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Quebec plans to fine unvaccinated adults
The amount hasn’t been decided yet, but it will be “significant” and more than $100. More details will be released at a later date, The Associated Press reported.
“Those who refuse to get their first doses in the coming weeks will have to pay a new health contribution,” Premier Francois Legault said during a news conference.
Not getting vaccinated burdens the health care system, and not all residents should pay for it, he said. About 10% of adults in Quebec are unvaccinated, but they represent about 50% of intensive care patients.
“I think it’s reasonable a majority of the population is asking that there be consequences,” he said. “It’s a question of fairness for the 90% of the population that have made some sacrifices. We owe them.”
The fine will apply to those who don’t qualify for a medical exemption, Mr. Legault said.
Provinces across Canada have reported a surge in COVID-19 cases due to the Omicron variant, with Quebec being one of the hardest-hit, according to Reuters. The province is regularly recording the highest daily case count across the country.
Quebec also has announced a 10 p.m. to 5 a.m. curfew, the AP reported. Starting Jan. 18, liquor and cannabis stores in the province will require proof of vaccination, and shopping malls and hair salons could soon require them as well.
About a quarter of all Canadians live in Quebec, according to CNN. The province was one of the first in Canada to require proof of vaccination for residents to eat in restaurants, go to the gym, or attend sporting events.
Some European countries have announced fees for unvaccinated residents, the AP reported, but Quebec is the first in Canada to announce a financial penalty for those who don’t get a shot.
In Greece, people older than 60 have until Jan. 16 to receive the first dose, or they will be fined 100 euros for every month they remain unvaccinated, the AP reported.
Austria will impose fines up to 3,600 euros for those who don’t follow the vaccine mandate for ages 14 and older, which is slated to start in February.
In Italy, residents who are 50 and older are required to be vaccinated. In mid-February, those who are unvaccinated could be fined up to 1,600 euros if they enter their workplaces, the AP reported.
A version of this article first appeared on WebMD.com.
The amount hasn’t been decided yet, but it will be “significant” and more than $100. More details will be released at a later date, The Associated Press reported.
“Those who refuse to get their first doses in the coming weeks will have to pay a new health contribution,” Premier Francois Legault said during a news conference.
Not getting vaccinated burdens the health care system, and not all residents should pay for it, he said. About 10% of adults in Quebec are unvaccinated, but they represent about 50% of intensive care patients.
“I think it’s reasonable a majority of the population is asking that there be consequences,” he said. “It’s a question of fairness for the 90% of the population that have made some sacrifices. We owe them.”
The fine will apply to those who don’t qualify for a medical exemption, Mr. Legault said.
Provinces across Canada have reported a surge in COVID-19 cases due to the Omicron variant, with Quebec being one of the hardest-hit, according to Reuters. The province is regularly recording the highest daily case count across the country.
Quebec also has announced a 10 p.m. to 5 a.m. curfew, the AP reported. Starting Jan. 18, liquor and cannabis stores in the province will require proof of vaccination, and shopping malls and hair salons could soon require them as well.
About a quarter of all Canadians live in Quebec, according to CNN. The province was one of the first in Canada to require proof of vaccination for residents to eat in restaurants, go to the gym, or attend sporting events.
Some European countries have announced fees for unvaccinated residents, the AP reported, but Quebec is the first in Canada to announce a financial penalty for those who don’t get a shot.
In Greece, people older than 60 have until Jan. 16 to receive the first dose, or they will be fined 100 euros for every month they remain unvaccinated, the AP reported.
Austria will impose fines up to 3,600 euros for those who don’t follow the vaccine mandate for ages 14 and older, which is slated to start in February.
In Italy, residents who are 50 and older are required to be vaccinated. In mid-February, those who are unvaccinated could be fined up to 1,600 euros if they enter their workplaces, the AP reported.
A version of this article first appeared on WebMD.com.
The amount hasn’t been decided yet, but it will be “significant” and more than $100. More details will be released at a later date, The Associated Press reported.
“Those who refuse to get their first doses in the coming weeks will have to pay a new health contribution,” Premier Francois Legault said during a news conference.
Not getting vaccinated burdens the health care system, and not all residents should pay for it, he said. About 10% of adults in Quebec are unvaccinated, but they represent about 50% of intensive care patients.
“I think it’s reasonable a majority of the population is asking that there be consequences,” he said. “It’s a question of fairness for the 90% of the population that have made some sacrifices. We owe them.”
The fine will apply to those who don’t qualify for a medical exemption, Mr. Legault said.
Provinces across Canada have reported a surge in COVID-19 cases due to the Omicron variant, with Quebec being one of the hardest-hit, according to Reuters. The province is regularly recording the highest daily case count across the country.
Quebec also has announced a 10 p.m. to 5 a.m. curfew, the AP reported. Starting Jan. 18, liquor and cannabis stores in the province will require proof of vaccination, and shopping malls and hair salons could soon require them as well.
About a quarter of all Canadians live in Quebec, according to CNN. The province was one of the first in Canada to require proof of vaccination for residents to eat in restaurants, go to the gym, or attend sporting events.
Some European countries have announced fees for unvaccinated residents, the AP reported, but Quebec is the first in Canada to announce a financial penalty for those who don’t get a shot.
In Greece, people older than 60 have until Jan. 16 to receive the first dose, or they will be fined 100 euros for every month they remain unvaccinated, the AP reported.
Austria will impose fines up to 3,600 euros for those who don’t follow the vaccine mandate for ages 14 and older, which is slated to start in February.
In Italy, residents who are 50 and older are required to be vaccinated. In mid-February, those who are unvaccinated could be fined up to 1,600 euros if they enter their workplaces, the AP reported.
A version of this article first appeared on WebMD.com.
Patient with tachycardia
On the basis of the patient's personal and family history together with his presentation, the likely diagnosis is latent autoimmune diabetes in adults (LADA). LADA is characterized by beta-cell loss and insulin resistance. This slowly evolving form of autoimmune diabetes comprises 2%-12% of all patients with adult-onset diabetes. Patients with LADA present with evidence of autoimmunity and varying C-peptide levels, which decrease more slowly in this subgroup than in patients with type 1 diabetes (T1D). They also have immunogenic markers associated with T1D, primarily anti-glutamic acid decarboxylase (GAD) antibodies.
Patients with LADA are often misdiagnosed as having T2D. The clinical picture of LADA overlaps with that of T2D, with patients being insulin resistant and often overweight. In addition, presenting symptoms of LADA — excessive thirst, blurred vision, and high blood glucose — are also seen in T2D. Although LADA is technically classified as T1D, some groups posit that the condition exists on a spectrum between T1D and T2D. Compared with patients with T2D, those with LADA are generally younger at diagnosis (often in their 30s), have lower BMI, and report a personal or family history of autoimmune diseases, such as the patient in this quiz. Throughout the disease course, individuals with LADA show a reduced frequency of metabolic syndrome compared with those with T2D.
Key to diagnosis is the absence of insulin requirement for at least 6 months. Anti-GAD antibodies are the most sensitive marker for LADA; other autoantibodies that occur less frequently include ICA, IA-2A, ZnT8A, and tetraspanin 7 autoantibodies. With a paucity of large-scale clinical trials in LADA, current treatment strategies are not based on consensus guidelines, though an expert panel has published management recommendations. Category 1 patients (defined as a C-peptide level < 0.3 nmol/L) are treated with intensive insulin therapy. The recommendation for category 2 patients (defined as C-peptide values ≥ 0.3 and ≤ 0.7 nmol/L) is a modified American Diabetes Association/European Association for the Study of Diabetes algorithm for T2D. However, patients with category 2 LADA may need to initiate insulin therapy earlier to combat beta-cell failure (ostensibly because LADA is an autoimmune disease beta-cell function declines much faster than in T2D). For category 3 patients (defined as C-peptide values > 0.7 nmol/L), treatment decisions are made in response to changing C-peptide levels.
Romesh K. Khardori, MD, PhD, Professor, Department of Internal Medicine, Division of Diabetes, Endocrine, and Metabolic Disorders, Eastern Virginia Medical School; EVMS Medical Group, Norfolk, Virginia.
Romesh K. Khardori, MD, PhD, has disclosed no relevant financial relationships.
On the basis of the patient's personal and family history together with his presentation, the likely diagnosis is latent autoimmune diabetes in adults (LADA). LADA is characterized by beta-cell loss and insulin resistance. This slowly evolving form of autoimmune diabetes comprises 2%-12% of all patients with adult-onset diabetes. Patients with LADA present with evidence of autoimmunity and varying C-peptide levels, which decrease more slowly in this subgroup than in patients with type 1 diabetes (T1D). They also have immunogenic markers associated with T1D, primarily anti-glutamic acid decarboxylase (GAD) antibodies.
Patients with LADA are often misdiagnosed as having T2D. The clinical picture of LADA overlaps with that of T2D, with patients being insulin resistant and often overweight. In addition, presenting symptoms of LADA — excessive thirst, blurred vision, and high blood glucose — are also seen in T2D. Although LADA is technically classified as T1D, some groups posit that the condition exists on a spectrum between T1D and T2D. Compared with patients with T2D, those with LADA are generally younger at diagnosis (often in their 30s), have lower BMI, and report a personal or family history of autoimmune diseases, such as the patient in this quiz. Throughout the disease course, individuals with LADA show a reduced frequency of metabolic syndrome compared with those with T2D.
Key to diagnosis is the absence of insulin requirement for at least 6 months. Anti-GAD antibodies are the most sensitive marker for LADA; other autoantibodies that occur less frequently include ICA, IA-2A, ZnT8A, and tetraspanin 7 autoantibodies. With a paucity of large-scale clinical trials in LADA, current treatment strategies are not based on consensus guidelines, though an expert panel has published management recommendations. Category 1 patients (defined as a C-peptide level < 0.3 nmol/L) are treated with intensive insulin therapy. The recommendation for category 2 patients (defined as C-peptide values ≥ 0.3 and ≤ 0.7 nmol/L) is a modified American Diabetes Association/European Association for the Study of Diabetes algorithm for T2D. However, patients with category 2 LADA may need to initiate insulin therapy earlier to combat beta-cell failure (ostensibly because LADA is an autoimmune disease beta-cell function declines much faster than in T2D). For category 3 patients (defined as C-peptide values > 0.7 nmol/L), treatment decisions are made in response to changing C-peptide levels.
Romesh K. Khardori, MD, PhD, Professor, Department of Internal Medicine, Division of Diabetes, Endocrine, and Metabolic Disorders, Eastern Virginia Medical School; EVMS Medical Group, Norfolk, Virginia.
Romesh K. Khardori, MD, PhD, has disclosed no relevant financial relationships.
On the basis of the patient's personal and family history together with his presentation, the likely diagnosis is latent autoimmune diabetes in adults (LADA). LADA is characterized by beta-cell loss and insulin resistance. This slowly evolving form of autoimmune diabetes comprises 2%-12% of all patients with adult-onset diabetes. Patients with LADA present with evidence of autoimmunity and varying C-peptide levels, which decrease more slowly in this subgroup than in patients with type 1 diabetes (T1D). They also have immunogenic markers associated with T1D, primarily anti-glutamic acid decarboxylase (GAD) antibodies.
Patients with LADA are often misdiagnosed as having T2D. The clinical picture of LADA overlaps with that of T2D, with patients being insulin resistant and often overweight. In addition, presenting symptoms of LADA — excessive thirst, blurred vision, and high blood glucose — are also seen in T2D. Although LADA is technically classified as T1D, some groups posit that the condition exists on a spectrum between T1D and T2D. Compared with patients with T2D, those with LADA are generally younger at diagnosis (often in their 30s), have lower BMI, and report a personal or family history of autoimmune diseases, such as the patient in this quiz. Throughout the disease course, individuals with LADA show a reduced frequency of metabolic syndrome compared with those with T2D.
Key to diagnosis is the absence of insulin requirement for at least 6 months. Anti-GAD antibodies are the most sensitive marker for LADA; other autoantibodies that occur less frequently include ICA, IA-2A, ZnT8A, and tetraspanin 7 autoantibodies. With a paucity of large-scale clinical trials in LADA, current treatment strategies are not based on consensus guidelines, though an expert panel has published management recommendations. Category 1 patients (defined as a C-peptide level < 0.3 nmol/L) are treated with intensive insulin therapy. The recommendation for category 2 patients (defined as C-peptide values ≥ 0.3 and ≤ 0.7 nmol/L) is a modified American Diabetes Association/European Association for the Study of Diabetes algorithm for T2D. However, patients with category 2 LADA may need to initiate insulin therapy earlier to combat beta-cell failure (ostensibly because LADA is an autoimmune disease beta-cell function declines much faster than in T2D). For category 3 patients (defined as C-peptide values > 0.7 nmol/L), treatment decisions are made in response to changing C-peptide levels.
Romesh K. Khardori, MD, PhD, Professor, Department of Internal Medicine, Division of Diabetes, Endocrine, and Metabolic Disorders, Eastern Virginia Medical School; EVMS Medical Group, Norfolk, Virginia.
Romesh K. Khardori, MD, PhD, has disclosed no relevant financial relationships.
A 33-year-old man presents with blurred vision and tachycardia. Physical examination is remarkable for a BMI of 27 kg/m2. The patient explains that he feels he has lost weight. However, he attributes this change to a new exercise regimen he undertook when he was diagnosed with type 2 diabetes (T2D) about 8 months ago. The patient also notes polydipsia over a series of weeks. He reports that his first cousin may have lupus, though her diagnosis is still uncertain. Axial noncontrast CT demonstrates hyperattenuation that is more pronounced on the left side and involves the lentiform and caudate nuclei bilaterally.
CDC to update mask recommendations as Omicron spreads
Director Rochelle Walensky, MD, said on Jan. 12.
“We are preparing an update to the info on our mask website to best reflect the options that are available to people and the different levels of protection different masks provide, and we want to provide Americans the best and most updated information to choose what mask is going to be right for them,” she said at a White House news briefing.
While the higher-quality masks provide better protection, they can be uncomfortable to wear, expensive, and harder to find. That’s why Dr. Walensky added an important caveat.
“Any mask is better than no mask, and we do encourage all Americans to wear a well-fitting mask to protect themselves and prevent the spread of COVID-19. That recommendation is not going to change,” she said.
“Most importantly, the best mask that you wear is the one you will wear and the one you can keep on all day long and tolerate in public indoor settings.”
Meanwhile, the World Health Organization was more focused on vaccines.
WHO officials stressed on Jan. 12 that global vaccine distribution is first priority in defeating the highly contagious Omicron variant, as well as other variants that may evolve.
The WHO’s Technical Advisory Group on COVID-19 Vaccine Composition – a group of experts assessing how COVID-19 vaccines perform against Omicron and other emerging variants – says there is an “urgent need” for broader access to vaccines, along with reviewing and updating current vaccines as needed to ensure protection.
The WHO also disputed the idea that COVID-19 could become endemic in one largely vaccinated nation, while the rest of the world remains unprotected.
“It is up to us how this pandemic unfolds,” Maria Van Kerkhove, PhD, the WHO’s technical lead on COVID-19 response, said at a news briefing.
The WHO has a goal of vaccinating 70% of the population of every country by the middle of the year.
But right now, 90 countries have yet to reach 40% vaccination rates, and 36 of those countries have less than 10% of their populations vaccinated, according to WHO Director General Tedros Adhanom Ghebreyesus, PhD.
A staggering 85% of the African population has not received a first dose.
But progress is being made, Dr. Ghebreyesus said at the briefing.
The WHO said there were over 15 million COVID-19 cases reported last week – the most ever in a single week – and this is likely an underestimate.
The Omicron variant, first identified in South Africa 2 months ago and now found on all seven continents, is “rapidly replacing Delta in almost all countries,” Dr. Ghebreyesus said.
Dr. Walensky said this week’s U.S. daily average COVID-19 case count was 751,000, an increase of 47% from last week. The average daily hospital admissions this week is 19,800, an increase of 33%. Deaths are up 40%, reaching 1,600 per day.
But she also reported new data that supports other research showing Omicron may produce less severe disease. Kaiser Permanente Southern California released a study on Jan. 11 showing that, compared with Delta infections, Omicron was associated with a 53% reduction in hospitalizations, a 74% reduction in intensive care unit admissions, and a 91% lower risk of death.
In the study, no patients with Omicron required mechanical ventilation. The strain now accounts for 98% of cases nationwide.
But Dr. Walensky warned the lower disease severity is not enough to make up for the sheer number of cases that continue to overwhelm hospital systems.
“While we are seeing early evidence that Omicron is less severe than Delta and that those infected are less likely to require hospitalization, it’s important to note that Omicron continues to be much more transmissible than Delta,” she said. “The sudden rise in cases due to Omicron is resulting in unprecedented daily case counts, sickness, absenteeism, and strains on our health care system.”
A version of this article first appeared on WebMD.com.
Director Rochelle Walensky, MD, said on Jan. 12.
“We are preparing an update to the info on our mask website to best reflect the options that are available to people and the different levels of protection different masks provide, and we want to provide Americans the best and most updated information to choose what mask is going to be right for them,” she said at a White House news briefing.
While the higher-quality masks provide better protection, they can be uncomfortable to wear, expensive, and harder to find. That’s why Dr. Walensky added an important caveat.
“Any mask is better than no mask, and we do encourage all Americans to wear a well-fitting mask to protect themselves and prevent the spread of COVID-19. That recommendation is not going to change,” she said.
