The COVID-19 pandemic has overshadowed innovations in HIV care and prevention, says Tonia Poteat, PhD, MPH, PA-C, a primary HIV care and HIV pre-exposure prophylaxis (PrEP) clinician and associate professor of social medicine at the University of North Carolina at Chapel Hill. Therefore, even though the U.S. Food and Drug Administration approved monthly injections of cabotegravir/rilpivirine (Cabenuva) in January, none of her patients are taking it.
“We moved our clinic three times during the pandemic,” Dr. Poteat said. “I’m really interested in how on earth we’re going to integrate injectable products into our workflow. We don’t have systems set up yet, so we’re in the process of figuring out what the structure is going to be like. We have people who are interested on a wait list.”
Indeed, in an HIV world still reeling from the dual impact of HIV and COVID-19, the International AIDS Society Conference on HIV Science (IAS 2021) will bring a more coherent narrative on the future of HIV treatment and prevention. That narrative involves long-acting treatment and setting up the systems to make it available to everyone. And IAS offers data showing exactly how much people living with HIV risk poor COVID-19 outcomes.
The conference will be online for the second year in a row and, unlike in 2020, the focus will be much more on HIV treatment and prevention than on that other big infectious disease making news these days.
There will be new data on long-acting forms of prevention, such as the intravaginal ring and monthly PrEP pills. There will be new data on PrEP on demand (2-1-1 PrEP) and the results of a large trial looking at breakthrough HIV infections among those taking daily oral PrEP.
On the cure front, intriguing animal studies and ex vivo studies look into the use of cancer immunotherapies for an HIV functional cure, as well as the use of CAR-T to stop HIV replication in the absence of daily medication.
Dr. Poteat is not alone in being interested specifically in the PrEP and long-acting studies. Jonathan Baker, a PA in private practice in New York City, also wants to see the data on the ring and other expanded PrEP options.
But “a prevention method can only work when people are able to use it,” he said. “So [the session] ‘Reducing Barriers to PrEP’ is really relevant as we see inequitable intake failing the populations who need PrEP most.”
This is a concern Dr. Poteat has too. That’s why she’s glad to see there will be sessions on systemic inequities, particularly around what it will take to address those inequities in the U.S. by 2030 in line with “Ending the HIV Epidemic: A Plan for America.” She’s looking forward to sessions on novel service-delivery models with low thresholds of entry for people experiencing homelessness or people who inject drugs; on access to affordable medications; on trans-led care for transgender women in the global South; and on the comorbidities of aging that are keeping her patients sick these days.
To that end, there are sessions on common comorbidities with HIV, such as reinfection with hepatitis C, sexually transmitted infections, heart disease, and weight gain as a result of newer drug options, as well as drug-drug interactions between HIV medications and those used in gender-affirming care for transgender adults.
“I can count on one hand the number of people for whom the issue is finding the right antiretroviral,” she said. “That’s rarely the issue. The issue is often how do we manage their other comorbid conditions, and what about drug-drug interactions with those conditions? HIV is not the only condition many of them have.”
Mr. Baker reports that his clinic receives funding from Merck, Innovio, and Antiva. Dr. Poteat is a consultant for ViiV Healthcare and serves on a study advisory board for Merck.
A version of this article first appeared on Medscape.com.
The COVID-19 pandemic has overshadowed innovations in HIV care and prevention, says Tonia Poteat, PhD, MPH, PA-C, a primary HIV care and HIV pre-exposure prophylaxis (PrEP) clinician and associate professor of social medicine at the University of North Carolina at Chapel Hill. Therefore, even though the U.S. Food and Drug Administration approved monthly injections of cabotegravir/rilpivirine (Cabenuva) in January, none of her patients are taking it.
“We moved our clinic three times during the pandemic,” Dr. Poteat said. “I’m really interested in how on earth we’re going to integrate injectable products into our workflow. We don’t have systems set up yet, so we’re in the process of figuring out what the structure is going to be like. We have people who are interested on a wait list.”
Indeed, in an HIV world still reeling from the dual impact of HIV and COVID-19, the International AIDS Society Conference on HIV Science (IAS 2021) will bring a more coherent narrative on the future of HIV treatment and prevention. That narrative involves long-acting treatment and setting up the systems to make it available to everyone. And IAS offers data showing exactly how much people living with HIV risk poor COVID-19 outcomes.
The conference will be online for the second year in a row and, unlike in 2020, the focus will be much more on HIV treatment and prevention than on that other big infectious disease making news these days.
There will be new data on long-acting forms of prevention, such as the intravaginal ring and monthly PrEP pills. There will be new data on PrEP on demand (2-1-1 PrEP) and the results of a large trial looking at breakthrough HIV infections among those taking daily oral PrEP.
On the cure front, intriguing animal studies and ex vivo studies look into the use of cancer immunotherapies for an HIV functional cure, as well as the use of CAR-T to stop HIV replication in the absence of daily medication.
Dr. Poteat is not alone in being interested specifically in the PrEP and long-acting studies. Jonathan Baker, a PA in private practice in New York City, also wants to see the data on the ring and other expanded PrEP options.
But “a prevention method can only work when people are able to use it,” he said. “So [the session] ‘Reducing Barriers to PrEP’ is really relevant as we see inequitable intake failing the populations who need PrEP most.”
This is a concern Dr. Poteat has too. That’s why she’s glad to see there will be sessions on systemic inequities, particularly around what it will take to address those inequities in the U.S. by 2030 in line with “Ending the HIV Epidemic: A Plan for America.” She’s looking forward to sessions on novel service-delivery models with low thresholds of entry for people experiencing homelessness or people who inject drugs; on access to affordable medications; on trans-led care for transgender women in the global South; and on the comorbidities of aging that are keeping her patients sick these days.
To that end, there are sessions on common comorbidities with HIV, such as reinfection with hepatitis C, sexually transmitted infections, heart disease, and weight gain as a result of newer drug options, as well as drug-drug interactions between HIV medications and those used in gender-affirming care for transgender adults.
“I can count on one hand the number of people for whom the issue is finding the right antiretroviral,” she said. “That’s rarely the issue. The issue is often how do we manage their other comorbid conditions, and what about drug-drug interactions with those conditions? HIV is not the only condition many of them have.”
Mr. Baker reports that his clinic receives funding from Merck, Innovio, and Antiva. Dr. Poteat is a consultant for ViiV Healthcare and serves on a study advisory board for Merck.
A version of this article first appeared on Medscape.com.
The COVID-19 pandemic has overshadowed innovations in HIV care and prevention, says Tonia Poteat, PhD, MPH, PA-C, a primary HIV care and HIV pre-exposure prophylaxis (PrEP) clinician and associate professor of social medicine at the University of North Carolina at Chapel Hill. Therefore, even though the U.S. Food and Drug Administration approved monthly injections of cabotegravir/rilpivirine (Cabenuva) in January, none of her patients are taking it.
“We moved our clinic three times during the pandemic,” Dr. Poteat said. “I’m really interested in how on earth we’re going to integrate injectable products into our workflow. We don’t have systems set up yet, so we’re in the process of figuring out what the structure is going to be like. We have people who are interested on a wait list.”
Indeed, in an HIV world still reeling from the dual impact of HIV and COVID-19, the International AIDS Society Conference on HIV Science (IAS 2021) will bring a more coherent narrative on the future of HIV treatment and prevention. That narrative involves long-acting treatment and setting up the systems to make it available to everyone. And IAS offers data showing exactly how much people living with HIV risk poor COVID-19 outcomes.
The conference will be online for the second year in a row and, unlike in 2020, the focus will be much more on HIV treatment and prevention than on that other big infectious disease making news these days.
There will be new data on long-acting forms of prevention, such as the intravaginal ring and monthly PrEP pills. There will be new data on PrEP on demand (2-1-1 PrEP) and the results of a large trial looking at breakthrough HIV infections among those taking daily oral PrEP.
On the cure front, intriguing animal studies and ex vivo studies look into the use of cancer immunotherapies for an HIV functional cure, as well as the use of CAR-T to stop HIV replication in the absence of daily medication.
Dr. Poteat is not alone in being interested specifically in the PrEP and long-acting studies. Jonathan Baker, a PA in private practice in New York City, also wants to see the data on the ring and other expanded PrEP options.
But “a prevention method can only work when people are able to use it,” he said. “So [the session] ‘Reducing Barriers to PrEP’ is really relevant as we see inequitable intake failing the populations who need PrEP most.”
This is a concern Dr. Poteat has too. That’s why she’s glad to see there will be sessions on systemic inequities, particularly around what it will take to address those inequities in the U.S. by 2030 in line with “Ending the HIV Epidemic: A Plan for America.” She’s looking forward to sessions on novel service-delivery models with low thresholds of entry for people experiencing homelessness or people who inject drugs; on access to affordable medications; on trans-led care for transgender women in the global South; and on the comorbidities of aging that are keeping her patients sick these days.
