Article

Key clinical point: As initial treatment, hepatic arterial infusion chemotherapy (HAIC) effectuates a greater survival and radiological response than transarterial chemoembolization (TACE) among patients with infiltrative hepatocellular carcinoma (HCC).

Main finding: HIAC vs TACE led to a longer median overall survival (13.3 months vs 10.8 months; P = .043) and progression-free survival (7.8 months vs 4.0 months; P = .035) along with higher objective response (34.8% vs 11.8%; P = .001) and disease control (54.3% vs 36.8%; P = .028) rates.

Study details: Findings are from a retrospective real-world study including 160 adult patients with large infiltrative HCCs who underwent either HAIC (n=92) or TACE (n=68) as initial treatment.

Disclosures: The authors declared receiving no financial assistance for the study and having no potential conflict of interests.

Source: An C et al. Front Oncol. 2021 Dec 16. doi: 10.3389/fonc.2021.747496.

Key clinical point: As initial treatment, hepatic arterial infusion chemotherapy (HAIC) effectuates a greater survival and radiological response than transarterial chemoembolization (TACE) among patients with infiltrative hepatocellular carcinoma (HCC).

Main finding: HIAC vs TACE led to a longer median overall survival (13.3 months vs 10.8 months; P = .043) and progression-free survival (7.8 months vs 4.0 months; P = .035) along with higher objective response (34.8% vs 11.8%; P = .001) and disease control (54.3% vs 36.8%; P = .028) rates.

Study details: Findings are from a retrospective real-world study including 160 adult patients with large infiltrative HCCs who underwent either HAIC (n=92) or TACE (n=68) as initial treatment.

Disclosures: The authors declared receiving no financial assistance for the study and having no potential conflict of interests.

Source: An C et al. Front Oncol. 2021 Dec 16. doi: 10.3389/fonc.2021.747496.

Key clinical point: As initial treatment, hepatic arterial infusion chemotherapy (HAIC) effectuates a greater survival and radiological response than transarterial chemoembolization (TACE) among patients with infiltrative hepatocellular carcinoma (HCC).

Main finding: HIAC vs TACE led to a longer median overall survival (13.3 months vs 10.8 months; P = .043) and progression-free survival (7.8 months vs 4.0 months; P = .035) along with higher objective response (34.8% vs 11.8%; P = .001) and disease control (54.3% vs 36.8%; P = .028) rates.

Study details: Findings are from a retrospective real-world study including 160 adult patients with large infiltrative HCCs who underwent either HAIC (n=92) or TACE (n=68) as initial treatment.

Disclosures: The authors declared receiving no financial assistance for the study and having no potential conflict of interests.

Source: An C et al. Front Oncol. 2021 Dec 16. doi: 10.3389/fonc.2021.747496.

Key clinical point: Modified Response Evaluation Criteria in Solid Tumors (mRECIST)-determined objective response (OR) and early tumor shrinkage (ETS) may serve as independent prognostic factors for overall survival (OS) in patients with advanced hepatocellular carcinoma (HCC) on sorafenib monotherapy.

Main finding: OR assessed by mRECIST (adjusted hazard ratio [aHR], 0.32; P < .001) and ETS (aHR, 0.44; P < .001) were independent prognostic factors for OS. A longer median OS was shown by responders vs nonresponders (30.3 months vs 11.4 months; P < .001) and by patients with ETS ≥20% vs those with ETS <20% (22.1 months vs 11.4 months; P < .001).

Study details: This was a post hoc analysis of data from the phase 2 SORAMIC trial and included 115 patients with advanced HCC receiving sorafenib monotherapy.

Disclosures: The study was sponsored by Sirtex Medical and Bayer Healthcare. Some of the authors declared receiving personal fees and research grants from various sources including Bayer and Sirtex.

Source: Öcal O et al. Cancer Imaging. 2022 Jan 4. doi: 10.1186/s40644-021-00439-x.

Key clinical point: Modified Response Evaluation Criteria in Solid Tumors (mRECIST)-determined objective response (OR) and early tumor shrinkage (ETS) may serve as independent prognostic factors for overall survival (OS) in patients with advanced hepatocellular carcinoma (HCC) on sorafenib monotherapy.

Main finding: OR assessed by mRECIST (adjusted hazard ratio [aHR], 0.32; P < .001) and ETS (aHR, 0.44; P < .001) were independent prognostic factors for OS. A longer median OS was shown by responders vs nonresponders (30.3 months vs 11.4 months; P < .001) and by patients with ETS ≥20% vs those with ETS <20% (22.1 months vs 11.4 months; P < .001).

Study details: This was a post hoc analysis of data from the phase 2 SORAMIC trial and included 115 patients with advanced HCC receiving sorafenib monotherapy.

Disclosures: The study was sponsored by Sirtex Medical and Bayer Healthcare. Some of the authors declared receiving personal fees and research grants from various sources including Bayer and Sirtex.

Source: Öcal O et al. Cancer Imaging. 2022 Jan 4. doi: 10.1186/s40644-021-00439-x.

Key clinical point: Modified Response Evaluation Criteria in Solid Tumors (mRECIST)-determined objective response (OR) and early tumor shrinkage (ETS) may serve as independent prognostic factors for overall survival (OS) in patients with advanced hepatocellular carcinoma (HCC) on sorafenib monotherapy.

Main finding: OR assessed by mRECIST (adjusted hazard ratio [aHR], 0.32; P < .001) and ETS (aHR, 0.44; P < .001) were independent prognostic factors for OS. A longer median OS was shown by responders vs nonresponders (30.3 months vs 11.4 months; P < .001) and by patients with ETS ≥20% vs those with ETS <20% (22.1 months vs 11.4 months; P < .001).

Study details: This was a post hoc analysis of data from the phase 2 SORAMIC trial and included 115 patients with advanced HCC receiving sorafenib monotherapy.

Disclosures: The study was sponsored by Sirtex Medical and Bayer Healthcare. Some of the authors declared receiving personal fees and research grants from various sources including Bayer and Sirtex.

Source: Öcal O et al. Cancer Imaging. 2022 Jan 4. doi: 10.1186/s40644-021-00439-x.

Key clinical point: Lowering the current United Network for Organ Sharing-recommended alpha-fetoprotein (AFP) level threshold for exclusion from liver transplant (LT) to ≥500 ng/mL for all patients with hepatocellular carcinoma (HCC) instead of only for those with AFP levels >1000 ng/mL could improve post-LT outcomes.

Main finding: After multivariable adjustment, an AFP level ≥500 ng/mL at LT was associated with an elevated risk of post-LT mortality (adjusted hazard ratio [aHR], 1.5; P = .02) and HCC recurrence (aHR, 1.88; P = .02) compared with an AFP level <100 ng/mL.

Study details: This was a retrospective cohort study involving 1,766 adult patients with HCC who had undergone LT and had listing AFP levels between 100 ng/mL and 999 ng/mL at initial model for end-stage liver disease exception.