“Most importantly, the best mask that you wear is the one you will wear and the one you can keep on all day long and tolerate in public indoor settings.”
Meanwhile, the World Health Organization was more focused on vaccines.
WHO officials stressed on Jan. 12 that global vaccine distribution is first priority in defeating the highly contagious Omicron variant, as well as other variants that may evolve.
The WHO’s Technical Advisory Group on COVID-19 Vaccine Composition – a group of experts assessing how COVID-19 vaccines perform against Omicron and other emerging variants – says there is an “urgent need” for broader access to vaccines, along with reviewing and updating current vaccines as needed to ensure protection.
The WHO also disputed the idea that COVID-19 could become endemic in one largely vaccinated nation, while the rest of the world remains unprotected.
“It is up to us how this pandemic unfolds,” Maria Van Kerkhove, PhD, the WHO’s technical lead on COVID-19 response, said at a news briefing.
The WHO has a goal of vaccinating 70% of the population of every country by the middle of the year.
But right now, 90 countries have yet to reach 40% vaccination rates, and 36 of those countries have less than 10% of their populations vaccinated, according to WHO Director General Tedros Adhanom Ghebreyesus, PhD.
A staggering 85% of the African population has not received a first dose.
But progress is being made, Dr. Ghebreyesus said at the briefing.
The WHO said there were over 15 million COVID-19 cases reported last week – the most ever in a single week – and this is likely an underestimate.
The Omicron variant, first identified in South Africa 2 months ago and now found on all seven continents, is “rapidly replacing Delta in almost all countries,” Dr. Ghebreyesus said.
Dr. Walensky said this week’s U.S. daily average COVID-19 case count was 751,000, an increase of 47% from last week. The average daily hospital admissions this week is 19,800, an increase of 33%. Deaths are up 40%, reaching 1,600 per day.
But she also reported new data that supports other research showing Omicron may produce less severe disease. Kaiser Permanente Southern California released a study on Jan. 11 showing that, compared with Delta infections, Omicron was associated with a 53% reduction in hospitalizations, a 74% reduction in intensive care unit admissions, and a 91% lower risk of death.
In the study, no patients with Omicron required mechanical ventilation. The strain now accounts for 98% of cases nationwide.
But Dr. Walensky warned the lower disease severity is not enough to make up for the sheer number of cases that continue to overwhelm hospital systems.
“While we are seeing early evidence that Omicron is less severe than Delta and that those infected are less likely to require hospitalization, it’s important to note that Omicron continues to be much more transmissible than Delta,” she said. “The sudden rise in cases due to Omicron is resulting in unprecedented daily case counts, sickness, absenteeism, and strains on our health care system.”
A version of this article first appeared on WebMD.com.
Director Rochelle Walensky, MD, said on Jan. 12.
“We are preparing an update to the info on our mask website to best reflect the options that are available to people and the different levels of protection different masks provide, and we want to provide Americans the best and most updated information to choose what mask is going to be right for them,” she said at a White House news briefing.
While the higher-quality masks provide better protection, they can be uncomfortable to wear, expensive, and harder to find. That’s why Dr. Walensky added an important caveat.
“Any mask is better than no mask, and we do encourage all Americans to wear a well-fitting mask to protect themselves and prevent the spread of COVID-19. That recommendation is not going to change,” she said.
“Most importantly, the best mask that you wear is the one you will wear and the one you can keep on all day long and tolerate in public indoor settings.”
Meanwhile, the World Health Organization was more focused on vaccines.
WHO officials stressed on Jan. 12 that global vaccine distribution is first priority in defeating the highly contagious Omicron variant, as well as other variants that may evolve.
The WHO’s Technical Advisory Group on COVID-19 Vaccine Composition – a group of experts assessing how COVID-19 vaccines perform against Omicron and other emerging variants – says there is an “urgent need” for broader access to vaccines, along with reviewing and updating current vaccines as needed to ensure protection.
The WHO also disputed the idea that COVID-19 could become endemic in one largely vaccinated nation, while the rest of the world remains unprotected.
“It is up to us how this pandemic unfolds,” Maria Van Kerkhove, PhD, the WHO’s technical lead on COVID-19 response, said at a news briefing.
The WHO has a goal of vaccinating 70% of the population of every country by the middle of the year.
But right now, 90 countries have yet to reach 40% vaccination rates, and 36 of those countries have less than 10% of their populations vaccinated, according to WHO Director General Tedros Adhanom Ghebreyesus, PhD.
A staggering 85% of the African population has not received a first dose.
But progress is being made, Dr. Ghebreyesus said at the briefing.
The WHO said there were over 15 million COVID-19 cases reported last week – the most ever in a single week – and this is likely an underestimate.
The Omicron variant, first identified in South Africa 2 months ago and now found on all seven continents, is “rapidly replacing Delta in almost all countries,” Dr. Ghebreyesus said.
Dr. Walensky said this week’s U.S. daily average COVID-19 case count was 751,000, an increase of 47% from last week. The average daily hospital admissions this week is 19,800, an increase of 33%. Deaths are up 40%, reaching 1,600 per day.
But she also reported new data that supports other research showing Omicron may produce less severe disease. Kaiser Permanente Southern California released a study on Jan. 11 showing that, compared with Delta infections, Omicron was associated with a 53% reduction in hospitalizations, a 74% reduction in intensive care unit admissions, and a 91% lower risk of death.
In the study, no patients with Omicron required mechanical ventilation. The strain now accounts for 98% of cases nationwide.
But Dr. Walensky warned the lower disease severity is not enough to make up for the sheer number of cases that continue to overwhelm hospital systems.
“While we are seeing early evidence that Omicron is less severe than Delta and that those infected are less likely to require hospitalization, it’s important to note that Omicron continues to be much more transmissible than Delta,” she said. “The sudden rise in cases due to Omicron is resulting in unprecedented daily case counts, sickness, absenteeism, and strains on our health care system.”
A version of this article first appeared on WebMD.com.
Urine for a new vaccine alternative
Urine for a new vaccine alternative
Yep, you read that right: Another vaccine alternative. Urine sounds disgusting, but you’ve got to admit, it’s resourceful at least.
Christopher Key, the leader of a group of antivaxxers known as the “Vaccine Police,” is now claiming that you should do “urine therapy,” when means drinking your own pee to ward off COVID-19. According to My. Key, “tons and tons of research” shows the benefits of drinking urine to fight COVID-19, the Guardian reported.
He doesn’t seem like the best source of information, especially since he’s been arrested in the past for refusing to wear a mask in a store. Not wanting to wear a mask in a store doesn’t seem like much, but he also believes that those who administer the COVID-19 vaccine should be “executed” and he tried to impersonate a law official toattempt to arrest a Democratic governor for vaccine mandates.
The overwhelming amount of COVID-19 misinformation has been stressful, yet sometimes laugh-worthy. Urine is not the first “cure” and probably won’t be the last. If you heard something works in a sketchy group on Facebook, it’s probably safe to assume that it absolutely does not. Please don’t recycle your urine.
Vaccine or beer? You must now choose
As the COVID-19 pandemic drags on toward its third year, the large subset of the population who refuse to get vaccinated has proved nearly intractable. Governments have tried numerous incentives to boost vaccination rates, ranging from free beer to million dollar lotteries. Needless to say, beyond their ability to generate LOTME stories, these incentives have been less than effective.
As the frankly unfairly contagious Omicron variant makes it way through the world, our friends in the Great White North have decided enough is enough. If the carrot doesn’t work, the people of Quebec are going to get the stick. Starting on Jan. 18, vaccination cards will be required to enter stores that sell alcohol or cannabis, better known as the things that have gotten us all through this pandemic.
And you know what? Cutting off the booze supply seems to be working. Christian Dubé, Quebec’s health minister, said that the number of vaccination appointments had quadrupled in the new year, rising from 1,500 per day to 6,000 per day, according to the CTV News report. Now, those aren’t massive numbers, but this is big empty Canada we’re talking about, and the unvaccinated make up about 10% of Quebec’s population, so 6,000 a day is quite impressive.
Mr. Dubé added that additional nonessential businesses could be added to the restriction list in the coming weeks, but we’re not sure it’ll be necessary. Those middle-aged soccer moms will do anything to secure their daily merlot. Also, alcohol and cannabis nonessential? The LOTME staff is appalled and offended at this insinuation.
All I need is the polyester that I breathe
When you do laundry, you’re probably thinking more of how to get that ketchup stain out of your white shirt than the effect it has on the environment. Well, research shows it actually has some significance.
That significance comes in the form of microfibers, which are released from natural fabrics such as cotton and from synthetic fabrics such as polyester, which are also considered to be microplastics.
The microfibers that get released in the water when we wash clothes are filtered out eventually, but the dryer is the real culprit, according to a study in Environmental Science & Technology Letters. We’re talking a discharge of up to 120 million microfiber fragments directly into the air annually from just one dryer!
Dryers, they found, emitted between 1.4-40 times more microfibers than did washing machines in previous studies. And polyester fabrics produced more fragments when load sizes increased, while fragment production from cotton fabrics remained constant.
Recent findings suggest that inhaling these microfibers can cause lung inflammation, increase cancer risk, and induce asthma attacks. The authors of the current study suggested additional filtration should be done on dryer vents to reduce the amount of pollutants emitted into the air.
Who would have thought just drying your sheets could be such a dangerous act?
It’s always in the last place you look
At least a million times every morning in this country, a million children yell something like this as they get ready for school: “Mom, have you seen my ...?”
Well, thanks to Defector.com, now we know what Mom should yell back: “Look in your weird cousin Mortimer!”
We will explain ... again.
When they’re not dealing with COVID-19, the folks who work in emergency departments spend a lot of their time removing things that are stuck in people’s bodily orifices. The U.S. Consumer Product Safety Commission even keeps track of them.
So if you’re looking for the number 8 button from the TV remote, or maybe a bullet, check Mortimer’s nose. Maybe you’re missing a lollipop, a hairpin, or some espresso beans. Mortimer’s friend Beulah might have put them in her ear.
Has an earbud gone missing? Another friend of Mortimer’s went to the ED with something stuck in his throat and said that he had a “pill in one hand and his earbud in the other hand, got distracted and took the earbud instead.” Yes, that is an actual quote (via Defector) from the CPSC database.
What about that old saying that someone’s lost his marbles? Well, the ED found one of Mortimer’s marbles ... in his penis. Also a spork, and a bread twist tie, and a chopstick. No, not all at the same time. As for Beulah, a barbell and a Spider-Man action figure somehow found their way – not at the same time, thank goodness – into her vagina.
And have you ever heard someone say that they’re “not going to stand for this”? Mortimer has, so he sat down ... on a light bulb, and a rolling pin, and a billiard ball. Yup, the ED had to remove these items from his rectum.
But not all at the same time, thank goodness.
Urine for a new vaccine alternative
Yep, you read that right: Another vaccine alternative. Urine sounds disgusting, but you’ve got to admit, it’s resourceful at least.
Christopher Key, the leader of a group of antivaxxers known as the “Vaccine Police,” is now claiming that you should do “urine therapy,” when means drinking your own pee to ward off COVID-19. According to My. Key, “tons and tons of research” shows the benefits of drinking urine to fight COVID-19, the Guardian reported.
He doesn’t seem like the best source of information, especially since he’s been arrested in the past for refusing to wear a mask in a store. Not wanting to wear a mask in a store doesn’t seem like much, but he also believes that those who administer the COVID-19 vaccine should be “executed” and he tried to impersonate a law official toattempt to arrest a Democratic governor for vaccine mandates.
The overwhelming amount of COVID-19 misinformation has been stressful, yet sometimes laugh-worthy. Urine is not the first “cure” and probably won’t be the last. If you heard something works in a sketchy group on Facebook, it’s probably safe to assume that it absolutely does not. Please don’t recycle your urine.
Vaccine or beer? You must now choose
As the COVID-19 pandemic drags on toward its third year, the large subset of the population who refuse to get vaccinated has proved nearly intractable. Governments have tried numerous incentives to boost vaccination rates, ranging from free beer to million dollar lotteries. Needless to say, beyond their ability to generate LOTME stories, these incentives have been less than effective.
As the frankly unfairly contagious Omicron variant makes it way through the world, our friends in the Great White North have decided enough is enough. If the carrot doesn’t work, the people of Quebec are going to get the stick. Starting on Jan. 18, vaccination cards will be required to enter stores that sell alcohol or cannabis, better known as the things that have gotten us all through this pandemic.
And you know what? Cutting off the booze supply seems to be working. Christian Dubé, Quebec’s health minister, said that the number of vaccination appointments had quadrupled in the new year, rising from 1,500 per day to 6,000 per day, according to the CTV News report. Now, those aren’t massive numbers, but this is big empty Canada we’re talking about, and the unvaccinated make up about 10% of Quebec’s population, so 6,000 a day is quite impressive.
Mr. Dubé added that additional nonessential businesses could be added to the restriction list in the coming weeks, but we’re not sure it’ll be necessary. Those middle-aged soccer moms will do anything to secure their daily merlot. Also, alcohol and cannabis nonessential? The LOTME staff is appalled and offended at this insinuation.
All I need is the polyester that I breathe
When you do laundry, you’re probably thinking more of how to get that ketchup stain out of your white shirt than the effect it has on the environment. Well, research shows it actually has some significance.
That significance comes in the form of microfibers, which are released from natural fabrics such as cotton and from synthetic fabrics such as polyester, which are also considered to be microplastics.
The microfibers that get released in the water when we wash clothes are filtered out eventually, but the dryer is the real culprit, according to a study in Environmental Science & Technology Letters. We’re talking a discharge of up to 120 million microfiber fragments directly into the air annually from just one dryer!
Dryers, they found, emitted between 1.4-40 times more microfibers than did washing machines in previous studies. And polyester fabrics produced more fragments when load sizes increased, while fragment production from cotton fabrics remained constant.
Recent findings suggest that inhaling these microfibers can cause lung inflammation, increase cancer risk, and induce asthma attacks. The authors of the current study suggested additional filtration should be done on dryer vents to reduce the amount of pollutants emitted into the air.
Who would have thought just drying your sheets could be such a dangerous act?
It’s always in the last place you look
At least a million times every morning in this country, a million children yell something like this as they get ready for school: “Mom, have you seen my ...?”
Well, thanks to Defector.com, now we know what Mom should yell back: “Look in your weird cousin Mortimer!”
We will explain ... again.
When they’re not dealing with COVID-19, the folks who work in emergency departments spend a lot of their time removing things that are stuck in people’s bodily orifices. The U.S. Consumer Product Safety Commission even keeps track of them.
So if you’re looking for the number 8 button from the TV remote, or maybe a bullet, check Mortimer’s nose. Maybe you’re missing a lollipop, a hairpin, or some espresso beans. Mortimer’s friend Beulah might have put them in her ear.
Has an earbud gone missing? Another friend of Mortimer’s went to the ED with something stuck in his throat and said that he had a “pill in one hand and his earbud in the other hand, got distracted and took the earbud instead.” Yes, that is an actual quote (via Defector) from the CPSC database.
What about that old saying that someone’s lost his marbles? Well, the ED found one of Mortimer’s marbles ... in his penis. Also a spork, and a bread twist tie, and a chopstick. No, not all at the same time. As for Beulah, a barbell and a Spider-Man action figure somehow found their way – not at the same time, thank goodness – into her vagina.
And have you ever heard someone say that they’re “not going to stand for this”? Mortimer has, so he sat down ... on a light bulb, and a rolling pin, and a billiard ball. Yup, the ED had to remove these items from his rectum.
But not all at the same time, thank goodness.
Urine for a new vaccine alternative
Yep, you read that right: Another vaccine alternative. Urine sounds disgusting, but you’ve got to admit, it’s resourceful at least.
Christopher Key, the leader of a group of antivaxxers known as the “Vaccine Police,” is now claiming that you should do “urine therapy,” when means drinking your own pee to ward off COVID-19. According to My. Key, “tons and tons of research” shows the benefits of drinking urine to fight COVID-19, the Guardian reported.
He doesn’t seem like the best source of information, especially since he’s been arrested in the past for refusing to wear a mask in a store. Not wanting to wear a mask in a store doesn’t seem like much, but he also believes that those who administer the COVID-19 vaccine should be “executed” and he tried to impersonate a law official toattempt to arrest a Democratic governor for vaccine mandates.
The overwhelming amount of COVID-19 misinformation has been stressful, yet sometimes laugh-worthy. Urine is not the first “cure” and probably won’t be the last. If you heard something works in a sketchy group on Facebook, it’s probably safe to assume that it absolutely does not. Please don’t recycle your urine.
Vaccine or beer? You must now choose
As the COVID-19 pandemic drags on toward its third year, the large subset of the population who refuse to get vaccinated has proved nearly intractable. Governments have tried numerous incentives to boost vaccination rates, ranging from free beer to million dollar lotteries. Needless to say, beyond their ability to generate LOTME stories, these incentives have been less than effective.
As the frankly unfairly contagious Omicron variant makes it way through the world, our friends in the Great White North have decided enough is enough. If the carrot doesn’t work, the people of Quebec are going to get the stick. Starting on Jan. 18, vaccination cards will be required to enter stores that sell alcohol or cannabis, better known as the things that have gotten us all through this pandemic.
And you know what? Cutting off the booze supply seems to be working. Christian Dubé, Quebec’s health minister, said that the number of vaccination appointments had quadrupled in the new year, rising from 1,500 per day to 6,000 per day, according to the CTV News report. Now, those aren’t massive numbers, but this is big empty Canada we’re talking about, and the unvaccinated make up about 10% of Quebec’s population, so 6,000 a day is quite impressive.