To that end, there are sessions on common comorbidities with HIV, such as reinfection with hepatitis C, sexually transmitted infections, heart disease, and weight gain as a result of newer drug options, as well as drug-drug interactions between HIV medications and those used in gender-affirming care for transgender adults.
“I can count on one hand the number of people for whom the issue is finding the right antiretroviral,” she said. “That’s rarely the issue. The issue is often how do we manage their other comorbid conditions, and what about drug-drug interactions with those conditions? HIV is not the only condition many of them have.”
Mr. Baker reports that his clinic receives funding from Merck, Innovio, and Antiva. Dr. Poteat is a consultant for ViiV Healthcare and serves on a study advisory board for Merck.
A version of this article first appeared on Medscape.com.
As restrictions lift and mask mandates become scarce, Americans are filling their social calendars and booking vacations. While some are rejoicing, health care professionals say others are emerging from the pandemic with more health-related fears.
COVID-19 has caused more anxiety and depression for many over the course of the pandemic. A survey from the CDC and the Census Bureau found the percentage of adults with symptoms of an anxiety or depressive disorder increased from 36.4% to 41.5% from August 2020 to February 2021.
But this phenomenon will not just disappear as COVID-19 cases decrease, said Reese Druckenmiller, a clinical social worker for the Mayo Clinic Health System.
“There are still people out there not wanting to leave home,” she said. “Some folks inherently struggle with anxiety more than others, and we know anxiety can come from different experiences and traumas. This pandemic has been traumatic for people.”
Though there is little research on the psychological effects of pandemic outbreaks, scientists are beginning to explore this. A recent review published in the International Journal of Cognitive Therapy concluded that, based on available research and the effects of previous pandemics, COVID-19 will likely have a significant effect on people’s mental health, particularly those who already have obsessive-compulsive disorder and health anxiety, along with people on the front line of health care.
According to the authors, since the virus doesn’t have symptoms among certain populations, there’s more anxiety about becoming infected and unknowingly spreading it to vulnerable people.
Not to mention the influx of anxiety-provoking news over the past year, Ms. Druckenmiller noted.
“One thing I noticed during the pandemic: The news changed. There were still regular news stories, but at the forefront of every single newscast was the numbers, how many people have died, how many people are hospitalized,” she said.
Some of Ms. Druckenmiller’s own patients who are more health-focused saw this as an added burden – another source of anxiety.
For those still uncomfortable with an abrupt reentry into public spaces, Ms. Druckenmiller recommended taking small steps. Start leaving the house every day, she suggested, even if it’s just for a walk. It is also important to be honest with loved ones about your own comfort level.
“Our brain is very flexible and fluid, but it also doesn’t just switch on a dime,” she said. “If I’ve been told over the past year this is a horrible thing that could kill me, my brain can’t adjust that fast. We need evidence through experience.”
A version of this article first appeared on WebMD.com.
As restrictions lift and mask mandates become scarce, Americans are filling their social calendars and booking vacations. While some are rejoicing, health care professionals say others are emerging from the pandemic with more health-related fears.
COVID-19 has caused more anxiety and depression for many over the course of the pandemic. A survey from the CDC and the Census Bureau found the percentage of adults with symptoms of an anxiety or depressive disorder increased from 36.4% to 41.5% from August 2020 to February 2021.
But this phenomenon will not just disappear as COVID-19 cases decrease, said Reese Druckenmiller, a clinical social worker for the Mayo Clinic Health System.
“There are still people out there not wanting to leave home,” she said. “Some folks inherently struggle with anxiety more than others, and we know anxiety can come from different experiences and traumas. This pandemic has been traumatic for people.”
Though there is little research on the psychological effects of pandemic outbreaks, scientists are beginning to explore this. A recent review published in the International Journal of Cognitive Therapy concluded that, based on available research and the effects of previous pandemics, COVID-19 will likely have a significant effect on people’s mental health, particularly those who already have obsessive-compulsive disorder and health anxiety, along with people on the front line of health care.
According to the authors, since the virus doesn’t have symptoms among certain populations, there’s more anxiety about becoming infected and unknowingly spreading it to vulnerable people.
Not to mention the influx of anxiety-provoking news over the past year, Ms. Druckenmiller noted.
“One thing I noticed during the pandemic: The news changed. There were still regular news stories, but at the forefront of every single newscast was the numbers, how many people have died, how many people are hospitalized,” she said.
Some of Ms. Druckenmiller’s own patients who are more health-focused saw this as an added burden – another source of anxiety.
For those still uncomfortable with an abrupt reentry into public spaces, Ms. Druckenmiller recommended taking small steps. Start leaving the house every day, she suggested, even if it’s just for a walk. It is also important to be honest with loved ones about your own comfort level.
“Our brain is very flexible and fluid, but it also doesn’t just switch on a dime,” she said. “If I’ve been told over the past year this is a horrible thing that could kill me, my brain can’t adjust that fast. We need evidence through experience.”
A version of this article first appeared on WebMD.com.
As restrictions lift and mask mandates become scarce, Americans are filling their social calendars and booking vacations. While some are rejoicing, health care professionals say others are emerging from the pandemic with more health-related fears.
COVID-19 has caused more anxiety and depression for many over the course of the pandemic. A survey from the CDC and the Census Bureau found the percentage of adults with symptoms of an anxiety or depressive disorder increased from 36.4% to 41.5% from August 2020 to February 2021.
But this phenomenon will not just disappear as COVID-19 cases decrease, said Reese Druckenmiller, a clinical social worker for the Mayo Clinic Health System.
“There are still people out there not wanting to leave home,” she said. “Some folks inherently struggle with anxiety more than others, and we know anxiety can come from different experiences and traumas. This pandemic has been traumatic for people.”
Though there is little research on the psychological effects of pandemic outbreaks, scientists are beginning to explore this. A recent review published in the International Journal of Cognitive Therapy concluded that, based on available research and the effects of previous pandemics, COVID-19 will likely have a significant effect on people’s mental health, particularly those who already have obsessive-compulsive disorder and health anxiety, along with people on the front line of health care.
According to the authors, since the virus doesn’t have symptoms among certain populations, there’s more anxiety about becoming infected and unknowingly spreading it to vulnerable people.
Not to mention the influx of anxiety-provoking news over the past year, Ms. Druckenmiller noted.
“One thing I noticed during the pandemic: The news changed. There were still regular news stories, but at the forefront of every single newscast was the numbers, how many people have died, how many people are hospitalized,” she said.
Some of Ms. Druckenmiller’s own patients who are more health-focused saw this as an added burden – another source of anxiety.
For those still uncomfortable with an abrupt reentry into public spaces, Ms. Druckenmiller recommended taking small steps. Start leaving the house every day, she suggested, even if it’s just for a walk. It is also important to be honest with loved ones about your own comfort level.
“Our brain is very flexible and fluid, but it also doesn’t just switch on a dime,” she said. “If I’ve been told over the past year this is a horrible thing that could kill me, my brain can’t adjust that fast. We need evidence through experience.”
A version of this article first appeared on WebMD.com.
An updated consensus statement from the American Headache Society (AHS) offers detailed recommendations on the use of novel acute and preventive treatments in adult patients with migraine.
“Because the benefit–risk profiles of newer treatments will continue to evolve as clinical trial and real-world data accrue, the American Headache Society intends to review this statement regularly and update, if appropriate, based on the emergence of evidence with implications for clinical practice,” wrote lead author Jessica Ailani, MD, of the department of neurology at Medstar Georgetown University Hospital, Washington, and colleagues. The statement was published in Headache.
To assess recent data on the efficacy, safety, and clinical use of newly introduced acute and preventive migraine treatments, the AHS convened a small task force to review relevant literature published from December 2018 through February 2021. The society’s board of directors, along with patients and patient advocates associated with the American Migraine Foundation, also provided pertinent commentary.
New migraine treatment
Five recently approved acute migraine treatments were specifically noted: two small-molecule calcitonin gene-related peptide (CGRP) receptor antagonists – rimegepant and ubrogepant – along with the nonsteroidal anti-inflammatory drug celecoxib, the serotonin 5-HT1F agonist lasmiditan, and remote electrical neuromodulation (REN). Highlighted risks include serious cardiovascular thrombotic events in patients on celecoxib, along with driving impairment, sleepiness, and the possibility of overuse in patients on lasmiditan. The authors added, however, that REN “has shown good tolerability and safety in clinical trials” and that frequent use of rimegepant or ubrogepant does not appear to lead to medication-overuse headache.
Regarding acute treatment overall, the statement recommended nonsteroidal anti-inflammatory drugs (NSAIDs), nonopioid analgesics, acetaminophen, or caffeinated analgesic combinations – such as aspirin plus acetaminophen plus caffeine – for mild to moderate attacks. For moderate or severe attacks, they recommended migraine-specific agents such as triptans, small-molecule CGRP receptor antagonists (gepants), or selective serotonin 5-HT1F receptor agonists (ditans). No matter the prescribed treatment, the statement pushed for patients to “treat at the first sign of pain to improve the probability of achieving freedom from pain and reduce attack-related disability.”