Disclosures: The study was funded by the UCSF Clinical and Translational Science Institute Research Funding Award and UCSF Liver Center. Some of the authors reported being on the advisory board of or receiving research grants from various organizations.

Source: Goldman ML et al. Liver Transpl. 2021 Dec 20. doi: 10.1002/lt.26392.

Key clinical point: Lowering the current United Network for Organ Sharing-recommended alpha-fetoprotein (AFP) level threshold for exclusion from liver transplant (LT) to ≥500 ng/mL for all patients with hepatocellular carcinoma (HCC) instead of only for those with AFP levels >1000 ng/mL could improve post-LT outcomes.

Main finding: After multivariable adjustment, an AFP level ≥500 ng/mL at LT was associated with an elevated risk of post-LT mortality (adjusted hazard ratio [aHR], 1.5; P = .02) and HCC recurrence (aHR, 1.88; P = .02) compared with an AFP level <100 ng/mL.

Study details: This was a retrospective cohort study involving 1,766 adult patients with HCC who had undergone LT and had listing AFP levels between 100 ng/mL and 999 ng/mL at initial model for end-stage liver disease exception.

Disclosures: The study was funded by the UCSF Clinical and Translational Science Institute Research Funding Award and UCSF Liver Center. Some of the authors reported being on the advisory board of or receiving research grants from various organizations.

Source: Goldman ML et al. Liver Transpl. 2021 Dec 20. doi: 10.1002/lt.26392.

Key clinical point: Lowering the current United Network for Organ Sharing-recommended alpha-fetoprotein (AFP) level threshold for exclusion from liver transplant (LT) to ≥500 ng/mL for all patients with hepatocellular carcinoma (HCC) instead of only for those with AFP levels >1000 ng/mL could improve post-LT outcomes.

Main finding: After multivariable adjustment, an AFP level ≥500 ng/mL at LT was associated with an elevated risk of post-LT mortality (adjusted hazard ratio [aHR], 1.5; P = .02) and HCC recurrence (aHR, 1.88; P = .02) compared with an AFP level <100 ng/mL.

Study details: This was a retrospective cohort study involving 1,766 adult patients with HCC who had undergone LT and had listing AFP levels between 100 ng/mL and 999 ng/mL at initial model for end-stage liver disease exception.

Disclosures: The study was funded by the UCSF Clinical and Translational Science Institute Research Funding Award and UCSF Liver Center. Some of the authors reported being on the advisory board of or receiving research grants from various organizations.

Source: Goldman ML et al. Liver Transpl. 2021 Dec 20. doi: 10.1002/lt.26392.

Key clinical point: Individuals with persistent or incident body fatness show an increased risk of developing hepatocellular carcinoma (HCC).

Main finding: Compared with their persistent no-fatness counterparts, both general fatness (persistent: adjusted hazard ratio [aHR], 1.28; 95% CI, 1.23-1.34; incident: aHR, 1.10; 95% CI, 1.01-1.20) and central fatness (persistent: aHR, 1.33; 95% CI, 1.26-1.40; incident: aHR, 1.19; 95% CI, 1.11-1.27) were associated with an increased risk of HCC.

Study details: The data come from a nationwide population-based cohort study including 6,789,472 individuals aged 20 years or older who were not previously diagnosed with HCC and underwent health examinations twice with a gap of 2 years.

Disclosures: The study was sponsored by the Research Supporting Program of The Korean Association for the Study of the Liver and the Korean Liver Foundation. The authors declared no conflict of interests.

Source: Kim MN et al. Int J Cancer. 2021 Dec 26. doi: 10.1002/ijc.33920.

Key clinical point: Individuals with persistent or incident body fatness show an increased risk of developing hepatocellular carcinoma (HCC).

Main finding: Compared with their persistent no-fatness counterparts, both general fatness (persistent: adjusted hazard ratio [aHR], 1.28; 95% CI, 1.23-1.34; incident: aHR, 1.10; 95% CI, 1.01-1.20) and central fatness (persistent: aHR, 1.33; 95% CI, 1.26-1.40; incident: aHR, 1.19; 95% CI, 1.11-1.27) were associated with an increased risk of HCC.

Study details: The data come from a nationwide population-based cohort study including 6,789,472 individuals aged 20 years or older who were not previously diagnosed with HCC and underwent health examinations twice with a gap of 2 years.

Disclosures: The study was sponsored by the Research Supporting Program of The Korean Association for the Study of the Liver and the Korean Liver Foundation. The authors declared no conflict of interests.

Source: Kim MN et al. Int J Cancer. 2021 Dec 26. doi: 10.1002/ijc.33920.

Key clinical point: Individuals with persistent or incident body fatness show an increased risk of developing hepatocellular carcinoma (HCC).

Main finding: Compared with their persistent no-fatness counterparts, both general fatness (persistent: adjusted hazard ratio [aHR], 1.28; 95% CI, 1.23-1.34; incident: aHR, 1.10; 95% CI, 1.01-1.20) and central fatness (persistent: aHR, 1.33; 95% CI, 1.26-1.40; incident: aHR, 1.19; 95% CI, 1.11-1.27) were associated with an increased risk of HCC.

Study details: The data come from a nationwide population-based cohort study including 6,789,472 individuals aged 20 years or older who were not previously diagnosed with HCC and underwent health examinations twice with a gap of 2 years.

Disclosures: The study was sponsored by the Research Supporting Program of The Korean Association for the Study of the Liver and the Korean Liver Foundation. The authors declared no conflict of interests.

Source: Kim MN et al. Int J Cancer. 2021 Dec 26. doi: 10.1002/ijc.33920.

Key clinical point: Patients with small hepatocellular carcinoma (HCC) show a comparable improvement in recurrence-free survival (RFS) after undergoing surgery or radiofrequency ablation (RFA).

Main finding: The median RFS of patients who had undergone surgery was not significantly different from that of patients receiving RFA (3.46 years vs 3.04 years; hazard ratio, 0.92; P = .58).

Study details: Findings are from the phase 3 SURF-trial including 301 patients aged between 20 and 80 years with the largest HCC diameter ≤3 cm and ≤3 HCC nodules who were randomly assigned (1:1) to undergo either surgery (n=150) or RFA (n=151).

Disclosures: The study was sponsored by the Japanese Foundation for Multidisciplinary Treatment of Cancer and the Health and Labor Sciences Research Grant for Clinical Cancer Research. Some of the authors declared receiving lecture fees or research funds from or serving as an advisor for various companies. A few authors reported being on the editorial team/board of Liver Cancer.

Source: Takayama T et al. Liver Cancer. 2021 Dec 29. doi: 10.1159/000521665.

Key clinical point: Patients with small hepatocellular carcinoma (HCC) show a comparable improvement in recurrence-free survival (RFS) after undergoing surgery or radiofrequency ablation (RFA).

Main finding: The median RFS of patients who had undergone surgery was not significantly different from that of patients receiving RFA (3.46 years vs 3.04 years; hazard ratio, 0.92; P = .58).

