reaffirms its position that the rights of adolescents to seek confidential care when considering abortion must be protected.1 It further reaffirms access to safe and legal abortion is a core tenant of sexual and reproductive health care.
A recent article published in AAP News by Elise D. Berlan, MD, “AAP’s teen reproductive health policies reaffirm right to comprehensive care,” further advises on the role of the pediatric provider.2 Pediatric providers should continue offering option counseling for pregnant adolescents, be prepared to provide accurate information regarding these options with awareness that some options such as the IUD may no longer be available, remain supportive of the decision they choose, and encourage discussion with a family member to support their decisions. It is imperative that we familiarize ourselves with the abortion policies in our states, advocate to prevent government interference with the patient-doctor relationship, and recognize the impact restrictive abortion has regarding marginalized individuals, she stated. Finally we must recognize our own bias regarding option counseling and refer appropriately to another professional if we are unable to confidently offer guidance.
Ms. Thew is the medical director of the department of adolescent medicine at Children’s Wisconsin in Milwaukee.
References
1. AAP Committee on Adolescence. Pediatrics. 2022. doi: 10.1542/peds.2022-058780.
2. Berlan ED. AAP’s teen reproductive health policies reaffirm right to comprehensive care. 2022. AAP News.
The Supreme Court decision to strike down the 50-year ruling on Roe v. Wade, which allowed legal abortion, will affect all patients and families seeking care in pediatric and adolescent medicine clinics. Regardless of how you view abortion, the reality is your adolescent female patients and their parents will seek your counsel.
The overturning of Roe has resulted in much confusion for both patients and providers. The overall effect of this decision in Wisconsin is yet to be known but currently we have had to create road maps to direct adolescent patients who experience an unplanned pregnancy and wish to abort. Unfortunately, these road maps include only resources out of state or online. Providing adolescents confidential care may be challenged as the teens may need to disclose the unplanned pregnancy to an adult to access resources.
Providers remain unsettled regarding their risk of assisting an adolescent who discloses an unplanned pregnancy. Recently, many questions arose regarding dispensing Plan B and the risk to prescribers. Communication was needed to assure providers that Plan B is contraception and at this time contraception remains legal in our state.
Daily I educate adolescent females on the risks of unplanned pregnancy and what the Supreme Court decision will mean to them if they become pregnant. Unfortunately, many teens do not understand the ruling and how this decision affects them personally. Education is needed today more than ever regarding pregnancy prevention.
The recent AAP policy statement reaffirms its position that the rights of adolescents to seek confidential care when considering abortion must be protected.1 It further reaffirms access to safe and legal abortion is a core tenant of sexual and reproductive health care.
A recent article published in AAP News by Elise D. Berlan, MD, “AAP’s teen reproductive health policies reaffirm right to comprehensive care,” further advises on the role of the pediatric provider.2 Pediatric providers should continue offering option counseling for pregnant adolescents, be prepared to provide accurate information regarding these options with awareness that some options such as the IUD may no longer be available, remain supportive of the decision they choose, and encourage discussion with a family member to support their decisions. It is imperative that we familiarize ourselves with the abortion policies in our states, advocate to prevent government interference with the patient-doctor relationship, and recognize the impact restrictive abortion has regarding marginalized individuals, she stated. Finally we must recognize our own bias regarding option counseling and refer appropriately to another professional if we are unable to confidently offer guidance.
Ms. Thew is the medical director of the department of adolescent medicine at Children’s Wisconsin in Milwaukee.
References
1. AAP Committee on Adolescence. Pediatrics. 2022. doi: 10.1542/peds.2022-058780.
2. Berlan ED. AAP’s teen reproductive health policies reaffirm right to comprehensive care. 2022. AAP News.
Five things most physicians don’t know about radiation oncology
As a field, radiation oncology is perhaps one of medicine’s best kept secrets. Sometimes, even our own colleagues don’t know where our department exists in the hospital or exactly what we do.
As two radiation oncologists who are, in fact, the children of radiation oncologists, we will admit that it’s possible we are a tiny bit biased. We cannot lie, though: Our field is a hidden gem.
What is well known is that radiation oncologists have a symbiotic relationship with our treatment technology. The evolution of treatment machines and radiation precision allows us to deliver patient-tailored treatment down to the millimeter. What may get lost in the discussions of isodose lines and penumbra, however, is that we’ve also got cutting-edge research and personalized patient care within a specialized team in the depths of the hospital.
Because the inner workings of what happens to patients as they come in and out of our office remains a mystery,
1. Nobody knows what goes on in the basement.
Misconceptions about our subspecialty are common, even among other oncologists. A frequent misconception is that a radiation oncologist’s involvement in patient care is limited, and radiation is delivered in a standardized manner. This essentially renders radiation oncologists technicians of expensive machines.
In reality however, radiation oncologists touch every aspect of a patient’s care, and customized radiation therapy may be indicated for virtually every cancer site in both curative and palliative settings. We strive to deliver precision medicine and practice truly patient-centered care.
To cure cancer, radiation may be used in the neoadjuvant (prior to local surgical resection), definitive (as the primary local therapy), and adjuvant (postsurgical) setting. In palliative cases, radiation can be used to treat areas of metastatic spread as well as primary unresectable tumors to alleviate obstruction and/or bleeding symptoms. Referral to radiation oncology, therefore, can be appropriate at many different points of time on the continuum of cancer care.
For many treating radiation oncologists, the close personal connections that we form with our patients is one of the primary reasons we went into this field. Not only are we making patient-centered clinical decisions during every step of the treatment plan evaluation and optimization but we also see our patients weekly for clinical visits and then ongoing in visits that may span many years of survivorship.
Our deep commitment to addressing patient needs as they are receiving treatment and responsibility for late radiation effects is absolutely an integral part of our training and lifelong practice.
2. We get down in the details.
The workflow from consultation to radiation delivery can be confusing for anyone outside our specialized field.
Once seen in consult and considered a good candidate for radiation, patients will enter the essential next step: the treatment planning imaging – or “simulation.”
The simulation scan – mostly CT, although occasionally fused MRI or PET – involves a separate appointment and another hour or so of arranging and scanning patients in the exact position that they will be treated. Given the precision of modern radiation, the simulation often includes making a customized mold so patients have minimal movement during treatment. These simulation images allow the radiation oncology team to create a treatment plan that is customized to each patient and precisely reproducible during their course of radiation treatments – what’s known as fractions.
Creating a treatment plan involves a radiation oncologist literally drawing – or contouring – on pictures of the patient’s internal anatomy in three dimensions. Radiation oncologists contour exactly where the cancer is – or where it was if the treatment is given postoperatively – and identify the surrounding organs so that the doses can be preferentially directed to the cancer target and minimize risk to nearby organs. This precision is within millimeters and accounts for microscopic disease, organ motion, and patient setup. Ultimately, we create colorful heat gradient volumes of the anticipated radiation dose delivery and optimize these to reflect our planning priorities.
We use advanced technologies to shape the beams of radiation to treat the tumor and avoid delivering high doses to the neighboring tissues with techniques such as intensity modulated radiation therapy (IMRT), stereotactic ablative radiation therapy (SABR or SBRT), and stereotactic radiosurgery. We can also take advantage of the unique properties of different modalities, such as proton therapy and electron therapy, to achieve these same goals if indicated. Radiation oncologists live for precision medicine in every aspect of their workflow.
3. We roll deep.
Radiation oncology is exemplary of “the art of medicine.” We fuse anatomy-based treatment design with advanced technology and orchestrate the daily functions of a large medical team.
But, the treatment plan and delivery would not be possible without the input and care given within a large multi- and intradisciplinary team of oncologists, medical physicists, dosimetrists, radiation therapists, nurses, social workers, and other support staff. Radiation oncologists participate in regular tumor boards with surgeons, medical oncologists, pathologists, and radiologists to optimize interdisciplinary management of complex patients, providing a thoughtful tumor localization and treatment plan, as well as to better understand an individual’s ongoing symptoms and well-being as a whole. Considering all aspects of what a patient may need involves communication with fellow physicians, nurse navigators, and social workers.
Within our own department, treatment plan creation and quality checking or verification can sometimes take over 2 weeks, with detailed input from dosimetrists and medical physicists. The actual treatment delivery involves daily communication with the radiation therapists who are dedicated to each treatment machine – like the linear accelerator – and symptom management with clinic nurses and supportive staff, such as physical therapists and registered dietitians.
This massive team effort is required to get each patient through daily radiation treatments that can last 7 weeks and may require rapid replanning if the tumor shrinks or the patient loses weight.
As part of this team, radiation oncologists are uniquely positioned to quarterback each play and guide the entire game strategy.
4. Radiation therapy takes a lot of heat.
Radiation therapy is often blamed for issues unrelated to the treatment. Irradiating the pelvis for prostate cancer, for instance, does not cause a headache or heartburn during or after treatment.
Other than fatigue, associated side effects are localized and related to the total radiation dose and fraction size – how much and how fast – that reaches the surrounding tissues.
Our colleagues often swap stories of the bizarre things radiation therapy has been blamed for, including dental problems in someone receiving vaginal cylinder treatment, heart dysfunction in someone treated for rectal cancer, and hip fracture in someone treated for breast cancer because the radiation “destroyed” their bones. At best, these are humorous stories, but at worst, they can delay diagnosis and treatment of what is truly causing someone’s symptoms.
5. We truly believe that less is more.
One of the most fundamental aspects of radiation oncology is our drive to optimize treatment delivery and continually improve patient care – sometimes at our own field’s economic detriment. We’re dedicated to showing that patients may get the same benefit from less and less radiation.
In the past 2 decades, the evolution and adoption of photon IMRT and proton therapy has allowed radiation plans to successfully spare surrounding tissue while improving our targeting. This evolution is coupled with technological and imaging advances that allow us to delivery of doses to certain tumors via SABR/SBRT in one to five total fractions.
A prime example: Treatment to eradicate lung or gastrointestinal tumors, which used to span up to 6 weeks, can now potentially be delivered in as little as 1 week.
For other common cancers, hypofractionation – slightly higher radiation doses per fraction at fewer total fractions overall – has revolutionized patient care, providing less radiation without impacting survival or increasing treatment toxicity.
Take breast cancer care: 50 years ago, virtually all patients with breast cancer received a mastectomy and lymph node dissections. Today, surgical techniques for lumpectomy paired with radiation therapy to the whole breast now allows us to preserve disease-free survival for those who elected to keep their breasts.
Over the past 20 years, the standards of care have shifted from 6-7 weeks of treatment to 3-4 weeks using a hypofractionated model that involves daily whole-breast radiation. The most recent clinical trials have shown that whole-breast radiation can be delivered safely and effectively for select women in as few as five fractions with either whole or partial breast targeting. Additional research driven by the idea of “right sizing” radiation treatment has even shown that certain women may not need radiation at all.
This evolution in radiation therapy illustrates how our subspecialty is constantly working to improve survival and patient well-being, form deep connections with our patients, and push the boundaries of medical innovations.
We are proud to be radiation oncologists and happy to share more. Want to know more about what goes on in the basement? Come on down, we’re happy to show you around.
Dr. Giap is a resident in the department of radiation oncology at the University of Florida, Gainesville. Dr. Chino is an assistant attending in the department of radiation oncology at Memorial Sloan Kettering Cancer Center, New York. Neither reported any relevant conflicts of interest.
A version of this article first appeared on Medscape.com.
As a field, radiation oncology is perhaps one of medicine’s best kept secrets. Sometimes, even our own colleagues don’t know where our department exists in the hospital or exactly what we do.
As two radiation oncologists who are, in fact, the children of radiation oncologists, we will admit that it’s possible we are a tiny bit biased. We cannot lie, though: Our field is a hidden gem.
What is well known is that radiation oncologists have a symbiotic relationship with our treatment technology. The evolution of treatment machines and radiation precision allows us to deliver patient-tailored treatment down to the millimeter. What may get lost in the discussions of isodose lines and penumbra, however, is that we’ve also got cutting-edge research and personalized patient care within a specialized team in the depths of the hospital.
Because the inner workings of what happens to patients as they come in and out of our office remains a mystery,
1. Nobody knows what goes on in the basement.
Misconceptions about our subspecialty are common, even among other oncologists. A frequent misconception is that a radiation oncologist’s involvement in patient care is limited, and radiation is delivered in a standardized manner. This essentially renders radiation oncologists technicians of expensive machines.
In reality however, radiation oncologists touch every aspect of a patient’s care, and customized radiation therapy may be indicated for virtually every cancer site in both curative and palliative settings. We strive to deliver precision medicine and practice truly patient-centered care.
To cure cancer, radiation may be used in the neoadjuvant (prior to local surgical resection), definitive (as the primary local therapy), and adjuvant (postsurgical) setting. In palliative cases, radiation can be used to treat areas of metastatic spread as well as primary unresectable tumors to alleviate obstruction and/or bleeding symptoms. Referral to radiation oncology, therefore, can be appropriate at many different points of time on the continuum of cancer care.
For many treating radiation oncologists, the close personal connections that we form with our patients is one of the primary reasons we went into this field. Not only are we making patient-centered clinical decisions during every step of the treatment plan evaluation and optimization but we also see our patients weekly for clinical visits and then ongoing in visits that may span many years of survivorship.
Our deep commitment to addressing patient needs as they are receiving treatment and responsibility for late radiation effects is absolutely an integral part of our training and lifelong practice.
2. We get down in the details.
The workflow from consultation to radiation delivery can be confusing for anyone outside our specialized field.
Once seen in consult and considered a good candidate for radiation, patients will enter the essential next step: the treatment planning imaging – or “simulation.”