The authors added that 30% of patients on triptans have an “insufficient response” and as such may benefit from a second triptan or – if certain criteria are met – switching to a gepant, a ditan, or a neuromodulatory device. They also recommended a nonoral formulation for patients whose attacks are often accompanied by severe nausea or vomiting.
More broadly, they addressed the tolerability and safety issues associated with certain treatments, including the gastrointestinal and cardiovascular side effects of NSAIDs and the dangers of using triptans in patients with coronary artery disease or other vascular disorders. And while gepants and ditans appeared in clinical trials to be safe choices for patients with stable cardiovascular disease, “benefit-risk should be assessed in each patient as the real-world database for these therapies grows,” they wrote.
Only one recently approved preventive treatment – eptinezumab, an intravenous anti-CGRP ligand monoclonal antibody (MAB) – was highlighted. The authors noted that its benefits can begin within 24 hours, and it can reduce acute medication use and therefore the risk of medication-overuse headache.
Regarding preventive treatments overall, the authors stated that prevention should be offered if patients suffer from 6 or more days of headache per month, or 3-4 days of headache plus some-to-severe disability. Preventive treatments should be considered in patients who range from at least 2 days of headache per month plus severe disability to 4 or 5 days of headache. Prevention should also be considered in patients with uncommon migraine subtypes, including hemiplegic migraine, migraine with brainstem aura, and migraine with prolonged aura.
Initiating treatment
When considering initiation of treatment with one of the four Food and Drug Administration–approved CGRP MABs – eptinezumab, erenumab, fremanezumab, or galcanezumab – the authors recommend their use if migraine patients show an inability to tolerate or respond to a trial of two or more older oral medications or other established effective therapies. Though they emphasized that oral preventive medications should be started at a low dose and titrated slowly until the target response is reached or tolerability issues emerge, no such need was specified for the parenteral treatments. They also endorsed the approach of patients staying on oral preventive drugs for a minimum of 8 weeks to determine effectiveness or a lack thereof; at that point, switching to another treatment is recommended.
The dual use of therapies such as neuromodulation, biobehavioral therapies, and gepants were also examined, including gepants’ potential as a “continuum between the acute and preventive treatment of migraine” and the limited use of neuromodulatory devices in clinical practice despite clear benefits in patients who prefer to avoid medication or those suffering from frequent attacks and subsequent medication overuse. In addition, it was stated that biobehavioral therapies have “grade A evidence” supporting their use in patients who either prefer nonpharmacologic treatments or have an adverse or poor reaction to the drugs.
From the patient perspective, one of the six reviewers shared concerns about migraine patients being required to try two established preventive medications before starting a recently introduced option, noting that the older drugs have lower efficacy and tolerability. Two reviewers would have liked to see the statement focus more on nonpharmacologic and device-related therapies, and one reviewer noted the possible value in guidance regarding “exploratory approaches” such as cannabis.
The authors acknowledged numerous potential conflicts of interest, including receiving speaking and consulting fees, grants, personal fees, and honoraria from various pharmaceutical and publishing companies.
Not everyone agrees
Commenting on the AHS consensus statement, James A Charles, MD, and Ira Turner, MD, had this to say: “This Consensus Statement incorporates the best available evidence including the newer CGRP therapies as well as the older treatments. The AHS posture is that the CGRP abortive and preventive treatments have a lesser amount of data and experience than the older treatments which have a wealth of literature and data because they have been around longer. As a result, there are 2 statements in these guidelines that the insurance companies quote in their manual of policies:
1. Inadequate response to two or more oral triptans before using a gepant as abortive treatment
2. Inadequate response to an 8-week trial at a dose established to be potentially effective of two or more of the following before using CGRP MAB for preventive treatment: topiramate, divalproex sodium/valproate sodium; beta-blocker: metoprolol, propranolol, timolol, atenolol, nadolol; tricyclic antidepressant: amitriptyline, nortriptyline; serotonin-norepinephrine reuptake inhibitor: venlafaxine, duloxetine; other Level A or B treatments.”
Dr. Charles, who is affiliated with Holy Name Medical Center in Teaneck N.J., and Dr. Turner, who is affiliated with the Center for Headache Care and Research at Island Neurological Associates in Plainview, N.Y., further said that “giving the CGRP MABs and gepants second-class status because they have not been around as long as the old boys is an insult to the research, development, and successful execution of gepant and CGRP MAB therapies in the last several years. The authors omitted the Hepp study and the long list of adverse effects of triptans leading to high discontinuance rates, and how trying a second triptan will probably not work.” Importantly, they said, “the authors have given the insurance carriers a weapon to deny direct access to gepants and CGRP MABs making direct access to these agents difficult for patients and physicians and their staffs.”
Dr. Charles and Dr. Turner point out that the AHS guidelines use the term “cost effective” – that it is better to use the cheaper, older drugs first. “Ineffective treatment of a patient for 8 weeks before using CGRP blocking therapies and using 2 triptans before a gepant is cost ineffective,” they said. “Inadequate delayed treatment results in loss of work productivity and loss of school and family participation and excessive use of ER visits. These guidelines forget that we ameliorate current disability and prevent chronification by treating with the most effective abortive and preventive therapies which may not commence with the cheaper old drugs.”
They explain: “Of course, we would use a beta-blocker for comorbid hypertension and/or anxiety, and venlafaxine for comorbid depression. And if a patient is pain free in 2 hrs with no adverse effects from a triptan used less than 10 times a month, it would not be appropriate to switch to a gepant. However, a treatment naive migraineur with accelerating migraine should have the option of going directly to a gepant and CGRP blocking MAB.” Dr. Charles and Dr. Turner concur that the phrase in the AHS consensus statement regarding the staging of therapy – two triptans before a gepant and two oral preventatives for 8 weeks before a CGRP MAB – “should be removed so that the CGRP drugs get the equal credit they deserve, as can be attested to by the migraine voices of lives saved by the sound research that led to their development and approval by the FDA.”
Ultimately, Dr. Charles and Dr. Turner said, “the final decision on treatment should be made by the physician and patient, not the insurance company or consensus statements.”
Alan Rapoport, MD, clinical professor of neurology at the University of California, Los Angeles, former president of the International Headache Society, and editor-in-chief of Neurology Reviews, said, “Although I think the consensus statement is well done, and the authors have the right to make the statements they have made, Drs. Charles and Turner are excellent experienced clinicians and they should be heard. They properly state that the restrictive statements highlighted by the authors have already been used by insurance companies to prevent access to the more expensive but more effective therapies with fewer adverse effects.”
Dr. Rapoport goes on to say, “I believe that the patient’s individual headache history and past responses to therapies must be analyzed by the treating physician and an appropriate treatment be agreed upon between the patient and doctor. It is time to let experienced headache-interested doctors make their own correct decision about treatment without the heavy hand of the insurance company, which is often more intent on saving money than helping the patient.
Suggested reading
Hepp Z et al. Adherence to oral migraine-preventive medications among patients with chronic migraine. Cephalalgia. 2015;35(6):478-88.
Alam A et al. Triptan use and discontinuation in a representative sample of persons with migraine: Results from Migraine in America Symptoms and Treatment (MAST) study. Headache. 2018;58:68‐69.
Buse DC et al. Adding additional acute medications to a triptan regimen for migraine and observed changes in headache-related disability: Results from the American Migraine Prevalence and Prevention (AMPP) study. Headache. 2015 Jun;55(6):825-39.
An updated consensus statement from the American Headache Society (AHS) offers detailed recommendations on the use of novel acute and preventive treatments in adult patients with migraine.
“Because the benefit–risk profiles of newer treatments will continue to evolve as clinical trial and real-world data accrue, the American Headache Society intends to review this statement regularly and update, if appropriate, based on the emergence of evidence with implications for clinical practice,” wrote lead author Jessica Ailani, MD, of the department of neurology at Medstar Georgetown University Hospital, Washington, and colleagues. The statement was published in Headache.
To assess recent data on the efficacy, safety, and clinical use of newly introduced acute and preventive migraine treatments, the AHS convened a small task force to review relevant literature published from December 2018 through February 2021. The society’s board of directors, along with patients and patient advocates associated with the American Migraine Foundation, also provided pertinent commentary.
New migraine treatment
Five recently approved acute migraine treatments were specifically noted: two small-molecule calcitonin gene-related peptide (CGRP) receptor antagonists – rimegepant and ubrogepant – along with the nonsteroidal anti-inflammatory drug celecoxib, the serotonin 5-HT1F agonist lasmiditan, and remote electrical neuromodulation (REN). Highlighted risks include serious cardiovascular thrombotic events in patients on celecoxib, along with driving impairment, sleepiness, and the possibility of overuse in patients on lasmiditan. The authors added, however, that REN “has shown good tolerability and safety in clinical trials” and that frequent use of rimegepant or ubrogepant does not appear to lead to medication-overuse headache.