Study details: Findings are from the phase 3 SURF-trial including 301 patients aged between 20 and 80 years with the largest HCC diameter ≤3 cm and ≤3 HCC nodules who were randomly assigned (1:1) to undergo either surgery (n=150) or RFA (n=151).

Disclosures: The study was sponsored by the Japanese Foundation for Multidisciplinary Treatment of Cancer and the Health and Labor Sciences Research Grant for Clinical Cancer Research. Some of the authors declared receiving lecture fees or research funds from or serving as an advisor for various companies. A few authors reported being on the editorial team/board of Liver Cancer.

Source: Takayama T et al. Liver Cancer. 2021 Dec 29. doi: 10.1159/000521665.

Key clinical point: Patients with small hepatocellular carcinoma (HCC) show a comparable improvement in recurrence-free survival (RFS) after undergoing surgery or radiofrequency ablation (RFA).

Main finding: The median RFS of patients who had undergone surgery was not significantly different from that of patients receiving RFA (3.46 years vs 3.04 years; hazard ratio, 0.92; P = .58).

Study details: Findings are from the phase 3 SURF-trial including 301 patients aged between 20 and 80 years with the largest HCC diameter ≤3 cm and ≤3 HCC nodules who were randomly assigned (1:1) to undergo either surgery (n=150) or RFA (n=151).

Disclosures: The study was sponsored by the Japanese Foundation for Multidisciplinary Treatment of Cancer and the Health and Labor Sciences Research Grant for Clinical Cancer Research. Some of the authors declared receiving lecture fees or research funds from or serving as an advisor for various companies. A few authors reported being on the editorial team/board of Liver Cancer.

Source: Takayama T et al. Liver Cancer. 2021 Dec 29. doi: 10.1159/000521665.

Key clinical point: The oncological outcome in patients with hepatocellular carcinoma (HCC) who underwent liver transplantation (LT) is strongly affected by the ABO blood group system.

Main finding: Blood group A showed an independent association with increased tumor recurrence risk (adjusted hazard ratio [aHR], 1.574; P = .034) with group A vs non-A recipients having higher 5-year tumor recurrence rates (20.1% vs 13.2%; aHR, 1.66; P = .011) and lower 5-year recurrence-free survival rates (66.8% vs 71.3%; aHR, 1.38; P = .045).

Study details: The data are derived from a multicentric retrospective observational study including 925 adult patients with HCC who underwent LT, of whom 406, 94, 380, and 45 had blood group A, B, O, and AB, respectively.

Disclosures: The authors reported no funding source or conflict of interests.

Source: Kayvan M et al. Transplantation. 2021 Dec 27. doi: 10.1097/TP.0000000000004004.

Key clinical point: The oncological outcome in patients with hepatocellular carcinoma (HCC) who underwent liver transplantation (LT) is strongly affected by the ABO blood group system.

Main finding: Blood group A showed an independent association with increased tumor recurrence risk (adjusted hazard ratio [aHR], 1.574; P = .034) with group A vs non-A recipients having higher 5-year tumor recurrence rates (20.1% vs 13.2%; aHR, 1.66; P = .011) and lower 5-year recurrence-free survival rates (66.8% vs 71.3%; aHR, 1.38; P = .045).

Study details: The data are derived from a multicentric retrospective observational study including 925 adult patients with HCC who underwent LT, of whom 406, 94, 380, and 45 had blood group A, B, O, and AB, respectively.

Disclosures: The authors reported no funding source or conflict of interests.

Source: Kayvan M et al. Transplantation. 2021 Dec 27. doi: 10.1097/TP.0000000000004004.

Key clinical point: The oncological outcome in patients with hepatocellular carcinoma (HCC) who underwent liver transplantation (LT) is strongly affected by the ABO blood group system.

Main finding: Blood group A showed an independent association with increased tumor recurrence risk (adjusted hazard ratio [aHR], 1.574; P = .034) with group A vs non-A recipients having higher 5-year tumor recurrence rates (20.1% vs 13.2%; aHR, 1.66; P = .011) and lower 5-year recurrence-free survival rates (66.8% vs 71.3%; aHR, 1.38; P = .045).

Study details: The data are derived from a multicentric retrospective observational study including 925 adult patients with HCC who underwent LT, of whom 406, 94, 380, and 45 had blood group A, B, O, and AB, respectively.

Disclosures: The authors reported no funding source or conflict of interests.

Source: Kayvan M et al. Transplantation. 2021 Dec 27. doi: 10.1097/TP.0000000000004004.

Migraine is a complex disorder characterized by recurrent episodes of headache, most often unilateral and in some cases associated with photophobia or phonophobia — a constellation known as aura — that usually arises before the head pain but may also occur during or afterward. Migraine is most common in women, and prevalence peaks between the ages of 25 and 55. In 2016, headache was the fifth most common reason for an ED visit and the third most common reason for an ED visit among female patients age 15-64.

Diagnosis of migraine is made on the basis of patient history. Examples of red flags in the differential would be the presence of neurologic symptoms, stiff neck, or fever, or history of head injury or major trauma. Migraine should also be distinguished from other common headaches. Tension-type headaches usually cause mild or moderate bilateral pain, with a deep, steady ache rather than the typical throbbing quality of migraine headache. In cluster headache, the patient experiences attacks of severe or very severe, strictly unilateral pain (orbital, supraorbital, or temporal pain), but the cadence of these headaches differs from that of migraines; these attacks last 15-180 minutes and occur from once every other day to eight times a day. Patients with basilar migraine, common among female patients, usually present with symptoms of vertebrobasilar insufficiency. 

The American Headache Society defines migraine as when a patient reports at least five attacks. These episodes must last 4-72 hours and have at least two of these four characteristics: unilateral location, pulsating quality, moderate or severe pain intensity, and aggravation by or causing avoidance of routine physical activity. In addition, during attacks, the patient must experience either nausea and/or vomiting or photophobia and phonophobia. Signs and symptoms cannot be accounted for by another diagnosis.

Treatment of migraines is often associated with a trial-and-error period. For mild to moderate migraines, these agents may be considered: NSAIDs, nonopioid analgesics, acetaminophen, or caffeinated analgesic combinations. For moderate or severe attacks, or even mild to moderate attacks that do not respond well to therapy, migraine-specific agents are recommended: triptans, dihydroergotamine (DHE), small-molecule CGRP receptor antagonists (gepants), and selective serotonin (5-HT1F) receptor agonists (ditans). Menstrual migraines are treated via the same approaches as nonmenstrual migraines.

Many patients, like the one described here, experience severe nausea or vomiting with their migraine attacks. For these cases, nonoral agents may be considered (these agents are also an option for patients whose headaches do not respond well to traditional oral medication). Patients should be advised to limit medication use to an average of two headache days per week, and those who feel it necessary to exceed this limit should be offered a preventive treatment.

Angeliki Vgontzas, MD, Instructor, Department of Neurology, Harvard Medical School; Associate Neurologist, Department of Neurology, Brigham and Women's Hospital/Brigham and Women's Faulkner Hospital, Boston, Massachusetts.