The simulation scan – mostly CT, although occasionally fused MRI or PET – involves a separate appointment and another hour or so of arranging and scanning patients in the exact position that they will be treated. Given the precision of modern radiation, the simulation often includes making a customized mold so patients have minimal movement during treatment. These simulation images allow the radiation oncology team to create a treatment plan that is customized to each patient and precisely reproducible during their course of radiation treatments – what’s known as fractions.
Creating a treatment plan involves a radiation oncologist literally drawing – or contouring – on pictures of the patient’s internal anatomy in three dimensions. Radiation oncologists contour exactly where the cancer is – or where it was if the treatment is given postoperatively – and identify the surrounding organs so that the doses can be preferentially directed to the cancer target and minimize risk to nearby organs. This precision is within millimeters and accounts for microscopic disease, organ motion, and patient setup. Ultimately, we create colorful heat gradient volumes of the anticipated radiation dose delivery and optimize these to reflect our planning priorities.
We use advanced technologies to shape the beams of radiation to treat the tumor and avoid delivering high doses to the neighboring tissues with techniques such as intensity modulated radiation therapy (IMRT), stereotactic ablative radiation therapy (SABR or SBRT), and stereotactic radiosurgery. We can also take advantage of the unique properties of different modalities, such as proton therapy and electron therapy, to achieve these same goals if indicated. Radiation oncologists live for precision medicine in every aspect of their workflow.
3. We roll deep.
Radiation oncology is exemplary of “the art of medicine.” We fuse anatomy-based treatment design with advanced technology and orchestrate the daily functions of a large medical team.
But, the treatment plan and delivery would not be possible without the input and care given within a large multi- and intradisciplinary team of oncologists, medical physicists, dosimetrists, radiation therapists, nurses, social workers, and other support staff. Radiation oncologists participate in regular tumor boards with surgeons, medical oncologists, pathologists, and radiologists to optimize interdisciplinary management of complex patients, providing a thoughtful tumor localization and treatment plan, as well as to better understand an individual’s ongoing symptoms and well-being as a whole. Considering all aspects of what a patient may need involves communication with fellow physicians, nurse navigators, and social workers.
Within our own department, treatment plan creation and quality checking or verification can sometimes take over 2 weeks, with detailed input from dosimetrists and medical physicists. The actual treatment delivery involves daily communication with the radiation therapists who are dedicated to each treatment machine – like the linear accelerator – and symptom management with clinic nurses and supportive staff, such as physical therapists and registered dietitians.
This massive team effort is required to get each patient through daily radiation treatments that can last 7 weeks and may require rapid replanning if the tumor shrinks or the patient loses weight.
As part of this team, radiation oncologists are uniquely positioned to quarterback each play and guide the entire game strategy.
4. Radiation therapy takes a lot of heat.
Radiation therapy is often blamed for issues unrelated to the treatment. Irradiating the pelvis for prostate cancer, for instance, does not cause a headache or heartburn during or after treatment.
Other than fatigue, associated side effects are localized and related to the total radiation dose and fraction size – how much and how fast – that reaches the surrounding tissues.
Our colleagues often swap stories of the bizarre things radiation therapy has been blamed for, including dental problems in someone receiving vaginal cylinder treatment, heart dysfunction in someone treated for rectal cancer, and hip fracture in someone treated for breast cancer because the radiation “destroyed” their bones. At best, these are humorous stories, but at worst, they can delay diagnosis and treatment of what is truly causing someone’s symptoms.
5. We truly believe that less is more.
One of the most fundamental aspects of radiation oncology is our drive to optimize treatment delivery and continually improve patient care – sometimes at our own field’s economic detriment. We’re dedicated to showing that patients may get the same benefit from less and less radiation.
In the past 2 decades, the evolution and adoption of photon IMRT and proton therapy has allowed radiation plans to successfully spare surrounding tissue while improving our targeting. This evolution is coupled with technological and imaging advances that allow us to delivery of doses to certain tumors via SABR/SBRT in one to five total fractions.
A prime example: Treatment to eradicate lung or gastrointestinal tumors, which used to span up to 6 weeks, can now potentially be delivered in as little as 1 week.
For other common cancers, hypofractionation – slightly higher radiation doses per fraction at fewer total fractions overall – has revolutionized patient care, providing less radiation without impacting survival or increasing treatment toxicity.
Take breast cancer care: 50 years ago, virtually all patients with breast cancer received a mastectomy and lymph node dissections. Today, surgical techniques for lumpectomy paired with radiation therapy to the whole breast now allows us to preserve disease-free survival for those who elected to keep their breasts.
Over the past 20 years, the standards of care have shifted from 6-7 weeks of treatment to 3-4 weeks using a hypofractionated model that involves daily whole-breast radiation. The most recent clinical trials have shown that whole-breast radiation can be delivered safely and effectively for select women in as few as five fractions with either whole or partial breast targeting. Additional research driven by the idea of “right sizing” radiation treatment has even shown that certain women may not need radiation at all.
This evolution in radiation therapy illustrates how our subspecialty is constantly working to improve survival and patient well-being, form deep connections with our patients, and push the boundaries of medical innovations.
We are proud to be radiation oncologists and happy to share more. Want to know more about what goes on in the basement? Come on down, we’re happy to show you around.
Dr. Giap is a resident in the department of radiation oncology at the University of Florida, Gainesville. Dr. Chino is an assistant attending in the department of radiation oncology at Memorial Sloan Kettering Cancer Center, New York. Neither reported any relevant conflicts of interest.
A version of this article first appeared on Medscape.com.
As a field, radiation oncology is perhaps one of medicine’s best kept secrets. Sometimes, even our own colleagues don’t know where our department exists in the hospital or exactly what we do.
As two radiation oncologists who are, in fact, the children of radiation oncologists, we will admit that it’s possible we are a tiny bit biased. We cannot lie, though: Our field is a hidden gem.
What is well known is that radiation oncologists have a symbiotic relationship with our treatment technology. The evolution of treatment machines and radiation precision allows us to deliver patient-tailored treatment down to the millimeter. What may get lost in the discussions of isodose lines and penumbra, however, is that we’ve also got cutting-edge research and personalized patient care within a specialized team in the depths of the hospital.
Because the inner workings of what happens to patients as they come in and out of our office remains a mystery,
1. Nobody knows what goes on in the basement.
Misconceptions about our subspecialty are common, even among other oncologists. A frequent misconception is that a radiation oncologist’s involvement in patient care is limited, and radiation is delivered in a standardized manner. This essentially renders radiation oncologists technicians of expensive machines.
In reality however, radiation oncologists touch every aspect of a patient’s care, and customized radiation therapy may be indicated for virtually every cancer site in both curative and palliative settings. We strive to deliver precision medicine and practice truly patient-centered care.
To cure cancer, radiation may be used in the neoadjuvant (prior to local surgical resection), definitive (as the primary local therapy), and adjuvant (postsurgical) setting. In palliative cases, radiation can be used to treat areas of metastatic spread as well as primary unresectable tumors to alleviate obstruction and/or bleeding symptoms. Referral to radiation oncology, therefore, can be appropriate at many different points of time on the continuum of cancer care.
For many treating radiation oncologists, the close personal connections that we form with our patients is one of the primary reasons we went into this field. Not only are we making patient-centered clinical decisions during every step of the treatment plan evaluation and optimization but we also see our patients weekly for clinical visits and then ongoing in visits that may span many years of survivorship.
Our deep commitment to addressing patient needs as they are receiving treatment and responsibility for late radiation effects is absolutely an integral part of our training and lifelong practice.
2. We get down in the details.
The workflow from consultation to radiation delivery can be confusing for anyone outside our specialized field.
Once seen in consult and considered a good candidate for radiation, patients will enter the essential next step: the treatment planning imaging – or “simulation.”
The simulation scan – mostly CT, although occasionally fused MRI or PET – involves a separate appointment and another hour or so of arranging and scanning patients in the exact position that they will be treated. Given the precision of modern radiation, the simulation often includes making a customized mold so patients have minimal movement during treatment. These simulation images allow the radiation oncology team to create a treatment plan that is customized to each patient and precisely reproducible during their course of radiation treatments – what’s known as fractions.
Creating a treatment plan involves a radiation oncologist literally drawing – or contouring – on pictures of the patient’s internal anatomy in three dimensions. Radiation oncologists contour exactly where the cancer is – or where it was if the treatment is given postoperatively – and identify the surrounding organs so that the doses can be preferentially directed to the cancer target and minimize risk to nearby organs. This precision is within millimeters and accounts for microscopic disease, organ motion, and patient setup. Ultimately, we create colorful heat gradient volumes of the anticipated radiation dose delivery and optimize these to reflect our planning priorities.
We use advanced technologies to shape the beams of radiation to treat the tumor and avoid delivering high doses to the neighboring tissues with techniques such as intensity modulated radiation therapy (IMRT), stereotactic ablative radiation therapy (SABR or SBRT), and stereotactic radiosurgery. We can also take advantage of the unique properties of different modalities, such as proton therapy and electron therapy, to achieve these same goals if indicated. Radiation oncologists live for precision medicine in every aspect of their workflow.
3. We roll deep.
Radiation oncology is exemplary of “the art of medicine.” We fuse anatomy-based treatment design with advanced technology and orchestrate the daily functions of a large medical team.
But, the treatment plan and delivery would not be possible without the input and care given within a large multi- and intradisciplinary team of oncologists, medical physicists, dosimetrists, radiation therapists, nurses, social workers, and other support staff. Radiation oncologists participate in regular tumor boards with surgeons, medical oncologists, pathologists, and radiologists to optimize interdisciplinary management of complex patients, providing a thoughtful tumor localization and treatment plan, as well as to better understand an individual’s ongoing symptoms and well-being as a whole. Considering all aspects of what a patient may need involves communication with fellow physicians, nurse navigators, and social workers.
Within our own department, treatment plan creation and quality checking or verification can sometimes take over 2 weeks, with detailed input from dosimetrists and medical physicists. The actual treatment delivery involves daily communication with the radiation therapists who are dedicated to each treatment machine – like the linear accelerator – and symptom management with clinic nurses and supportive staff, such as physical therapists and registered dietitians.
This massive team effort is required to get each patient through daily radiation treatments that can last 7 weeks and may require rapid replanning if the tumor shrinks or the patient loses weight.
As part of this team, radiation oncologists are uniquely positioned to quarterback each play and guide the entire game strategy.
4. Radiation therapy takes a lot of heat.
Radiation therapy is often blamed for issues unrelated to the treatment. Irradiating the pelvis for prostate cancer, for instance, does not cause a headache or heartburn during or after treatment.
Other than fatigue, associated side effects are localized and related to the total radiation dose and fraction size – how much and how fast – that reaches the surrounding tissues.
Our colleagues often swap stories of the bizarre things radiation therapy has been blamed for, including dental problems in someone receiving vaginal cylinder treatment, heart dysfunction in someone treated for rectal cancer, and hip fracture in someone treated for breast cancer because the radiation “destroyed” their bones. At best, these are humorous stories, but at worst, they can delay diagnosis and treatment of what is truly causing someone’s symptoms.
5. We truly believe that less is more.
One of the most fundamental aspects of radiation oncology is our drive to optimize treatment delivery and continually improve patient care – sometimes at our own field’s economic detriment. We’re dedicated to showing that patients may get the same benefit from less and less radiation.
In the past 2 decades, the evolution and adoption of photon IMRT and proton therapy has allowed radiation plans to successfully spare surrounding tissue while improving our targeting. This evolution is coupled with technological and imaging advances that allow us to delivery of doses to certain tumors via SABR/SBRT in one to five total fractions.
A prime example: Treatment to eradicate lung or gastrointestinal tumors, which used to span up to 6 weeks, can now potentially be delivered in as little as 1 week.
For other common cancers, hypofractionation – slightly higher radiation doses per fraction at fewer total fractions overall – has revolutionized patient care, providing less radiation without impacting survival or increasing treatment toxicity.
Take breast cancer care: 50 years ago, virtually all patients with breast cancer received a mastectomy and lymph node dissections. Today, surgical techniques for lumpectomy paired with radiation therapy to the whole breast now allows us to preserve disease-free survival for those who elected to keep their breasts.
Over the past 20 years, the standards of care have shifted from 6-7 weeks of treatment to 3-4 weeks using a hypofractionated model that involves daily whole-breast radiation. The most recent clinical trials have shown that whole-breast radiation can be delivered safely and effectively for select women in as few as five fractions with either whole or partial breast targeting. Additional research driven by the idea of “right sizing” radiation treatment has even shown that certain women may not need radiation at all.
This evolution in radiation therapy illustrates how our subspecialty is constantly working to improve survival and patient well-being, form deep connections with our patients, and push the boundaries of medical innovations.
We are proud to be radiation oncologists and happy to share more. Want to know more about what goes on in the basement? Come on down, we’re happy to show you around.
Dr. Giap is a resident in the department of radiation oncology at the University of Florida, Gainesville. Dr. Chino is an assistant attending in the department of radiation oncology at Memorial Sloan Kettering Cancer Center, New York. Neither reported any relevant conflicts of interest.
A version of this article first appeared on Medscape.com.
Medical assistants
When I began in private practice several eons ago, I employed only registered nurses (RNs) and licensed practical nurses (LPNs) in my office – as did, I think, most other physicians.
That is still the preferred way to go from an efficiency perspective, as well as the ability to delegate such tasks as blood collection and administering intramuscular injections. Unfortunately,
Given this reality, it makes sense to understand how the use of medical assistants has changed private medical practice, and how the most effective MAs manage their roles and maximize their efficiency in the office.