Regarding acute treatment overall, the statement recommended nonsteroidal anti-inflammatory drugs (NSAIDs), nonopioid analgesics, acetaminophen, or caffeinated analgesic combinations – such as aspirin plus acetaminophen plus caffeine – for mild to moderate attacks. For moderate or severe attacks, they recommended migraine-specific agents such as triptans, small-molecule CGRP receptor antagonists (gepants), or selective serotonin 5-HT1F receptor agonists (ditans). No matter the prescribed treatment, the statement pushed for patients to “treat at the first sign of pain to improve the probability of achieving freedom from pain and reduce attack-related disability.”
The authors added that 30% of patients on triptans have an “insufficient response” and as such may benefit from a second triptan or – if certain criteria are met – switching to a gepant, a ditan, or a neuromodulatory device. They also recommended a nonoral formulation for patients whose attacks are often accompanied by severe nausea or vomiting.
More broadly, they addressed the tolerability and safety issues associated with certain treatments, including the gastrointestinal and cardiovascular side effects of NSAIDs and the dangers of using triptans in patients with coronary artery disease or other vascular disorders. And while gepants and ditans appeared in clinical trials to be safe choices for patients with stable cardiovascular disease, “benefit-risk should be assessed in each patient as the real-world database for these therapies grows,” they wrote.
Only one recently approved preventive treatment – eptinezumab, an intravenous anti-CGRP ligand monoclonal antibody (MAB) – was highlighted. The authors noted that its benefits can begin within 24 hours, and it can reduce acute medication use and therefore the risk of medication-overuse headache.
Regarding preventive treatments overall, the authors stated that prevention should be offered if patients suffer from 6 or more days of headache per month, or 3-4 days of headache plus some-to-severe disability. Preventive treatments should be considered in patients who range from at least 2 days of headache per month plus severe disability to 4 or 5 days of headache. Prevention should also be considered in patients with uncommon migraine subtypes, including hemiplegic migraine, migraine with brainstem aura, and migraine with prolonged aura.
Initiating treatment
When considering initiation of treatment with one of the four Food and Drug Administration–approved CGRP MABs – eptinezumab, erenumab, fremanezumab, or galcanezumab – the authors recommend their use if migraine patients show an inability to tolerate or respond to a trial of two or more older oral medications or other established effective therapies. Though they emphasized that oral preventive medications should be started at a low dose and titrated slowly until the target response is reached or tolerability issues emerge, no such need was specified for the parenteral treatments. They also endorsed the approach of patients staying on oral preventive drugs for a minimum of 8 weeks to determine effectiveness or a lack thereof; at that point, switching to another treatment is recommended.
The dual use of therapies such as neuromodulation, biobehavioral therapies, and gepants were also examined, including gepants’ potential as a “continuum between the acute and preventive treatment of migraine” and the limited use of neuromodulatory devices in clinical practice despite clear benefits in patients who prefer to avoid medication or those suffering from frequent attacks and subsequent medication overuse. In addition, it was stated that biobehavioral therapies have “grade A evidence” supporting their use in patients who either prefer nonpharmacologic treatments or have an adverse or poor reaction to the drugs.
From the patient perspective, one of the six reviewers shared concerns about migraine patients being required to try two established preventive medications before starting a recently introduced option, noting that the older drugs have lower efficacy and tolerability. Two reviewers would have liked to see the statement focus more on nonpharmacologic and device-related therapies, and one reviewer noted the possible value in guidance regarding “exploratory approaches” such as cannabis.
The authors acknowledged numerous potential conflicts of interest, including receiving speaking and consulting fees, grants, personal fees, and honoraria from various pharmaceutical and publishing companies.
Not everyone agrees
Commenting on the AHS consensus statement, James A Charles, MD, and Ira Turner, MD, had this to say: “This Consensus Statement incorporates the best available evidence including the newer CGRP therapies as well as the older treatments. The AHS posture is that the CGRP abortive and preventive treatments have a lesser amount of data and experience than the older treatments which have a wealth of literature and data because they have been around longer. As a result, there are 2 statements in these guidelines that the insurance companies quote in their manual of policies:
1. Inadequate response to two or more oral triptans before using a gepant as abortive treatment
2. Inadequate response to an 8-week trial at a dose established to be potentially effective of two or more of the following before using CGRP MAB for preventive treatment: topiramate, divalproex sodium/valproate sodium; beta-blocker: metoprolol, propranolol, timolol, atenolol, nadolol; tricyclic antidepressant: amitriptyline, nortriptyline; serotonin-norepinephrine reuptake inhibitor: venlafaxine, duloxetine; other Level A or B treatments.”
Dr. Charles, who is affiliated with Holy Name Medical Center in Teaneck N.J., and Dr. Turner, who is affiliated with the Center for Headache Care and Research at Island Neurological Associates in Plainview, N.Y., further said that “giving the CGRP MABs and gepants second-class status because they have not been around as long as the old boys is an insult to the research, development, and successful execution of gepant and CGRP MAB therapies in the last several years. The authors omitted the Hepp study and the long list of adverse effects of triptans leading to high discontinuance rates, and how trying a second triptan will probably not work.” Importantly, they said, “the authors have given the insurance carriers a weapon to deny direct access to gepants and CGRP MABs making direct access to these agents difficult for patients and physicians and their staffs.”
Dr. Charles and Dr. Turner point out that the AHS guidelines use the term “cost effective” – that it is better to use the cheaper, older drugs first. “Ineffective treatment of a patient for 8 weeks before using CGRP blocking therapies and using 2 triptans before a gepant is cost ineffective,” they said. “Inadequate delayed treatment results in loss of work productivity and loss of school and family participation and excessive use of ER visits. These guidelines forget that we ameliorate current disability and prevent chronification by treating with the most effective abortive and preventive therapies which may not commence with the cheaper old drugs.”
They explain: “Of course, we would use a beta-blocker for comorbid hypertension and/or anxiety, and venlafaxine for comorbid depression. And if a patient is pain free in 2 hrs with no adverse effects from a triptan used less than 10 times a month, it would not be appropriate to switch to a gepant. However, a treatment naive migraineur with accelerating migraine should have the option of going directly to a gepant and CGRP blocking MAB.” Dr. Charles and Dr. Turner concur that the phrase in the AHS consensus statement regarding the staging of therapy – two triptans before a gepant and two oral preventatives for 8 weeks before a CGRP MAB – “should be removed so that the CGRP drugs get the equal credit they deserve, as can be attested to by the migraine voices of lives saved by the sound research that led to their development and approval by the FDA.”
Ultimately, Dr. Charles and Dr. Turner said, “the final decision on treatment should be made by the physician and patient, not the insurance company or consensus statements.”
Alan Rapoport, MD, clinical professor of neurology at the University of California, Los Angeles, former president of the International Headache Society, and editor-in-chief of Neurology Reviews, said, “Although I think the consensus statement is well done, and the authors have the right to make the statements they have made, Drs. Charles and Turner are excellent experienced clinicians and they should be heard. They properly state that the restrictive statements highlighted by the authors have already been used by insurance companies to prevent access to the more expensive but more effective therapies with fewer adverse effects.”
Dr. Rapoport goes on to say, “I believe that the patient’s individual headache history and past responses to therapies must be analyzed by the treating physician and an appropriate treatment be agreed upon between the patient and doctor. It is time to let experienced headache-interested doctors make their own correct decision about treatment without the heavy hand of the insurance company, which is often more intent on saving money than helping the patient.
Suggested reading
Hepp Z et al. Adherence to oral migraine-preventive medications among patients with chronic migraine. Cephalalgia. 2015;35(6):478-88.
Alam A et al. Triptan use and discontinuation in a representative sample of persons with migraine: Results from Migraine in America Symptoms and Treatment (MAST) study. Headache. 2018;58:68‐69.
Buse DC et al. Adding additional acute medications to a triptan regimen for migraine and observed changes in headache-related disability: Results from the American Migraine Prevalence and Prevention (AMPP) study. Headache. 2015 Jun;55(6):825-39.
An updated consensus statement from the American Headache Society (AHS) offers detailed recommendations on the use of novel acute and preventive treatments in adult patients with migraine.
“Because the benefit–risk profiles of newer treatments will continue to evolve as clinical trial and real-world data accrue, the American Headache Society intends to review this statement regularly and update, if appropriate, based on the emergence of evidence with implications for clinical practice,” wrote lead author Jessica Ailani, MD, of the department of neurology at Medstar Georgetown University Hospital, Washington, and colleagues. The statement was published in Headache.
To assess recent data on the efficacy, safety, and clinical use of newly introduced acute and preventive migraine treatments, the AHS convened a small task force to review relevant literature published from December 2018 through February 2021. The society’s board of directors, along with patients and patient advocates associated with the American Migraine Foundation, also provided pertinent commentary.