Mr. Dubé added that additional nonessential businesses could be added to the restriction list in the coming weeks, but we’re not sure it’ll be necessary. Those middle-aged soccer moms will do anything to secure their daily merlot. Also, alcohol and cannabis nonessential? The LOTME staff is appalled and offended at this insinuation.
All I need is the polyester that I breathe
When you do laundry, you’re probably thinking more of how to get that ketchup stain out of your white shirt than the effect it has on the environment. Well, research shows it actually has some significance.
That significance comes in the form of microfibers, which are released from natural fabrics such as cotton and from synthetic fabrics such as polyester, which are also considered to be microplastics.
The microfibers that get released in the water when we wash clothes are filtered out eventually, but the dryer is the real culprit, according to a study in Environmental Science & Technology Letters. We’re talking a discharge of up to 120 million microfiber fragments directly into the air annually from just one dryer!
Dryers, they found, emitted between 1.4-40 times more microfibers than did washing machines in previous studies. And polyester fabrics produced more fragments when load sizes increased, while fragment production from cotton fabrics remained constant.
Recent findings suggest that inhaling these microfibers can cause lung inflammation, increase cancer risk, and induce asthma attacks. The authors of the current study suggested additional filtration should be done on dryer vents to reduce the amount of pollutants emitted into the air.
Who would have thought just drying your sheets could be such a dangerous act?
It’s always in the last place you look
At least a million times every morning in this country, a million children yell something like this as they get ready for school: “Mom, have you seen my ...?”
Well, thanks to Defector.com, now we know what Mom should yell back: “Look in your weird cousin Mortimer!”
We will explain ... again.
When they’re not dealing with COVID-19, the folks who work in emergency departments spend a lot of their time removing things that are stuck in people’s bodily orifices. The U.S. Consumer Product Safety Commission even keeps track of them.
So if you’re looking for the number 8 button from the TV remote, or maybe a bullet, check Mortimer’s nose. Maybe you’re missing a lollipop, a hairpin, or some espresso beans. Mortimer’s friend Beulah might have put them in her ear.
Has an earbud gone missing? Another friend of Mortimer’s went to the ED with something stuck in his throat and said that he had a “pill in one hand and his earbud in the other hand, got distracted and took the earbud instead.” Yes, that is an actual quote (via Defector) from the CPSC database.
What about that old saying that someone’s lost his marbles? Well, the ED found one of Mortimer’s marbles ... in his penis. Also a spork, and a bread twist tie, and a chopstick. No, not all at the same time. As for Beulah, a barbell and a Spider-Man action figure somehow found their way – not at the same time, thank goodness – into her vagina.
And have you ever heard someone say that they’re “not going to stand for this”? Mortimer has, so he sat down ... on a light bulb, and a rolling pin, and a billiard ball. Yup, the ED had to remove these items from his rectum.
But not all at the same time, thank goodness.
Plaque on heel
Physical exam revealed a plaque with multiple verrucous projections and clusters of smaller circular papules, all with associated thrombosed vessels. The plaque interrupted normal skin lines, consistent with a large, benign, plantar wart, also termed a mosaic wart when clusters of individual plantar warts form a single plaque.
Mosaic warts are caused by infection with human papillomavirus (HPV). They begin as individual papules or macules with a rough surface and small pinpoint capillaries. Plantar warts can be painful if located over a weight-bearing area of the foot. Plantar warts spread by autoinoculation from microtrauma to the foot. Picking at the wart, having it rub against a shoe insert, or exposing it to contaminated surfaces (such as a shower floor) can lead to the wart’s spread. Usually, the diagnosis of a plantar wart is based on clinical examination, with the main differential including a corn or callus. However, rare instances of squamous cell carcinoma or arsenical keratoses can mimic a plantar wart.
Although plantar warts can resolve spontaneously over months or years, patients often seek treatment. Warts may require multiple treatments and various therapies. Common first-line therapies include over-the-counter (OTC) salicylic acid and cryotherapy. The list of other therapies is lengthy, with no single agent credited with high cure rates in well-controlled trials. These therapies include intralesional candida antigen, topical 5 fluorouracil, and topical imiquimod, among many others.
Salicylic acid is available in several forms including 40% acid pads that may be cut to size and applied daily to affected areas. These pads may need to be reinforced with tape to improve adherence. Salicylic acid is also available as a 17% paint-on formulation that can be applied daily, with or without occlusion. This treatment usually requires 2 to 3 months of daily application.
When treated in the office, cryotherapy with liquid nitrogen (LN2) is a first-line therapy, with a cure rate of approximately 65%—similar to that of OTC salicylic acid.1 Application of LN2 via a spray cannister every 2 to 4 weeks until clear is a common strategy. Freezing the area, letting it thaw, and repeating the freeze again in 1 sitting improves clearance. Pain from LN2 can be significant and not all patients can tolerate it. However, for a motivated patient, this can be more convenient than home treatments or a good option when home treatment has failed.
This patient chose cryotherapy, and his foot cleared completely after several rounds of in-office treatments.
Text courtesy of Jonathan Karnes, MD, medical director, MDFMR Dermatology Services, Augusta, ME. Photos courtesy of Jonathan Karnes, MD (copyright retained).
1. Lipke MM. An armamentarium of wart treatments. Clin Med Res. 2006;4:273-293. doi: 10.3121/cmr.4.4.273
Physical exam revealed a plaque with multiple verrucous projections and clusters of smaller circular papules, all with associated thrombosed vessels. The plaque interrupted normal skin lines, consistent with a large, benign, plantar wart, also termed a mosaic wart when clusters of individual plantar warts form a single plaque.
Mosaic warts are caused by infection with human papillomavirus (HPV). They begin as individual papules or macules with a rough surface and small pinpoint capillaries. Plantar warts can be painful if located over a weight-bearing area of the foot. Plantar warts spread by autoinoculation from microtrauma to the foot. Picking at the wart, having it rub against a shoe insert, or exposing it to contaminated surfaces (such as a shower floor) can lead to the wart’s spread. Usually, the diagnosis of a plantar wart is based on clinical examination, with the main differential including a corn or callus. However, rare instances of squamous cell carcinoma or arsenical keratoses can mimic a plantar wart.
Although plantar warts can resolve spontaneously over months or years, patients often seek treatment. Warts may require multiple treatments and various therapies. Common first-line therapies include over-the-counter (OTC) salicylic acid and cryotherapy. The list of other therapies is lengthy, with no single agent credited with high cure rates in well-controlled trials. These therapies include intralesional candida antigen, topical 5 fluorouracil, and topical imiquimod, among many others.
Salicylic acid is available in several forms including 40% acid pads that may be cut to size and applied daily to affected areas. These pads may need to be reinforced with tape to improve adherence. Salicylic acid is also available as a 17% paint-on formulation that can be applied daily, with or without occlusion. This treatment usually requires 2 to 3 months of daily application.
When treated in the office, cryotherapy with liquid nitrogen (LN2) is a first-line therapy, with a cure rate of approximately 65%—similar to that of OTC salicylic acid.1 Application of LN2 via a spray cannister every 2 to 4 weeks until clear is a common strategy. Freezing the area, letting it thaw, and repeating the freeze again in 1 sitting improves clearance. Pain from LN2 can be significant and not all patients can tolerate it. However, for a motivated patient, this can be more convenient than home treatments or a good option when home treatment has failed.
This patient chose cryotherapy, and his foot cleared completely after several rounds of in-office treatments.
Text courtesy of Jonathan Karnes, MD, medical director, MDFMR Dermatology Services, Augusta, ME. Photos courtesy of Jonathan Karnes, MD (copyright retained).
Physical exam revealed a plaque with multiple verrucous projections and clusters of smaller circular papules, all with associated thrombosed vessels. The plaque interrupted normal skin lines, consistent with a large, benign, plantar wart, also termed a mosaic wart when clusters of individual plantar warts form a single plaque.
Mosaic warts are caused by infection with human papillomavirus (HPV). They begin as individual papules or macules with a rough surface and small pinpoint capillaries. Plantar warts can be painful if located over a weight-bearing area of the foot. Plantar warts spread by autoinoculation from microtrauma to the foot. Picking at the wart, having it rub against a shoe insert, or exposing it to contaminated surfaces (such as a shower floor) can lead to the wart’s spread. Usually, the diagnosis of a plantar wart is based on clinical examination, with the main differential including a corn or callus. However, rare instances of squamous cell carcinoma or arsenical keratoses can mimic a plantar wart.
Although plantar warts can resolve spontaneously over months or years, patients often seek treatment. Warts may require multiple treatments and various therapies. Common first-line therapies include over-the-counter (OTC) salicylic acid and cryotherapy. The list of other therapies is lengthy, with no single agent credited with high cure rates in well-controlled trials. These therapies include intralesional candida antigen, topical 5 fluorouracil, and topical imiquimod, among many others.
Salicylic acid is available in several forms including 40% acid pads that may be cut to size and applied daily to affected areas. These pads may need to be reinforced with tape to improve adherence. Salicylic acid is also available as a 17% paint-on formulation that can be applied daily, with or without occlusion. This treatment usually requires 2 to 3 months of daily application.
When treated in the office, cryotherapy with liquid nitrogen (LN2) is a first-line therapy, with a cure rate of approximately 65%—similar to that of OTC salicylic acid.1 Application of LN2 via a spray cannister every 2 to 4 weeks until clear is a common strategy. Freezing the area, letting it thaw, and repeating the freeze again in 1 sitting improves clearance. Pain from LN2 can be significant and not all patients can tolerate it. However, for a motivated patient, this can be more convenient than home treatments or a good option when home treatment has failed.
This patient chose cryotherapy, and his foot cleared completely after several rounds of in-office treatments.
Text courtesy of Jonathan Karnes, MD, medical director, MDFMR Dermatology Services, Augusta, ME. Photos courtesy of Jonathan Karnes, MD (copyright retained).
1. Lipke MM. An armamentarium of wart treatments. Clin Med Res. 2006;4:273-293. doi: 10.3121/cmr.4.4.273
1. Lipke MM. An armamentarium of wart treatments. Clin Med Res. 2006;4:273-293. doi: 10.3121/cmr.4.4.273
The limits of education
For more than a decade, studies on the dubious value of education in the face of vaccine refusal and hesitancy have been accumulating. But, too often, the research has been ignored by folks who believe that they can teach the “misinformed” into dropping their resistance. Among some circles education ranks right up there with apple pie and motherhood as one of the pillars of Americana. Those wedded to the education mantra may acknowledge that teaching and preaching hasn’t worked well in the past. But, they may claim it’s because we haven’t done enough of it or hit the right buttons. The notion that if we can just share the facts with the uninformed everything will be fine is a myth that obviously is going to die slowly.
In a recent op-ed piece in the New York Times two physicians at Harvard Medical School reported on their study of about three-quarters of a million children who were eligible to receive HPV vaccines (2021 Dec 21. “Facts alone aren’t going to win over the unvaccinated. This might,” Anupam B. Jena and Christopher M. Worsham). The researchers found that children whose mothers had been diagnosed with cervical cancer were no more likely to be immunized than those children whose mothers had not had the disease. Who could be better informed about risks and hazards of contracting HPV than women with cervical cancer? If the facts won’t motivate, where does that leave us?
Those of you born before 1960 may remember or at least have heard about a television show called “Truth or Consequences.” It was a silly farce of a game show which has no bearing on our nation’s crisis of widespread vaccine refusal. However, buried in its title is the answer. If the truth isn’t convincing the resistors, then the obvious choice is consequences.
I hope that you have discovered that same strategy when counseling parents of misbehaving children. Talk is cheap and often ineffective. Explaining the error of his ways to a child who probably already knows what he is doing wrong is a waste of everyone’s time and unpleasant for those within earshot. At some point, sooner better than later, it’s time to say there is going to be a consequence for this misbehavior – going home from the playground, spending a few minutes in time-out, removing a privilege, etc. If consequences are chosen well and instituted with a minimum of idle threats, they work.
And, we are beginning to see it work in the face of pandemic shot refusal. Here in Maine the governor mandated that all health care workers be vaccinated. There was plenty of gnashing of teeth and threats of mass job walk offs. And, there were a few hospital workers who quit, but in the end it worked.
The trick is choosing consequences that have some teeth and make sense. Clearly, some folks who have read about the consequences of not getting vaccinated and may have even lost family members to the disease don’t see those losses as significant consequences for whatever reason. The threat of losing a job is likely to get their attention.
Threats must be carried out even though they may be disruptive in the short term. The good thing about well-crafted mandates is that they can be a win-win for everyone. The vaccine resisters don’t need to admit they were wrong. “Those shots are B.S., but the governor made me do it.” The problem is finding leaders who understand that education has its limits and who have the courage to create and administer the consequences.
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].
For more than a decade, studies on the dubious value of education in the face of vaccine refusal and hesitancy have been accumulating. But, too often, the research has been ignored by folks who believe that they can teach the “misinformed” into dropping their resistance. Among some circles education ranks right up there with apple pie and motherhood as one of the pillars of Americana. Those wedded to the education mantra may acknowledge that teaching and preaching hasn’t worked well in the past. But, they may claim it’s because we haven’t done enough of it or hit the right buttons. The notion that if we can just share the facts with the uninformed everything will be fine is a myth that obviously is going to die slowly.
In a recent op-ed piece in the New York Times two physicians at Harvard Medical School reported on their study of about three-quarters of a million children who were eligible to receive HPV vaccines (2021 Dec 21. “Facts alone aren’t going to win over the unvaccinated. This might,” Anupam B. Jena and Christopher M. Worsham). The researchers found that children whose mothers had been diagnosed with cervical cancer were no more likely to be immunized than those children whose mothers had not had the disease. Who could be better informed about risks and hazards of contracting HPV than women with cervical cancer? If the facts won’t motivate, where does that leave us?
Those of you born before 1960 may remember or at least have heard about a television show called “Truth or Consequences.” It was a silly farce of a game show which has no bearing on our nation’s crisis of widespread vaccine refusal. However, buried in its title is the answer. If the truth isn’t convincing the resistors, then the obvious choice is consequences.
I hope that you have discovered that same strategy when counseling parents of misbehaving children. Talk is cheap and often ineffective. Explaining the error of his ways to a child who probably already knows what he is doing wrong is a waste of everyone’s time and unpleasant for those within earshot. At some point, sooner better than later, it’s time to say there is going to be a consequence for this misbehavior – going home from the playground, spending a few minutes in time-out, removing a privilege, etc. If consequences are chosen well and instituted with a minimum of idle threats, they work.
And, we are beginning to see it work in the face of pandemic shot refusal. Here in Maine the governor mandated that all health care workers be vaccinated. There was plenty of gnashing of teeth and threats of mass job walk offs. And, there were a few hospital workers who quit, but in the end it worked.
The trick is choosing consequences that have some teeth and make sense. Clearly, some folks who have read about the consequences of not getting vaccinated and may have even lost family members to the disease don’t see those losses as significant consequences for whatever reason. The threat of losing a job is likely to get their attention.
Threats must be carried out even though they may be disruptive in the short term. The good thing about well-crafted mandates is that they can be a win-win for everyone. The vaccine resisters don’t need to admit they were wrong. “Those shots are B.S., but the governor made me do it.” The problem is finding leaders who understand that education has its limits and who have the courage to create and administer the consequences.
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].
For more than a decade, studies on the dubious value of education in the face of vaccine refusal and hesitancy have been accumulating. But, too often, the research has been ignored by folks who believe that they can teach the “misinformed” into dropping their resistance. Among some circles education ranks right up there with apple pie and motherhood as one of the pillars of Americana. Those wedded to the education mantra may acknowledge that teaching and preaching hasn’t worked well in the past. But, they may claim it’s because we haven’t done enough of it or hit the right buttons. The notion that if we can just share the facts with the uninformed everything will be fine is a myth that obviously is going to die slowly.
In a recent op-ed piece in the New York Times two physicians at Harvard Medical School reported on their study of about three-quarters of a million children who were eligible to receive HPV vaccines (2021 Dec 21. “Facts alone aren’t going to win over the unvaccinated. This might,” Anupam B. Jena and Christopher M. Worsham). The researchers found that children whose mothers had been diagnosed with cervical cancer were no more likely to be immunized than those children whose mothers had not had the disease. Who could be better informed about risks and hazards of contracting HPV than women with cervical cancer? If the facts won’t motivate, where does that leave us?
Those of you born before 1960 may remember or at least have heard about a television show called “Truth or Consequences.” It was a silly farce of a game show which has no bearing on our nation’s crisis of widespread vaccine refusal. However, buried in its title is the answer. If the truth isn’t convincing the resistors, then the obvious choice is consequences.
I hope that you have discovered that same strategy when counseling parents of misbehaving children. Talk is cheap and often ineffective. Explaining the error of his ways to a child who probably already knows what he is doing wrong is a waste of everyone’s time and unpleasant for those within earshot. At some point, sooner better than later, it’s time to say there is going to be a consequence for this misbehavior – going home from the playground, spending a few minutes in time-out, removing a privilege, etc. If consequences are chosen well and instituted with a minimum of idle threats, they work.
And, we are beginning to see it work in the face of pandemic shot refusal. Here in Maine the governor mandated that all health care workers be vaccinated. There was plenty of gnashing of teeth and threats of mass job walk offs. And, there were a few hospital workers who quit, but in the end it worked.