Angeliki Vgontzas, MD, has disclosed no relevant financial relationships.

Migraine is a complex disorder characterized by recurrent episodes of headache, most often unilateral and in some cases associated with photophobia or phonophobia — a constellation known as aura — that usually arises before the head pain but may also occur during or afterward. Migraine is most common in women, and prevalence peaks between the ages of 25 and 55. In 2016, headache was the fifth most common reason for an ED visit and the third most common reason for an ED visit among female patients age 15-64.

Diagnosis of migraine is made on the basis of patient history. Examples of red flags in the differential would be the presence of neurologic symptoms, stiff neck, or fever, or history of head injury or major trauma. Migraine should also be distinguished from other common headaches. Tension-type headaches usually cause mild or moderate bilateral pain, with a deep, steady ache rather than the typical throbbing quality of migraine headache. In cluster headache, the patient experiences attacks of severe or very severe, strictly unilateral pain (orbital, supraorbital, or temporal pain), but the cadence of these headaches differs from that of migraines; these attacks last 15-180 minutes and occur from once every other day to eight times a day. Patients with basilar migraine, common among female patients, usually present with symptoms of vertebrobasilar insufficiency. 

The American Headache Society defines migraine as when a patient reports at least five attacks. These episodes must last 4-72 hours and have at least two of these four characteristics: unilateral location, pulsating quality, moderate or severe pain intensity, and aggravation by or causing avoidance of routine physical activity. In addition, during attacks, the patient must experience either nausea and/or vomiting or photophobia and phonophobia. Signs and symptoms cannot be accounted for by another diagnosis.

Treatment of migraines is often associated with a trial-and-error period. For mild to moderate migraines, these agents may be considered: NSAIDs, nonopioid analgesics, acetaminophen, or caffeinated analgesic combinations. For moderate or severe attacks, or even mild to moderate attacks that do not respond well to therapy, migraine-specific agents are recommended: triptans, dihydroergotamine (DHE), small-molecule CGRP receptor antagonists (gepants), and selective serotonin (5-HT1F) receptor agonists (ditans). Menstrual migraines are treated via the same approaches as nonmenstrual migraines.

Many patients, like the one described here, experience severe nausea or vomiting with their migraine attacks. For these cases, nonoral agents may be considered (these agents are also an option for patients whose headaches do not respond well to traditional oral medication). Patients should be advised to limit medication use to an average of two headache days per week, and those who feel it necessary to exceed this limit should be offered a preventive treatment.

Angeliki Vgontzas, MD, Instructor, Department of Neurology, Harvard Medical School; Associate Neurologist, Department of Neurology, Brigham and Women's Hospital/Brigham and Women's Faulkner Hospital, Boston, Massachusetts.

Angeliki Vgontzas, MD, has disclosed no relevant financial relationships.

Migraine is a complex disorder characterized by recurrent episodes of headache, most often unilateral and in some cases associated with photophobia or phonophobia — a constellation known as aura — that usually arises before the head pain but may also occur during or afterward. Migraine is most common in women, and prevalence peaks between the ages of 25 and 55. In 2016, headache was the fifth most common reason for an ED visit and the third most common reason for an ED visit among female patients age 15-64.

Diagnosis of migraine is made on the basis of patient history. Examples of red flags in the differential would be the presence of neurologic symptoms, stiff neck, or fever, or history of head injury or major trauma. Migraine should also be distinguished from other common headaches. Tension-type headaches usually cause mild or moderate bilateral pain, with a deep, steady ache rather than the typical throbbing quality of migraine headache. In cluster headache, the patient experiences attacks of severe or very severe, strictly unilateral pain (orbital, supraorbital, or temporal pain), but the cadence of these headaches differs from that of migraines; these attacks last 15-180 minutes and occur from once every other day to eight times a day. Patients with basilar migraine, common among female patients, usually present with symptoms of vertebrobasilar insufficiency. 

The American Headache Society defines migraine as when a patient reports at least five attacks. These episodes must last 4-72 hours and have at least two of these four characteristics: unilateral location, pulsating quality, moderate or severe pain intensity, and aggravation by or causing avoidance of routine physical activity. In addition, during attacks, the patient must experience either nausea and/or vomiting or photophobia and phonophobia. Signs and symptoms cannot be accounted for by another diagnosis.

Treatment of migraines is often associated with a trial-and-error period. For mild to moderate migraines, these agents may be considered: NSAIDs, nonopioid analgesics, acetaminophen, or caffeinated analgesic combinations. For moderate or severe attacks, or even mild to moderate attacks that do not respond well to therapy, migraine-specific agents are recommended: triptans, dihydroergotamine (DHE), small-molecule CGRP receptor antagonists (gepants), and selective serotonin (5-HT1F) receptor agonists (ditans). Menstrual migraines are treated via the same approaches as nonmenstrual migraines.

Many patients, like the one described here, experience severe nausea or vomiting with their migraine attacks. For these cases, nonoral agents may be considered (these agents are also an option for patients whose headaches do not respond well to traditional oral medication). Patients should be advised to limit medication use to an average of two headache days per week, and those who feel it necessary to exceed this limit should be offered a preventive treatment.

Angeliki Vgontzas, MD, Instructor, Department of Neurology, Harvard Medical School; Associate Neurologist, Department of Neurology, Brigham and Women's Hospital/Brigham and Women's Faulkner Hospital, Boston, Massachusetts.

Angeliki Vgontzas, MD, has disclosed no relevant financial relationships.

The White Coat Ceremony is an enduring memory from my medical school years. Amidst the tumult of memories of seemingly endless sleepless nights spent in libraries and cramming for clerkship examinations between surgical cases, I recall a sunny spring day in 2016 where I gathered with my classmates, family, and friends in the medical school campus courtyard. There were several short, mostly forgotten speeches after which proud fathers and mothers, partners, or siblings slipped the all-important white coat onto the shoulders of the physicians-to-be. At that moment, I felt the weight of tradition centuries in the making resting on my shoulders. Of course, the pomp of the ceremony might have felt a tad overblown had I known that the whole thing had fewer years under its belt than the movie Die Hard.

That’s right, the first White Coat Ceremony was held 5 years after the release of that Bruce Willis classic. Dr. Arnold Gold, a pediatric neurologist on faculty at Columbia University, conceived the ceremony in 1993, and it spread rapidly to medical schools—and later nursing schools—across the United States.¹ Although the values highlighted by the White Coat Ceremony—humanism and compassion in medicine—are timeless, the ceremony itself is a more modern undertaking. What, then, of the white coat itself? Is it the timeless symbol of doctoring—of medicine—that we all presume it to be? Or is it a symbol of modern marketing, just a trend that caught on? And is it encountering its twilight—as trends often do—in the face of changing fashion and, more fundamentally, in changes to who our physicians are and to their roles in our society?