A recent article by two physicians at the University of Michigan, Ann Arbor, is one of the few published papers to address this issue. It presents the results of a cross-sectional study examining the MA’s experience and key factors that enhance or reduce efficiencies.
The authors sent an email survey to 86 MAs working in six clinics within the department of family medicine at the University of Michigan Medical Center, and received responses from 75 of them, including 61 who completed the entire survey. They then singled out 18 individuals deemed “most efficient” by their peers and conducted face-to-face interviews with them.
The surveys and interviews looked at how MAs identified personal strategies for efficiency, dealt with barriers to implementing those strategies, and navigated interoffice relationships, as well as how all of this affected overall job satisfaction.
All 61 respondents who completed the full survey agreed that the MA role was “very important to keep the clinic functioning” and nearly all said that working in health care was “a calling” for them. About half agreed that their work was very stressful, and about the same percentage reported that there was inadequate MA staffing at their clinic. Others complained of limited pay and promotion opportunities.
The surveyed MAs described important work values that increased their efficiency. These included good communication, strong teamwork, and workload sharing, as well as individual strategies such as multitasking, limiting patient conversations, and completing tasks in a consistent way to improve accuracy.
Other strategies identified as contributing to an efficient operation included preclinic huddles, reviews of patient records before the patient’s arrival, and completing routine office duties before the start of office hours.
Respondents were then asked to identify barriers to clinic efficiency, and most of them involved physicians who barked orders at them, did not complete paperwork or sign orders in a timely manner, and agreed to see late-arriving patients. Some MAs suggested that physicians refrain from “talking down” to them, and teach rather than criticize. They also faulted decisions affecting patient flow made by other staffers without soliciting the MAs’ input.
Despite these barriers, the authors found that most of the surveyed MAs agreed that their work was valued by doctors. “Proper training of managers to provide ... support and ensure equitable workloads may be one strategy to ensure that staff members feel the workplace is fair and collegial,” they said.
“Many described the working relationships with physicians as critical to their satisfaction at work and indicated that strong partnerships motivated them to do their best to make the physician’s day easier,” they added.
At the same time, the authors noted that most survey subjects reported that their jobs were “stressful,” and believed that their stress went underrecognized by physicians. They argued that “it’s important for physicians to be cognizant of these patterns and clinic culture, as reducing a hierarchy-based environment will be appreciated by MAs.”
Since this study involved only MAs in a family practice setting, further studies will be needed to determine whether these results translate to specialty offices – and whether the unique issues inherent in various specialty environments elicit different efficiency contributors and barriers.
Overall, though, “staff job satisfaction is linked to improved quality of care, so treating staff well contributes to high-value care for patients,” the authors wrote. “Disseminating practices that staff members themselves have identified as effective, and being attentive to how staff members are treated, may increase individual efficiency while improving staff retention and satisfaction.”
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].
When I began in private practice several eons ago, I employed only registered nurses (RNs) and licensed practical nurses (LPNs) in my office – as did, I think, most other physicians.
That is still the preferred way to go from an efficiency perspective, as well as the ability to delegate such tasks as blood collection and administering intramuscular injections. Unfortunately,
Given this reality, it makes sense to understand how the use of medical assistants has changed private medical practice, and how the most effective MAs manage their roles and maximize their efficiency in the office.
A recent article by two physicians at the University of Michigan, Ann Arbor, is one of the few published papers to address this issue. It presents the results of a cross-sectional study examining the MA’s experience and key factors that enhance or reduce efficiencies.
The authors sent an email survey to 86 MAs working in six clinics within the department of family medicine at the University of Michigan Medical Center, and received responses from 75 of them, including 61 who completed the entire survey. They then singled out 18 individuals deemed “most efficient” by their peers and conducted face-to-face interviews with them.
The surveys and interviews looked at how MAs identified personal strategies for efficiency, dealt with barriers to implementing those strategies, and navigated interoffice relationships, as well as how all of this affected overall job satisfaction.
All 61 respondents who completed the full survey agreed that the MA role was “very important to keep the clinic functioning” and nearly all said that working in health care was “a calling” for them. About half agreed that their work was very stressful, and about the same percentage reported that there was inadequate MA staffing at their clinic. Others complained of limited pay and promotion opportunities.
The surveyed MAs described important work values that increased their efficiency. These included good communication, strong teamwork, and workload sharing, as well as individual strategies such as multitasking, limiting patient conversations, and completing tasks in a consistent way to improve accuracy.
Other strategies identified as contributing to an efficient operation included preclinic huddles, reviews of patient records before the patient’s arrival, and completing routine office duties before the start of office hours.
Respondents were then asked to identify barriers to clinic efficiency, and most of them involved physicians who barked orders at them, did not complete paperwork or sign orders in a timely manner, and agreed to see late-arriving patients. Some MAs suggested that physicians refrain from “talking down” to them, and teach rather than criticize. They also faulted decisions affecting patient flow made by other staffers without soliciting the MAs’ input.
Despite these barriers, the authors found that most of the surveyed MAs agreed that their work was valued by doctors. “Proper training of managers to provide ... support and ensure equitable workloads may be one strategy to ensure that staff members feel the workplace is fair and collegial,” they said.
“Many described the working relationships with physicians as critical to their satisfaction at work and indicated that strong partnerships motivated them to do their best to make the physician’s day easier,” they added.
At the same time, the authors noted that most survey subjects reported that their jobs were “stressful,” and believed that their stress went underrecognized by physicians. They argued that “it’s important for physicians to be cognizant of these patterns and clinic culture, as reducing a hierarchy-based environment will be appreciated by MAs.”
Since this study involved only MAs in a family practice setting, further studies will be needed to determine whether these results translate to specialty offices – and whether the unique issues inherent in various specialty environments elicit different efficiency contributors and barriers.
Overall, though, “staff job satisfaction is linked to improved quality of care, so treating staff well contributes to high-value care for patients,” the authors wrote. “Disseminating practices that staff members themselves have identified as effective, and being attentive to how staff members are treated, may increase individual efficiency while improving staff retention and satisfaction.”
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].
When I began in private practice several eons ago, I employed only registered nurses (RNs) and licensed practical nurses (LPNs) in my office – as did, I think, most other physicians.
That is still the preferred way to go from an efficiency perspective, as well as the ability to delegate such tasks as blood collection and administering intramuscular injections. Unfortunately,
Given this reality, it makes sense to understand how the use of medical assistants has changed private medical practice, and how the most effective MAs manage their roles and maximize their efficiency in the office.
A recent article by two physicians at the University of Michigan, Ann Arbor, is one of the few published papers to address this issue. It presents the results of a cross-sectional study examining the MA’s experience and key factors that enhance or reduce efficiencies.
The authors sent an email survey to 86 MAs working in six clinics within the department of family medicine at the University of Michigan Medical Center, and received responses from 75 of them, including 61 who completed the entire survey. They then singled out 18 individuals deemed “most efficient” by their peers and conducted face-to-face interviews with them.
The surveys and interviews looked at how MAs identified personal strategies for efficiency, dealt with barriers to implementing those strategies, and navigated interoffice relationships, as well as how all of this affected overall job satisfaction.
All 61 respondents who completed the full survey agreed that the MA role was “very important to keep the clinic functioning” and nearly all said that working in health care was “a calling” for them. About half agreed that their work was very stressful, and about the same percentage reported that there was inadequate MA staffing at their clinic. Others complained of limited pay and promotion opportunities.
The surveyed MAs described important work values that increased their efficiency. These included good communication, strong teamwork, and workload sharing, as well as individual strategies such as multitasking, limiting patient conversations, and completing tasks in a consistent way to improve accuracy.
Other strategies identified as contributing to an efficient operation included preclinic huddles, reviews of patient records before the patient’s arrival, and completing routine office duties before the start of office hours.
Respondents were then asked to identify barriers to clinic efficiency, and most of them involved physicians who barked orders at them, did not complete paperwork or sign orders in a timely manner, and agreed to see late-arriving patients. Some MAs suggested that physicians refrain from “talking down” to them, and teach rather than criticize. They also faulted decisions affecting patient flow made by other staffers without soliciting the MAs’ input.
Despite these barriers, the authors found that most of the surveyed MAs agreed that their work was valued by doctors. “Proper training of managers to provide ... support and ensure equitable workloads may be one strategy to ensure that staff members feel the workplace is fair and collegial,” they said.
“Many described the working relationships with physicians as critical to their satisfaction at work and indicated that strong partnerships motivated them to do their best to make the physician’s day easier,” they added.
At the same time, the authors noted that most survey subjects reported that their jobs were “stressful,” and believed that their stress went underrecognized by physicians. They argued that “it’s important for physicians to be cognizant of these patterns and clinic culture, as reducing a hierarchy-based environment will be appreciated by MAs.”
Since this study involved only MAs in a family practice setting, further studies will be needed to determine whether these results translate to specialty offices – and whether the unique issues inherent in various specialty environments elicit different efficiency contributors and barriers.
Overall, though, “staff job satisfaction is linked to improved quality of care, so treating staff well contributes to high-value care for patients,” the authors wrote. “Disseminating practices that staff members themselves have identified as effective, and being attentive to how staff members are treated, may increase individual efficiency while improving staff retention and satisfaction.”
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].
A healthy White male presented with a rash consisting of erythematous to purpuric macules
Vasculitis is a process in which blood vessels become inflamed and necrotic. Classic small vessel vasculitis reveals a leukocytoclastic vasculitis and most commonly presents as palpable purpura. .” A form of EIV has been described in the literature as “Disney dermatitis.” It is often seen in healthy adults after a long day of walking at the parks. Other forms of exercise, such as jogging, hiking, or swimming, may also cause the condition.
Clinically, EIV affects the lower legs and presents as purpuric macules. Edema may be present. Lesions may be asymptomatic or may present with pruritus or burning. Diagnosis is often made clinically. Skin biopsies for H&E and DIF (direct immunofluorescence) can help distinguish the type of vasculitis that is present. Laboratory tests may be needed to exclude other causes of vasculitis. Episodes may be recurrent.
Henoch-Schönlein purpura (HSP), also called anaphylactoid purpura, is a subtype of small-vessel vasculitis where IgA immunoglobulin is deposited in the vessel walls. It is the most common form of vasculitis is children (usually ages 4-8). In addition to skin, organs such as joints, kidneys, and intestines can be involved. Schamberg’s disease, or capillaritis, is also called pigmented purpura. In this benign condition, leakage from capillaries results in erythematous to brown patches on the lower extremities. A true vasculitis is not seen. The brown discoloration is due to hemosiderin deposition. Cryoglobulinemia is a rare condition in which abnormal immunoglobulin complexes deposit in tissues and vessels. Leukocytoclastic vasculitis is present in small vessels. Palpable purpura and livedo may be seen clinically, and systemic symptoms may be present.
Treatment of EIV is largely supportive as lesions will resolve on their own over 3-4 weeks. Postinflammatory hyperpigmentation may result. Temporary cessation of exercise and compression stockings can help speed up the resolution of lesions. Systemic medications used in the treatment of severe vasculitis, such as systemic steroids, dapsone, and colchicine, are not needed in EIV.
Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to [email protected].
Vasculitis is a process in which blood vessels become inflamed and necrotic. Classic small vessel vasculitis reveals a leukocytoclastic vasculitis and most commonly presents as palpable purpura. .” A form of EIV has been described in the literature as “Disney dermatitis.” It is often seen in healthy adults after a long day of walking at the parks. Other forms of exercise, such as jogging, hiking, or swimming, may also cause the condition.
Clinically, EIV affects the lower legs and presents as purpuric macules. Edema may be present. Lesions may be asymptomatic or may present with pruritus or burning. Diagnosis is often made clinically. Skin biopsies for H&E and DIF (direct immunofluorescence) can help distinguish the type of vasculitis that is present. Laboratory tests may be needed to exclude other causes of vasculitis. Episodes may be recurrent.
Henoch-Schönlein purpura (HSP), also called anaphylactoid purpura, is a subtype of small-vessel vasculitis where IgA immunoglobulin is deposited in the vessel walls. It is the most common form of vasculitis is children (usually ages 4-8). In addition to skin, organs such as joints, kidneys, and intestines can be involved. Schamberg’s disease, or capillaritis, is also called pigmented purpura. In this benign condition, leakage from capillaries results in erythematous to brown patches on the lower extremities. A true vasculitis is not seen. The brown discoloration is due to hemosiderin deposition. Cryoglobulinemia is a rare condition in which abnormal immunoglobulin complexes deposit in tissues and vessels. Leukocytoclastic vasculitis is present in small vessels. Palpable purpura and livedo may be seen clinically, and systemic symptoms may be present.
Treatment of EIV is largely supportive as lesions will resolve on their own over 3-4 weeks. Postinflammatory hyperpigmentation may result. Temporary cessation of exercise and compression stockings can help speed up the resolution of lesions. Systemic medications used in the treatment of severe vasculitis, such as systemic steroids, dapsone, and colchicine, are not needed in EIV.
Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to [email protected].
Vasculitis is a process in which blood vessels become inflamed and necrotic. Classic small vessel vasculitis reveals a leukocytoclastic vasculitis and most commonly presents as palpable purpura. .” A form of EIV has been described in the literature as “Disney dermatitis.” It is often seen in healthy adults after a long day of walking at the parks. Other forms of exercise, such as jogging, hiking, or swimming, may also cause the condition.
Clinically, EIV affects the lower legs and presents as purpuric macules. Edema may be present. Lesions may be asymptomatic or may present with pruritus or burning. Diagnosis is often made clinically. Skin biopsies for H&E and DIF (direct immunofluorescence) can help distinguish the type of vasculitis that is present. Laboratory tests may be needed to exclude other causes of vasculitis. Episodes may be recurrent.