The trick is choosing consequences that have some teeth and make sense. Clearly, some folks who have read about the consequences of not getting vaccinated and may have even lost family members to the disease don’t see those losses as significant consequences for whatever reason. The threat of losing a job is likely to get their attention.
Threats must be carried out even though they may be disruptive in the short term. The good thing about well-crafted mandates is that they can be a win-win for everyone. The vaccine resisters don’t need to admit they were wrong. “Those shots are B.S., but the governor made me do it.” The problem is finding leaders who understand that education has its limits and who have the courage to create and administer the consequences.
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 troubling trend of repackaging feminine hygiene products for the next generation
Feminine hygiene products have been commercially available for decades. They are commonly marketed to reduce odor or clean vaginal discharge and menses. Multiple formulas are available as topical washes, wipes, creams, sprays, powders, deodorants, and douches.1 Products on the market range from those used externally on the vulva, such as wipes and sprays, to liquid solutions used intravaginally, such as washes and douches.
Who uses feminine hygiene products?
According to a 2006 study, the majority of women who use douches started using them between age 15 and 19 years, but some women initiate this practice habit as early as age 10 to 14.1 Predictably, women who douche are more likely to perceive douche products as safe.1
Demographic data on douche utilization are mixed: Some studies show that there are no significant racial differences in douching practices,2 while others have found that Black and African American women are more likely to practice douching than White and Hispanic women.1,3 Studies have shown a significant difference in attitudes toward douching and knowledge of normal vaginal symptoms among US racial demographics, although this must be examined through the historical context of racism and the lens of medical anthropology.4
Women cite that common reasons they use feminine hygiene products are to feel clean, to control odor, and to use after menses and intercourse.1,2
Modern marketing approaches
From wipes to soaps to douches, feminine hygiene products often are advertised to promote “funk-free periods”5 and “freshness,” fostering an environment in which women and men develop unrealistic standards for what is considered normal genital odor and resulting in poor body image.6
Recently, Vagisil (Combe Incorporated) marketing efforts faced backlash from the ObGyn community for targeting younger populations with a specific product line for adolescents called OMV! In addition, attention has been drawn to VCF vaginal odor eliminating film (Apothecus Pharmaceutical Corp), small stamp-sized dissolving films that are placed in the vaginal canal in contact with the epithelium. This product has entered the market of feminine hygiene products accompanied by slogans of eliminating “feminine odor” and providing “confidence for women to be intimate.”
Continue to: Effects of feminine hygiene products on the vaginal microbiome...
Effects of feminine hygiene products on the vaginal microbiome
Frequent use of feminine hygiene products has been associated with recurrent vaginitis, bacterial vaginosis, and general irritation/itch,7,8 which can cause more discharge and odor. Ironically, this may result in women using the product more frequently since they often seek out these products to eliminate odor and discharge.1,2
The pH of the vagina changes during a woman’s lifetime, but in the reproductive years, the normal pH range is typically 3.8 to 4.4.9 This range allows for a normal vaginal flora to form with bacteria such as Lactobacillus species and Gardnerella vaginalis, while feminine hygiene products have a wide range of pH.9,10
Regardless of the formulation, most feminine hygiene products contain ingredients and compositions that potentially are detrimental to the health of the vulva and vagina. Many products contain acidic ingredients, such as citric acid, lactic acid, and dehydroacetic acid, that can alter the vaginal pH and weaken the vaginal barrier by wiping out normal vaginal flora10 despite being advertised for use on “sensitive areas” (TABLE). Lactic acid also has been found to increase diverse anaerobic bacteria in the vaginal microbiome.11 Some feminine hygiene products have been shown to suppress Lactobacillus growth at 2 hours after use and to kill all lactobacilli at 24 hours.10 Shifts in microbiota numbers often occur when the vaginal pH has been altered, as is frequently the case with feminine hygiene products. In the absence of microbiome bacteria, the presence of vaginal hygiene products has been shown to increase interleukin-8 (IL-8), suggesting a proinflammatory reaction.10
A study in the United Kingdom found that women who used bubble bath, antiseptics, or douche products had a higher incidence of bacterial vaginosis compared with women who did not use such products.7 Women in Canada who used feminine hygiene products were more likely to report adverse conditions, including yeast infections, bacterial vaginosis, urinary tract infections, and sexually transmitted diseases.8 Furthermore, a significant association exists between vaginal douching and endometrial infection by bacterial vaginosis–associated organisms.12
Additionally, a study that analyzed volatile organic compound levels in the blood with the use of feminine hygiene products revealed a significant positive dose-exposure relationship between the frequency of vaginal douching in the last 6 months and concentrations of 1,4-dichloromethane, one of the volatile organic compounds.3 This points to the issue of not only disruption of pH and vaginal flora but also to the introduction of harmful substances that can further disrupt the vaginal barrier.
Understand the products to help educate patients
Use of feminine hygiene products is common among women. While women depend on the market to filter out products that are considered unsafe or may have harmful side effects,1 unfortunately that is not necessarily the case. With increasingly more feminine products on the market and the target demographic becoming younger, women of all ages are susceptible to misinformation that could affect their vaginal health long term.
It is vital that clinicians understand the topical effects of these products in order to properly educate and counsel patients. Ultimately, research on feminine hygiene products is limited and, as more products come to market, we must continue to reassess the effects of topical products on the vaginal epithelium and vulvar tissues. ●
- Grimley DM, Annang L, Foushee HR, et al. Vaginal douches and other feminine hygiene products: women’s practices and perceptions of product safety. Matern Child Health J. 2006;10:303-310. doi: 10.1007/s10995-005-0054-y.
- Foch BJ, McDaniel ND, Chacko MR. Racial differences in vaginal douching knowledge, attitude, and practices among sexually active adolescents. J Pediatr Adolesc Gynecol. 2001;14:29-33. doi: 10.1016/S1083-3188(00)00080-2.
- Lin N, Ding N, Meza-Wilson E, et al. Volatile organic compounds in feminine hygiene products sold in the US market: a survey of products and health risks. Environ Int. 2020;144:105740. doi: 10.1016/j.envint.2020.105740.
- Wayne State University Digital Commons. Guy-Lee AK. Rituals reproducing race: African American women’s feminine hygiene practices, shared experiences, and power. 2017. http://digitalcommons.wayne.edu/oa_dissertations/1806. Accessed December 13, 2021.
- YouTube. OMV! by Vagisil—Intimate care products designed by teens. July 10, 2020. www.youtube.com/ watch?v=VkVsCagrAw0. Accessed December 13, 2021.
- Jenkins A, O’Doherty KC. The clean vagina, the healthy vagina, and the dirty vagina: exploring women’s portrayals of the vagina in relation to vaginal cleansing product use. Fem Psychol. 2021;31:192-211. doi: 10.1177/0959353520944144.
- Rajamanoharan S, Low N, Jones SB, et al. Bacterial vaginosis, ethnicity, and the use of genital cleansing agents: a case control study. Sex Transm Dis. 1999;26:404-409.
- Crann SE, Cunningham S, Albert A, et al. Vaginal health and hygiene practices and product use in Canada: a national cross-sectional survey. BMC Womens Health. 2018;18:52. doi: 10.1186/s12905-018-0543-y.
- Chen Y, Bruning E, Rubino J, et al. Role of female intimate hygiene in vulvovaginal health: global hygiene practices and product usage. Womens Health (London). 2017;13:58-67. doi: 10.1177/1745505717731011.
- Fashemi B, Delaney ML, Onderdonk AB, et al. Effects of feminine hygiene products on the vaginal mucosal biome. Microb Ecol Health Dis. 2013;24. doi: 10.3402/mehd. v24i0.19703.
- Van der Veer C, Bruisten SM, Van Houdt R, et al. Effects of an over-the-counter lactic-acid containing intra-vaginal douching product on the vaginal microbiota. BMC Microbiol. 2019;19:168. doi: 10.1186/s12866-019-1545-0.
- Gondwe T, Ness R, Totten PA, et al. Novel bacterial vaginosis-associated organisms mediate the relationship between vaginal douching and pelvic inflammatory disease. Sex Transm Infect. 2020;96:439-444. doi: 10.1136/ sextrans-2019-054191.
Dr. Guirguis is a Fellow, Female Pelvic Medicine and Reconstructive Surgery, Magee-Womens Hospital at University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
Dr. Fitzgerald is an Assistant Professor, Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Urogynecology and Reconstructive Pelvic Surgery, University of Pittsburgh School of Medicine/ Magee-Women’s Hospital at University of Pittsburgh Medical Center.
The authors report no financial relationships relevant to this article.
Dr. Guirguis is a Fellow, Female Pelvic Medicine and Reconstructive Surgery, Magee-Womens Hospital at University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
Dr. Fitzgerald is an Assistant Professor, Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Urogynecology and Reconstructive Pelvic Surgery, University of Pittsburgh School of Medicine/ Magee-Women’s Hospital at University of Pittsburgh Medical Center.
The authors report no financial relationships relevant to this article.
Dr. Guirguis is a Fellow, Female Pelvic Medicine and Reconstructive Surgery, Magee-Womens Hospital at University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
Dr. Fitzgerald is an Assistant Professor, Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Urogynecology and Reconstructive Pelvic Surgery, University of Pittsburgh School of Medicine/ Magee-Women’s Hospital at University of Pittsburgh Medical Center.
The authors report no financial relationships relevant to this article.
Feminine hygiene products have been commercially available for decades. They are commonly marketed to reduce odor or clean vaginal discharge and menses. Multiple formulas are available as topical washes, wipes, creams, sprays, powders, deodorants, and douches.1 Products on the market range from those used externally on the vulva, such as wipes and sprays, to liquid solutions used intravaginally, such as washes and douches.
Who uses feminine hygiene products?
According to a 2006 study, the majority of women who use douches started using them between age 15 and 19 years, but some women initiate this practice habit as early as age 10 to 14.1 Predictably, women who douche are more likely to perceive douche products as safe.1
Demographic data on douche utilization are mixed: Some studies show that there are no significant racial differences in douching practices,2 while others have found that Black and African American women are more likely to practice douching than White and Hispanic women.1,3 Studies have shown a significant difference in attitudes toward douching and knowledge of normal vaginal symptoms among US racial demographics, although this must be examined through the historical context of racism and the lens of medical anthropology.4
Women cite that common reasons they use feminine hygiene products are to feel clean, to control odor, and to use after menses and intercourse.1,2
Modern marketing approaches
From wipes to soaps to douches, feminine hygiene products often are advertised to promote “funk-free periods”5 and “freshness,” fostering an environment in which women and men develop unrealistic standards for what is considered normal genital odor and resulting in poor body image.6
Recently, Vagisil (Combe Incorporated) marketing efforts faced backlash from the ObGyn community for targeting younger populations with a specific product line for adolescents called OMV! In addition, attention has been drawn to VCF vaginal odor eliminating film (Apothecus Pharmaceutical Corp), small stamp-sized dissolving films that are placed in the vaginal canal in contact with the epithelium. This product has entered the market of feminine hygiene products accompanied by slogans of eliminating “feminine odor” and providing “confidence for women to be intimate.”
Continue to: Effects of feminine hygiene products on the vaginal microbiome...
Effects of feminine hygiene products on the vaginal microbiome
Frequent use of feminine hygiene products has been associated with recurrent vaginitis, bacterial vaginosis, and general irritation/itch,7,8 which can cause more discharge and odor. Ironically, this may result in women using the product more frequently since they often seek out these products to eliminate odor and discharge.1,2
The pH of the vagina changes during a woman’s lifetime, but in the reproductive years, the normal pH range is typically 3.8 to 4.4.9 This range allows for a normal vaginal flora to form with bacteria such as Lactobacillus species and Gardnerella vaginalis, while feminine hygiene products have a wide range of pH.9,10
Regardless of the formulation, most feminine hygiene products contain ingredients and compositions that potentially are detrimental to the health of the vulva and vagina. Many products contain acidic ingredients, such as citric acid, lactic acid, and dehydroacetic acid, that can alter the vaginal pH and weaken the vaginal barrier by wiping out normal vaginal flora10 despite being advertised for use on “sensitive areas” (TABLE). Lactic acid also has been found to increase diverse anaerobic bacteria in the vaginal microbiome.11 Some feminine hygiene products have been shown to suppress Lactobacillus growth at 2 hours after use and to kill all lactobacilli at 24 hours.10 Shifts in microbiota numbers often occur when the vaginal pH has been altered, as is frequently the case with feminine hygiene products. In the absence of microbiome bacteria, the presence of vaginal hygiene products has been shown to increase interleukin-8 (IL-8), suggesting a proinflammatory reaction.10
A study in the United Kingdom found that women who used bubble bath, antiseptics, or douche products had a higher incidence of bacterial vaginosis compared with women who did not use such products.7 Women in Canada who used feminine hygiene products were more likely to report adverse conditions, including yeast infections, bacterial vaginosis, urinary tract infections, and sexually transmitted diseases.8 Furthermore, a significant association exists between vaginal douching and endometrial infection by bacterial vaginosis–associated organisms.12
Additionally, a study that analyzed volatile organic compound levels in the blood with the use of feminine hygiene products revealed a significant positive dose-exposure relationship between the frequency of vaginal douching in the last 6 months and concentrations of 1,4-dichloromethane, one of the volatile organic compounds.3 This points to the issue of not only disruption of pH and vaginal flora but also to the introduction of harmful substances that can further disrupt the vaginal barrier.
Understand the products to help educate patients
Use of feminine hygiene products is common among women. While women depend on the market to filter out products that are considered unsafe or may have harmful side effects,1 unfortunately that is not necessarily the case. With increasingly more feminine products on the market and the target demographic becoming younger, women of all ages are susceptible to misinformation that could affect their vaginal health long term.
It is vital that clinicians understand the topical effects of these products in order to properly educate and counsel patients. Ultimately, research on feminine hygiene products is limited and, as more products come to market, we must continue to reassess the effects of topical products on the vaginal epithelium and vulvar tissues. ●
Feminine hygiene products have been commercially available for decades. They are commonly marketed to reduce odor or clean vaginal discharge and menses. Multiple formulas are available as topical washes, wipes, creams, sprays, powders, deodorants, and douches.1 Products on the market range from those used externally on the vulva, such as wipes and sprays, to liquid solutions used intravaginally, such as washes and douches.
Who uses feminine hygiene products?
According to a 2006 study, the majority of women who use douches started using them between age 15 and 19 years, but some women initiate this practice habit as early as age 10 to 14.1 Predictably, women who douche are more likely to perceive douche products as safe.1
Demographic data on douche utilization are mixed: Some studies show that there are no significant racial differences in douching practices,2 while others have found that Black and African American women are more likely to practice douching than White and Hispanic women.1,3 Studies have shown a significant difference in attitudes toward douching and knowledge of normal vaginal symptoms among US racial demographics, although this must be examined through the historical context of racism and the lens of medical anthropology.4
Women cite that common reasons they use feminine hygiene products are to feel clean, to control odor, and to use after menses and intercourse.1,2
Modern marketing approaches
From wipes to soaps to douches, feminine hygiene products often are advertised to promote “funk-free periods”5 and “freshness,” fostering an environment in which women and men develop unrealistic standards for what is considered normal genital odor and resulting in poor body image.6
Recently, Vagisil (Combe Incorporated) marketing efforts faced backlash from the ObGyn community for targeting younger populations with a specific product line for adolescents called OMV! In addition, attention has been drawn to VCF vaginal odor eliminating film (Apothecus Pharmaceutical Corp), small stamp-sized dissolving films that are placed in the vaginal canal in contact with the epithelium. This product has entered the market of feminine hygiene products accompanied by slogans of eliminating “feminine odor” and providing “confidence for women to be intimate.”
Continue to: Effects of feminine hygiene products on the vaginal microbiome...
Effects of feminine hygiene products on the vaginal microbiome
Frequent use of feminine hygiene products has been associated with recurrent vaginitis, bacterial vaginosis, and general irritation/itch,7,8 which can cause more discharge and odor. Ironically, this may result in women using the product more frequently since they often seek out these products to eliminate odor and discharge.1,2
The pH of the vagina changes during a woman’s lifetime, but in the reproductive years, the normal pH range is typically 3.8 to 4.4.9 This range allows for a normal vaginal flora to form with bacteria such as Lactobacillus species and Gardnerella vaginalis, while feminine hygiene products have a wide range of pH.9,10
Regardless of the formulation, most feminine hygiene products contain ingredients and compositions that potentially are detrimental to the health of the vulva and vagina. Many products contain acidic ingredients, such as citric acid, lactic acid, and dehydroacetic acid, that can alter the vaginal pH and weaken the vaginal barrier by wiping out normal vaginal flora10 despite being advertised for use on “sensitive areas” (TABLE). Lactic acid also has been found to increase diverse anaerobic bacteria in the vaginal microbiome.11 Some feminine hygiene products have been shown to suppress Lactobacillus growth at 2 hours after use and to kill all lactobacilli at 24 hours.10 Shifts in microbiota numbers often occur when the vaginal pH has been altered, as is frequently the case with feminine hygiene products. In the absence of microbiome bacteria, the presence of vaginal hygiene products has been shown to increase interleukin-8 (IL-8), suggesting a proinflammatory reaction.10
A study in the United Kingdom found that women who used bubble bath, antiseptics, or douche products had a higher incidence of bacterial vaginosis compared with women who did not use such products.7 Women in Canada who used feminine hygiene products were more likely to report adverse conditions, including yeast infections, bacterial vaginosis, urinary tract infections, and sexually transmitted diseases.8 Furthermore, a significant association exists between vaginal douching and endometrial infection by bacterial vaginosis–associated organisms.12
Additionally, a study that analyzed volatile organic compound levels in the blood with the use of feminine hygiene products revealed a significant positive dose-exposure relationship between the frequency of vaginal douching in the last 6 months and concentrations of 1,4-dichloromethane, one of the volatile organic compounds.3 This points to the issue of not only disruption of pH and vaginal flora but also to the introduction of harmful substances that can further disrupt the vaginal barrier.