The Cleanliness of the White Coat

Until the end of the 19th century, physicians in the Western world most frequently dressed in black formal wear. The rationale behind this attire seems to have been twofold. First, society as a whole perceived the physician’s work as a serious and formal matter, and any medical encounter had to reflect the gravity of the occasion. Additionally, physicians’ visits often were a portent of impending demise, as physicians in the era prior to antibiotics and antisepsis frequently had little to offer their patients outside of—at best—anecdotal treatments and—at worst—sheer quackery.² Black may have seemed a respectful choice for patients who likely faced dire outcomes regardless of the treatment afforded.³

With the turn of the century came a new understanding of the concepts of antisepsis and disease transmission. While Joseph Lister first published on the use of antisepsis in 1867, his practices did not become commonplace until the early 1900s.⁴ Around the same time came the Flexner report,⁵ the publication of William Osler’s Principles and Practice of Medicine,⁶ and the establishment of the modern medical residency, all of which contributed to the shift from the patient’s own bedside and to the hospital as the house of medicine, with cleanliness and antisepsis as part of its core principles.⁷ The white coat arose as a symbol of purity and freedom from disease. Throughout the 20th century and into the 21st, it has remained the predominant symbol of cleanliness and professionalism for the medical practitioner.

Patient Preference of Physician Attire

Although the white coat may serve as a professional symbol and is well respected medicine, it also plays an important role in the layperson’s perception of their health care providers.⁸ There is little denying that patients prefer their physicians, almost uniformly, to wear a white coat. A systematic review of physician attire that included 30 studies mainly from North America, Europe, and the United Kingdom found that patient preference for formal attire and white coats is near universal.⁹ Patients routinely rate physicians wearing a white coat as more intelligent and trustworthy and feel more confident in the care they will receive.^10-13 They also freely admit that a physician’s appearance influences their satisfaction with their care.¹⁴ The recent adoption of the fleece, or softshell, jacket has not yet pervaded patients’ perceptions of what is considered appropriate physician attire. A 500-respondent survey found that patients were more likely to rate a model wearing a white coat as more professional and experienced compared to the same model wearing a fleece or softshell jacket or other formal attire sans white coat.¹⁵

Closer examination of the same data, however, reveals results reproduced with startling consistency across several studies, which suggest those of us adopting other attire need not dig those white coats out of the closet just yet. First, while many studies point to patient preference for white coats, this preference is uniformly strongest in older patients, beginning around age 40 years and becoming an entrenched preference in those older than 65 years.^9,14,16-18 On the other hand, younger patient populations display little to no such preference, and some studies indicate that younger patients actually prefer scrubs over formal attire in specific settings such as surgical offices, procedural spaces, or the emergency department.^12,14,19 This suggests that bias in favor of traditional physician garb may be more linked to age demographics and may continue to shift as the overall population ages. Additionally, although patients might profess a strong preference for physician attire in theory, it often does not translate into any impact on the patient’s perception of the physician following a clinic visit. The large systematic review on the topic noted that only 25% of studies that surveyed patients about a clinical visit following the encounter reported that physician attire influenced their satisfaction with that visit, suggesting that attire may be less likely to influence patients in the real-world context of receiving care.⁹ In fact, a prospective study of patient perception of medical staff and interactions found that staff style of dress not only had no bearing on the perception of staff or visit satisfaction but that patients often failed to even accurately recall physician attire when surveyed.²⁰ Another survey study echoed these conclusions, finding that physician attire had no effect on the perception of a proposed treatment plan.²¹

What do we know about patient perception of physician attire in the dermatology setting specifically, where visits can be unique in their tendency to transition from medical to procedural in the span of a 15-minute encounter depending on the patient’s chief concern? A survey study of dermatology patients at the general, surgical, and wound care dermatology clinics of an academic medical center (Miami, Florida) found that professional attire with a white coat was strongly preferred across a litany of scenarios assessing many aspects of dermatologic care.²¹ Similarly, a study of patients visiting a single institution’s dermatology and pediatric dermatology clinics surveyed patients and parents regarding attire prior to an appointment and specifically asked if a white coat should be worn.¹³ Fifty-four percent of the adult patients (n=176) surveyed professed a preference for physicians in white coats, with a stronger preference for white coats reported by those 50 years and older (55%; n=113). Parents or guardians presenting to the pediatric dermatology clinic, on the other hand, favored less formal attire.¹³ A recent, real-world study performed at an outpatient dermatology clinic examined the influence of changing physician attire on a patient’s perceptions of care received during clinic encounters. They found no substantial difference in patient satisfaction scores before and following the adoption of a new clinic uniform that transitioned from formal attire to fitted scrubs.²²

 

 

Racial and Gender Bias Affecting Attire Preference

With any study of preference, there is the underlying concern over respondent bias. Many of the studies discussed here have found secondarily that a patient’s implicit bias does not end at the clothes their physician is wearing. The survey study of dermatology patients from the academic medical center in Miami, Florida, found that patients preferred that Black physicians of either sex be garbed in professional attire at all times but generally were more accepting of White physicians in less formal attire.²¹ Adamson et al²³ published a response to the study’s findings urging dermatologists to recognize that a physician’s race and gender influence patients’ perceptions in much the same way that physician attire seems to and encouraged the development of a more diverse dermatologic workforce to help combat this prejudice. The issue of bias is not limited to the specialty of dermatology; the recent survey study by Xun et al¹⁵ found that respondents consistently rated female models garbed in physician attire as less professional than male model counterparts. Additionally, female models wearing white coats were mistakenly identified as medical technicians, physician assistants, or nurses with substantially more frequency than males, despite being clothed in the traditional physician garb. Several other publications on the subject have uncovered implicit bias, though it is rarely, if ever, the principle focus of the study.^10,24,25 As is unfortunately true in many professions, female physicians and physicians from ethnic minorities face barriers to being perceived as fully competent physicians.

Impact of the COVID-19 Pandemic

Finally, of course, there is the ever-present question of the effect of the pandemic. Although the exact role of the white coat as a fomite for infection—and especially for the spread of viral illness—remains controversial, the perception nonetheless has helped catalyze the movement to alternatives such as short-sleeved white coats, technical jackets, and more recently, fitted scrubs.^26-29 As with much in this realm, facts seem less important than perceptions; Zahrina et al³⁰ found that when patients were presented with information regarding the risk for microbial contamination associated with white coats, preference for physicians in professional garb plummeted from 72% to only 22%. To date no articles have examined patient perceptions of the white coat in the context of microbial transmission in the age of COVID-19, but future articles on this topic are likely and may serve to further the demise of the white coat.

Final Thoughts

From my vantage point, it seems the white coat will be claimed by the outgoing tide. During this most recent residency interview season, I do not recall a single medical student wearing a short white coat. The closest I came was a quick glimpse of a crumpled white jacket slung over an arm or stuffed in a shoulder bag. Rotating interns and residents from other services on rotation in our department present in softshell or fleece jackets. Fitted scrubs in the newest trendy colors speckle a previously all-white canvas. I, for one, have not donned my own white coat in at least a year, and perhaps it is all for the best. Physician attire is one small aspect of the practice of medicine and likely bears little, if any, relation to the wearer’s qualifications. Our focus should be on building rapport with our patients, providing high-quality care, reducing the risk for nosocomial infection, and developing a health care system that is fair and equitable for patients and health care workers alike, not on who is wearing what. Perhaps the introduction of new physician attire is a small part of the disruption we need to help address persistent gender and racial biases in our field and help shepherd our patients and colleagues to a worldview that is more open and accepting of physicians of diverse backgrounds.