Henoch-Schönlein purpura (HSP), also called anaphylactoid purpura, is a subtype of small-vessel vasculitis where IgA immunoglobulin is deposited in the vessel walls. It is the most common form of vasculitis is children (usually ages 4-8). In addition to skin, organs such as joints, kidneys, and intestines can be involved. Schamberg’s disease, or capillaritis, is also called pigmented purpura. In this benign condition, leakage from capillaries results in erythematous to brown patches on the lower extremities. A true vasculitis is not seen. The brown discoloration is due to hemosiderin deposition. Cryoglobulinemia is a rare condition in which abnormal immunoglobulin complexes deposit in tissues and vessels. Leukocytoclastic vasculitis is present in small vessels. Palpable purpura and livedo may be seen clinically, and systemic symptoms may be present.
Treatment of EIV is largely supportive as lesions will resolve on their own over 3-4 weeks. Postinflammatory hyperpigmentation may result. Temporary cessation of exercise and compression stockings can help speed up the resolution of lesions. Systemic medications used in the treatment of severe vasculitis, such as systemic steroids, dapsone, and colchicine, are not needed in EIV.
Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to [email protected].
Ten steps for clinicians to avoid being racist: The Francis commitment
As a Black man who grew up in this country, I can tell you first-hand what it does to you. The scars never go away, and your status is always in question, no matter your title or uniforms of respect. Eventually it wears you down.
I was born into poverty and the segregation of southwest Louisiana. I experienced the dehumanization intended for me: separate drinking fountains and poor foundational education. I was lucky to attend a historically Black college or university (Southern University, Baton Rouge, La.), that gave me my bearings. I then went to some of the very best, predominantly White institutions.
When I looked for a job after training, there were few integrated medical groups, so I started my own. It included practitioners who were White, Black, Jewish, Asian, Middle Eastern, Muslim, Christian, etc. We cross covered and treated patients from every corner of the globe.
In medicine, we treat human beings with disease. The disease should be the only difference that sets us apart. There is absolutely no place for racism.
It is difficult to be called a racist, and I have met only a handful of people in health care whom I would label as such. But racism is structural and institutionalized so that it is often hidden.
One way to overcome this is to make every effort possible to get to know people as individuals. Only then can we see that there are few real differences between us. I would often seek out a colleague from a different culture or race to have lunch with so I could learn more about them.
We all strive for the same things – validation, happiness, love, family, and a future. We all grieve over the same things.
What some caregivers may not realize is that, just as clinicians have been trained to recognize subtle signs and symptoms of disease, minorities can recognize racism immediately during a medical encounter. Our past experiences make us skilled at picking up a lack of eye contact or body language and tone of voice that are dismissive and disrespectful.
A patient who has felt racism may still return for care because of insurance coverage limitations, location, or a lack of alternatives. But trust and loyalty will never develop on the part of this patient, and empathy will be absent on the part of their caregiver.
To counter this in my own practice, I developed the Francis Commitment to avoid any hint of racism or bias toward my patients.
I commit to the following:
1. I see you.
2. I hear you.
3. I accept who you are.
4. I will try to understand how you must feel (empathy).
5. Treating you is very important to me.
6. I would like to gain your trust that I will do my very best to make you better.
7. I value you as a human being and will treat you as if you are family.
8. I care about what happens to you.
9. I want us to work together to fight this disease.
10. I am grateful that you chose me as your caregiver.
The INOVA health care system where I work has undertaken an initiative called What Matters Most to better understand the needs of every patient. We are currently working on a strategy of patient personalization to not only learn about their medical needs but also to discover who they are as a person. We incorporate Social Determinants of Health in our dealings with patients. We also have participated in a program called “A Long Talk”, where we learned that those of us who remain silent when we see or hear racism are responsible for its persistence and growth.
But we must do more. Racism will propagate if we live in silos surrounded by people whose ideas reflect our own. As long as we have nondiversified board rooms, departments, and staff, the problem will persist.
A lot of the biases that we unconsciously carry in our heads and hearts have no basis in reality and were placed there without our permission by parents, society, and friends. But we can replace these divisive thoughts and impulses.
What’s in your heart can only be known and controlled by you. How tolerant we are of racism is up to us: Do you call out racism; do you challenge any inkling of racism from friends or acquaintances; do you put pressure on institutions where you work to diversify in recruiting and hiring?
Think of all the advances in medicine that were achieved by people from different cultures and races. Racism has no place in what we have all devoted our lives to do – take care of our fellow humans.
A version of this article first appeared on Medscape.com.
As a Black man who grew up in this country, I can tell you first-hand what it does to you. The scars never go away, and your status is always in question, no matter your title or uniforms of respect. Eventually it wears you down.
I was born into poverty and the segregation of southwest Louisiana. I experienced the dehumanization intended for me: separate drinking fountains and poor foundational education. I was lucky to attend a historically Black college or university (Southern University, Baton Rouge, La.), that gave me my bearings. I then went to some of the very best, predominantly White institutions.
When I looked for a job after training, there were few integrated medical groups, so I started my own. It included practitioners who were White, Black, Jewish, Asian, Middle Eastern, Muslim, Christian, etc. We cross covered and treated patients from every corner of the globe.
In medicine, we treat human beings with disease. The disease should be the only difference that sets us apart. There is absolutely no place for racism.
It is difficult to be called a racist, and I have met only a handful of people in health care whom I would label as such. But racism is structural and institutionalized so that it is often hidden.
One way to overcome this is to make every effort possible to get to know people as individuals. Only then can we see that there are few real differences between us. I would often seek out a colleague from a different culture or race to have lunch with so I could learn more about them.
We all strive for the same things – validation, happiness, love, family, and a future. We all grieve over the same things.
What some caregivers may not realize is that, just as clinicians have been trained to recognize subtle signs and symptoms of disease, minorities can recognize racism immediately during a medical encounter. Our past experiences make us skilled at picking up a lack of eye contact or body language and tone of voice that are dismissive and disrespectful.
A patient who has felt racism may still return for care because of insurance coverage limitations, location, or a lack of alternatives. But trust and loyalty will never develop on the part of this patient, and empathy will be absent on the part of their caregiver.
To counter this in my own practice, I developed the Francis Commitment to avoid any hint of racism or bias toward my patients.
I commit to the following:
1. I see you.
2. I hear you.
3. I accept who you are.
4. I will try to understand how you must feel (empathy).
5. Treating you is very important to me.
6. I would like to gain your trust that I will do my very best to make you better.
7. I value you as a human being and will treat you as if you are family.
8. I care about what happens to you.
9. I want us to work together to fight this disease.
10. I am grateful that you chose me as your caregiver.
The INOVA health care system where I work has undertaken an initiative called What Matters Most to better understand the needs of every patient. We are currently working on a strategy of patient personalization to not only learn about their medical needs but also to discover who they are as a person. We incorporate Social Determinants of Health in our dealings with patients. We also have participated in a program called “A Long Talk”, where we learned that those of us who remain silent when we see or hear racism are responsible for its persistence and growth.
But we must do more. Racism will propagate if we live in silos surrounded by people whose ideas reflect our own. As long as we have nondiversified board rooms, departments, and staff, the problem will persist.
A lot of the biases that we unconsciously carry in our heads and hearts have no basis in reality and were placed there without our permission by parents, society, and friends. But we can replace these divisive thoughts and impulses.
What’s in your heart can only be known and controlled by you. How tolerant we are of racism is up to us: Do you call out racism; do you challenge any inkling of racism from friends or acquaintances; do you put pressure on institutions where you work to diversify in recruiting and hiring?
Think of all the advances in medicine that were achieved by people from different cultures and races. Racism has no place in what we have all devoted our lives to do – take care of our fellow humans.
A version of this article first appeared on Medscape.com.
As a Black man who grew up in this country, I can tell you first-hand what it does to you. The scars never go away, and your status is always in question, no matter your title or uniforms of respect. Eventually it wears you down.
I was born into poverty and the segregation of southwest Louisiana. I experienced the dehumanization intended for me: separate drinking fountains and poor foundational education. I was lucky to attend a historically Black college or university (Southern University, Baton Rouge, La.), that gave me my bearings. I then went to some of the very best, predominantly White institutions.
When I looked for a job after training, there were few integrated medical groups, so I started my own. It included practitioners who were White, Black, Jewish, Asian, Middle Eastern, Muslim, Christian, etc. We cross covered and treated patients from every corner of the globe.
In medicine, we treat human beings with disease. The disease should be the only difference that sets us apart. There is absolutely no place for racism.
It is difficult to be called a racist, and I have met only a handful of people in health care whom I would label as such. But racism is structural and institutionalized so that it is often hidden.
One way to overcome this is to make every effort possible to get to know people as individuals. Only then can we see that there are few real differences between us. I would often seek out a colleague from a different culture or race to have lunch with so I could learn more about them.
We all strive for the same things – validation, happiness, love, family, and a future. We all grieve over the same things.
What some caregivers may not realize is that, just as clinicians have been trained to recognize subtle signs and symptoms of disease, minorities can recognize racism immediately during a medical encounter. Our past experiences make us skilled at picking up a lack of eye contact or body language and tone of voice that are dismissive and disrespectful.
A patient who has felt racism may still return for care because of insurance coverage limitations, location, or a lack of alternatives. But trust and loyalty will never develop on the part of this patient, and empathy will be absent on the part of their caregiver.
To counter this in my own practice, I developed the Francis Commitment to avoid any hint of racism or bias toward my patients.
I commit to the following:
1. I see you.
2. I hear you.
3. I accept who you are.
4. I will try to understand how you must feel (empathy).
5. Treating you is very important to me.
6. I would like to gain your trust that I will do my very best to make you better.
7. I value you as a human being and will treat you as if you are family.
8. I care about what happens to you.
9. I want us to work together to fight this disease.
10. I am grateful that you chose me as your caregiver.
The INOVA health care system where I work has undertaken an initiative called What Matters Most to better understand the needs of every patient. We are currently working on a strategy of patient personalization to not only learn about their medical needs but also to discover who they are as a person. We incorporate Social Determinants of Health in our dealings with patients. We also have participated in a program called “A Long Talk”, where we learned that those of us who remain silent when we see or hear racism are responsible for its persistence and growth.
But we must do more. Racism will propagate if we live in silos surrounded by people whose ideas reflect our own. As long as we have nondiversified board rooms, departments, and staff, the problem will persist.
A lot of the biases that we unconsciously carry in our heads and hearts have no basis in reality and were placed there without our permission by parents, society, and friends. But we can replace these divisive thoughts and impulses.
What’s in your heart can only be known and controlled by you. How tolerant we are of racism is up to us: Do you call out racism; do you challenge any inkling of racism from friends or acquaintances; do you put pressure on institutions where you work to diversify in recruiting and hiring?
Think of all the advances in medicine that were achieved by people from different cultures and races. Racism has no place in what we have all devoted our lives to do – take care of our fellow humans.
A version of this article first appeared on Medscape.com.
Eight must-read GI studies for the primary care physician
This transcript has been edited for clarity.
Hi. I’m Dr. Vivek Kaul, and I’m professor of medicine in the division of gastroenterology and hepatology at the University of Rochester (N.Y.) Medical Center. It gives me great pleasure to do this presentation in collaboration with Medscape. I have just returned from Digestive Disease Week 2022, which is the largest international GI conference, and it was held in person for the first time in 3 years because of the pandemic.
Whereas there are a lot of “Best of DDW” presentations for gastroenterologists, there are not that many for primary care providers, so I thought it would be a good idea to do this. , talk a little about the middle-future range where things will become available in the next few months to years, and then, of course, reflect upon concepts that might become more standard paradigms of care in the distant future.
My collection of papers is divided into the esophagus and the colon, and then finishes up with the liver. [Editor’s note: Some of the abstracts that Dr Kaul refers to are available here.]
The first paper in the esophagus realm is a multicenter study called “The Association of Proton Pump Inhibitor Use and Cognitive Decline and Incident Dementia in Older Adults.” The researchers looked at about 19,000 patients, 65 years and older, who were on PPI therapy and had no significant disability or prior dementia. They followed them for about 5 years and found that a total of about 566 of them developed dementia in this time frame and 235 or so had Alzheimer’s. What they concluded based on that analysis was that PPI use was not associated with dementia or changes in the overall cognitive score.
This is important information. As the American Gastroenterological Association guidelines and others have recommended, those patients who do require a PPI on clinical grounds should definitely receive it, and the side-effect profiles are quite acceptable.
The second paper, “Double-Blind Randomized Trial of the Potassium-Competitive Acid Blocker Vonoprazan vs. the Proton Pump Inhibitor Lansoprazole in U.S. and European Patients with Erosive Esophagitis,” is also related to GERD [gastroesophageal reflux disease] therapy but introduces a new paradigm known as potassium-competitive channel blockers. This is a new drug that has now become available, called vonoprazan.
This was a double-blinded, randomized trial of the potassium-competitive acid blocker vonoprazan in comparison with lansoprazole, which is a well-established medical agent available for the treatment of esophagitis. These are patients with erosive esophagitis in a multicenter U.S. and European cohort of about 1,000 patients who were prospectively treated. The crux of this study was to say that vonoprazan is quicker to provide healing and symptom relief, and that these results are maintained in both the initial phase, which is the treatment phase, and the maintenance phase.
So, there might be some advantages in terms of how quickly we can treat these patients and get them symptom free. I thought that study was worth mentioning because it reflects, after a long period of time, a new class of acid-suppression therapy, which we should all be familiar with, and certainly at the primary care level.