New migraine treatment
Five recently approved acute migraine treatments were specifically noted: two small-molecule calcitonin gene-related peptide (CGRP) receptor antagonists – rimegepant and ubrogepant – along with the nonsteroidal anti-inflammatory drug celecoxib, the serotonin 5-HT1F agonist lasmiditan, and remote electrical neuromodulation (REN). Highlighted risks include serious cardiovascular thrombotic events in patients on celecoxib, along with driving impairment, sleepiness, and the possibility of overuse in patients on lasmiditan. The authors added, however, that REN “has shown good tolerability and safety in clinical trials” and that frequent use of rimegepant or ubrogepant does not appear to lead to medication-overuse headache.
Regarding acute treatment overall, the statement recommended nonsteroidal anti-inflammatory drugs (NSAIDs), nonopioid analgesics, acetaminophen, or caffeinated analgesic combinations – such as aspirin plus acetaminophen plus caffeine – for mild to moderate attacks. For moderate or severe attacks, they recommended migraine-specific agents such as triptans, small-molecule CGRP receptor antagonists (gepants), or selective serotonin 5-HT1F receptor agonists (ditans). No matter the prescribed treatment, the statement pushed for patients to “treat at the first sign of pain to improve the probability of achieving freedom from pain and reduce attack-related disability.”
The authors added that 30% of patients on triptans have an “insufficient response” and as such may benefit from a second triptan or – if certain criteria are met – switching to a gepant, a ditan, or a neuromodulatory device. They also recommended a nonoral formulation for patients whose attacks are often accompanied by severe nausea or vomiting.
More broadly, they addressed the tolerability and safety issues associated with certain treatments, including the gastrointestinal and cardiovascular side effects of NSAIDs and the dangers of using triptans in patients with coronary artery disease or other vascular disorders. And while gepants and ditans appeared in clinical trials to be safe choices for patients with stable cardiovascular disease, “benefit-risk should be assessed in each patient as the real-world database for these therapies grows,” they wrote.
Only one recently approved preventive treatment – eptinezumab, an intravenous anti-CGRP ligand monoclonal antibody (MAB) – was highlighted. The authors noted that its benefits can begin within 24 hours, and it can reduce acute medication use and therefore the risk of medication-overuse headache.
Regarding preventive treatments overall, the authors stated that prevention should be offered if patients suffer from 6 or more days of headache per month, or 3-4 days of headache plus some-to-severe disability. Preventive treatments should be considered in patients who range from at least 2 days of headache per month plus severe disability to 4 or 5 days of headache. Prevention should also be considered in patients with uncommon migraine subtypes, including hemiplegic migraine, migraine with brainstem aura, and migraine with prolonged aura.
Initiating treatment
When considering initiation of treatment with one of the four Food and Drug Administration–approved CGRP MABs – eptinezumab, erenumab, fremanezumab, or galcanezumab – the authors recommend their use if migraine patients show an inability to tolerate or respond to a trial of two or more older oral medications or other established effective therapies. Though they emphasized that oral preventive medications should be started at a low dose and titrated slowly until the target response is reached or tolerability issues emerge, no such need was specified for the parenteral treatments. They also endorsed the approach of patients staying on oral preventive drugs for a minimum of 8 weeks to determine effectiveness or a lack thereof; at that point, switching to another treatment is recommended.
The dual use of therapies such as neuromodulation, biobehavioral therapies, and gepants were also examined, including gepants’ potential as a “continuum between the acute and preventive treatment of migraine” and the limited use of neuromodulatory devices in clinical practice despite clear benefits in patients who prefer to avoid medication or those suffering from frequent attacks and subsequent medication overuse. In addition, it was stated that biobehavioral therapies have “grade A evidence” supporting their use in patients who either prefer nonpharmacologic treatments or have an adverse or poor reaction to the drugs.
From the patient perspective, one of the six reviewers shared concerns about migraine patients being required to try two established preventive medications before starting a recently introduced option, noting that the older drugs have lower efficacy and tolerability. Two reviewers would have liked to see the statement focus more on nonpharmacologic and device-related therapies, and one reviewer noted the possible value in guidance regarding “exploratory approaches” such as cannabis.
The authors acknowledged numerous potential conflicts of interest, including receiving speaking and consulting fees, grants, personal fees, and honoraria from various pharmaceutical and publishing companies.
Not everyone agrees
Commenting on the AHS consensus statement, James A Charles, MD, and Ira Turner, MD, had this to say: “This Consensus Statement incorporates the best available evidence including the newer CGRP therapies as well as the older treatments. The AHS posture is that the CGRP abortive and preventive treatments have a lesser amount of data and experience than the older treatments which have a wealth of literature and data because they have been around longer. As a result, there are 2 statements in these guidelines that the insurance companies quote in their manual of policies:
1. Inadequate response to two or more oral triptans before using a gepant as abortive treatment
2. Inadequate response to an 8-week trial at a dose established to be potentially effective of two or more of the following before using CGRP MAB for preventive treatment: topiramate, divalproex sodium/valproate sodium; beta-blocker: metoprolol, propranolol, timolol, atenolol, nadolol; tricyclic antidepressant: amitriptyline, nortriptyline; serotonin-norepinephrine reuptake inhibitor: venlafaxine, duloxetine; other Level A or B treatments.”
Dr. Charles, who is affiliated with Holy Name Medical Center in Teaneck N.J., and Dr. Turner, who is affiliated with the Center for Headache Care and Research at Island Neurological Associates in Plainview, N.Y., further said that “giving the CGRP MABs and gepants second-class status because they have not been around as long as the old boys is an insult to the research, development, and successful execution of gepant and CGRP MAB therapies in the last several years. The authors omitted the Hepp study and the long list of adverse effects of triptans leading to high discontinuance rates, and how trying a second triptan will probably not work.” Importantly, they said, “the authors have given the insurance carriers a weapon to deny direct access to gepants and CGRP MABs making direct access to these agents difficult for patients and physicians and their staffs.”
Dr. Charles and Dr. Turner point out that the AHS guidelines use the term “cost effective” – that it is better to use the cheaper, older drugs first. “Ineffective treatment of a patient for 8 weeks before using CGRP blocking therapies and using 2 triptans before a gepant is cost ineffective,” they said. “Inadequate delayed treatment results in loss of work productivity and loss of school and family participation and excessive use of ER visits. These guidelines forget that we ameliorate current disability and prevent chronification by treating with the most effective abortive and preventive therapies which may not commence with the cheaper old drugs.”
They explain: “Of course, we would use a beta-blocker for comorbid hypertension and/or anxiety, and venlafaxine for comorbid depression. And if a patient is pain free in 2 hrs with no adverse effects from a triptan used less than 10 times a month, it would not be appropriate to switch to a gepant. However, a treatment naive migraineur with accelerating migraine should have the option of going directly to a gepant and CGRP blocking MAB.” Dr. Charles and Dr. Turner concur that the phrase in the AHS consensus statement regarding the staging of therapy – two triptans before a gepant and two oral preventatives for 8 weeks before a CGRP MAB – “should be removed so that the CGRP drugs get the equal credit they deserve, as can be attested to by the migraine voices of lives saved by the sound research that led to their development and approval by the FDA.”
Ultimately, Dr. Charles and Dr. Turner said, “the final decision on treatment should be made by the physician and patient, not the insurance company or consensus statements.”
Alan Rapoport, MD, clinical professor of neurology at the University of California, Los Angeles, former president of the International Headache Society, and editor-in-chief of Neurology Reviews, said, “Although I think the consensus statement is well done, and the authors have the right to make the statements they have made, Drs. Charles and Turner are excellent experienced clinicians and they should be heard. They properly state that the restrictive statements highlighted by the authors have already been used by insurance companies to prevent access to the more expensive but more effective therapies with fewer adverse effects.”
Dr. Rapoport goes on to say, “I believe that the patient’s individual headache history and past responses to therapies must be analyzed by the treating physician and an appropriate treatment be agreed upon between the patient and doctor. It is time to let experienced headache-interested doctors make their own correct decision about treatment without the heavy hand of the insurance company, which is often more intent on saving money than helping the patient.
Suggested reading
Hepp Z et al. Adherence to oral migraine-preventive medications among patients with chronic migraine. Cephalalgia. 2015;35(6):478-88.
Alam A et al. Triptan use and discontinuation in a representative sample of persons with migraine: Results from Migraine in America Symptoms and Treatment (MAST) study. Headache. 2018;58:68‐69.
Buse DC et al. Adding additional acute medications to a triptan regimen for migraine and observed changes in headache-related disability: Results from the American Migraine Prevalence and Prevention (AMPP) study. Headache. 2015 Jun;55(6):825-39.