The White Coat Ceremony is an enduring memory from my medical school years. Amidst the tumult of memories of seemingly endless sleepless nights spent in libraries and cramming for clerkship examinations between surgical cases, I recall a sunny spring day in 2016 where I gathered with my classmates, family, and friends in the medical school campus courtyard. There were several short, mostly forgotten speeches after which proud fathers and mothers, partners, or siblings slipped the all-important white coat onto the shoulders of the physicians-to-be. At that moment, I felt the weight of tradition centuries in the making resting on my shoulders. Of course, the pomp of the ceremony might have felt a tad overblown had I known that the whole thing had fewer years under its belt than the movie Die Hard.

That’s right, the first White Coat Ceremony was held 5 years after the release of that Bruce Willis classic. Dr. Arnold Gold, a pediatric neurologist on faculty at Columbia University, conceived the ceremony in 1993, and it spread rapidly to medical schools—and later nursing schools—across the United States.¹ Although the values highlighted by the White Coat Ceremony—humanism and compassion in medicine—are timeless, the ceremony itself is a more modern undertaking. What, then, of the white coat itself? Is it the timeless symbol of doctoring—of medicine—that we all presume it to be? Or is it a symbol of modern marketing, just a trend that caught on? And is it encountering its twilight—as trends often do—in the face of changing fashion and, more fundamentally, in changes to who our physicians are and to their roles in our society?

The Cleanliness of the White Coat

Until the end of the 19th century, physicians in the Western world most frequently dressed in black formal wear. The rationale behind this attire seems to have been twofold. First, society as a whole perceived the physician’s work as a serious and formal matter, and any medical encounter had to reflect the gravity of the occasion. Additionally, physicians’ visits often were a portent of impending demise, as physicians in the era prior to antibiotics and antisepsis frequently had little to offer their patients outside of—at best—anecdotal treatments and—at worst—sheer quackery.² Black may have seemed a respectful choice for patients who likely faced dire outcomes regardless of the treatment afforded.³

With the turn of the century came a new understanding of the concepts of antisepsis and disease transmission. While Joseph Lister first published on the use of antisepsis in 1867, his practices did not become commonplace until the early 1900s.⁴ Around the same time came the Flexner report,⁵ the publication of William Osler’s Principles and Practice of Medicine,⁶ and the establishment of the modern medical residency, all of which contributed to the shift from the patient’s own bedside and to the hospital as the house of medicine, with cleanliness and antisepsis as part of its core principles.⁷ The white coat arose as a symbol of purity and freedom from disease. Throughout the 20th century and into the 21st, it has remained the predominant symbol of cleanliness and professionalism for the medical practitioner.

Patient Preference of Physician Attire

Although the white coat may serve as a professional symbol and is well respected medicine, it also plays an important role in the layperson’s perception of their health care providers.⁸ There is little denying that patients prefer their physicians, almost uniformly, to wear a white coat. A systematic review of physician attire that included 30 studies mainly from North America, Europe, and the United Kingdom found that patient preference for formal attire and white coats is near universal.⁹ Patients routinely rate physicians wearing a white coat as more intelligent and trustworthy and feel more confident in the care they will receive.^10-13 They also freely admit that a physician’s appearance influences their satisfaction with their care.¹⁴ The recent adoption of the fleece, or softshell, jacket has not yet pervaded patients’ perceptions of what is considered appropriate physician attire. A 500-respondent survey found that patients were more likely to rate a model wearing a white coat as more professional and experienced compared to the same model wearing a fleece or softshell jacket or other formal attire sans white coat.¹⁵

Closer examination of the same data, however, reveals results reproduced with startling consistency across several studies, which suggest those of us adopting other attire need not dig those white coats out of the closet just yet. First, while many studies point to patient preference for white coats, this preference is uniformly strongest in older patients, beginning around age 40 years and becoming an entrenched preference in those older than 65 years.^9,14,16-18 On the other hand, younger patient populations display little to no such preference, and some studies indicate that younger patients actually prefer scrubs over formal attire in specific settings such as surgical offices, procedural spaces, or the emergency department.^12,14,19 This suggests that bias in favor of traditional physician garb may be more linked to age demographics and may continue to shift as the overall population ages. Additionally, although patients might profess a strong preference for physician attire in theory, it often does not translate into any impact on the patient’s perception of the physician following a clinic visit. The large systematic review on the topic noted that only 25% of studies that surveyed patients about a clinical visit following the encounter reported that physician attire influenced their satisfaction with that visit, suggesting that attire may be less likely to influence patients in the real-world context of receiving care.⁹ In fact, a prospective study of patient perception of medical staff and interactions found that staff style of dress not only had no bearing on the perception of staff or visit satisfaction but that patients often failed to even accurately recall physician attire when surveyed.²⁰ Another survey study echoed these conclusions, finding that physician attire had no effect on the perception of a proposed treatment plan.²¹

What do we know about patient perception of physician attire in the dermatology setting specifically, where visits can be unique in their tendency to transition from medical to procedural in the span of a 15-minute encounter depending on the patient’s chief concern? A survey study of dermatology patients at the general, surgical, and wound care dermatology clinics of an academic medical center (Miami, Florida) found that professional attire with a white coat was strongly preferred across a litany of scenarios assessing many aspects of dermatologic care.²¹ Similarly, a study of patients visiting a single institution’s dermatology and pediatric dermatology clinics surveyed patients and parents regarding attire prior to an appointment and specifically asked if a white coat should be worn.¹³ Fifty-four percent of the adult patients (n=176) surveyed professed a preference for physicians in white coats, with a stronger preference for white coats reported by those 50 years and older (55%; n=113). Parents or guardians presenting to the pediatric dermatology clinic, on the other hand, favored less formal attire.¹³ A recent, real-world study performed at an outpatient dermatology clinic examined the influence of changing physician attire on a patient’s perceptions of care received during clinic encounters. They found no substantial difference in patient satisfaction scores before and following the adoption of a new clinic uniform that transitioned from formal attire to fitted scrubs.²²

 

 

Racial and Gender Bias Affecting Attire Preference

With any study of preference, there is the underlying concern over respondent bias. Many of the studies discussed here have found secondarily that a patient’s implicit bias does not end at the clothes their physician is wearing. The survey study of dermatology patients from the academic medical center in Miami, Florida, found that patients preferred that Black physicians of either sex be garbed in professional attire at all times but generally were more accepting of White physicians in less formal attire.²¹ Adamson et al²³ published a response to the study’s findings urging dermatologists to recognize that a physician’s race and gender influence patients’ perceptions in much the same way that physician attire seems to and encouraged the development of a more diverse dermatologic workforce to help combat this prejudice. The issue of bias is not limited to the specialty of dermatology; the recent survey study by Xun et al¹⁵ found that respondents consistently rated female models garbed in physician attire as less professional than male model counterparts. Additionally, female models wearing white coats were mistakenly identified as medical technicians, physician assistants, or nurses with substantially more frequency than males, despite being clothed in the traditional physician garb. Several other publications on the subject have uncovered implicit bias, though it is rarely, if ever, the principle focus of the study.^10,24,25 As is unfortunately true in many professions, female physicians and physicians from ethnic minorities face barriers to being perceived as fully competent physicians.