The next paper relates to Barrett’s esophagus and esophageal cancer. This paper came out of the OneFlorida+ Clinical Research Network and was titled “Alarming Rise Found in Esophageal Cancer and Barrett’s Esophagus in Middle-Aged Adults: Findings From a Statewide Database of Over 5 Million Patients.” This paper talks about the increasing prevalence of esophageal cancer in Barrett’s in middle-aged patients – those in the 45- to 64-years age group; the prevalence of esophageal cancer is rising in this cohort. So, as is shown in the first graph, the orange line is depicting the 45-64 age group patients whose esophageal cancer prevalence has gone up. And in the second graph, it’s actually the gray line which looks at the Barrett’s esophagus prevalence, which is also increasing. And all the other cohorts have either plateaued or are declining.
This is important information because these patients who are at risk in these age groups with these demographic profiles should be referred on for endoscopic screening to rule out Barrett’s at least once in their lifetime. And most certainly a percentage of them will be found to have dysplasia and or early esophageal cancer that might be amenable to endoscopic therapy.
The next section that we’ll talk about is the colon section. We have a few very good, high-quality papers with some provocative information in this realm. The first paper (“Multi-modal Blood-based Colorectal Cancer Screening Is a Viable Colorectal Cancer Screening Option – a Prospective Study”) in the colonoscopy section involves the concept of colorectal cancer screening. While we have multiple modalities available for colorectal cancer screening today, a third of eligible patients are not getting screened.
This study looks at a blood test for colorectal cancer screening. We have colonoscopy, we have stool DNA and other tests, but now we have a blood test looking at circulating tumor DNA. For this prospective, multicenter study, researchers from Madrid enrolled about 550 patients between 45 and 84 years of age. The blood test was completed prior to the complete colonoscopy. The prevalence of colorectal cancer screening in this study was about 2%; the sensitivity ranged from about 90% to 95%, and the specificity ranged from about 100% to 88%, depending on what confidence levels you were looking at.
In this prospective study, a blood-based colorectal cancer screening test was able to perform very similarly to stool-based options. Therefore, it may further increase the probability that patients might come in for screening.
The message from this paper is that there’s yet another modality for colorectal cancer screening, and now we have a blood test potentially, but obviously we look forward to more data on how the test itself performs. And there probably will be other candidates in the same realm.
The second paper (“Real-World Comparative Effectiveness of Fidaxomicin vs. Vancomycin Among Medicare Beneficiaries with Clostridioides difficile Infection”) in the colon section is also about a very important topic in clinical practice for all of us, and that is C. difficile infection. As you may know, current guidelines have recommended the use of fidaxomicin over vancomycin as the initial treatment for C. diff infection. This paper looked retrospectively at a cohort of patients in the real world and compared the efficacy of fidaxomicin vs. vancomycin among Medicare beneficiaries with C. diff infection.
The initial results of this multicenter study suggest that treatment with fidaxomicin had higher sustained response compared with vancomycin at both weeks 4 and 8, as well as decreased recurrence of C. difficile.
This retrospective study further confirms that C. diff infection remains a problem and that we might have better solutions now with fidaxomicin compared with vancomycin. That’s important information and is already endorsed by the guidelines.
The next paper in the colon realm, “A Randomized Controlled Trial on the Effectiveness of Cognitive-Behavioral and Mindfulness Intervention on Pain, Fatigue and Impairments at Work and Daily Activity in Patients With Crohn’s Disease,” is also an important paradigm that has entered our medical practice. When we are treating patients with GI symptoms, the role for cognitive-behavioral therapy and mindfulness interventions has now come of age.
This paper was a randomized controlled trial on the effectiveness of cognitive-behavioral therapy and mindfulness intervention on the aspects of pain and fatigue, as well as impairments at work and daily activity in patients with Crohn’s disease.
This is a difficult population with chronic illness, and this study comes out of Israel. About 120 patients were randomized to seven 1-hour sessions of psychological training over 12 weeks. The placebo group was the control group that did not get this treatment.
These interventions reduced both fatigue as well as pain levels, and also reduced work and home impairment, and so overall led to a better quality of life.
This paper is important because it shows us in a randomized trial design fashion that a difficult clinical population with Crohn’s disease, with a multitude of systemic symptoms and psychological, psychosomatic issues as well, can be positively impacted by these newer strategies related to cognitive-behavioral therapy and mindfulness interventions. We’ll likely be seeing more of these types of papers coming out, not just for Crohn’s and inflammatory bowel disease, but also for functional disease, which is where this started.
Our final paper in the colon section relates to an interesting concept, which is the treatment of chronic idiopathic constipation – not irritable bowel syndrome with constipation, but chronic idiopathic constipation – being managed with a novel device known as the Vibrant capsule. The Vibrant capsule is exactly that: It’s a capsule that the patient ingests, and it vibrates and therefore creates a mechanical movement.
“Efficacy and Safety of Vibrant Capsule vs. Placebo for the Treatment of Chronic Idiopathic Constipation (Vibrant)” was a U.S. multicenter study. The device is an orally ingestible, programmable vibrating capsule developed in Israel. It basically mimics the biological clock and increases the stool frequency by augmenting the circadian rhythm. This was a prospective trial of around 350 patients, and there was significant improvement in the complete spontaneous bowel movement pattern, both for one and two bowel movements per week. This significant improvement persisted at week 3, peaked at about week 6, and then remained sustained through 8 weeks.
The Vibrant capsule also was able to improve stool consistency and the overall quality of life. So this is a novel treatment intervention over and above all the medical therapies in the bowel regimens, which of course our patients find somewhat difficult, understandably. But this might be a complementary direction to go in, and we’ll probably hear more of these novel interventions for chronic constipation, which is a huge problem both at the primary care level as well as in subspecialty practice.
In the final section, which is the liver section, I found one paper very interesting, which refers to the concept of lean nonalcoholic fatty liver disease (NAFLD) (“Lean NAFLD in the United States is Characterized by Increased Central and Visceral Adiposity That Is Comparable to Overweight and Obese Persons”). NAFLD is an epidemic throughout the country, with obvious implications both for the metabolic syndrome as well as chronic liver disease. This paper from Wisconsin looks at lean NALFD in the United States, characterizes the central and visceral adiposity, and compares it with that of overweight and obese patients. Lean NAFLD occurs in about 10%-20% of patients with a normal body mass index; 1,800 patients were evaluated in this particular study, and they underwent cross-sectional analysis and the so-called gap score, which looks at the measurement of fat in the liver, DEXA measurements, and so forth.
What they found was that patients with lean NAFLD are more likely to have hypertension, diabetes, high triglycerides, and are more likely to smoke, compared with lean patients without NAFLD, despite having similar BMIs.
A couple of additional observations from the study were that central adiposity was similar in lean NAFLD compared with the obese non-NAFLD population, and the visceral abdominal fat in patients who have lean NAFLD was slightly higher, actually, than in the obese NAFLD patients, but the P values were not significant.
The overall summary from this paper was that NAFLD should be considered in lean patients with risk factors of the metabolic syndrome. This is an important paper because it highlights the fact that we don’t necessarily have to be externally obese or have a high BMI to be at risk for the metabolic syndrome. I think the importance of evaluating for the metabolic syndrome, even in those patients who have a relatively lower BMI, is underscored by this paper, which has significant implications given the larger denominator of this population in this country.
So, with that, we come to the conclusion of these top papers from Digestive Disease Week 2022. We covered the gamut of conditions, from the esophagus to the colon and to the liver. And these represent some of the best science that was presented at this very large international meeting. I hope you will find value in this information for the care of your patients, and I look forward to presenting again when the next opportunity arises.
Vivek Kaul, MD, is Segal-Watson Professor of Medicine in the gastroenterology & hepatology division at the University of Rochester Medical Center in Rochester, N.Y.
A version of this article first appeared on Medscape.com.
This transcript has been edited for clarity.
Hi. I’m Dr. Vivek Kaul, and I’m professor of medicine in the division of gastroenterology and hepatology at the University of Rochester (N.Y.) Medical Center. It gives me great pleasure to do this presentation in collaboration with Medscape. I have just returned from Digestive Disease Week 2022, which is the largest international GI conference, and it was held in person for the first time in 3 years because of the pandemic.
Whereas there are a lot of “Best of DDW” presentations for gastroenterologists, there are not that many for primary care providers, so I thought it would be a good idea to do this. , talk a little about the middle-future range where things will become available in the next few months to years, and then, of course, reflect upon concepts that might become more standard paradigms of care in the distant future.
My collection of papers is divided into the esophagus and the colon, and then finishes up with the liver. [Editor’s note: Some of the abstracts that Dr Kaul refers to are available here.]
The first paper in the esophagus realm is a multicenter study called “The Association of Proton Pump Inhibitor Use and Cognitive Decline and Incident Dementia in Older Adults.” The researchers looked at about 19,000 patients, 65 years and older, who were on PPI therapy and had no significant disability or prior dementia. They followed them for about 5 years and found that a total of about 566 of them developed dementia in this time frame and 235 or so had Alzheimer’s. What they concluded based on that analysis was that PPI use was not associated with dementia or changes in the overall cognitive score.
This is important information. As the American Gastroenterological Association guidelines and others have recommended, those patients who do require a PPI on clinical grounds should definitely receive it, and the side-effect profiles are quite acceptable.
The second paper, “Double-Blind Randomized Trial of the Potassium-Competitive Acid Blocker Vonoprazan vs. the Proton Pump Inhibitor Lansoprazole in U.S. and European Patients with Erosive Esophagitis,” is also related to GERD [gastroesophageal reflux disease] therapy but introduces a new paradigm known as potassium-competitive channel blockers. This is a new drug that has now become available, called vonoprazan.
This was a double-blinded, randomized trial of the potassium-competitive acid blocker vonoprazan in comparison with lansoprazole, which is a well-established medical agent available for the treatment of esophagitis. These are patients with erosive esophagitis in a multicenter U.S. and European cohort of about 1,000 patients who were prospectively treated. The crux of this study was to say that vonoprazan is quicker to provide healing and symptom relief, and that these results are maintained in both the initial phase, which is the treatment phase, and the maintenance phase.
So, there might be some advantages in terms of how quickly we can treat these patients and get them symptom free. I thought that study was worth mentioning because it reflects, after a long period of time, a new class of acid-suppression therapy, which we should all be familiar with, and certainly at the primary care level.
The next paper relates to Barrett’s esophagus and esophageal cancer. This paper came out of the OneFlorida+ Clinical Research Network and was titled “Alarming Rise Found in Esophageal Cancer and Barrett’s Esophagus in Middle-Aged Adults: Findings From a Statewide Database of Over 5 Million Patients.” This paper talks about the increasing prevalence of esophageal cancer in Barrett’s in middle-aged patients – those in the 45- to 64-years age group; the prevalence of esophageal cancer is rising in this cohort. So, as is shown in the first graph, the orange line is depicting the 45-64 age group patients whose esophageal cancer prevalence has gone up. And in the second graph, it’s actually the gray line which looks at the Barrett’s esophagus prevalence, which is also increasing. And all the other cohorts have either plateaued or are declining.
This is important information because these patients who are at risk in these age groups with these demographic profiles should be referred on for endoscopic screening to rule out Barrett’s at least once in their lifetime. And most certainly a percentage of them will be found to have dysplasia and or early esophageal cancer that might be amenable to endoscopic therapy.
The next section that we’ll talk about is the colon section. We have a few very good, high-quality papers with some provocative information in this realm. The first paper (“Multi-modal Blood-based Colorectal Cancer Screening Is a Viable Colorectal Cancer Screening Option – a Prospective Study”) in the colonoscopy section involves the concept of colorectal cancer screening. While we have multiple modalities available for colorectal cancer screening today, a third of eligible patients are not getting screened.
This study looks at a blood test for colorectal cancer screening. We have colonoscopy, we have stool DNA and other tests, but now we have a blood test looking at circulating tumor DNA. For this prospective, multicenter study, researchers from Madrid enrolled about 550 patients between 45 and 84 years of age. The blood test was completed prior to the complete colonoscopy. The prevalence of colorectal cancer screening in this study was about 2%; the sensitivity ranged from about 90% to 95%, and the specificity ranged from about 100% to 88%, depending on what confidence levels you were looking at.
In this prospective study, a blood-based colorectal cancer screening test was able to perform very similarly to stool-based options. Therefore, it may further increase the probability that patients might come in for screening.
The message from this paper is that there’s yet another modality for colorectal cancer screening, and now we have a blood test potentially, but obviously we look forward to more data on how the test itself performs. And there probably will be other candidates in the same realm.
The second paper (“Real-World Comparative Effectiveness of Fidaxomicin vs. Vancomycin Among Medicare Beneficiaries with Clostridioides difficile Infection”) in the colon section is also about a very important topic in clinical practice for all of us, and that is C. difficile infection. As you may know, current guidelines have recommended the use of fidaxomicin over vancomycin as the initial treatment for C. diff infection. This paper looked retrospectively at a cohort of patients in the real world and compared the efficacy of fidaxomicin vs. vancomycin among Medicare beneficiaries with C. diff infection.
The initial results of this multicenter study suggest that treatment with fidaxomicin had higher sustained response compared with vancomycin at both weeks 4 and 8, as well as decreased recurrence of C. difficile.
This retrospective study further confirms that C. diff infection remains a problem and that we might have better solutions now with fidaxomicin compared with vancomycin. That’s important information and is already endorsed by the guidelines.
The next paper in the colon realm, “A Randomized Controlled Trial on the Effectiveness of Cognitive-Behavioral and Mindfulness Intervention on Pain, Fatigue and Impairments at Work and Daily Activity in Patients With Crohn’s Disease,” is also an important paradigm that has entered our medical practice. When we are treating patients with GI symptoms, the role for cognitive-behavioral therapy and mindfulness interventions has now come of age.