Understand the products to help educate patients
Use of feminine hygiene products is common among women. While women depend on the market to filter out products that are considered unsafe or may have harmful side effects,1 unfortunately that is not necessarily the case. With increasingly more feminine products on the market and the target demographic becoming younger, women of all ages are susceptible to misinformation that could affect their vaginal health long term.
It is vital that clinicians understand the topical effects of these products in order to properly educate and counsel patients. Ultimately, research on feminine hygiene products is limited and, as more products come to market, we must continue to reassess the effects of topical products on the vaginal epithelium and vulvar tissues. ●
- Grimley DM, Annang L, Foushee HR, et al. Vaginal douches and other feminine hygiene products: women’s practices and perceptions of product safety. Matern Child Health J. 2006;10:303-310. doi: 10.1007/s10995-005-0054-y.
- Foch BJ, McDaniel ND, Chacko MR. Racial differences in vaginal douching knowledge, attitude, and practices among sexually active adolescents. J Pediatr Adolesc Gynecol. 2001;14:29-33. doi: 10.1016/S1083-3188(00)00080-2.
- Lin N, Ding N, Meza-Wilson E, et al. Volatile organic compounds in feminine hygiene products sold in the US market: a survey of products and health risks. Environ Int. 2020;144:105740. doi: 10.1016/j.envint.2020.105740.
- Wayne State University Digital Commons. Guy-Lee AK. Rituals reproducing race: African American women’s feminine hygiene practices, shared experiences, and power. 2017. http://digitalcommons.wayne.edu/oa_dissertations/1806. Accessed December 13, 2021.
- YouTube. OMV! by Vagisil—Intimate care products designed by teens. July 10, 2020. www.youtube.com/ watch?v=VkVsCagrAw0. Accessed December 13, 2021.
- Jenkins A, O’Doherty KC. The clean vagina, the healthy vagina, and the dirty vagina: exploring women’s portrayals of the vagina in relation to vaginal cleansing product use. Fem Psychol. 2021;31:192-211. doi: 10.1177/0959353520944144.
- Rajamanoharan S, Low N, Jones SB, et al. Bacterial vaginosis, ethnicity, and the use of genital cleansing agents: a case control study. Sex Transm Dis. 1999;26:404-409.
- Crann SE, Cunningham S, Albert A, et al. Vaginal health and hygiene practices and product use in Canada: a national cross-sectional survey. BMC Womens Health. 2018;18:52. doi: 10.1186/s12905-018-0543-y.
- Chen Y, Bruning E, Rubino J, et al. Role of female intimate hygiene in vulvovaginal health: global hygiene practices and product usage. Womens Health (London). 2017;13:58-67. doi: 10.1177/1745505717731011.
- Fashemi B, Delaney ML, Onderdonk AB, et al. Effects of feminine hygiene products on the vaginal mucosal biome. Microb Ecol Health Dis. 2013;24. doi: 10.3402/mehd. v24i0.19703.
- Van der Veer C, Bruisten SM, Van Houdt R, et al. Effects of an over-the-counter lactic-acid containing intra-vaginal douching product on the vaginal microbiota. BMC Microbiol. 2019;19:168. doi: 10.1186/s12866-019-1545-0.
- Gondwe T, Ness R, Totten PA, et al. Novel bacterial vaginosis-associated organisms mediate the relationship between vaginal douching and pelvic inflammatory disease. Sex Transm Infect. 2020;96:439-444. doi: 10.1136/ sextrans-2019-054191.
- Grimley DM, Annang L, Foushee HR, et al. Vaginal douches and other feminine hygiene products: women’s practices and perceptions of product safety. Matern Child Health J. 2006;10:303-310. doi: 10.1007/s10995-005-0054-y.
- Foch BJ, McDaniel ND, Chacko MR. Racial differences in vaginal douching knowledge, attitude, and practices among sexually active adolescents. J Pediatr Adolesc Gynecol. 2001;14:29-33. doi: 10.1016/S1083-3188(00)00080-2.
- Lin N, Ding N, Meza-Wilson E, et al. Volatile organic compounds in feminine hygiene products sold in the US market: a survey of products and health risks. Environ Int. 2020;144:105740. doi: 10.1016/j.envint.2020.105740.
- Wayne State University Digital Commons. Guy-Lee AK. Rituals reproducing race: African American women’s feminine hygiene practices, shared experiences, and power. 2017. http://digitalcommons.wayne.edu/oa_dissertations/1806. Accessed December 13, 2021.
- YouTube. OMV! by Vagisil—Intimate care products designed by teens. July 10, 2020. www.youtube.com/ watch?v=VkVsCagrAw0. Accessed December 13, 2021.
- Jenkins A, O’Doherty KC. The clean vagina, the healthy vagina, and the dirty vagina: exploring women’s portrayals of the vagina in relation to vaginal cleansing product use. Fem Psychol. 2021;31:192-211. doi: 10.1177/0959353520944144.
- Rajamanoharan S, Low N, Jones SB, et al. Bacterial vaginosis, ethnicity, and the use of genital cleansing agents: a case control study. Sex Transm Dis. 1999;26:404-409.
- Crann SE, Cunningham S, Albert A, et al. Vaginal health and hygiene practices and product use in Canada: a national cross-sectional survey. BMC Womens Health. 2018;18:52. doi: 10.1186/s12905-018-0543-y.
- Chen Y, Bruning E, Rubino J, et al. Role of female intimate hygiene in vulvovaginal health: global hygiene practices and product usage. Womens Health (London). 2017;13:58-67. doi: 10.1177/1745505717731011.
- Fashemi B, Delaney ML, Onderdonk AB, et al. Effects of feminine hygiene products on the vaginal mucosal biome. Microb Ecol Health Dis. 2013;24. doi: 10.3402/mehd. v24i0.19703.
- Van der Veer C, Bruisten SM, Van Houdt R, et al. Effects of an over-the-counter lactic-acid containing intra-vaginal douching product on the vaginal microbiota. BMC Microbiol. 2019;19:168. doi: 10.1186/s12866-019-1545-0.
- Gondwe T, Ness R, Totten PA, et al. Novel bacterial vaginosis-associated organisms mediate the relationship between vaginal douching and pelvic inflammatory disease. Sex Transm Infect. 2020;96:439-444. doi: 10.1136/ sextrans-2019-054191.
What is the diagnosis?
Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition that is becoming more recognized in children. It has a variable presentation, most commonly presenting as painful, recurrent cysts, abscesses, nodules, and/or pustules in classic locations with associated scarring and sinus tract formation.
The majority of patients present with bilateral lesions found most commonly in the axillae and inguinal folds.1 There are myriad other potential sites of involvement including the inframammary folds, inner thighs, buttocks, and groin.1 Diagnosis is made based on history and physical exam. There is a standard severity classification scheme called the Hurley score, which stratifies disease severity based on the presence of sinus tracts and extent of disease.1 HS is associated with comorbid conditions such as obesity, overweight, acne, and inflammatory bowel and joint disease.2 This painful, persistent condition is well documented to have a negative impact on quality of life in adult patients, and similar impairment has been found in pediatric patients.3,4
HS may be increasing in pediatric and adolescent patients, with recent studies showing onset coinciding most commonly with the onset of puberty.1,2 There is often a period of several years between symptom onset and diagnosis.1 A recent editorial highlighted the disparities that exist in HS, with disease more common in Black children and limited information about disease prevalence in Hispanic children.5
What’s the treatment plan?
HS is a difficult disease to treat, with few patients achieving remission and a significant proportion of patients with treatment-refractory disease.1 There are limited studies of HS treatment in pediatric patients. Topical and systemic antibiotic therapy are mainstays of HS treatment, with tetracyclines and a combination of clindamycin plus rifampin commonly used in adults and children alike. Topical therapies including topical antibiotics and antibacterial solutions are frequently used as adjunctive therapy.6 Adalimumab, a tumor necrosis factor receptor blocker, has been Food and Drug Administration approved for HS for ages 12 and up and is currently the only FDA-approved medication for HS in pediatric patients. Our patient was started on 100 mg doxycycline twice daily, with short-dose topical corticosteroids for symptom management of the most inflamed lesions.
What’s on the differential?
Acne conglobata
Acne conglobata is an uncommon, severe variant of acne vulgaris which arise in patients with a history of acne vulgaris and presents with comedones, cysts, abscesses, and scarring with possible drainage of pus. Lesions can present diffusely on the face, back, and body, including in the axillae, groin, and buttocks, and as such can be confused with HS.7
However, in contrast with HS, patients with acne conglobata will also develop disease in non–apocrine gland–bearing skin. This patient’s lack of preceding acne and restriction of lesions to the axillae, inguinal folds, and buttocks makes acne conglobata less likely.
Epidermal inclusion cyst
Epidermal inclusion cyst (EIC) is a common cutaneous cyst, presenting as a well-circumscribed nodule(s) with a central punctum. If not excised, lesions can sometimes become infected and painful.8 In contrast with HS, EIC presents only uncommonly as multiple lesions arising in different areas, and spontaneous drainage is uncommon. Our patient’s development of multiple draining lesions makes this diagnosis unlikely.
Furunculosis
Furunculosis is a common bacterial infection of the skin, presenting with inflammatory nodules or pustules centered around the hair follicle. Lesions may commonly present at sites of skin trauma and are found most frequently on the extremities.9 Though furunculosis lesions may drain pus and can coalesce to form larger “carbuncles,” our patient’s presence of significant scarring and lack of extremity involvement makes HS more likely.
Recurrent MRSA abscesses
Methicillin-resistant Staphylococcus aureus skin and soft-tissue infections are not uncommon in the pediatric population, with presentation of infection ranging from cellulitis to fluid-containing abscesses.10 Recurrent abscesses may be seen in MRSA infection, however in this patient the presence of draining, scarring lesions in multiple locations typical for HS over time is more consistent with a diagnosis of HS.
Dr. Eichenfield is vice chair of the department of dermatology and professor of dermatology and pediatrics at the University of California, San Diego, and Rady Children’s Hospital, San Diego. Ms. Appiah is a pediatric dermatology research associate in the division of pediatric and adolescent dermatology at the University of California, San Diego, and Rady Children’s Hospital. Dr. Eichenfield and Ms. Appiah have no relevant financial disclosures.
References
1. Liy-Wong C et al. JAMA Dermatol. 2021;157(4):385-91.
2. Choi E et al. J Am Acad Dermatol. 2022;86(1):140-7.
3. Machado MO et al. JAMA Dermatol. 2019;155(8):939-45.
4. McAndrew R et al. J Am Acad Dermatol. 2021;84(3):829-30.
5. Kirby JS and Zaenglein AL. JAMA Dermatol. 2021;157(4):379-80.
6. Alikhan A et al. J Am Acad Dermatol. 2019;81(1):91-101.
7. Greydanus DE et al. Dis Mon. 2021;67(4):101103.
8. Weir CB, St. Hilaire NJ. Epidermal Inclusion Cyst, in “StatPearls.” Treasure Island, Fla: StatPearls Publishing, 2021.
9. Atanaskova N and Tomecki KJ. Dermatol Clin. 2010;28(3):479-87.
10. Papastefan ST et al. J Surg Res. 2019;242:70-7.
Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition that is becoming more recognized in children. It has a variable presentation, most commonly presenting as painful, recurrent cysts, abscesses, nodules, and/or pustules in classic locations with associated scarring and sinus tract formation.
The majority of patients present with bilateral lesions found most commonly in the axillae and inguinal folds.1 There are myriad other potential sites of involvement including the inframammary folds, inner thighs, buttocks, and groin.1 Diagnosis is made based on history and physical exam. There is a standard severity classification scheme called the Hurley score, which stratifies disease severity based on the presence of sinus tracts and extent of disease.1 HS is associated with comorbid conditions such as obesity, overweight, acne, and inflammatory bowel and joint disease.2 This painful, persistent condition is well documented to have a negative impact on quality of life in adult patients, and similar impairment has been found in pediatric patients.3,4
HS may be increasing in pediatric and adolescent patients, with recent studies showing onset coinciding most commonly with the onset of puberty.1,2 There is often a period of several years between symptom onset and diagnosis.1 A recent editorial highlighted the disparities that exist in HS, with disease more common in Black children and limited information about disease prevalence in Hispanic children.5
What’s the treatment plan?
HS is a difficult disease to treat, with few patients achieving remission and a significant proportion of patients with treatment-refractory disease.1 There are limited studies of HS treatment in pediatric patients. Topical and systemic antibiotic therapy are mainstays of HS treatment, with tetracyclines and a combination of clindamycin plus rifampin commonly used in adults and children alike. Topical therapies including topical antibiotics and antibacterial solutions are frequently used as adjunctive therapy.6 Adalimumab, a tumor necrosis factor receptor blocker, has been Food and Drug Administration approved for HS for ages 12 and up and is currently the only FDA-approved medication for HS in pediatric patients. Our patient was started on 100 mg doxycycline twice daily, with short-dose topical corticosteroids for symptom management of the most inflamed lesions.
What’s on the differential?
Acne conglobata
Acne conglobata is an uncommon, severe variant of acne vulgaris which arise in patients with a history of acne vulgaris and presents with comedones, cysts, abscesses, and scarring with possible drainage of pus. Lesions can present diffusely on the face, back, and body, including in the axillae, groin, and buttocks, and as such can be confused with HS.7
However, in contrast with HS, patients with acne conglobata will also develop disease in non–apocrine gland–bearing skin. This patient’s lack of preceding acne and restriction of lesions to the axillae, inguinal folds, and buttocks makes acne conglobata less likely.
Epidermal inclusion cyst
Epidermal inclusion cyst (EIC) is a common cutaneous cyst, presenting as a well-circumscribed nodule(s) with a central punctum. If not excised, lesions can sometimes become infected and painful.8 In contrast with HS, EIC presents only uncommonly as multiple lesions arising in different areas, and spontaneous drainage is uncommon. Our patient’s development of multiple draining lesions makes this diagnosis unlikely.
Furunculosis
Furunculosis is a common bacterial infection of the skin, presenting with inflammatory nodules or pustules centered around the hair follicle. Lesions may commonly present at sites of skin trauma and are found most frequently on the extremities.9 Though furunculosis lesions may drain pus and can coalesce to form larger “carbuncles,” our patient’s presence of significant scarring and lack of extremity involvement makes HS more likely.
Recurrent MRSA abscesses
Methicillin-resistant Staphylococcus aureus skin and soft-tissue infections are not uncommon in the pediatric population, with presentation of infection ranging from cellulitis to fluid-containing abscesses.10 Recurrent abscesses may be seen in MRSA infection, however in this patient the presence of draining, scarring lesions in multiple locations typical for HS over time is more consistent with a diagnosis of HS.
Dr. Eichenfield is vice chair of the department of dermatology and professor of dermatology and pediatrics at the University of California, San Diego, and Rady Children’s Hospital, San Diego. Ms. Appiah is a pediatric dermatology research associate in the division of pediatric and adolescent dermatology at the University of California, San Diego, and Rady Children’s Hospital. Dr. Eichenfield and Ms. Appiah have no relevant financial disclosures.
References
1. Liy-Wong C et al. JAMA Dermatol. 2021;157(4):385-91.
2. Choi E et al. J Am Acad Dermatol. 2022;86(1):140-7.
3. Machado MO et al. JAMA Dermatol. 2019;155(8):939-45.
4. McAndrew R et al. J Am Acad Dermatol. 2021;84(3):829-30.
5. Kirby JS and Zaenglein AL. JAMA Dermatol. 2021;157(4):379-80.
6. Alikhan A et al. J Am Acad Dermatol. 2019;81(1):91-101.
7. Greydanus DE et al. Dis Mon. 2021;67(4):101103.
8. Weir CB, St. Hilaire NJ. Epidermal Inclusion Cyst, in “StatPearls.” Treasure Island, Fla: StatPearls Publishing, 2021.
9. Atanaskova N and Tomecki KJ. Dermatol Clin. 2010;28(3):479-87.
10. Papastefan ST et al. J Surg Res. 2019;242:70-7.
Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition that is becoming more recognized in children. It has a variable presentation, most commonly presenting as painful, recurrent cysts, abscesses, nodules, and/or pustules in classic locations with associated scarring and sinus tract formation.
The majority of patients present with bilateral lesions found most commonly in the axillae and inguinal folds.1 There are myriad other potential sites of involvement including the inframammary folds, inner thighs, buttocks, and groin.1 Diagnosis is made based on history and physical exam. There is a standard severity classification scheme called the Hurley score, which stratifies disease severity based on the presence of sinus tracts and extent of disease.1 HS is associated with comorbid conditions such as obesity, overweight, acne, and inflammatory bowel and joint disease.2 This painful, persistent condition is well documented to have a negative impact on quality of life in adult patients, and similar impairment has been found in pediatric patients.3,4
HS may be increasing in pediatric and adolescent patients, with recent studies showing onset coinciding most commonly with the onset of puberty.1,2 There is often a period of several years between symptom onset and diagnosis.1 A recent editorial highlighted the disparities that exist in HS, with disease more common in Black children and limited information about disease prevalence in Hispanic children.5
What’s the treatment plan?