Impact of the COVID-19 Pandemic

Finally, of course, there is the ever-present question of the effect of the pandemic. Although the exact role of the white coat as a fomite for infection—and especially for the spread of viral illness—remains controversial, the perception nonetheless has helped catalyze the movement to alternatives such as short-sleeved white coats, technical jackets, and more recently, fitted scrubs.^26-29 As with much in this realm, facts seem less important than perceptions; Zahrina et al³⁰ found that when patients were presented with information regarding the risk for microbial contamination associated with white coats, preference for physicians in professional garb plummeted from 72% to only 22%. To date no articles have examined patient perceptions of the white coat in the context of microbial transmission in the age of COVID-19, but future articles on this topic are likely and may serve to further the demise of the white coat.

Final Thoughts

From my vantage point, it seems the white coat will be claimed by the outgoing tide. During this most recent residency interview season, I do not recall a single medical student wearing a short white coat. The closest I came was a quick glimpse of a crumpled white jacket slung over an arm or stuffed in a shoulder bag. Rotating interns and residents from other services on rotation in our department present in softshell or fleece jackets. Fitted scrubs in the newest trendy colors speckle a previously all-white canvas. I, for one, have not donned my own white coat in at least a year, and perhaps it is all for the best. Physician attire is one small aspect of the practice of medicine and likely bears little, if any, relation to the wearer’s qualifications. Our focus should be on building rapport with our patients, providing high-quality care, reducing the risk for nosocomial infection, and developing a health care system that is fair and equitable for patients and health care workers alike, not on who is wearing what. Perhaps the introduction of new physician attire is a small part of the disruption we need to help address persistent gender and racial biases in our field and help shepherd our patients and colleagues to a worldview that is more open and accepting of physicians of diverse backgrounds.

The White Coat Ceremony is an enduring memory from my medical school years. Amidst the tumult of memories of seemingly endless sleepless nights spent in libraries and cramming for clerkship examinations between surgical cases, I recall a sunny spring day in 2016 where I gathered with my classmates, family, and friends in the medical school campus courtyard. There were several short, mostly forgotten speeches after which proud fathers and mothers, partners, or siblings slipped the all-important white coat onto the shoulders of the physicians-to-be. At that moment, I felt the weight of tradition centuries in the making resting on my shoulders. Of course, the pomp of the ceremony might have felt a tad overblown had I known that the whole thing had fewer years under its belt than the movie Die Hard.

That’s right, the first White Coat Ceremony was held 5 years after the release of that Bruce Willis classic. Dr. Arnold Gold, a pediatric neurologist on faculty at Columbia University, conceived the ceremony in 1993, and it spread rapidly to medical schools—and later nursing schools—across the United States.¹ Although the values highlighted by the White Coat Ceremony—humanism and compassion in medicine—are timeless, the ceremony itself is a more modern undertaking. What, then, of the white coat itself? Is it the timeless symbol of doctoring—of medicine—that we all presume it to be? Or is it a symbol of modern marketing, just a trend that caught on? And is it encountering its twilight—as trends often do—in the face of changing fashion and, more fundamentally, in changes to who our physicians are and to their roles in our society?

The Cleanliness of the White Coat

Until the end of the 19th century, physicians in the Western world most frequently dressed in black formal wear. The rationale behind this attire seems to have been twofold. First, society as a whole perceived the physician’s work as a serious and formal matter, and any medical encounter had to reflect the gravity of the occasion. Additionally, physicians’ visits often were a portent of impending demise, as physicians in the era prior to antibiotics and antisepsis frequently had little to offer their patients outside of—at best—anecdotal treatments and—at worst—sheer quackery.² Black may have seemed a respectful choice for patients who likely faced dire outcomes regardless of the treatment afforded.³

With the turn of the century came a new understanding of the concepts of antisepsis and disease transmission. While Joseph Lister first published on the use of antisepsis in 1867, his practices did not become commonplace until the early 1900s.⁴ Around the same time came the Flexner report,⁵ the publication of William Osler’s Principles and Practice of Medicine,⁶ and the establishment of the modern medical residency, all of which contributed to the shift from the patient’s own bedside and to the hospital as the house of medicine, with cleanliness and antisepsis as part of its core principles.⁷ The white coat arose as a symbol of purity and freedom from disease. Throughout the 20th century and into the 21st, it has remained the predominant symbol of cleanliness and professionalism for the medical practitioner.

Patient Preference of Physician Attire

Although the white coat may serve as a professional symbol and is well respected medicine, it also plays an important role in the layperson’s perception of their health care providers.⁸ There is little denying that patients prefer their physicians, almost uniformly, to wear a white coat. A systematic review of physician attire that included 30 studies mainly from North America, Europe, and the United Kingdom found that patient preference for formal attire and white coats is near universal.⁹ Patients routinely rate physicians wearing a white coat as more intelligent and trustworthy and feel more confident in the care they will receive.^10-13 They also freely admit that a physician’s appearance influences their satisfaction with their care.¹⁴ The recent adoption of the fleece, or softshell, jacket has not yet pervaded patients’ perceptions of what is considered appropriate physician attire. A 500-respondent survey found that patients were more likely to rate a model wearing a white coat as more professional and experienced compared to the same model wearing a fleece or softshell jacket or other formal attire sans white coat.¹⁵

Closer examination of the same data, however, reveals results reproduced with startling consistency across several studies, which suggest those of us adopting other attire need not dig those white coats out of the closet just yet. First, while many studies point to patient preference for white coats, this preference is uniformly strongest in older patients, beginning around age 40 years and becoming an entrenched preference in those older than 65 years.^9,14,16-18 On the other hand, younger patient populations display little to no such preference, and some studies indicate that younger patients actually prefer scrubs over formal attire in specific settings such as surgical offices, procedural spaces, or the emergency department.^12,14,19 This suggests that bias in favor of traditional physician garb may be more linked to age demographics and may continue to shift as the overall population ages. Additionally, although patients might profess a strong preference for physician attire in theory, it often does not translate into any impact on the patient’s perception of the physician following a clinic visit. The large systematic review on the topic noted that only 25% of studies that surveyed patients about a clinical visit following the encounter reported that physician attire influenced their satisfaction with that visit, suggesting that attire may be less likely to influence patients in the real-world context of receiving care.⁹ In fact, a prospective study of patient perception of medical staff and interactions found that staff style of dress not only had no bearing on the perception of staff or visit satisfaction but that patients often failed to even accurately recall physician attire when surveyed.²⁰ Another survey study echoed these conclusions, finding that physician attire had no effect on the perception of a proposed treatment plan.²¹