This paper was a randomized controlled trial on the effectiveness of cognitive-behavioral therapy and mindfulness intervention on the aspects of pain and fatigue, as well as impairments at work and daily activity in patients with Crohn’s disease.
This is a difficult population with chronic illness, and this study comes out of Israel. About 120 patients were randomized to seven 1-hour sessions of psychological training over 12 weeks. The placebo group was the control group that did not get this treatment.
These interventions reduced both fatigue as well as pain levels, and also reduced work and home impairment, and so overall led to a better quality of life.
This paper is important because it shows us in a randomized trial design fashion that a difficult clinical population with Crohn’s disease, with a multitude of systemic symptoms and psychological, psychosomatic issues as well, can be positively impacted by these newer strategies related to cognitive-behavioral therapy and mindfulness interventions. We’ll likely be seeing more of these types of papers coming out, not just for Crohn’s and inflammatory bowel disease, but also for functional disease, which is where this started.
Our final paper in the colon section relates to an interesting concept, which is the treatment of chronic idiopathic constipation – not irritable bowel syndrome with constipation, but chronic idiopathic constipation – being managed with a novel device known as the Vibrant capsule. The Vibrant capsule is exactly that: It’s a capsule that the patient ingests, and it vibrates and therefore creates a mechanical movement.
“Efficacy and Safety of Vibrant Capsule vs. Placebo for the Treatment of Chronic Idiopathic Constipation (Vibrant)” was a U.S. multicenter study. The device is an orally ingestible, programmable vibrating capsule developed in Israel. It basically mimics the biological clock and increases the stool frequency by augmenting the circadian rhythm. This was a prospective trial of around 350 patients, and there was significant improvement in the complete spontaneous bowel movement pattern, both for one and two bowel movements per week. This significant improvement persisted at week 3, peaked at about week 6, and then remained sustained through 8 weeks.
The Vibrant capsule also was able to improve stool consistency and the overall quality of life. So this is a novel treatment intervention over and above all the medical therapies in the bowel regimens, which of course our patients find somewhat difficult, understandably. But this might be a complementary direction to go in, and we’ll probably hear more of these novel interventions for chronic constipation, which is a huge problem both at the primary care level as well as in subspecialty practice.
In the final section, which is the liver section, I found one paper very interesting, which refers to the concept of lean nonalcoholic fatty liver disease (NAFLD) (“Lean NAFLD in the United States is Characterized by Increased Central and Visceral Adiposity That Is Comparable to Overweight and Obese Persons”). NAFLD is an epidemic throughout the country, with obvious implications both for the metabolic syndrome as well as chronic liver disease. This paper from Wisconsin looks at lean NALFD in the United States, characterizes the central and visceral adiposity, and compares it with that of overweight and obese patients. Lean NAFLD occurs in about 10%-20% of patients with a normal body mass index; 1,800 patients were evaluated in this particular study, and they underwent cross-sectional analysis and the so-called gap score, which looks at the measurement of fat in the liver, DEXA measurements, and so forth.
What they found was that patients with lean NAFLD are more likely to have hypertension, diabetes, high triglycerides, and are more likely to smoke, compared with lean patients without NAFLD, despite having similar BMIs.
A couple of additional observations from the study were that central adiposity was similar in lean NAFLD compared with the obese non-NAFLD population, and the visceral abdominal fat in patients who have lean NAFLD was slightly higher, actually, than in the obese NAFLD patients, but the P values were not significant.
The overall summary from this paper was that NAFLD should be considered in lean patients with risk factors of the metabolic syndrome. This is an important paper because it highlights the fact that we don’t necessarily have to be externally obese or have a high BMI to be at risk for the metabolic syndrome. I think the importance of evaluating for the metabolic syndrome, even in those patients who have a relatively lower BMI, is underscored by this paper, which has significant implications given the larger denominator of this population in this country.
So, with that, we come to the conclusion of these top papers from Digestive Disease Week 2022. We covered the gamut of conditions, from the esophagus to the colon and to the liver. And these represent some of the best science that was presented at this very large international meeting. I hope you will find value in this information for the care of your patients, and I look forward to presenting again when the next opportunity arises.
Vivek Kaul, MD, is Segal-Watson Professor of Medicine in the gastroenterology & hepatology division at the University of Rochester Medical Center in Rochester, N.Y.
A version of this article first appeared on Medscape.com.
This transcript has been edited for clarity.
Hi. I’m Dr. Vivek Kaul, and I’m professor of medicine in the division of gastroenterology and hepatology at the University of Rochester (N.Y.) Medical Center. It gives me great pleasure to do this presentation in collaboration with Medscape. I have just returned from Digestive Disease Week 2022, which is the largest international GI conference, and it was held in person for the first time in 3 years because of the pandemic.
Whereas there are a lot of “Best of DDW” presentations for gastroenterologists, there are not that many for primary care providers, so I thought it would be a good idea to do this. , talk a little about the middle-future range where things will become available in the next few months to years, and then, of course, reflect upon concepts that might become more standard paradigms of care in the distant future.
My collection of papers is divided into the esophagus and the colon, and then finishes up with the liver. [Editor’s note: Some of the abstracts that Dr Kaul refers to are available here.]
The first paper in the esophagus realm is a multicenter study called “The Association of Proton Pump Inhibitor Use and Cognitive Decline and Incident Dementia in Older Adults.” The researchers looked at about 19,000 patients, 65 years and older, who were on PPI therapy and had no significant disability or prior dementia. They followed them for about 5 years and found that a total of about 566 of them developed dementia in this time frame and 235 or so had Alzheimer’s. What they concluded based on that analysis was that PPI use was not associated with dementia or changes in the overall cognitive score.
This is important information. As the American Gastroenterological Association guidelines and others have recommended, those patients who do require a PPI on clinical grounds should definitely receive it, and the side-effect profiles are quite acceptable.
The second paper, “Double-Blind Randomized Trial of the Potassium-Competitive Acid Blocker Vonoprazan vs. the Proton Pump Inhibitor Lansoprazole in U.S. and European Patients with Erosive Esophagitis,” is also related to GERD [gastroesophageal reflux disease] therapy but introduces a new paradigm known as potassium-competitive channel blockers. This is a new drug that has now become available, called vonoprazan.
This was a double-blinded, randomized trial of the potassium-competitive acid blocker vonoprazan in comparison with lansoprazole, which is a well-established medical agent available for the treatment of esophagitis. These are patients with erosive esophagitis in a multicenter U.S. and European cohort of about 1,000 patients who were prospectively treated. The crux of this study was to say that vonoprazan is quicker to provide healing and symptom relief, and that these results are maintained in both the initial phase, which is the treatment phase, and the maintenance phase.
So, there might be some advantages in terms of how quickly we can treat these patients and get them symptom free. I thought that study was worth mentioning because it reflects, after a long period of time, a new class of acid-suppression therapy, which we should all be familiar with, and certainly at the primary care level.
The next paper relates to Barrett’s esophagus and esophageal cancer. This paper came out of the OneFlorida+ Clinical Research Network and was titled “Alarming Rise Found in Esophageal Cancer and Barrett’s Esophagus in Middle-Aged Adults: Findings From a Statewide Database of Over 5 Million Patients.” This paper talks about the increasing prevalence of esophageal cancer in Barrett’s in middle-aged patients – those in the 45- to 64-years age group; the prevalence of esophageal cancer is rising in this cohort. So, as is shown in the first graph, the orange line is depicting the 45-64 age group patients whose esophageal cancer prevalence has gone up. And in the second graph, it’s actually the gray line which looks at the Barrett’s esophagus prevalence, which is also increasing. And all the other cohorts have either plateaued or are declining.
This is important information because these patients who are at risk in these age groups with these demographic profiles should be referred on for endoscopic screening to rule out Barrett’s at least once in their lifetime. And most certainly a percentage of them will be found to have dysplasia and or early esophageal cancer that might be amenable to endoscopic therapy.
The next section that we’ll talk about is the colon section. We have a few very good, high-quality papers with some provocative information in this realm. The first paper (“Multi-modal Blood-based Colorectal Cancer Screening Is a Viable Colorectal Cancer Screening Option – a Prospective Study”) in the colonoscopy section involves the concept of colorectal cancer screening. While we have multiple modalities available for colorectal cancer screening today, a third of eligible patients are not getting screened.
This study looks at a blood test for colorectal cancer screening. We have colonoscopy, we have stool DNA and other tests, but now we have a blood test looking at circulating tumor DNA. For this prospective, multicenter study, researchers from Madrid enrolled about 550 patients between 45 and 84 years of age. The blood test was completed prior to the complete colonoscopy. The prevalence of colorectal cancer screening in this study was about 2%; the sensitivity ranged from about 90% to 95%, and the specificity ranged from about 100% to 88%, depending on what confidence levels you were looking at.
In this prospective study, a blood-based colorectal cancer screening test was able to perform very similarly to stool-based options. Therefore, it may further increase the probability that patients might come in for screening.
The message from this paper is that there’s yet another modality for colorectal cancer screening, and now we have a blood test potentially, but obviously we look forward to more data on how the test itself performs. And there probably will be other candidates in the same realm.
The second paper (“Real-World Comparative Effectiveness of Fidaxomicin vs. Vancomycin Among Medicare Beneficiaries with Clostridioides difficile Infection”) in the colon section is also about a very important topic in clinical practice for all of us, and that is C. difficile infection. As you may know, current guidelines have recommended the use of fidaxomicin over vancomycin as the initial treatment for C. diff infection. This paper looked retrospectively at a cohort of patients in the real world and compared the efficacy of fidaxomicin vs. vancomycin among Medicare beneficiaries with C. diff infection.
The initial results of this multicenter study suggest that treatment with fidaxomicin had higher sustained response compared with vancomycin at both weeks 4 and 8, as well as decreased recurrence of C. difficile.
This retrospective study further confirms that C. diff infection remains a problem and that we might have better solutions now with fidaxomicin compared with vancomycin. That’s important information and is already endorsed by the guidelines.
The next paper in the colon realm, “A Randomized Controlled Trial on the Effectiveness of Cognitive-Behavioral and Mindfulness Intervention on Pain, Fatigue and Impairments at Work and Daily Activity in Patients With Crohn’s Disease,” is also an important paradigm that has entered our medical practice. When we are treating patients with GI symptoms, the role for cognitive-behavioral therapy and mindfulness interventions has now come of age.
This paper was a randomized controlled trial on the effectiveness of cognitive-behavioral therapy and mindfulness intervention on the aspects of pain and fatigue, as well as impairments at work and daily activity in patients with Crohn’s disease.
This is a difficult population with chronic illness, and this study comes out of Israel. About 120 patients were randomized to seven 1-hour sessions of psychological training over 12 weeks. The placebo group was the control group that did not get this treatment.
These interventions reduced both fatigue as well as pain levels, and also reduced work and home impairment, and so overall led to a better quality of life.
This paper is important because it shows us in a randomized trial design fashion that a difficult clinical population with Crohn’s disease, with a multitude of systemic symptoms and psychological, psychosomatic issues as well, can be positively impacted by these newer strategies related to cognitive-behavioral therapy and mindfulness interventions. We’ll likely be seeing more of these types of papers coming out, not just for Crohn’s and inflammatory bowel disease, but also for functional disease, which is where this started.
Our final paper in the colon section relates to an interesting concept, which is the treatment of chronic idiopathic constipation – not irritable bowel syndrome with constipation, but chronic idiopathic constipation – being managed with a novel device known as the Vibrant capsule. The Vibrant capsule is exactly that: It’s a capsule that the patient ingests, and it vibrates and therefore creates a mechanical movement.
“Efficacy and Safety of Vibrant Capsule vs. Placebo for the Treatment of Chronic Idiopathic Constipation (Vibrant)” was a U.S. multicenter study. The device is an orally ingestible, programmable vibrating capsule developed in Israel. It basically mimics the biological clock and increases the stool frequency by augmenting the circadian rhythm. This was a prospective trial of around 350 patients, and there was significant improvement in the complete spontaneous bowel movement pattern, both for one and two bowel movements per week. This significant improvement persisted at week 3, peaked at about week 6, and then remained sustained through 8 weeks.
The Vibrant capsule also was able to improve stool consistency and the overall quality of life. So this is a novel treatment intervention over and above all the medical therapies in the bowel regimens, which of course our patients find somewhat difficult, understandably. But this might be a complementary direction to go in, and we’ll probably hear more of these novel interventions for chronic constipation, which is a huge problem both at the primary care level as well as in subspecialty practice.
In the final section, which is the liver section, I found one paper very interesting, which refers to the concept of lean nonalcoholic fatty liver disease (NAFLD) (“Lean NAFLD in the United States is Characterized by Increased Central and Visceral Adiposity That Is Comparable to Overweight and Obese Persons”). NAFLD is an epidemic throughout the country, with obvious implications both for the metabolic syndrome as well as chronic liver disease. This paper from Wisconsin looks at lean NALFD in the United States, characterizes the central and visceral adiposity, and compares it with that of overweight and obese patients. Lean NAFLD occurs in about 10%-20% of patients with a normal body mass index; 1,800 patients were evaluated in this particular study, and they underwent cross-sectional analysis and the so-called gap score, which looks at the measurement of fat in the liver, DEXA measurements, and so forth.
What they found was that patients with lean NAFLD are more likely to have hypertension, diabetes, high triglycerides, and are more likely to smoke, compared with lean patients without NAFLD, despite having similar BMIs.