HS is a difficult disease to treat, with few patients achieving remission and a significant proportion of patients with treatment-refractory disease.1 There are limited studies of HS treatment in pediatric patients. Topical and systemic antibiotic therapy are mainstays of HS treatment, with tetracyclines and a combination of clindamycin plus rifampin commonly used in adults and children alike. Topical therapies including topical antibiotics and antibacterial solutions are frequently used as adjunctive therapy.6 Adalimumab, a tumor necrosis factor receptor blocker, has been Food and Drug Administration approved for HS for ages 12 and up and is currently the only FDA-approved medication for HS in pediatric patients. Our patient was started on 100 mg doxycycline twice daily, with short-dose topical corticosteroids for symptom management of the most inflamed lesions.
What’s on the differential?
Acne conglobata
Acne conglobata is an uncommon, severe variant of acne vulgaris which arise in patients with a history of acne vulgaris and presents with comedones, cysts, abscesses, and scarring with possible drainage of pus. Lesions can present diffusely on the face, back, and body, including in the axillae, groin, and buttocks, and as such can be confused with HS.7
However, in contrast with HS, patients with acne conglobata will also develop disease in non–apocrine gland–bearing skin. This patient’s lack of preceding acne and restriction of lesions to the axillae, inguinal folds, and buttocks makes acne conglobata less likely.
Epidermal inclusion cyst
Epidermal inclusion cyst (EIC) is a common cutaneous cyst, presenting as a well-circumscribed nodule(s) with a central punctum. If not excised, lesions can sometimes become infected and painful.8 In contrast with HS, EIC presents only uncommonly as multiple lesions arising in different areas, and spontaneous drainage is uncommon. Our patient’s development of multiple draining lesions makes this diagnosis unlikely.
Furunculosis
Furunculosis is a common bacterial infection of the skin, presenting with inflammatory nodules or pustules centered around the hair follicle. Lesions may commonly present at sites of skin trauma and are found most frequently on the extremities.9 Though furunculosis lesions may drain pus and can coalesce to form larger “carbuncles,” our patient’s presence of significant scarring and lack of extremity involvement makes HS more likely.
Recurrent MRSA abscesses
Methicillin-resistant Staphylococcus aureus skin and soft-tissue infections are not uncommon in the pediatric population, with presentation of infection ranging from cellulitis to fluid-containing abscesses.10 Recurrent abscesses may be seen in MRSA infection, however in this patient the presence of draining, scarring lesions in multiple locations typical for HS over time is more consistent with a diagnosis of HS.
Dr. Eichenfield is vice chair of the department of dermatology and professor of dermatology and pediatrics at the University of California, San Diego, and Rady Children’s Hospital, San Diego. Ms. Appiah is a pediatric dermatology research associate in the division of pediatric and adolescent dermatology at the University of California, San Diego, and Rady Children’s Hospital. Dr. Eichenfield and Ms. Appiah have no relevant financial disclosures.
References
1. Liy-Wong C et al. JAMA Dermatol. 2021;157(4):385-91.
2. Choi E et al. J Am Acad Dermatol. 2022;86(1):140-7.
3. Machado MO et al. JAMA Dermatol. 2019;155(8):939-45.
4. McAndrew R et al. J Am Acad Dermatol. 2021;84(3):829-30.
5. Kirby JS and Zaenglein AL. JAMA Dermatol. 2021;157(4):379-80.
6. Alikhan A et al. J Am Acad Dermatol. 2019;81(1):91-101.
7. Greydanus DE et al. Dis Mon. 2021;67(4):101103.
8. Weir CB, St. Hilaire NJ. Epidermal Inclusion Cyst, in “StatPearls.” Treasure Island, Fla: StatPearls Publishing, 2021.
9. Atanaskova N and Tomecki KJ. Dermatol Clin. 2010;28(3):479-87.
10. Papastefan ST et al. J Surg Res. 2019;242:70-7.
Despite the stigma, ECT remains a gold standard
For Clayton Lively, electroconvulsive therapy, or ECT, has been a lifesaver.
“ECT was like a last resort to treat mania and psychosis for bipolar disorder,” said the 31-year-old financial firm associate who lives in Silver Spring, Md. “I had tried lots of different medications.”
The first course of treatments – three times per week for several weeks – was in 2005. They helped tremendously. “I came down from my mania,” Mr. Lively said. “The hallucinations stopped. The psychosis disappeared.”
He reached a point where medications and psychotherapy worked again. And for a decade, his condition was under control.
But in 2017, another episode of hallucinations and mania jolted him off course. Intrusive thoughts returned. For instance, while driving, he would visualize veering off the road. The thoughts were jarring, and yet, he couldn’t stop them from recurring.
“I wasn’t sleeping, and it just kind of wreaked havoc on my life,” Mr. Lively recalled. “I ended up being hospitalized again.”
Once again, ECT came to the rescue – and yet again, in 2018. Now, he’s on an effective maintenance regimen, receiving ECT once every 4 weeks, after tapering down from more frequent sessions.
When a combination of antidepressants and psychotherapy fails to control severe mental illness, there’s hope on the horizon. ECT can be a reliably safe and effective option.
For some patients, using it as maintenance therapy makes sense, said Vaughn McCall, MD, editor-in-chief of The Journal of ECT and professor and chairman of psychiatry at the Medical College of Georgia in Augusta. “I would think of it the same way as you have to treat any chronic illness,” such as blood pressure medicine to keep hypertension in check and dialysis to prevent kidney failure.
Despite a cacophony of contrarian voices – mainly from the Church of Scientology – “the number of psychiatrists who see controversy in ECT is vanishingly small,” Dr. McCall said.
In weighing the pros and cons of ECT, he noted that “when you’re trying to decide if it’s worth doing a treatment, you’re looking at the effectiveness on one hand and the side effects on the other hand.”
The answer to that emerges from several scales measuring patients’ quality of life by posing questions such as: “After receiving ECT, are you more able or less able to take care of yourself, to work, and enjoy the company of other people?”
In the end, Dr. McCall said, “we’ve applied these scales in probably half a dozen studies or more, and they always show that the patients’ qualify of life as a group is improved.”
A recent study published in The Lancet Psychiatry provides a significant degree of reassurance that ECT – also called “electroshock” or colloquially just “shock” therapy – does not increase the risk of serious medical side effects. In fact, the study suggests a potential benefit in reducing suicide risk.
First performed in 1938, the treatment has been well documented in the medical literature. But negative portrayals in books and movies, such as the 1975 film “One Flew Over the Cuckoo’s Nest,” have contributed to casting it in an unfavorable light.
“Unfortunately, over the past decades and years, there’s a lot of stigma and fear around the treatment,” said the study’s lead author, Tyler Kaster, MD, a psychiatrist and clinical fellow in brain stimulation at the University of Toronto.
For the study, Canadian investigators reviewed the admission records of 10,000 patients hospitalized for at least 3 days because of a severe depressive episode. Nearly two-thirds of the patients were women, and the average age for the entire group approached 57 years.
While half of the patients underwent ECT, the others received medication and psychotherapy. Researchers found that the group undergoing ECT did not have a heightened risk of death over the next 30 days and were not any more likely to be hospitalized for a medical problem.
Previous ECT comparative studies were at high risk of bias because of their inability to sufficiently account for confounding variables and differences between those who received the treatment and those who did not. The current study employed “rigorous methods with careful attention to bias and confounding to overcome limitations of previous work,” the authors wrote.
They used propensity score matching, which included more than 75 variables, such as measures of cognitive impairment, depression severity, medication use, other illnesses, and use of psychiatric and various medical services, capacity to consent to treatment, and sociodemographic factors.
“This is really a landmark study in terms of showing the medical safety of ECT,” said Mark S. George, MD, professor of psychiatry and neurology at the Medical University of South Carolina, Charleston, who was not involved in the study.
He added that “ECT is a life-saving treatment” for individuals with severe depression. “It’s good that we have this option for our patients.”
The authors highlight that depression is a major cause of illness and disability worldwide, with many individuals failing to achieve remission from initial therapies. Treatment-resistant depression is often described as being nonresponsive “to two or more medication trials of adequate dose and duration from different classes,” they wrote. In these instances, the authors point out, there is little evidence that psychotherapy would be helpful.
“The reason we consider ECT is someone has very severe depression that hasn’t responded to medications and talk therapy,” Dr. Kaster said. “The advantage of ECT is that it’s very effective in those circumstances.”
Of all therapies for treatment-resistant depression, ECT has the highest success rate, with 60% of patients attaining remission, according to the study, which cites prior research.
Compared with neurosurgery, the procedure is not invasive but requires general anesthesia. While the patient is asleep, Dr. Kaster said, the treating clinician places an electrical stimulus on the patient’s scalp, causing a generalized seizure inside the brain that lasts from 15 seconds to 2 minutes.
A course of ECT usually takes a total of 8-12 treatments, delivered two to three times per week over a month to a month and a half, Dr. George said.
Some patients need a new course of ECT if they relapse after several months. Others are unable to control their depression between courses and require repeated doses for maintenance. The time between these ECT sessions varies for each individual, Dr. George said, but is typically one session every 3-4 weeks.
To improve the odds of staying well, patients typically need to continue taking antidepressants and engaging in psychotherapy.
“It helps improve the efficacy of ECT and also down the road helps prevent relapse,” Dr. Kaster said, noting that “depression is, unfortunately, a chronic illness. We don’t have a cure.”
Murat Altinay, MD, associate professor of psychiatry at the Cleveland Clinic and a mood disorders specialist, said his patients generally need to demonstrate a lack of response to at least three or four antidepressants before he considers recommending ECT.
Confusion, short-term memory impairment, and muscle aches and pains may occur after the procedure, but they are relatively mild. Patients are monitored in a recovery room before discharge from the hospital, Dr. Altinay said.
The first few treatments will affect everyday function. After that initial period, however, people can resume most of their daily activities, he said.
“Maybe they won’t be able to work full-time right away, but anecdotally, we have had patients who were able to go back to the workforce relatively quickly or while they’re getting ECT,” Dr. Altinay said.
More significant adverse events are very rare, he noted, although heart rate and blood pressure can become elevated because of the electrical stimulus.
Dr. Altinay said he is pleased that the large-scale journal article has been published to help dispel myths surrounding ECT. While psychiatrists feel that ECT is generally safe and effective, the public maintains a negative view.
“It is an underutilized treatment,” he said. “In the media, it is almost depicted as a barbaric and archaic treatment in psychiatry.”
Patients are afraid of major side effects such as personality changes. Some fear they will forget someone’s birthday or other important factual information, “but that kind of stuff obviously does not happen,” Dr. Altinay said.
Sometimes it’s not only the patients who are hesitant to try ECT; it’s the family members who express concerns, said Irving Reti, MBBS, professor of psychiatry and neuroscience and director of the brain stimulation program at the Johns Hopkins University, Baltimore.
“It varies from one patient to another how agreeable or reluctant or cautious they are about their treatment if the doctor thinks it’s indicated for them,” Dr. Reti said. “Family members’ concerns may be very legitimate but may also be influenced by stigma and misunderstanding about the treatment. They may also not fully appreciate the severity of their loved one’s depression that warrants the administration of ECT.”
Hospitalized patients who are at risk of suicide have benefited from ECT. “It’s very effective,” he said. “I think it’s still the gold standard for severe treatment-resistant depression and also particularly helpful in people who are acutely suicidal.”
Dr. George cautioned that psychiatrists and the public should beware of questionable online sources that attempt to discredit ECT. “A quick Google search will find plenty of nonmedical doctors, many funded through Scientology, who will speak poorly of ECT. But they do not use evidence-based arguments and commonly do not treat patients,” he said.
“All good practicing psychiatrists that I know are in favor of ECT, as it clearly saves lives,” Dr. George added. “We all hope that the future will provide refinements of ECT, or even disruptive technologies that are more effective and with less hassle and will make ECT as we do it now obsolete. But we are not there yet.”
A version of this article first appeared on Medscape.com.
For Clayton Lively, electroconvulsive therapy, or ECT, has been a lifesaver.
“ECT was like a last resort to treat mania and psychosis for bipolar disorder,” said the 31-year-old financial firm associate who lives in Silver Spring, Md. “I had tried lots of different medications.”
The first course of treatments – three times per week for several weeks – was in 2005. They helped tremendously. “I came down from my mania,” Mr. Lively said. “The hallucinations stopped. The psychosis disappeared.”
He reached a point where medications and psychotherapy worked again. And for a decade, his condition was under control.
But in 2017, another episode of hallucinations and mania jolted him off course. Intrusive thoughts returned. For instance, while driving, he would visualize veering off the road. The thoughts were jarring, and yet, he couldn’t stop them from recurring.
“I wasn’t sleeping, and it just kind of wreaked havoc on my life,” Mr. Lively recalled. “I ended up being hospitalized again.”
Once again, ECT came to the rescue – and yet again, in 2018. Now, he’s on an effective maintenance regimen, receiving ECT once every 4 weeks, after tapering down from more frequent sessions.
When a combination of antidepressants and psychotherapy fails to control severe mental illness, there’s hope on the horizon. ECT can be a reliably safe and effective option.
For some patients, using it as maintenance therapy makes sense, said Vaughn McCall, MD, editor-in-chief of The Journal of ECT and professor and chairman of psychiatry at the Medical College of Georgia in Augusta. “I would think of it the same way as you have to treat any chronic illness,” such as blood pressure medicine to keep hypertension in check and dialysis to prevent kidney failure.
Despite a cacophony of contrarian voices – mainly from the Church of Scientology – “the number of psychiatrists who see controversy in ECT is vanishingly small,” Dr. McCall said.
In weighing the pros and cons of ECT, he noted that “when you’re trying to decide if it’s worth doing a treatment, you’re looking at the effectiveness on one hand and the side effects on the other hand.”
The answer to that emerges from several scales measuring patients’ quality of life by posing questions such as: “After receiving ECT, are you more able or less able to take care of yourself, to work, and enjoy the company of other people?”
In the end, Dr. McCall said, “we’ve applied these scales in probably half a dozen studies or more, and they always show that the patients’ qualify of life as a group is improved.”
A recent study published in The Lancet Psychiatry provides a significant degree of reassurance that ECT – also called “electroshock” or colloquially just “shock” therapy – does not increase the risk of serious medical side effects. In fact, the study suggests a potential benefit in reducing suicide risk.
First performed in 1938, the treatment has been well documented in the medical literature. But negative portrayals in books and movies, such as the 1975 film “One Flew Over the Cuckoo’s Nest,” have contributed to casting it in an unfavorable light.
“Unfortunately, over the past decades and years, there’s a lot of stigma and fear around the treatment,” said the study’s lead author, Tyler Kaster, MD, a psychiatrist and clinical fellow in brain stimulation at the University of Toronto.
For the study, Canadian investigators reviewed the admission records of 10,000 patients hospitalized for at least 3 days because of a severe depressive episode. Nearly two-thirds of the patients were women, and the average age for the entire group approached 57 years.
While half of the patients underwent ECT, the others received medication and psychotherapy. Researchers found that the group undergoing ECT did not have a heightened risk of death over the next 30 days and were not any more likely to be hospitalized for a medical problem.
Previous ECT comparative studies were at high risk of bias because of their inability to sufficiently account for confounding variables and differences between those who received the treatment and those who did not. The current study employed “rigorous methods with careful attention to bias and confounding to overcome limitations of previous work,” the authors wrote.
They used propensity score matching, which included more than 75 variables, such as measures of cognitive impairment, depression severity, medication use, other illnesses, and use of psychiatric and various medical services, capacity to consent to treatment, and sociodemographic factors.
“This is really a landmark study in terms of showing the medical safety of ECT,” said Mark S. George, MD, professor of psychiatry and neurology at the Medical University of South Carolina, Charleston, who was not involved in the study.
He added that “ECT is a life-saving treatment” for individuals with severe depression. “It’s good that we have this option for our patients.”
The authors highlight that depression is a major cause of illness and disability worldwide, with many individuals failing to achieve remission from initial therapies. Treatment-resistant depression is often described as being nonresponsive “to two or more medication trials of adequate dose and duration from different classes,” they wrote. In these instances, the authors point out, there is little evidence that psychotherapy would be helpful.
“The reason we consider ECT is someone has very severe depression that hasn’t responded to medications and talk therapy,” Dr. Kaster said. “The advantage of ECT is that it’s very effective in those circumstances.”
Of all therapies for treatment-resistant depression, ECT has the highest success rate, with 60% of patients attaining remission, according to the study, which cites prior research.
Compared with neurosurgery, the procedure is not invasive but requires general anesthesia. While the patient is asleep, Dr. Kaster said, the treating clinician places an electrical stimulus on the patient’s scalp, causing a generalized seizure inside the brain that lasts from 15 seconds to 2 minutes.
A course of ECT usually takes a total of 8-12 treatments, delivered two to three times per week over a month to a month and a half, Dr. George said.
Some patients need a new course of ECT if they relapse after several months. Others are unable to control their depression between courses and require repeated doses for maintenance. The time between these ECT sessions varies for each individual, Dr. George said, but is typically one session every 3-4 weeks.
To improve the odds of staying well, patients typically need to continue taking antidepressants and engaging in psychotherapy.
“It helps improve the efficacy of ECT and also down the road helps prevent relapse,” Dr. Kaster said, noting that “depression is, unfortunately, a chronic illness. We don’t have a cure.”