Leishmaniasis is caused by protozoa of the family Trypanosomatidae, called Leishmania. The vector is a sandfly infected with the protozoa.1
The three main forms of leishmaniasis – cutaneous, mucocutaneous, or visceral – varies with the species of organism involved, the geographic distribution, and the immune response of the patient. A majority of the cases seen in the United States are from patients who contracted the disease elsewhere, particularly from Peru and Brazil.2Cutaneous leishmaniasis (CL) is categorized as Old World (Baghdad boil, leishmaniasis tropica) or New World (uta, pian bois, bay sore, chiclero ulcer).3,4
Lesions can vary from asymptomatic to severe. The initial lesion typically develops within weeks or months, and presents as an erythematous papule that is seen at the bite site.3 The papule evolves into a nodule or plaque that may ulcerate and crust.3 The ulcer can be distinguished by a raised and distinct border. In older stages, atrophic scarring may be seen. In some cases, the lesions may present years after exposure, because of immunosuppression or trauma.
Histology of CL reveals tuberculoid granulomas with parasitized histiocytes present. Amastigotes with distinct nuclei and kinetoplasts characterize Leishmania.2 In addition to histology, the biopsy may be sent for the press-imprint-smear method (PIS). In a study of 75 patients, the PIS method showed a higher sensitivity, as well as being a less costly and more rapid option for diagnosis.5
The treatment depends on the severity of the lesion and the species of the Leishmania genus. Mild lesions may resolve spontaneously. Topical imiquimod, cryotherapy, photodynamic therapy, and heat therapy may aid in the healing process.5 Systemic azole antifungal medications, miltefosine, and amphotericin B, and pentamidine may be used for more persistent lesions. In very severe cases, pentavalent antimonials (sodium stibogluconate, Pentostam) may be administered intravenously, although there is a high occurrence of recorded side effects.2
Dr. Donna Bilu Martin
This case and the photos were submitted by Sabrina Liao, BS, University of California, San Diego; and Brooke Resh Sateesh, MD, San Diego Family Dermatology The case was edited by Donna Bilu Martin, MD.
Leishmaniasis is caused by protozoa of the family Trypanosomatidae, called Leishmania. The vector is a sandfly infected with the protozoa.1
The three main forms of leishmaniasis – cutaneous, mucocutaneous, or visceral – varies with the species of organism involved, the geographic distribution, and the immune response of the patient. A majority of the cases seen in the United States are from patients who contracted the disease elsewhere, particularly from Peru and Brazil.2Cutaneous leishmaniasis (CL) is categorized as Old World (Baghdad boil, leishmaniasis tropica) or New World (uta, pian bois, bay sore, chiclero ulcer).3,4
Lesions can vary from asymptomatic to severe. The initial lesion typically develops within weeks or months, and presents as an erythematous papule that is seen at the bite site.3 The papule evolves into a nodule or plaque that may ulcerate and crust.3 The ulcer can be distinguished by a raised and distinct border. In older stages, atrophic scarring may be seen. In some cases, the lesions may present years after exposure, because of immunosuppression or trauma.
Histology of CL reveals tuberculoid granulomas with parasitized histiocytes present. Amastigotes with distinct nuclei and kinetoplasts characterize Leishmania.2 In addition to histology, the biopsy may be sent for the press-imprint-smear method (PIS). In a study of 75 patients, the PIS method showed a higher sensitivity, as well as being a less costly and more rapid option for diagnosis.5
The treatment depends on the severity of the lesion and the species of the Leishmania genus. Mild lesions may resolve spontaneously. Topical imiquimod, cryotherapy, photodynamic therapy, and heat therapy may aid in the healing process.5 Systemic azole antifungal medications, miltefosine, and amphotericin B, and pentamidine may be used for more persistent lesions. In very severe cases, pentavalent antimonials (sodium stibogluconate, Pentostam) may be administered intravenously, although there is a high occurrence of recorded side effects.2
Dr. Donna Bilu Martin
This case and the photos were submitted by Sabrina Liao, BS, University of California, San Diego; and Brooke Resh Sateesh, MD, San Diego Family Dermatology The case was edited by Donna Bilu Martin, MD.
Leishmaniasis is caused by protozoa of the family Trypanosomatidae, called Leishmania. The vector is a sandfly infected with the protozoa.1
The three main forms of leishmaniasis – cutaneous, mucocutaneous, or visceral – varies with the species of organism involved, the geographic distribution, and the immune response of the patient. A majority of the cases seen in the United States are from patients who contracted the disease elsewhere, particularly from Peru and Brazil.2Cutaneous leishmaniasis (CL) is categorized as Old World (Baghdad boil, leishmaniasis tropica) or New World (uta, pian bois, bay sore, chiclero ulcer).3,4
Lesions can vary from asymptomatic to severe. The initial lesion typically develops within weeks or months, and presents as an erythematous papule that is seen at the bite site.3 The papule evolves into a nodule or plaque that may ulcerate and crust.3 The ulcer can be distinguished by a raised and distinct border. In older stages, atrophic scarring may be seen. In some cases, the lesions may present years after exposure, because of immunosuppression or trauma.
Histology of CL reveals tuberculoid granulomas with parasitized histiocytes present. Amastigotes with distinct nuclei and kinetoplasts characterize Leishmania.2 In addition to histology, the biopsy may be sent for the press-imprint-smear method (PIS). In a study of 75 patients, the PIS method showed a higher sensitivity, as well as being a less costly and more rapid option for diagnosis.5
The treatment depends on the severity of the lesion and the species of the Leishmania genus. Mild lesions may resolve spontaneously. Topical imiquimod, cryotherapy, photodynamic therapy, and heat therapy may aid in the healing process.5 Systemic azole antifungal medications, miltefosine, and amphotericin B, and pentamidine may be used for more persistent lesions. In very severe cases, pentavalent antimonials (sodium stibogluconate, Pentostam) may be administered intravenously, although there is a high occurrence of recorded side effects.2
Dr. Donna Bilu Martin
This case and the photos were submitted by Sabrina Liao, BS, University of California, San Diego; and Brooke Resh Sateesh, MD, San Diego Family Dermatology The case was edited by Donna Bilu Martin, MD.
A healthy family (33-year-old mother, 35-year-old father, and their 4-year-old son) from Sierre Leone who had been living in Brazil presented to the emergency department with asymptomatic crusted plaques on their extremities. The child also had a crusted plaque on his chin. Three months prior to presentation, the family had been walking in the jungles of Colombia and Panama. The lesions began as small erythematous papules that developed into crusted ulcerations and then scaly patches and plaques.
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Traction alopecia (TA)--one of the most common types of hair loss in Black women (although not exclusive to Black women)--is reversible when early corrective measures are taken; if chronic tension continues, however, permanent scarring alopecia ensues. Dermatologists can prevent worsening of this distressing hair loss. Due to a dearth of training among dermatologists in conditions occurring in patients with tightly coiled hair, it is imperative to add practical methods to the body of dermatology literature, with the goal of enhancing cultural humility.
Hairstyling among Black women often is a lengthy process and often results in relationship bonding with the hair care giver, in turn imparting hair care traditions to the next generation. Therefore, a well-received discussion about TA prevention not only has an impact on the patient but potentially on a multigenerational family of women and friends. We present a memory aid for discussing TA, with a focus on cultural humility and patient-centered communication.
Factors contributing to the risk of TA are hairstyles and hair care practices commonly used in Black individuals, including braids, locs, weaves, wigs, and chemical straightening.1 These styles often are worn to increase hair manageability or as a creative expression of beauty.
Discussing TA can be distressing for physicians and patients, especially in the setting of hair texture discordance. In a study that surveyed Black patients' perception of their dermatologic care both in and outside of a skin of color clinic, 71% of respondents (12/17) said that they prefer a race-concordant dermatologist. Some respondents reported that non-skin of color clinic dermatologists examined their hair with the end of a pencil or not at all; patients interpreted these interactions as disrespectful and racially insensitive.2 Another study found that only 30.2% (19/63) of dermatology chief residents and 12.2% (5/41) of program directors reported a specific rotation during which residents gained experience treating skin of color patients.3
Due to a paucity of training in diagnosing and treating patients with tightly coiled hair who experience hair loss, some physicians might feel uncomfortable caring for patients who have tightly coiled hair. Although many Black patients prefer to see a race-concordant dermatologist because of their perceived cultural competence and shared experience, there is a paucity of Black dermatologists to see all patients who have tightly coiled hair.4 Therefore, all dermatologists should become skilled and comfortable discussing and treating TA in patients with all hair types.
METHOD FOR COUNSELING
The following scenarios are a guide to begin closing the competency gap in counseling about TA, using a "compliment, discuss, and suggest" method.
Scenario 1 A Black woman presents with a concern of "thinning edges" (a popular term on social media for TA). A hair-discordant dermatologist tells her, first, that she has TA caused by wearing tight hairstyles and, second, that the treatment is to stop wearing tight braids and weaves and to discontinue chemical relaxers. The dermatologist then leaves the room.