A couple of additional observations from the study were that central adiposity was similar in lean NAFLD compared with the obese non-NAFLD population, and the visceral abdominal fat in patients who have lean NAFLD was slightly higher, actually, than in the obese NAFLD patients, but the P values were not significant.
The overall summary from this paper was that NAFLD should be considered in lean patients with risk factors of the metabolic syndrome. This is an important paper because it highlights the fact that we don’t necessarily have to be externally obese or have a high BMI to be at risk for the metabolic syndrome. I think the importance of evaluating for the metabolic syndrome, even in those patients who have a relatively lower BMI, is underscored by this paper, which has significant implications given the larger denominator of this population in this country.
So, with that, we come to the conclusion of these top papers from Digestive Disease Week 2022. We covered the gamut of conditions, from the esophagus to the colon and to the liver. And these represent some of the best science that was presented at this very large international meeting. I hope you will find value in this information for the care of your patients, and I look forward to presenting again when the next opportunity arises.
Vivek Kaul, MD, is Segal-Watson Professor of Medicine in the gastroenterology & hepatology division at the University of Rochester Medical Center in Rochester, N.Y.
A version of this article first appeared on Medscape.com.
LGBTQ+ Youth Consult: Let’s talk about PrEP!
As pediatricians, almost all of our clinic visits include some anticipatory guidance and recommendations on ways to promote well-being and prevent illness and injury for our patients. Because of minority stress, discrimination, and increased exposure to adverse childhood experiences, LGBTQ+ patients are disproportionately affected by certain health conditions including depression, anxiety, substance use, homelessness, as well as HIV and other sexually transmitted infections (STIs).1 While LGBTQ+ youth could benefit from additional guidance, counseling, and interventions related to these health disparities and have expressed interest in talking about these topics with their providers, sexual and gender minority youth also stress that they want to be treated as any other youth.2 Extending counseling for preventive care measures such as preexposure prophylaxis (PrEP) for HIV to all sexually active youth could help to destigmatize LGBTQ+ youth as being “different” from other youth and also help to increase overall access to HIV prevention services.3
Described by some as the “birth control” for HIV infection, PrEP is taken on an ongoing basis by those who are HIV negative before potential exposures to HIV in order to prevent new HIV infections. PrEP was first approved as a daily pill for adults in 2015 by the Food and Drug Administration with extension in 2018 to all individuals at risk for HIV weighing at least 35 kg after safety and efficacy data showed it could be used routinely for adolescents.4 When taken daily, oral PrEP can decrease the risk of HIV from sexual contact by more than 90% and from injection drug use by around 70%. As PrEP is highly effective with low risk for side effects, the U.S. Preventive Services Task Force (USPSTF) gave PrEP a “Grade A” recommendation for use in those at high risk for HIV infection in 2019.5 Since efficacy is closely tied to adherence, the first injectable PrEP (given at 0, 1, and 2 months with dosing then every 2 months) was also recently FDA approved in late 2021.6
Since HIV infection disproportionately affects LBGTQ+ individuals, and particularly LBGTQ+ youth of color, counseling related to PrEP has been largely targeted to these groups.7 Insurance and financial barriers to PrEP have been greatly reduced over the past several years through changes in insurance coverage (strengthened by the USPSTF recommendation), supplemental insurance programs, and pharmaceutical copay programs. Many states (but not all) also include HIV in the definition of STIs and allow minors to consent to PrEP services without a parent or guardian. Unfortunately, despite the high efficacy of PrEP and efforts to decrease barriers, rates of PrEP use continue to be extremely low, especially in youth, with only 15.6% of those aged 16-24 who are at risk for HIV in the United States actually taking PrEP in 2019.8 Many barriers to PrEP continue to exist including lack of awareness of PrEP, stigma surrounding HIV and PrEP, and lack of PrEP providers.
In order to address these low rates of PrEP uptake, the Centers for Disease Control and Prevention now recommends that medical providers discuss PrEP with all sexually active patients.6 PrEP should not be seen or discussed as something only relevant to LBGTQ+ populations, but rather as another tool in everyone’s “sexual health toolbox” that can allow us to experience human connection and pleasure through sexual activity while also having more control over what happens to our bodies. Not only will this allow more patients to access PrEP directly, it will also decrease the stigma of talking about HIV and PrEP and strengthen youths’ sense of autonomy and control over their own sexual health.
Since PrEP is a relatively new medical service, many providers will need to learn more about PrEP to at least have initial discussions with patients and to feel comfortable prescribing this themselves (See Resources). Below are also some suggestions to incorporate into your practice in order to advocate for the health and well-being of all your patients, including LGBTQ+ youth.
- Once your patients are 13 years and older, spend time with them alone to confidentially discuss more sensitive topics such as sexual health, mental health, and substance use.
- For all patients who are sexually active or considering sexual activity in the near future, discuss topics to help them control what happens to their bodies including consent, condoms, birth control, PrEP, and routine STI screening.
- Recommend PrEP to anyone who is sexually active and may be at increased risk for HIV infection or who is interested in taking PrEP for HIV prevention.
- Learn more about PrEP and start prescribing it to your own patients or become familiar with providers in your area to whom you could refer patients who are interested. While no certification is needed to prescribe PrEP, programs exist to help providers become more familiar with how to prescribe PrEP.
Dr. Warus is an adolescent medicine physician who specializes in care for transgender and gender-nonconforming youth, HIV prevention for adolescents and young adults, and LGBTQ health for youth at Children’s Hospital of Los Angeles. He is an assistant professor of clinical pediatrics and a University of Southern California faculty member.
Resources
CDC PrEP resources for clinicians: www.cdc.gov/hiv/clinicians/prevention/prep.html.Health HIV’s HIV Prevention Certified Provider Certification Program: https://healthhiv.org/programs/hpcp/.PrEP providers in the United States: https://preplocator.org/.Adolescent Health Working Group’s Sexual and Reproductive Health Toolkit for Adolescent Providers: https://ahwg.org/download/sexual-and-reproductive-health-toolkit-for-adolescent-providers/.
References
1. Lund EM and Burgess CM. Prim Care Clin Office Pract. 2021:48:179-89.
2. Hoffman ND et al. J Adolesc Health. 2009;45:222-9.
3. Mayer KH et al. Adv Ther. 2020;37:1778-811.
4. Hosek SG et al. JAMA Pediatr. 2017;171(11):1063-71.
5. U.S. Preventive Services Task Force; Owens DK et al. JAMA. 2019;321(22):2203-13.
6. Centers for Disease Control and Prevention: U.S. Public Health Service: Preexposure Prophylaxis for the Prevention of HIV Infection in the United States – 2021 Update: A Clinical Practice Guideline. Published 2021. Accessed July 10, 2022.
7. Centers for Disease Control and Prevention. Estimated HIV Incidence and Prevalence in the United States, 2015-2019. HIV Surveillance Supplemental Report. 2021;26(1). Published May 2021. Accessed July 10, 2022.
8. Centers for Disease Control and Prevention. Monitoring Selected National HIV Prevention and Care Objectives by Using HIV Surveillance Data–United States and 6 Dependent Areas, 2020. HIV Surveillance Supplemental Report. 2022;27(3).
As pediatricians, almost all of our clinic visits include some anticipatory guidance and recommendations on ways to promote well-being and prevent illness and injury for our patients. Because of minority stress, discrimination, and increased exposure to adverse childhood experiences, LGBTQ+ patients are disproportionately affected by certain health conditions including depression, anxiety, substance use, homelessness, as well as HIV and other sexually transmitted infections (STIs).1 While LGBTQ+ youth could benefit from additional guidance, counseling, and interventions related to these health disparities and have expressed interest in talking about these topics with their providers, sexual and gender minority youth also stress that they want to be treated as any other youth.2 Extending counseling for preventive care measures such as preexposure prophylaxis (PrEP) for HIV to all sexually active youth could help to destigmatize LGBTQ+ youth as being “different” from other youth and also help to increase overall access to HIV prevention services.3
Described by some as the “birth control” for HIV infection, PrEP is taken on an ongoing basis by those who are HIV negative before potential exposures to HIV in order to prevent new HIV infections. PrEP was first approved as a daily pill for adults in 2015 by the Food and Drug Administration with extension in 2018 to all individuals at risk for HIV weighing at least 35 kg after safety and efficacy data showed it could be used routinely for adolescents.4 When taken daily, oral PrEP can decrease the risk of HIV from sexual contact by more than 90% and from injection drug use by around 70%. As PrEP is highly effective with low risk for side effects, the U.S. Preventive Services Task Force (USPSTF) gave PrEP a “Grade A” recommendation for use in those at high risk for HIV infection in 2019.5 Since efficacy is closely tied to adherence, the first injectable PrEP (given at 0, 1, and 2 months with dosing then every 2 months) was also recently FDA approved in late 2021.6
Since HIV infection disproportionately affects LBGTQ+ individuals, and particularly LBGTQ+ youth of color, counseling related to PrEP has been largely targeted to these groups.7 Insurance and financial barriers to PrEP have been greatly reduced over the past several years through changes in insurance coverage (strengthened by the USPSTF recommendation), supplemental insurance programs, and pharmaceutical copay programs. Many states (but not all) also include HIV in the definition of STIs and allow minors to consent to PrEP services without a parent or guardian. Unfortunately, despite the high efficacy of PrEP and efforts to decrease barriers, rates of PrEP use continue to be extremely low, especially in youth, with only 15.6% of those aged 16-24 who are at risk for HIV in the United States actually taking PrEP in 2019.8 Many barriers to PrEP continue to exist including lack of awareness of PrEP, stigma surrounding HIV and PrEP, and lack of PrEP providers.
In order to address these low rates of PrEP uptake, the Centers for Disease Control and Prevention now recommends that medical providers discuss PrEP with all sexually active patients.6 PrEP should not be seen or discussed as something only relevant to LBGTQ+ populations, but rather as another tool in everyone’s “sexual health toolbox” that can allow us to experience human connection and pleasure through sexual activity while also having more control over what happens to our bodies. Not only will this allow more patients to access PrEP directly, it will also decrease the stigma of talking about HIV and PrEP and strengthen youths’ sense of autonomy and control over their own sexual health.
Since PrEP is a relatively new medical service, many providers will need to learn more about PrEP to at least have initial discussions with patients and to feel comfortable prescribing this themselves (See Resources). Below are also some suggestions to incorporate into your practice in order to advocate for the health and well-being of all your patients, including LGBTQ+ youth.
- Once your patients are 13 years and older, spend time with them alone to confidentially discuss more sensitive topics such as sexual health, mental health, and substance use.
- For all patients who are sexually active or considering sexual activity in the near future, discuss topics to help them control what happens to their bodies including consent, condoms, birth control, PrEP, and routine STI screening.
- Recommend PrEP to anyone who is sexually active and may be at increased risk for HIV infection or who is interested in taking PrEP for HIV prevention.
- Learn more about PrEP and start prescribing it to your own patients or become familiar with providers in your area to whom you could refer patients who are interested. While no certification is needed to prescribe PrEP, programs exist to help providers become more familiar with how to prescribe PrEP.
Dr. Warus is an adolescent medicine physician who specializes in care for transgender and gender-nonconforming youth, HIV prevention for adolescents and young adults, and LGBTQ health for youth at Children’s Hospital of Los Angeles. He is an assistant professor of clinical pediatrics and a University of Southern California faculty member.
Resources
CDC PrEP resources for clinicians: www.cdc.gov/hiv/clinicians/prevention/prep.html.Health HIV’s HIV Prevention Certified Provider Certification Program: https://healthhiv.org/programs/hpcp/.PrEP providers in the United States: https://preplocator.org/.Adolescent Health Working Group’s Sexual and Reproductive Health Toolkit for Adolescent Providers: https://ahwg.org/download/sexual-and-reproductive-health-toolkit-for-adolescent-providers/.
References
1. Lund EM and Burgess CM. Prim Care Clin Office Pract. 2021:48:179-89.
2. Hoffman ND et al. J Adolesc Health. 2009;45:222-9.
3. Mayer KH et al. Adv Ther. 2020;37:1778-811.
4. Hosek SG et al. JAMA Pediatr. 2017;171(11):1063-71.
5. U.S. Preventive Services Task Force; Owens DK et al. JAMA. 2019;321(22):2203-13.
6. Centers for Disease Control and Prevention: U.S. Public Health Service: Preexposure Prophylaxis for the Prevention of HIV Infection in the United States – 2021 Update: A Clinical Practice Guideline. Published 2021. Accessed July 10, 2022.
7. Centers for Disease Control and Prevention. Estimated HIV Incidence and Prevalence in the United States, 2015-2019. HIV Surveillance Supplemental Report. 2021;26(1). Published May 2021. Accessed July 10, 2022.
8. Centers for Disease Control and Prevention. Monitoring Selected National HIV Prevention and Care Objectives by Using HIV Surveillance Data–United States and 6 Dependent Areas, 2020. HIV Surveillance Supplemental Report. 2022;27(3).