Murat Altinay, MD, associate professor of psychiatry at the Cleveland Clinic and a mood disorders specialist, said his patients generally need to demonstrate a lack of response to at least three or four antidepressants before he considers recommending ECT.
Confusion, short-term memory impairment, and muscle aches and pains may occur after the procedure, but they are relatively mild. Patients are monitored in a recovery room before discharge from the hospital, Dr. Altinay said.
The first few treatments will affect everyday function. After that initial period, however, people can resume most of their daily activities, he said.
“Maybe they won’t be able to work full-time right away, but anecdotally, we have had patients who were able to go back to the workforce relatively quickly or while they’re getting ECT,” Dr. Altinay said.
More significant adverse events are very rare, he noted, although heart rate and blood pressure can become elevated because of the electrical stimulus.
Dr. Altinay said he is pleased that the large-scale journal article has been published to help dispel myths surrounding ECT. While psychiatrists feel that ECT is generally safe and effective, the public maintains a negative view.
“It is an underutilized treatment,” he said. “In the media, it is almost depicted as a barbaric and archaic treatment in psychiatry.”
Patients are afraid of major side effects such as personality changes. Some fear they will forget someone’s birthday or other important factual information, “but that kind of stuff obviously does not happen,” Dr. Altinay said.
Sometimes it’s not only the patients who are hesitant to try ECT; it’s the family members who express concerns, said Irving Reti, MBBS, professor of psychiatry and neuroscience and director of the brain stimulation program at the Johns Hopkins University, Baltimore.
“It varies from one patient to another how agreeable or reluctant or cautious they are about their treatment if the doctor thinks it’s indicated for them,” Dr. Reti said. “Family members’ concerns may be very legitimate but may also be influenced by stigma and misunderstanding about the treatment. They may also not fully appreciate the severity of their loved one’s depression that warrants the administration of ECT.”
Hospitalized patients who are at risk of suicide have benefited from ECT. “It’s very effective,” he said. “I think it’s still the gold standard for severe treatment-resistant depression and also particularly helpful in people who are acutely suicidal.”
Dr. George cautioned that psychiatrists and the public should beware of questionable online sources that attempt to discredit ECT. “A quick Google search will find plenty of nonmedical doctors, many funded through Scientology, who will speak poorly of ECT. But they do not use evidence-based arguments and commonly do not treat patients,” he said.
“All good practicing psychiatrists that I know are in favor of ECT, as it clearly saves lives,” Dr. George added. “We all hope that the future will provide refinements of ECT, or even disruptive technologies that are more effective and with less hassle and will make ECT as we do it now obsolete. But we are not there yet.”
A version of this article first appeared on Medscape.com.
For Clayton Lively, electroconvulsive therapy, or ECT, has been a lifesaver.
“ECT was like a last resort to treat mania and psychosis for bipolar disorder,” said the 31-year-old financial firm associate who lives in Silver Spring, Md. “I had tried lots of different medications.”
The first course of treatments – three times per week for several weeks – was in 2005. They helped tremendously. “I came down from my mania,” Mr. Lively said. “The hallucinations stopped. The psychosis disappeared.”
He reached a point where medications and psychotherapy worked again. And for a decade, his condition was under control.
But in 2017, another episode of hallucinations and mania jolted him off course. Intrusive thoughts returned. For instance, while driving, he would visualize veering off the road. The thoughts were jarring, and yet, he couldn’t stop them from recurring.
“I wasn’t sleeping, and it just kind of wreaked havoc on my life,” Mr. Lively recalled. “I ended up being hospitalized again.”
Once again, ECT came to the rescue – and yet again, in 2018. Now, he’s on an effective maintenance regimen, receiving ECT once every 4 weeks, after tapering down from more frequent sessions.
When a combination of antidepressants and psychotherapy fails to control severe mental illness, there’s hope on the horizon. ECT can be a reliably safe and effective option.
For some patients, using it as maintenance therapy makes sense, said Vaughn McCall, MD, editor-in-chief of The Journal of ECT and professor and chairman of psychiatry at the Medical College of Georgia in Augusta. “I would think of it the same way as you have to treat any chronic illness,” such as blood pressure medicine to keep hypertension in check and dialysis to prevent kidney failure.
Despite a cacophony of contrarian voices – mainly from the Church of Scientology – “the number of psychiatrists who see controversy in ECT is vanishingly small,” Dr. McCall said.
In weighing the pros and cons of ECT, he noted that “when you’re trying to decide if it’s worth doing a treatment, you’re looking at the effectiveness on one hand and the side effects on the other hand.”
The answer to that emerges from several scales measuring patients’ quality of life by posing questions such as: “After receiving ECT, are you more able or less able to take care of yourself, to work, and enjoy the company of other people?”
In the end, Dr. McCall said, “we’ve applied these scales in probably half a dozen studies or more, and they always show that the patients’ qualify of life as a group is improved.”
A recent study published in The Lancet Psychiatry provides a significant degree of reassurance that ECT – also called “electroshock” or colloquially just “shock” therapy – does not increase the risk of serious medical side effects. In fact, the study suggests a potential benefit in reducing suicide risk.
First performed in 1938, the treatment has been well documented in the medical literature. But negative portrayals in books and movies, such as the 1975 film “One Flew Over the Cuckoo’s Nest,” have contributed to casting it in an unfavorable light.
“Unfortunately, over the past decades and years, there’s a lot of stigma and fear around the treatment,” said the study’s lead author, Tyler Kaster, MD, a psychiatrist and clinical fellow in brain stimulation at the University of Toronto.
For the study, Canadian investigators reviewed the admission records of 10,000 patients hospitalized for at least 3 days because of a severe depressive episode. Nearly two-thirds of the patients were women, and the average age for the entire group approached 57 years.
While half of the patients underwent ECT, the others received medication and psychotherapy. Researchers found that the group undergoing ECT did not have a heightened risk of death over the next 30 days and were not any more likely to be hospitalized for a medical problem.
Previous ECT comparative studies were at high risk of bias because of their inability to sufficiently account for confounding variables and differences between those who received the treatment and those who did not. The current study employed “rigorous methods with careful attention to bias and confounding to overcome limitations of previous work,” the authors wrote.
They used propensity score matching, which included more than 75 variables, such as measures of cognitive impairment, depression severity, medication use, other illnesses, and use of psychiatric and various medical services, capacity to consent to treatment, and sociodemographic factors.
“This is really a landmark study in terms of showing the medical safety of ECT,” said Mark S. George, MD, professor of psychiatry and neurology at the Medical University of South Carolina, Charleston, who was not involved in the study.
He added that “ECT is a life-saving treatment” for individuals with severe depression. “It’s good that we have this option for our patients.”
The authors highlight that depression is a major cause of illness and disability worldwide, with many individuals failing to achieve remission from initial therapies. Treatment-resistant depression is often described as being nonresponsive “to two or more medication trials of adequate dose and duration from different classes,” they wrote. In these instances, the authors point out, there is little evidence that psychotherapy would be helpful.
“The reason we consider ECT is someone has very severe depression that hasn’t responded to medications and talk therapy,” Dr. Kaster said. “The advantage of ECT is that it’s very effective in those circumstances.”
Of all therapies for treatment-resistant depression, ECT has the highest success rate, with 60% of patients attaining remission, according to the study, which cites prior research.
Compared with neurosurgery, the procedure is not invasive but requires general anesthesia. While the patient is asleep, Dr. Kaster said, the treating clinician places an electrical stimulus on the patient’s scalp, causing a generalized seizure inside the brain that lasts from 15 seconds to 2 minutes.
A course of ECT usually takes a total of 8-12 treatments, delivered two to three times per week over a month to a month and a half, Dr. George said.
Some patients need a new course of ECT if they relapse after several months. Others are unable to control their depression between courses and require repeated doses for maintenance. The time between these ECT sessions varies for each individual, Dr. George said, but is typically one session every 3-4 weeks.
To improve the odds of staying well, patients typically need to continue taking antidepressants and engaging in psychotherapy.
“It helps improve the efficacy of ECT and also down the road helps prevent relapse,” Dr. Kaster said, noting that “depression is, unfortunately, a chronic illness. We don’t have a cure.”
Murat Altinay, MD, associate professor of psychiatry at the Cleveland Clinic and a mood disorders specialist, said his patients generally need to demonstrate a lack of response to at least three or four antidepressants before he considers recommending ECT.
Confusion, short-term memory impairment, and muscle aches and pains may occur after the procedure, but they are relatively mild. Patients are monitored in a recovery room before discharge from the hospital, Dr. Altinay said.
The first few treatments will affect everyday function. After that initial period, however, people can resume most of their daily activities, he said.
“Maybe they won’t be able to work full-time right away, but anecdotally, we have had patients who were able to go back to the workforce relatively quickly or while they’re getting ECT,” Dr. Altinay said.
More significant adverse events are very rare, he noted, although heart rate and blood pressure can become elevated because of the electrical stimulus.
Dr. Altinay said he is pleased that the large-scale journal article has been published to help dispel myths surrounding ECT. While psychiatrists feel that ECT is generally safe and effective, the public maintains a negative view.
“It is an underutilized treatment,” he said. “In the media, it is almost depicted as a barbaric and archaic treatment in psychiatry.”
Patients are afraid of major side effects such as personality changes. Some fear they will forget someone’s birthday or other important factual information, “but that kind of stuff obviously does not happen,” Dr. Altinay said.
Sometimes it’s not only the patients who are hesitant to try ECT; it’s the family members who express concerns, said Irving Reti, MBBS, professor of psychiatry and neuroscience and director of the brain stimulation program at the Johns Hopkins University, Baltimore.
“It varies from one patient to another how agreeable or reluctant or cautious they are about their treatment if the doctor thinks it’s indicated for them,” Dr. Reti said. “Family members’ concerns may be very legitimate but may also be influenced by stigma and misunderstanding about the treatment. They may also not fully appreciate the severity of their loved one’s depression that warrants the administration of ECT.”
Hospitalized patients who are at risk of suicide have benefited from ECT. “It’s very effective,” he said. “I think it’s still the gold standard for severe treatment-resistant depression and also particularly helpful in people who are acutely suicidal.”
Dr. George cautioned that psychiatrists and the public should beware of questionable online sources that attempt to discredit ECT. “A quick Google search will find plenty of nonmedical doctors, many funded through Scientology, who will speak poorly of ECT. But they do not use evidence-based arguments and commonly do not treat patients,” he said.
“All good practicing psychiatrists that I know are in favor of ECT, as it clearly saves lives,” Dr. George added. “We all hope that the future will provide refinements of ECT, or even disruptive technologies that are more effective and with less hassle and will make ECT as we do it now obsolete. But we are not there yet.”
A version of this article first appeared on Medscape.com.
Increased access to LARC may improve birth outcomes
Policies increasing access to immediate postpartum long-acting reversible contraception (LARC) were associated with reductions in preterm birth and low birth weight, based on data from South Carolina’s Medicaid program.
Preterm birth and low birth weight represent the second-leading cause of infant mortality in the United States, wrote Maria W. Steenland, SD, of Brown University, Providence, R.I., and colleagues. Previous policy interventions to reduce preterm birth and low birth weight have focused on services before and during pregnancy, they said. LARC is a safe and effective postpartum intervention, but cost has been a limiting factor, they noted.
In 2012, the Medicaid program in South Carolina began reimbursing hospitals for immediate postpartum LARC independent of global maternity payments. In a previous study, the researchers found that the implementation of this policy had reduced the number of short-interval births among adolescents.
The goal of the current study, published in JAMA Pediatrics, was to analyze the association between South Carolina’s policy change and rates of preterm birth and low birth weight among individuals with Medicaid coverage during childbirth. The researchers analyzed data from 186,953 Medicaid-paid births between January 2009 and December 2015 in South Carolina. Of these, 46,414 births (24.8%) occurred in hospitals that provided immediate postpartum LARC in response to the policy change. Overall, the implementing hospitals had more annual births paid for by Medicaid compared to nonimplementing hospitals (1,105 vs. 511) and were less likely to be rural (33.3% vs. 46.8%) and had a greater share of preterm births (15.5% vs. 9.5%). Prior to the policy change, the probability of a preterm birth in the next 4 years was 4.4% for patients at implementing hospitals and 3.5% for those in nonimplementing hospitals, and the probability of a low-birth-weight birth was 3.6% and 2.9%, respectively.
The policy change was associated with a decrease of 0.4 percentage points for preterm birth and 0.3 percentage points for subsequent low-birth-weight birth.
When the results were stratified based on race and ethnicity, the policy change was associated with a decrease of 0.5 percentage points in the probability of preterm birth in both non-Hispanic Blacks and non-Hispanic Whites. No significant differences appeared in the association between the policy change and rates of preterm birth or low-birth-weight birth between non-Hispanic Black and non-Hispanic White individuals.
However, the policy was associated with a significant decrease of 0.6 percentage points in the probability of short-interval birth among non-Hispanic Blacks, and a decrease of 1.6 percentage points in the probability of another birth within 4 years overall. The policy change also was associated with a significant increase of 27 days between births among non-Hispanic Blacks, but not with any significant change among non-Hispanic Whites or the study population overall.
“In addition, although our data cannot speak to this, the policy may have affected the intendedness of subsequent pregnancies, leading to healthier behaviors before and during pregnancy, such as early initiation of prenatal care,” the researchers wrote in their discussion of the findings.
The study findings were limited by several factors including the lack of data on pregnancy intention or abortion, and the lack of data on patient-reported outcomes, notably the provision of patient-centered counseling and whether such counseling was biased, the researchers noted. Other limitations included a lack of data on infant mortality and potential confounding from risk profiles of patients in implementing vs. nonimplementing hospitals, they wrote.
Also, the study provides population-level data, which does not guide clinical decision-making about intervals between childbirth and subsequent pregnancy, the researchers emphasized.
Although the data support the value of postpartum contraception in improving birth outcomes, “it is imperative that efforts to expand access focus on assuring comprehensive access to all forms of contraception without coercion,” the researchers concluded. “Additional policy solutions are needed to improve infant health, including those that directly address structural and interpersonal racism to reduce racial disparities in infant health,” they said.
The study is important because, although immediate postpartum LARC policies were first implemented almost a decade ago in the United States, population-level evidence on the effects of these policies remains scarce, Dr. Steenland said in an interview.
Existing barriers to improving access to immediate postpartum LARC include health professional training and logistics within hospitals, as well as ensuring correct billing and timely reimbursements, Dr. Steenland said. “Simple and clear billing procedures, and advanced reimbursement so that hospitals can have devices stocked would make it easier to provide this service,” she noted.
“This service has gone from being almost completely unavailable, to available in some hospitals, mainly those that are urban, teaching, and high volume,” said Dr. Steenland. “Additional research is needed to determine how health systems can make this service available to all birthing persons,” she said. “Also, critically, additional research is needed to identify strategies to ensure that counseling for immediate postpartum LARC, and family planning more generally, is patient-centered, so that the availability of immediate postpartum LARC increases, rather than restricts, choice,” she added. “Finally, additional research is needed to determine whether postpartum people have affordable and accessible access to LARC removal services,” Dr. Steenland emphasized.
Immediate post partum is critical period
The immediate postpartum period is a critical time for access to contraception because many women do not return for postpartum visits after hospital discharge, Tracey A. Wilkinson, MD, and Jeffrey F. Peipert, MD, of Indiana University, Indianapolis, wrote in an accompanying editorial. “The focus on contraception access during the postpartum period prior to hospital discharge is important because of the potential sequelae of a subsequent unintended pregnancy or short interpregnancy intervals,” they noted. These issues may be more acute in marginalized communities, and policies to expand immediate postpartum LARC are in place in a majority of states, the editorialists said.
However, they agreed with the authors’ statements that implementation of LARC must be done in a manner that supports patient choice and avoids coercion. Given the baseline disparities of the infant outcomes studied, increased access to immediate postpartum LARC must be provided in a way that does not exacerbate these disparities, they said. “This ultimately means that plans to increase access to contraception should emphasize availability while avoiding coercion, and if a patient ultimately decides to discontinue a method, enable that to occur easily and seamlessly, including LARC device removal,” they explained.
“Future studies examining patient centeredness of these postpartum LARC implementation efforts would be an important element to augment these data and show the impact in additional spheres beyond infant outcomes,” they added.
Overcome trust barriers and offer options
“In a time of restrictive access to abortion and contraception in many states, any additional increase in access can potentially be meaningful,” Sarah W. Prager, MD, of the University of Washington, Seattle, said in an interview. “Additionally, given the significantly higher rates of infant and maternal morbidity and mortality among the non-Hispanic Black population, seeing an intervention that can improve outcomes for both mothers and babies is also potentially very positive,” she said.
Dr. Prager said she was not surprised by the study findings, as immediate LARC is much more common in other countries and has shown similar outcomes. “Additionally, I am reassured by the fact that the increased number of days until the next pregnancy is not higher, as this indirectly indicates that patients were able to get their LARC removed when they desired another pregnancy,” she noted.
Barriers to improving access to immediate postpartum LARC in the Medicaid population may include mistrust for any long-acting contraception, “especially if they perceive that cessation of the method will be difficult to achieve,” Dr. Prager noted. “Certainly, counseling about LARC removal should be an element of counseling prior to any initiation, and lack of access to removal of an IUD or implant can be categorized as a form of reproductive coercion,” she said. Dr. Prager said that such counseling might be more effective if it occurred during prenatal visits, “so if providers are not talking about this during routine OB visits and patients only hear about immediate postpartum LARC when they are in the hospital for delivery, they may be less likely to accept the practice,” she said. “Finally, although Medicaid will cover the cost of immediate postpartum LARC, private insurers do not do so consistently in all states, so some hospitals may find this process too difficult to navigate and therefore not offer immediate postpartum LARC,” Dr. Prager emphasized.