The Patient's Perspective It is not uncommon for the patient to have feelings of frustration about how they will style their hair, especially if they are unfamiliar with caring for their hair in its natural state.5 Also, they might have feelings of dismay that the loving childhood hair care giver, often their mother or grandmother, unintentionally harmed them with a tight style. They also might feel betrayed by their hairstylist, who might not have encouraged them to see a dermatologist, or who continued to oblige their request for a high-risk hairstyle. The patient might feel uncomfortable communicating the dermatologist's new recommendations to their hair care team, who also are part of her emotional support system. The patient also might think that the hair-discordant dermatologist has no idea what they "go through" with their hair.
"Compliment, Discuss, and Suggest" Counseling Traction alopecia is caused by tight hairstyles that often hurt when they are put in as tight braids, weaves, and ponytails.6 Risk increases if tight styles are applied to chemically straightened hair.1 Braids, sew-in weaves, and wigs with adhesive sometimes are referred to as protective styles. However, these styles can still lead to TA due to excessive tension.
Compliment: "Your hair looks great. I know that you get many compliments."
Discuss: "However, some of the styles might be increasing your risk for hair loss. Our goal is to preserve as many of your follicles as possible."
Suggest: "Let's start by loosening the hairstyle if it is painful when being applied. Pain means inflammation, which can lead to scarring of hair follicles and worsening of hair loss."
Using pronouns such as we, us, and our is intentional. Doing so signals that the dermatologist is a partner with the patient in the treatment of TA. Starting with a simple initial recommendation gives the patient time to process the common thoughts highlighted in The Patient's Perspective section.6
Scenario 2 A Black child (we'll call her "Janet") is accompanied by her mother for follow-up of mild atopic dermatitis on the body and scalp. When the dermatologist examines the patient's scalp, they note that she has the fringe sign--retained short hairs along the frontal hairline--that is consistent with TA. Janet's hair is adorned with 2 tight ponytails in the front with colorful decorative balls on ponytail ties, barrettes, and 6 cornrow braids in the back with plastic beads on the ends. The dermatologist counsels about the atopic dermatitis and leaves the room.
"Compliment, Discuss, and Suggest" Counseling The use of tight decorative balls on ponytail ties and numerous plastic beads increases the amount of tension and weight on the hair, which may lead to a higher risk for developing traction alopecia.6 It is quite common for children of African descent to wear hair adornments. Proper counseling regarding their use and possible implications is essential.
Compliment: "You're doing a great job controlling the atopic dermatitis, which can cause Janet's scalp to be dry. Also, her hair is beautiful--it looks like you spent a lot of time on her hair. And Janet, I like the color of your barrettes."
Discuss: "Mom, I just noticed that a few areas look tight. Let's look together." (The dermatologist points out areas where the scalp is tented upward due to traction, follicular pustules or papules, or the frontal fringe sign.) "I'm on a mission to #savetheedges because we want Janet to grow up with full edges." (Again, loss of "edges" refers to TA.)
Suggest: "When you do Janet's hair, it's OK if every hair is not in place. In fact, making styles look and feel 1 or 2 weeks old will lessen tension on the scalp. Remove Janet's hair ties to release tension when she is at home and while she's sleeping, if possible. Every minute that the hair is loose really does help."6
The Parent's Perspective
All parents take pride in their children. In some Black communities, mothers are judged by how well they manage and style their children's hair. Some people might even suggest that parents of children with nonstyled, tightly coiled hair are not fit parents. Anthropologist Sylvia Boone, PhD, found that among the Mende tribe in Sierra Leone, "unkempt, 'neglected,' or 'messy' hair implied that a woman either had loose morals or was insane."7
Braids are commonly worn by people of African heritage for a variety of reasons, including ease of manageability, to decrease daily hairstyling time, and as an expression of creativity. Intricate neat hairstyles, despite the risk of pain and TA, are perceived as a sign that the child is cared for and loved.6
FINAL THOUGHTS
Patient-centered communication is associated with the patient trusting the physician, which is especially important in race-discordant physician-patient relationships. A study found that patient-physician race discordance led to shorter visits, a lower rating of patient affect, and less shared decision-making.8 Moreover, in a study of primary care clinicians, implicit bias was found to affect communication patterns and social interactions, impacting patient outcomes. Downstream effects of racial bias resulted in less speaking, smiling, and social comments when interacting with Black patients.9
These findings highlight the need to address interpersonal barriers to effective communication in race-discordant patient-physician dyads. A history of segregated neighborhoods and schools might contribute to structural barriers, resulting in lack of familiarity with cultural norms outside one's culture, which might globally perpetuate poor communication and patient outcomes.
The "compliment, discuss, and suggest" method might lead to more positive physician-patient encounters by having the dermatologist focus on empathetically understanding the patient's perspective.10 Effective communication, understanding cultural hair care practices, and a thorough scalp examination are paramount for patients with tightly coiled hair.11 Early intervention in TA is crucial and involves partnering with patients and parents to amend high-risk hairstyling routines with cultural humility.
Dr. Grayson is from the Florida State University College of Medicine Internal Medicine Residency Program, Tallahassee. Dr. Heath is from the Department of Dermatology, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania.
The authors report no conflict of interest.
Correspondence: Candrice R. Heath, MD, 3401 N Broad St, 5OB, Philadelphia, PA 19140 ([email protected]).
Dr. Grayson is from the Florida State University College of Medicine Internal Medicine Residency Program, Tallahassee. Dr. Heath is from the Department of Dermatology, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania.
The authors report no conflict of interest.
Correspondence: Candrice R. Heath, MD, 3401 N Broad St, 5OB, Philadelphia, PA 19140 ([email protected]).
Author and Disclosure Information
Dr. Grayson is from the Florida State University College of Medicine Internal Medicine Residency Program, Tallahassee. Dr. Heath is from the Department of Dermatology, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania.
The authors report no conflict of interest.
Correspondence: Candrice R. Heath, MD, 3401 N Broad St, 5OB, Philadelphia, PA 19140 ([email protected]).
Traction alopecia (TA)--one of the most common types of hair loss in Black women (although not exclusive to Black women)--is reversible when early corrective measures are taken; if chronic tension continues, however, permanent scarring alopecia ensues. Dermatologists can prevent worsening of this distressing hair loss. Due to a dearth of training among dermatologists in conditions occurring in patients with tightly coiled hair, it is imperative to add practical methods to the body of dermatology literature, with the goal of enhancing cultural humility.
Hairstyling among Black women often is a lengthy process and often results in relationship bonding with the hair care giver, in turn imparting hair care traditions to the next generation. Therefore, a well-received discussion about TA prevention not only has an impact on the patient but potentially on a multigenerational family of women and friends. We present a memory aid for discussing TA, with a focus on cultural humility and patient-centered communication.
Factors contributing to the risk of TA are hairstyles and hair care practices commonly used in Black individuals, including braids, locs, weaves, wigs, and chemical straightening.1 These styles often are worn to increase hair manageability or as a creative expression of beauty.
Discussing TA can be distressing for physicians and patients, especially in the setting of hair texture discordance. In a study that surveyed Black patients' perception of their dermatologic care both in and outside of a skin of color clinic, 71% of respondents (12/17) said that they prefer a race-concordant dermatologist. Some respondents reported that non-skin of color clinic dermatologists examined their hair with the end of a pencil or not at all; patients interpreted these interactions as disrespectful and racially insensitive.2 Another study found that only 30.2% (19/63) of dermatology chief residents and 12.2% (5/41) of program directors reported a specific rotation during which residents gained experience treating skin of color patients.3
Due to a paucity of training in diagnosing and treating patients with tightly coiled hair who experience hair loss, some physicians might feel uncomfortable caring for patients who have tightly coiled hair. Although many Black patients prefer to see a race-concordant dermatologist because of their perceived cultural competence and shared experience, there is a paucity of Black dermatologists to see all patients who have tightly coiled hair.4 Therefore, all dermatologists should become skilled and comfortable discussing and treating TA in patients with all hair types.
METHOD FOR COUNSELING
The following scenarios are a guide to begin closing the competency gap in counseling about TA, using a "compliment, discuss, and suggest" method.
Scenario 1 A Black woman presents with a concern of "thinning edges" (a popular term on social media for TA). A hair-discordant dermatologist tells her, first, that she has TA caused by wearing tight hairstyles and, second, that the treatment is to stop wearing tight braids and weaves and to discontinue chemical relaxers. The dermatologist then leaves the room.
The Patient's Perspective It is not uncommon for the patient to have feelings of frustration about how they will style their hair, especially if they are unfamiliar with caring for their hair in its natural state.5 Also, they might have feelings of dismay that the loving childhood hair care giver, often their mother or grandmother, unintentionally harmed them with a tight style. They also might feel betrayed by their hairstylist, who might not have encouraged them to see a dermatologist, or who continued to oblige their request for a high-risk hairstyle. The patient might feel uncomfortable communicating the dermatologist's new recommendations to their hair care team, who also are part of her emotional support system. The patient also might think that the hair-discordant dermatologist has no idea what they "go through" with their hair.