What do we know about patient perception of physician attire in the dermatology setting specifically, where visits can be unique in their tendency to transition from medical to procedural in the span of a 15-minute encounter depending on the patient’s chief concern? A survey study of dermatology patients at the general, surgical, and wound care dermatology clinics of an academic medical center (Miami, Florida) found that professional attire with a white coat was strongly preferred across a litany of scenarios assessing many aspects of dermatologic care.²¹ Similarly, a study of patients visiting a single institution’s dermatology and pediatric dermatology clinics surveyed patients and parents regarding attire prior to an appointment and specifically asked if a white coat should be worn.¹³ Fifty-four percent of the adult patients (n=176) surveyed professed a preference for physicians in white coats, with a stronger preference for white coats reported by those 50 years and older (55%; n=113). Parents or guardians presenting to the pediatric dermatology clinic, on the other hand, favored less formal attire.¹³ A recent, real-world study performed at an outpatient dermatology clinic examined the influence of changing physician attire on a patient’s perceptions of care received during clinic encounters. They found no substantial difference in patient satisfaction scores before and following the adoption of a new clinic uniform that transitioned from formal attire to fitted scrubs.²²

 

 

Racial and Gender Bias Affecting Attire Preference

With any study of preference, there is the underlying concern over respondent bias. Many of the studies discussed here have found secondarily that a patient’s implicit bias does not end at the clothes their physician is wearing. The survey study of dermatology patients from the academic medical center in Miami, Florida, found that patients preferred that Black physicians of either sex be garbed in professional attire at all times but generally were more accepting of White physicians in less formal attire.²¹ Adamson et al²³ published a response to the study’s findings urging dermatologists to recognize that a physician’s race and gender influence patients’ perceptions in much the same way that physician attire seems to and encouraged the development of a more diverse dermatologic workforce to help combat this prejudice. The issue of bias is not limited to the specialty of dermatology; the recent survey study by Xun et al¹⁵ found that respondents consistently rated female models garbed in physician attire as less professional than male model counterparts. Additionally, female models wearing white coats were mistakenly identified as medical technicians, physician assistants, or nurses with substantially more frequency than males, despite being clothed in the traditional physician garb. Several other publications on the subject have uncovered implicit bias, though it is rarely, if ever, the principle focus of the study.^10,24,25 As is unfortunately true in many professions, female physicians and physicians from ethnic minorities face barriers to being perceived as fully competent physicians.

Impact of the COVID-19 Pandemic

Finally, of course, there is the ever-present question of the effect of the pandemic. Although the exact role of the white coat as a fomite for infection—and especially for the spread of viral illness—remains controversial, the perception nonetheless has helped catalyze the movement to alternatives such as short-sleeved white coats, technical jackets, and more recently, fitted scrubs.^26-29 As with much in this realm, facts seem less important than perceptions; Zahrina et al³⁰ found that when patients were presented with information regarding the risk for microbial contamination associated with white coats, preference for physicians in professional garb plummeted from 72% to only 22%. To date no articles have examined patient perceptions of the white coat in the context of microbial transmission in the age of COVID-19, but future articles on this topic are likely and may serve to further the demise of the white coat.

Final Thoughts

From my vantage point, it seems the white coat will be claimed by the outgoing tide. During this most recent residency interview season, I do not recall a single medical student wearing a short white coat. The closest I came was a quick glimpse of a crumpled white jacket slung over an arm or stuffed in a shoulder bag. Rotating interns and residents from other services on rotation in our department present in softshell or fleece jackets. Fitted scrubs in the newest trendy colors speckle a previously all-white canvas. I, for one, have not donned my own white coat in at least a year, and perhaps it is all for the best. Physician attire is one small aspect of the practice of medicine and likely bears little, if any, relation to the wearer’s qualifications. Our focus should be on building rapport with our patients, providing high-quality care, reducing the risk for nosocomial infection, and developing a health care system that is fair and equitable for patients and health care workers alike, not on who is wearing what. Perhaps the introduction of new physician attire is a small part of the disruption we need to help address persistent gender and racial biases in our field and help shepherd our patients and colleagues to a worldview that is more open and accepting of physicians of diverse backgrounds.

Key clinical point: Compared with the general population, patients with multiple sclerosis (MS) may be at a slightly higher risk of developing myocardial infarction (MI) but not stroke.

Major finding: An increased risk for MI was found to be causally associated with MS (odds ratio [OR], 1.03; P = .0243). MS and stroke showed no significant causal association (OR, 1.01; P = .2974).

Study details: This was a 2-sample Mendelian randomization analysis of genetic summary data for MS (14,498 patients and 24,091 healthy controls), MI (43,676 patients and 128,199 healthy controls), and stroke (40,585 patients and 446,696 healthy controls) from large-scale genome-wide association studies.

Disclosures: The study was supported by Cultivation of Guangdong College Students' Scientific and Technological Innovation. The authors declared no conflict of interests.

Source: Peng H et al. Mult Scler Relat Disord. 2022 Jan 6. doi: 10.1016/j.msard.2022.103501.

Key clinical point: Compared with the general population, patients with multiple sclerosis (MS) may be at a slightly higher risk of developing myocardial infarction (MI) but not stroke.

Major finding: An increased risk for MI was found to be causally associated with MS (odds ratio [OR], 1.03; P = .0243). MS and stroke showed no significant causal association (OR, 1.01; P = .2974).

Study details: This was a 2-sample Mendelian randomization analysis of genetic summary data for MS (14,498 patients and 24,091 healthy controls), MI (43,676 patients and 128,199 healthy controls), and stroke (40,585 patients and 446,696 healthy controls) from large-scale genome-wide association studies.

Disclosures: The study was supported by Cultivation of Guangdong College Students' Scientific and Technological Innovation. The authors declared no conflict of interests.

Source: Peng H et al. Mult Scler Relat Disord. 2022 Jan 6. doi: 10.1016/j.msard.2022.103501.

Key clinical point: Compared with the general population, patients with multiple sclerosis (MS) may be at a slightly higher risk of developing myocardial infarction (MI) but not stroke.

Major finding: An increased risk for MI was found to be causally associated with MS (odds ratio [OR], 1.03; P = .0243). MS and stroke showed no significant causal association (OR, 1.01; P = .2974).

Study details: This was a 2-sample Mendelian randomization analysis of genetic summary data for MS (14,498 patients and 24,091 healthy controls), MI (43,676 patients and 128,199 healthy controls), and stroke (40,585 patients and 446,696 healthy controls) from large-scale genome-wide association studies.

Disclosures: The study was supported by Cultivation of Guangdong College Students' Scientific and Technological Innovation. The authors declared no conflict of interests.

Source: Peng H et al. Mult Scler Relat Disord. 2022 Jan 6. doi: 10.1016/j.msard.2022.103501.