As for additional research, Dr. Prager said she would like to see more studies in an overall United States population of pregnant people, both Medicaid patients and others, on whether the immediate postpartum timing of LARC is desired.
“I would like to couple that with patients’ impressions or experiences of their ability to access contraception outside of the immediate postpartum time period, and also their impressions or experience with ability to have LARC removed, since they are the only contraceptives not necessarily within personal control for initiation or cessation,” Dr. Prager said.
The study was supported by the National Institute for Child Health and Development, and lead author Dr. Steenland received support from other National Institutes of Health grants. The researchers had no financial conflicts to disclose. The editorial was supported in part by the Eunice Kennedy Shriver National Institute of Child Health and Human Development. Dr. Peipert disclosed serving on advisory boards for Bayer and CooperSurgical, and receiving research support from Merck, Bayer, and CooperSurgical/Teva. Dr. Wilkinson had no financial conflicts to disclose. Dr. Prager had no financial conflicts to disclose and serves on the editorial advisory board of Ob.Gyn. News.
Policies increasing access to immediate postpartum long-acting reversible contraception (LARC) were associated with reductions in preterm birth and low birth weight, based on data from South Carolina’s Medicaid program.
Preterm birth and low birth weight represent the second-leading cause of infant mortality in the United States, wrote Maria W. Steenland, SD, of Brown University, Providence, R.I., and colleagues. Previous policy interventions to reduce preterm birth and low birth weight have focused on services before and during pregnancy, they said. LARC is a safe and effective postpartum intervention, but cost has been a limiting factor, they noted.
In 2012, the Medicaid program in South Carolina began reimbursing hospitals for immediate postpartum LARC independent of global maternity payments. In a previous study, the researchers found that the implementation of this policy had reduced the number of short-interval births among adolescents.
The goal of the current study, published in JAMA Pediatrics, was to analyze the association between South Carolina’s policy change and rates of preterm birth and low birth weight among individuals with Medicaid coverage during childbirth. The researchers analyzed data from 186,953 Medicaid-paid births between January 2009 and December 2015 in South Carolina. Of these, 46,414 births (24.8%) occurred in hospitals that provided immediate postpartum LARC in response to the policy change. Overall, the implementing hospitals had more annual births paid for by Medicaid compared to nonimplementing hospitals (1,105 vs. 511) and were less likely to be rural (33.3% vs. 46.8%) and had a greater share of preterm births (15.5% vs. 9.5%). Prior to the policy change, the probability of a preterm birth in the next 4 years was 4.4% for patients at implementing hospitals and 3.5% for those in nonimplementing hospitals, and the probability of a low-birth-weight birth was 3.6% and 2.9%, respectively.
The policy change was associated with a decrease of 0.4 percentage points for preterm birth and 0.3 percentage points for subsequent low-birth-weight birth.
When the results were stratified based on race and ethnicity, the policy change was associated with a decrease of 0.5 percentage points in the probability of preterm birth in both non-Hispanic Blacks and non-Hispanic Whites. No significant differences appeared in the association between the policy change and rates of preterm birth or low-birth-weight birth between non-Hispanic Black and non-Hispanic White individuals.
However, the policy was associated with a significant decrease of 0.6 percentage points in the probability of short-interval birth among non-Hispanic Blacks, and a decrease of 1.6 percentage points in the probability of another birth within 4 years overall. The policy change also was associated with a significant increase of 27 days between births among non-Hispanic Blacks, but not with any significant change among non-Hispanic Whites or the study population overall.
“In addition, although our data cannot speak to this, the policy may have affected the intendedness of subsequent pregnancies, leading to healthier behaviors before and during pregnancy, such as early initiation of prenatal care,” the researchers wrote in their discussion of the findings.
The study findings were limited by several factors including the lack of data on pregnancy intention or abortion, and the lack of data on patient-reported outcomes, notably the provision of patient-centered counseling and whether such counseling was biased, the researchers noted. Other limitations included a lack of data on infant mortality and potential confounding from risk profiles of patients in implementing vs. nonimplementing hospitals, they wrote.
Also, the study provides population-level data, which does not guide clinical decision-making about intervals between childbirth and subsequent pregnancy, the researchers emphasized.
Although the data support the value of postpartum contraception in improving birth outcomes, “it is imperative that efforts to expand access focus on assuring comprehensive access to all forms of contraception without coercion,” the researchers concluded. “Additional policy solutions are needed to improve infant health, including those that directly address structural and interpersonal racism to reduce racial disparities in infant health,” they said.
The study is important because, although immediate postpartum LARC policies were first implemented almost a decade ago in the United States, population-level evidence on the effects of these policies remains scarce, Dr. Steenland said in an interview.
Existing barriers to improving access to immediate postpartum LARC include health professional training and logistics within hospitals, as well as ensuring correct billing and timely reimbursements, Dr. Steenland said. “Simple and clear billing procedures, and advanced reimbursement so that hospitals can have devices stocked would make it easier to provide this service,” she noted.
“This service has gone from being almost completely unavailable, to available in some hospitals, mainly those that are urban, teaching, and high volume,” said Dr. Steenland. “Additional research is needed to determine how health systems can make this service available to all birthing persons,” she said. “Also, critically, additional research is needed to identify strategies to ensure that counseling for immediate postpartum LARC, and family planning more generally, is patient-centered, so that the availability of immediate postpartum LARC increases, rather than restricts, choice,” she added. “Finally, additional research is needed to determine whether postpartum people have affordable and accessible access to LARC removal services,” Dr. Steenland emphasized.
Immediate post partum is critical period
The immediate postpartum period is a critical time for access to contraception because many women do not return for postpartum visits after hospital discharge, Tracey A. Wilkinson, MD, and Jeffrey F. Peipert, MD, of Indiana University, Indianapolis, wrote in an accompanying editorial. “The focus on contraception access during the postpartum period prior to hospital discharge is important because of the potential sequelae of a subsequent unintended pregnancy or short interpregnancy intervals,” they noted. These issues may be more acute in marginalized communities, and policies to expand immediate postpartum LARC are in place in a majority of states, the editorialists said.
However, they agreed with the authors’ statements that implementation of LARC must be done in a manner that supports patient choice and avoids coercion. Given the baseline disparities of the infant outcomes studied, increased access to immediate postpartum LARC must be provided in a way that does not exacerbate these disparities, they said. “This ultimately means that plans to increase access to contraception should emphasize availability while avoiding coercion, and if a patient ultimately decides to discontinue a method, enable that to occur easily and seamlessly, including LARC device removal,” they explained.
“Future studies examining patient centeredness of these postpartum LARC implementation efforts would be an important element to augment these data and show the impact in additional spheres beyond infant outcomes,” they added.
Overcome trust barriers and offer options
“In a time of restrictive access to abortion and contraception in many states, any additional increase in access can potentially be meaningful,” Sarah W. Prager, MD, of the University of Washington, Seattle, said in an interview. “Additionally, given the significantly higher rates of infant and maternal morbidity and mortality among the non-Hispanic Black population, seeing an intervention that can improve outcomes for both mothers and babies is also potentially very positive,” she said.
Dr. Prager said she was not surprised by the study findings, as immediate LARC is much more common in other countries and has shown similar outcomes. “Additionally, I am reassured by the fact that the increased number of days until the next pregnancy is not higher, as this indirectly indicates that patients were able to get their LARC removed when they desired another pregnancy,” she noted.
Barriers to improving access to immediate postpartum LARC in the Medicaid population may include mistrust for any long-acting contraception, “especially if they perceive that cessation of the method will be difficult to achieve,” Dr. Prager noted. “Certainly, counseling about LARC removal should be an element of counseling prior to any initiation, and lack of access to removal of an IUD or implant can be categorized as a form of reproductive coercion,” she said. Dr. Prager said that such counseling might be more effective if it occurred during prenatal visits, “so if providers are not talking about this during routine OB visits and patients only hear about immediate postpartum LARC when they are in the hospital for delivery, they may be less likely to accept the practice,” she said. “Finally, although Medicaid will cover the cost of immediate postpartum LARC, private insurers do not do so consistently in all states, so some hospitals may find this process too difficult to navigate and therefore not offer immediate postpartum LARC,” Dr. Prager emphasized.
As for additional research, Dr. Prager said she would like to see more studies in an overall United States population of pregnant people, both Medicaid patients and others, on whether the immediate postpartum timing of LARC is desired.
“I would like to couple that with patients’ impressions or experiences of their ability to access contraception outside of the immediate postpartum time period, and also their impressions or experience with ability to have LARC removed, since they are the only contraceptives not necessarily within personal control for initiation or cessation,” Dr. Prager said.
The study was supported by the National Institute for Child Health and Development, and lead author Dr. Steenland received support from other National Institutes of Health grants. The researchers had no financial conflicts to disclose. The editorial was supported in part by the Eunice Kennedy Shriver National Institute of Child Health and Human Development. Dr. Peipert disclosed serving on advisory boards for Bayer and CooperSurgical, and receiving research support from Merck, Bayer, and CooperSurgical/Teva. Dr. Wilkinson had no financial conflicts to disclose. Dr. Prager had no financial conflicts to disclose and serves on the editorial advisory board of Ob.Gyn. News.
Policies increasing access to immediate postpartum long-acting reversible contraception (LARC) were associated with reductions in preterm birth and low birth weight, based on data from South Carolina’s Medicaid program.
Preterm birth and low birth weight represent the second-leading cause of infant mortality in the United States, wrote Maria W. Steenland, SD, of Brown University, Providence, R.I., and colleagues. Previous policy interventions to reduce preterm birth and low birth weight have focused on services before and during pregnancy, they said. LARC is a safe and effective postpartum intervention, but cost has been a limiting factor, they noted.
In 2012, the Medicaid program in South Carolina began reimbursing hospitals for immediate postpartum LARC independent of global maternity payments. In a previous study, the researchers found that the implementation of this policy had reduced the number of short-interval births among adolescents.
The goal of the current study, published in JAMA Pediatrics, was to analyze the association between South Carolina’s policy change and rates of preterm birth and low birth weight among individuals with Medicaid coverage during childbirth. The researchers analyzed data from 186,953 Medicaid-paid births between January 2009 and December 2015 in South Carolina. Of these, 46,414 births (24.8%) occurred in hospitals that provided immediate postpartum LARC in response to the policy change. Overall, the implementing hospitals had more annual births paid for by Medicaid compared to nonimplementing hospitals (1,105 vs. 511) and were less likely to be rural (33.3% vs. 46.8%) and had a greater share of preterm births (15.5% vs. 9.5%). Prior to the policy change, the probability of a preterm birth in the next 4 years was 4.4% for patients at implementing hospitals and 3.5% for those in nonimplementing hospitals, and the probability of a low-birth-weight birth was 3.6% and 2.9%, respectively.
The policy change was associated with a decrease of 0.4 percentage points for preterm birth and 0.3 percentage points for subsequent low-birth-weight birth.
When the results were stratified based on race and ethnicity, the policy change was associated with a decrease of 0.5 percentage points in the probability of preterm birth in both non-Hispanic Blacks and non-Hispanic Whites. No significant differences appeared in the association between the policy change and rates of preterm birth or low-birth-weight birth between non-Hispanic Black and non-Hispanic White individuals.
However, the policy was associated with a significant decrease of 0.6 percentage points in the probability of short-interval birth among non-Hispanic Blacks, and a decrease of 1.6 percentage points in the probability of another birth within 4 years overall. The policy change also was associated with a significant increase of 27 days between births among non-Hispanic Blacks, but not with any significant change among non-Hispanic Whites or the study population overall.
“In addition, although our data cannot speak to this, the policy may have affected the intendedness of subsequent pregnancies, leading to healthier behaviors before and during pregnancy, such as early initiation of prenatal care,” the researchers wrote in their discussion of the findings.
The study findings were limited by several factors including the lack of data on pregnancy intention or abortion, and the lack of data on patient-reported outcomes, notably the provision of patient-centered counseling and whether such counseling was biased, the researchers noted. Other limitations included a lack of data on infant mortality and potential confounding from risk profiles of patients in implementing vs. nonimplementing hospitals, they wrote.
Also, the study provides population-level data, which does not guide clinical decision-making about intervals between childbirth and subsequent pregnancy, the researchers emphasized.
Although the data support the value of postpartum contraception in improving birth outcomes, “it is imperative that efforts to expand access focus on assuring comprehensive access to all forms of contraception without coercion,” the researchers concluded. “Additional policy solutions are needed to improve infant health, including those that directly address structural and interpersonal racism to reduce racial disparities in infant health,” they said.
The study is important because, although immediate postpartum LARC policies were first implemented almost a decade ago in the United States, population-level evidence on the effects of these policies remains scarce, Dr. Steenland said in an interview.
Existing barriers to improving access to immediate postpartum LARC include health professional training and logistics within hospitals, as well as ensuring correct billing and timely reimbursements, Dr. Steenland said. “Simple and clear billing procedures, and advanced reimbursement so that hospitals can have devices stocked would make it easier to provide this service,” she noted.
“This service has gone from being almost completely unavailable, to available in some hospitals, mainly those that are urban, teaching, and high volume,” said Dr. Steenland. “Additional research is needed to determine how health systems can make this service available to all birthing persons,” she said. “Also, critically, additional research is needed to identify strategies to ensure that counseling for immediate postpartum LARC, and family planning more generally, is patient-centered, so that the availability of immediate postpartum LARC increases, rather than restricts, choice,” she added. “Finally, additional research is needed to determine whether postpartum people have affordable and accessible access to LARC removal services,” Dr. Steenland emphasized.
Immediate post partum is critical period
The immediate postpartum period is a critical time for access to contraception because many women do not return for postpartum visits after hospital discharge, Tracey A. Wilkinson, MD, and Jeffrey F. Peipert, MD, of Indiana University, Indianapolis, wrote in an accompanying editorial. “The focus on contraception access during the postpartum period prior to hospital discharge is important because of the potential sequelae of a subsequent unintended pregnancy or short interpregnancy intervals,” they noted. These issues may be more acute in marginalized communities, and policies to expand immediate postpartum LARC are in place in a majority of states, the editorialists said.
However, they agreed with the authors’ statements that implementation of LARC must be done in a manner that supports patient choice and avoids coercion. Given the baseline disparities of the infant outcomes studied, increased access to immediate postpartum LARC must be provided in a way that does not exacerbate these disparities, they said. “This ultimately means that plans to increase access to contraception should emphasize availability while avoiding coercion, and if a patient ultimately decides to discontinue a method, enable that to occur easily and seamlessly, including LARC device removal,” they explained.
“Future studies examining patient centeredness of these postpartum LARC implementation efforts would be an important element to augment these data and show the impact in additional spheres beyond infant outcomes,” they added.
Overcome trust barriers and offer options
“In a time of restrictive access to abortion and contraception in many states, any additional increase in access can potentially be meaningful,” Sarah W. Prager, MD, of the University of Washington, Seattle, said in an interview. “Additionally, given the significantly higher rates of infant and maternal morbidity and mortality among the non-Hispanic Black population, seeing an intervention that can improve outcomes for both mothers and babies is also potentially very positive,” she said.
Dr. Prager said she was not surprised by the study findings, as immediate LARC is much more common in other countries and has shown similar outcomes. “Additionally, I am reassured by the fact that the increased number of days until the next pregnancy is not higher, as this indirectly indicates that patients were able to get their LARC removed when they desired another pregnancy,” she noted.
Barriers to improving access to immediate postpartum LARC in the Medicaid population may include mistrust for any long-acting contraception, “especially if they perceive that cessation of the method will be difficult to achieve,” Dr. Prager noted. “Certainly, counseling about LARC removal should be an element of counseling prior to any initiation, and lack of access to removal of an IUD or implant can be categorized as a form of reproductive coercion,” she said. Dr. Prager said that such counseling might be more effective if it occurred during prenatal visits, “so if providers are not talking about this during routine OB visits and patients only hear about immediate postpartum LARC when they are in the hospital for delivery, they may be less likely to accept the practice,” she said. “Finally, although Medicaid will cover the cost of immediate postpartum LARC, private insurers do not do so consistently in all states, so some hospitals may find this process too difficult to navigate and therefore not offer immediate postpartum LARC,” Dr. Prager emphasized.
As for additional research, Dr. Prager said she would like to see more studies in an overall United States population of pregnant people, both Medicaid patients and others, on whether the immediate postpartum timing of LARC is desired.
“I would like to couple that with patients’ impressions or experiences of their ability to access contraception outside of the immediate postpartum time period, and also their impressions or experience with ability to have LARC removed, since they are the only contraceptives not necessarily within personal control for initiation or cessation,” Dr. Prager said.
The study was supported by the National Institute for Child Health and Development, and lead author Dr. Steenland received support from other National Institutes of Health grants. The researchers had no financial conflicts to disclose. The editorial was supported in part by the Eunice Kennedy Shriver National Institute of Child Health and Human Development. Dr. Peipert disclosed serving on advisory boards for Bayer and CooperSurgical, and receiving research support from Merck, Bayer, and CooperSurgical/Teva. Dr. Wilkinson had no financial conflicts to disclose. Dr. Prager had no financial conflicts to disclose and serves on the editorial advisory board of Ob.Gyn. News.
FROM JAMA PEDIATRICS