As pediatricians, almost all of our clinic visits include some anticipatory guidance and recommendations on ways to promote well-being and prevent illness and injury for our patients. Because of minority stress, discrimination, and increased exposure to adverse childhood experiences, LGBTQ+ patients are disproportionately affected by certain health conditions including depression, anxiety, substance use, homelessness, as well as HIV and other sexually transmitted infections (STIs).1 While LGBTQ+ youth could benefit from additional guidance, counseling, and interventions related to these health disparities and have expressed interest in talking about these topics with their providers, sexual and gender minority youth also stress that they want to be treated as any other youth.2 Extending counseling for preventive care measures such as preexposure prophylaxis (PrEP) for HIV to all sexually active youth could help to destigmatize LGBTQ+ youth as being “different” from other youth and also help to increase overall access to HIV prevention services.3
Described by some as the “birth control” for HIV infection, PrEP is taken on an ongoing basis by those who are HIV negative before potential exposures to HIV in order to prevent new HIV infections. PrEP was first approved as a daily pill for adults in 2015 by the Food and Drug Administration with extension in 2018 to all individuals at risk for HIV weighing at least 35 kg after safety and efficacy data showed it could be used routinely for adolescents.4 When taken daily, oral PrEP can decrease the risk of HIV from sexual contact by more than 90% and from injection drug use by around 70%. As PrEP is highly effective with low risk for side effects, the U.S. Preventive Services Task Force (USPSTF) gave PrEP a “Grade A” recommendation for use in those at high risk for HIV infection in 2019.5 Since efficacy is closely tied to adherence, the first injectable PrEP (given at 0, 1, and 2 months with dosing then every 2 months) was also recently FDA approved in late 2021.6
Since HIV infection disproportionately affects LBGTQ+ individuals, and particularly LBGTQ+ youth of color, counseling related to PrEP has been largely targeted to these groups.7 Insurance and financial barriers to PrEP have been greatly reduced over the past several years through changes in insurance coverage (strengthened by the USPSTF recommendation), supplemental insurance programs, and pharmaceutical copay programs. Many states (but not all) also include HIV in the definition of STIs and allow minors to consent to PrEP services without a parent or guardian. Unfortunately, despite the high efficacy of PrEP and efforts to decrease barriers, rates of PrEP use continue to be extremely low, especially in youth, with only 15.6% of those aged 16-24 who are at risk for HIV in the United States actually taking PrEP in 2019.8 Many barriers to PrEP continue to exist including lack of awareness of PrEP, stigma surrounding HIV and PrEP, and lack of PrEP providers.
In order to address these low rates of PrEP uptake, the Centers for Disease Control and Prevention now recommends that medical providers discuss PrEP with all sexually active patients.6 PrEP should not be seen or discussed as something only relevant to LBGTQ+ populations, but rather as another tool in everyone’s “sexual health toolbox” that can allow us to experience human connection and pleasure through sexual activity while also having more control over what happens to our bodies. Not only will this allow more patients to access PrEP directly, it will also decrease the stigma of talking about HIV and PrEP and strengthen youths’ sense of autonomy and control over their own sexual health.
Since PrEP is a relatively new medical service, many providers will need to learn more about PrEP to at least have initial discussions with patients and to feel comfortable prescribing this themselves (See Resources). Below are also some suggestions to incorporate into your practice in order to advocate for the health and well-being of all your patients, including LGBTQ+ youth.
- Once your patients are 13 years and older, spend time with them alone to confidentially discuss more sensitive topics such as sexual health, mental health, and substance use.
- For all patients who are sexually active or considering sexual activity in the near future, discuss topics to help them control what happens to their bodies including consent, condoms, birth control, PrEP, and routine STI screening.
- Recommend PrEP to anyone who is sexually active and may be at increased risk for HIV infection or who is interested in taking PrEP for HIV prevention.
- Learn more about PrEP and start prescribing it to your own patients or become familiar with providers in your area to whom you could refer patients who are interested. While no certification is needed to prescribe PrEP, programs exist to help providers become more familiar with how to prescribe PrEP.
Dr. Warus is an adolescent medicine physician who specializes in care for transgender and gender-nonconforming youth, HIV prevention for adolescents and young adults, and LGBTQ health for youth at Children’s Hospital of Los Angeles. He is an assistant professor of clinical pediatrics and a University of Southern California faculty member.
Resources
CDC PrEP resources for clinicians: www.cdc.gov/hiv/clinicians/prevention/prep.html.Health HIV’s HIV Prevention Certified Provider Certification Program: https://healthhiv.org/programs/hpcp/.PrEP providers in the United States: https://preplocator.org/.Adolescent Health Working Group’s Sexual and Reproductive Health Toolkit for Adolescent Providers: https://ahwg.org/download/sexual-and-reproductive-health-toolkit-for-adolescent-providers/.
References
1. Lund EM and Burgess CM. Prim Care Clin Office Pract. 2021:48:179-89.
2. Hoffman ND et al. J Adolesc Health. 2009;45:222-9.
3. Mayer KH et al. Adv Ther. 2020;37:1778-811.
4. Hosek SG et al. JAMA Pediatr. 2017;171(11):1063-71.
5. U.S. Preventive Services Task Force; Owens DK et al. JAMA. 2019;321(22):2203-13.
6. Centers for Disease Control and Prevention: U.S. Public Health Service: Preexposure Prophylaxis for the Prevention of HIV Infection in the United States – 2021 Update: A Clinical Practice Guideline. Published 2021. Accessed July 10, 2022.
7. Centers for Disease Control and Prevention. Estimated HIV Incidence and Prevalence in the United States, 2015-2019. HIV Surveillance Supplemental Report. 2021;26(1). Published May 2021. Accessed July 10, 2022.
8. Centers for Disease Control and Prevention. Monitoring Selected National HIV Prevention and Care Objectives by Using HIV Surveillance Data–United States and 6 Dependent Areas, 2020. HIV Surveillance Supplemental Report. 2022;27(3).
Recommendations on breastfeeding: A case of too much information
The American Academy of Pediatrics is built on good intentions. It wants the best for children in the world, and it hopes to support its members in their efforts to achieve this goal. But from time to time, the academy loses sight of reality and makes recommendations that are counterproductive to its stated goals.
The recent release of its new policy “Breastfeeding and the Use of Human Milk” is another unfortunate example of poorly aimed recommendations. A careful reading of the document reveals it to be a well-researched treatise on breastfeeding and the value of human milk, including a discussion of the numerous impediments to the universal adoption of breastfeeding in our society. However, when a document of this breadth and complexity is released to the public it is never surprising that the messages deserving the most attention are lost in the press coverage. Most of the headlines I saw mentioned pediatricians supporting breastfeeding for a year or 2.
Who was the target audience? If it was pediatricians, most of us don’t need a longer list of the health benefits of breastfeeding. We already believe it is the best nutritional source for human babies and realize that the institutional framework in this country continues to be unfriendly to women who intend to breastfeed.
If the audience is politicians and public health decision-makers, the new policy contains a wealth of supportive evidence. However, most pediatricians I know are too busy or lack the skills and enthusiasm to become political activists. For the rest of population, including parents, the recommendations represent a collection of TMI (too much information).
If the audience is women who are considering breastfeeding I suspect nearly 100% already know pediatricians think it is the preferred way to feed their babies. And, likewise, a longer list won’t convince them to try nursing. Additional evidence may simply make them feel more guilty when they aren’t successful.
Many pregnant women have already been told that breastfeeding can be a challenge and given their situation breast milk alone for the first 6 months may sound like an unreasonable goal. The new recommendation that breastfeeding for a year or 2 is good is not a message they want to hear.
On the other hand, if the target audience is women who will be comforted to hear an official statement that normalizes breastfeeding longer than a year, the new policy statement has hit the nail on the head.
Of course the new policy document is sprinkled with caveats that vaguely hint at the possibility that pediatricians are sensitive human beings who under certain circumstances may be able to compromise when it comes to the duration of breastfeeding and the introduction of formula. But this whiff of reality is certainly not the dominant odor in these new recommendations.
Don’t get me wrong: I think the academy was overdue for a policy revision on breastfeeding. However, it should have been one that was reality based. It should acknowledge that there are institutional and societal biases against breastfeeding, and it should remind pediatricians that they can effect change by discussing these realities honestly with parents, while making it clear that we are there for them and their children regardless of how they feed their baby. Pediatricians believe that breastfeeding is the best but not the only way to feed a baby. We have (or will provide) the skills to assist parents succeed in whatever method they choose and strive to minimize the impediments that are within our power to change.
If the academy had chosen to release a separate statement simply supporting mothers who chose to nurse longer than a year, then that would have been a good idea. However, when presented as part of the larger document, that message dominated in the media and only served to fuel the guilt that many new mothers must endure.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].
The American Academy of Pediatrics is built on good intentions. It wants the best for children in the world, and it hopes to support its members in their efforts to achieve this goal. But from time to time, the academy loses sight of reality and makes recommendations that are counterproductive to its stated goals.
The recent release of its new policy “Breastfeeding and the Use of Human Milk” is another unfortunate example of poorly aimed recommendations. A careful reading of the document reveals it to be a well-researched treatise on breastfeeding and the value of human milk, including a discussion of the numerous impediments to the universal adoption of breastfeeding in our society. However, when a document of this breadth and complexity is released to the public it is never surprising that the messages deserving the most attention are lost in the press coverage. Most of the headlines I saw mentioned pediatricians supporting breastfeeding for a year or 2.
Who was the target audience? If it was pediatricians, most of us don’t need a longer list of the health benefits of breastfeeding. We already believe it is the best nutritional source for human babies and realize that the institutional framework in this country continues to be unfriendly to women who intend to breastfeed.
If the audience is politicians and public health decision-makers, the new policy contains a wealth of supportive evidence. However, most pediatricians I know are too busy or lack the skills and enthusiasm to become political activists. For the rest of population, including parents, the recommendations represent a collection of TMI (too much information).
If the audience is women who are considering breastfeeding I suspect nearly 100% already know pediatricians think it is the preferred way to feed their babies. And, likewise, a longer list won’t convince them to try nursing. Additional evidence may simply make them feel more guilty when they aren’t successful.
Many pregnant women have already been told that breastfeeding can be a challenge and given their situation breast milk alone for the first 6 months may sound like an unreasonable goal. The new recommendation that breastfeeding for a year or 2 is good is not a message they want to hear.
On the other hand, if the target audience is women who will be comforted to hear an official statement that normalizes breastfeeding longer than a year, the new policy statement has hit the nail on the head.
Of course the new policy document is sprinkled with caveats that vaguely hint at the possibility that pediatricians are sensitive human beings who under certain circumstances may be able to compromise when it comes to the duration of breastfeeding and the introduction of formula. But this whiff of reality is certainly not the dominant odor in these new recommendations.
Don’t get me wrong: I think the academy was overdue for a policy revision on breastfeeding. However, it should have been one that was reality based. It should acknowledge that there are institutional and societal biases against breastfeeding, and it should remind pediatricians that they can effect change by discussing these realities honestly with parents, while making it clear that we are there for them and their children regardless of how they feed their baby. Pediatricians believe that breastfeeding is the best but not the only way to feed a baby. We have (or will provide) the skills to assist parents succeed in whatever method they choose and strive to minimize the impediments that are within our power to change.
If the academy had chosen to release a separate statement simply supporting mothers who chose to nurse longer than a year, then that would have been a good idea. However, when presented as part of the larger document, that message dominated in the media and only served to fuel the guilt that many new mothers must endure.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].
The American Academy of Pediatrics is built on good intentions. It wants the best for children in the world, and it hopes to support its members in their efforts to achieve this goal. But from time to time, the academy loses sight of reality and makes recommendations that are counterproductive to its stated goals.
The recent release of its new policy “Breastfeeding and the Use of Human Milk” is another unfortunate example of poorly aimed recommendations. A careful reading of the document reveals it to be a well-researched treatise on breastfeeding and the value of human milk, including a discussion of the numerous impediments to the universal adoption of breastfeeding in our society. However, when a document of this breadth and complexity is released to the public it is never surprising that the messages deserving the most attention are lost in the press coverage. Most of the headlines I saw mentioned pediatricians supporting breastfeeding for a year or 2.
Who was the target audience? If it was pediatricians, most of us don’t need a longer list of the health benefits of breastfeeding. We already believe it is the best nutritional source for human babies and realize that the institutional framework in this country continues to be unfriendly to women who intend to breastfeed.
If the audience is politicians and public health decision-makers, the new policy contains a wealth of supportive evidence. However, most pediatricians I know are too busy or lack the skills and enthusiasm to become political activists. For the rest of population, including parents, the recommendations represent a collection of TMI (too much information).
If the audience is women who are considering breastfeeding I suspect nearly 100% already know pediatricians think it is the preferred way to feed their babies. And, likewise, a longer list won’t convince them to try nursing. Additional evidence may simply make them feel more guilty when they aren’t successful.
Many pregnant women have already been told that breastfeeding can be a challenge and given their situation breast milk alone for the first 6 months may sound like an unreasonable goal. The new recommendation that breastfeeding for a year or 2 is good is not a message they want to hear.
On the other hand, if the target audience is women who will be comforted to hear an official statement that normalizes breastfeeding longer than a year, the new policy statement has hit the nail on the head.
Of course the new policy document is sprinkled with caveats that vaguely hint at the possibility that pediatricians are sensitive human beings who under certain circumstances may be able to compromise when it comes to the duration of breastfeeding and the introduction of formula. But this whiff of reality is certainly not the dominant odor in these new recommendations.
Don’t get me wrong: I think the academy was overdue for a policy revision on breastfeeding. However, it should have been one that was reality based. It should acknowledge that there are institutional and societal biases against breastfeeding, and it should remind pediatricians that they can effect change by discussing these realities honestly with parents, while making it clear that we are there for them and their children regardless of how they feed their baby. Pediatricians believe that breastfeeding is the best but not the only way to feed a baby. We have (or will provide) the skills to assist parents succeed in whatever method they choose and strive to minimize the impediments that are within our power to change.
If the academy had chosen to release a separate statement simply supporting mothers who chose to nurse longer than a year, then that would have been a good idea. However, when presented as part of the larger document, that message dominated in the media and only served to fuel the guilt that many new mothers must endure.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].