"Compliment, Discuss, and Suggest" Counseling Traction alopecia is caused by tight hairstyles that often hurt when they are put in as tight braids, weaves, and ponytails.6 Risk increases if tight styles are applied to chemically straightened hair.1 Braids, sew-in weaves, and wigs with adhesive sometimes are referred to as protective styles. However, these styles can still lead to TA due to excessive tension.
Compliment: "Your hair looks great. I know that you get many compliments."
Discuss: "However, some of the styles might be increasing your risk for hair loss. Our goal is to preserve as many of your follicles as possible."
Suggest: "Let's start by loosening the hairstyle if it is painful when being applied. Pain means inflammation, which can lead to scarring of hair follicles and worsening of hair loss."
Using pronouns such as we, us, and our is intentional. Doing so signals that the dermatologist is a partner with the patient in the treatment of TA. Starting with a simple initial recommendation gives the patient time to process the common thoughts highlighted in The Patient's Perspective section.6
Scenario 2 A Black child (we'll call her "Janet") is accompanied by her mother for follow-up of mild atopic dermatitis on the body and scalp. When the dermatologist examines the patient's scalp, they note that she has the fringe sign--retained short hairs along the frontal hairline--that is consistent with TA. Janet's hair is adorned with 2 tight ponytails in the front with colorful decorative balls on ponytail ties, barrettes, and 6 cornrow braids in the back with plastic beads on the ends. The dermatologist counsels about the atopic dermatitis and leaves the room.
"Compliment, Discuss, and Suggest" Counseling The use of tight decorative balls on ponytail ties and numerous plastic beads increases the amount of tension and weight on the hair, which may lead to a higher risk for developing traction alopecia.6 It is quite common for children of African descent to wear hair adornments. Proper counseling regarding their use and possible implications is essential.
Compliment: "You're doing a great job controlling the atopic dermatitis, which can cause Janet's scalp to be dry. Also, her hair is beautiful--it looks like you spent a lot of time on her hair. And Janet, I like the color of your barrettes."
Discuss: "Mom, I just noticed that a few areas look tight. Let's look together." (The dermatologist points out areas where the scalp is tented upward due to traction, follicular pustules or papules, or the frontal fringe sign.) "I'm on a mission to #savetheedges because we want Janet to grow up with full edges." (Again, loss of "edges" refers to TA.)
Suggest: "When you do Janet's hair, it's OK if every hair is not in place. In fact, making styles look and feel 1 or 2 weeks old will lessen tension on the scalp. Remove Janet's hair ties to release tension when she is at home and while she's sleeping, if possible. Every minute that the hair is loose really does help."6
The Parent's Perspective
All parents take pride in their children. In some Black communities, mothers are judged by how well they manage and style their children's hair. Some people might even suggest that parents of children with nonstyled, tightly coiled hair are not fit parents. Anthropologist Sylvia Boone, PhD, found that among the Mende tribe in Sierra Leone, "unkempt, 'neglected,' or 'messy' hair implied that a woman either had loose morals or was insane."7
Braids are commonly worn by people of African heritage for a variety of reasons, including ease of manageability, to decrease daily hairstyling time, and as an expression of creativity. Intricate neat hairstyles, despite the risk of pain and TA, are perceived as a sign that the child is cared for and loved.6
FINAL THOUGHTS
Patient-centered communication is associated with the patient trusting the physician, which is especially important in race-discordant physician-patient relationships. A study found that patient-physician race discordance led to shorter visits, a lower rating of patient affect, and less shared decision-making.8 Moreover, in a study of primary care clinicians, implicit bias was found to affect communication patterns and social interactions, impacting patient outcomes. Downstream effects of racial bias resulted in less speaking, smiling, and social comments when interacting with Black patients.9
These findings highlight the need to address interpersonal barriers to effective communication in race-discordant patient-physician dyads. A history of segregated neighborhoods and schools might contribute to structural barriers, resulting in lack of familiarity with cultural norms outside one's culture, which might globally perpetuate poor communication and patient outcomes.
The "compliment, discuss, and suggest" method might lead to more positive physician-patient encounters by having the dermatologist focus on empathetically understanding the patient's perspective.10 Effective communication, understanding cultural hair care practices, and a thorough scalp examination are paramount for patients with tightly coiled hair.11 Early intervention in TA is crucial and involves partnering with patients and parents to amend high-risk hairstyling routines with cultural humility.
Traction alopecia (TA)--one of the most common types of hair loss in Black women (although not exclusive to Black women)--is reversible when early corrective measures are taken; if chronic tension continues, however, permanent scarring alopecia ensues. Dermatologists can prevent worsening of this distressing hair loss. Due to a dearth of training among dermatologists in conditions occurring in patients with tightly coiled hair, it is imperative to add practical methods to the body of dermatology literature, with the goal of enhancing cultural humility.
Hairstyling among Black women often is a lengthy process and often results in relationship bonding with the hair care giver, in turn imparting hair care traditions to the next generation. Therefore, a well-received discussion about TA prevention not only has an impact on the patient but potentially on a multigenerational family of women and friends. We present a memory aid for discussing TA, with a focus on cultural humility and patient-centered communication.
Factors contributing to the risk of TA are hairstyles and hair care practices commonly used in Black individuals, including braids, locs, weaves, wigs, and chemical straightening.1 These styles often are worn to increase hair manageability or as a creative expression of beauty.
Discussing TA can be distressing for physicians and patients, especially in the setting of hair texture discordance. In a study that surveyed Black patients' perception of their dermatologic care both in and outside of a skin of color clinic, 71% of respondents (12/17) said that they prefer a race-concordant dermatologist. Some respondents reported that non-skin of color clinic dermatologists examined their hair with the end of a pencil or not at all; patients interpreted these interactions as disrespectful and racially insensitive.2 Another study found that only 30.2% (19/63) of dermatology chief residents and 12.2% (5/41) of program directors reported a specific rotation during which residents gained experience treating skin of color patients.3
Due to a paucity of training in diagnosing and treating patients with tightly coiled hair who experience hair loss, some physicians might feel uncomfortable caring for patients who have tightly coiled hair. Although many Black patients prefer to see a race-concordant dermatologist because of their perceived cultural competence and shared experience, there is a paucity of Black dermatologists to see all patients who have tightly coiled hair.4 Therefore, all dermatologists should become skilled and comfortable discussing and treating TA in patients with all hair types.
METHOD FOR COUNSELING
The following scenarios are a guide to begin closing the competency gap in counseling about TA, using a "compliment, discuss, and suggest" method.
Scenario 1 A Black woman presents with a concern of "thinning edges" (a popular term on social media for TA). A hair-discordant dermatologist tells her, first, that she has TA caused by wearing tight hairstyles and, second, that the treatment is to stop wearing tight braids and weaves and to discontinue chemical relaxers. The dermatologist then leaves the room.
The Patient's Perspective It is not uncommon for the patient to have feelings of frustration about how they will style their hair, especially if they are unfamiliar with caring for their hair in its natural state.5 Also, they might have feelings of dismay that the loving childhood hair care giver, often their mother or grandmother, unintentionally harmed them with a tight style. They also might feel betrayed by their hairstylist, who might not have encouraged them to see a dermatologist, or who continued to oblige their request for a high-risk hairstyle. The patient might feel uncomfortable communicating the dermatologist's new recommendations to their hair care team, who also are part of her emotional support system. The patient also might think that the hair-discordant dermatologist has no idea what they "go through" with their hair.
"Compliment, Discuss, and Suggest" Counseling Traction alopecia is caused by tight hairstyles that often hurt when they are put in as tight braids, weaves, and ponytails.6 Risk increases if tight styles are applied to chemically straightened hair.1 Braids, sew-in weaves, and wigs with adhesive sometimes are referred to as protective styles. However, these styles can still lead to TA due to excessive tension.
Compliment: "Your hair looks great. I know that you get many compliments."
Discuss: "However, some of the styles might be increasing your risk for hair loss. Our goal is to preserve as many of your follicles as possible."
Suggest: "Let's start by loosening the hairstyle if it is painful when being applied. Pain means inflammation, which can lead to scarring of hair follicles and worsening of hair loss."
Using pronouns such as we, us, and our is intentional. Doing so signals that the dermatologist is a partner with the patient in the treatment of TA. Starting with a simple initial recommendation gives the patient time to process the common thoughts highlighted in The Patient's Perspective section.6
Scenario 2 A Black child (we'll call her "Janet") is accompanied by her mother for follow-up of mild atopic dermatitis on the body and scalp. When the dermatologist examines the patient's scalp, they note that she has the fringe sign--retained short hairs along the frontal hairline--that is consistent with TA. Janet's hair is adorned with 2 tight ponytails in the front with colorful decorative balls on ponytail ties, barrettes, and 6 cornrow braids in the back with plastic beads on the ends. The dermatologist counsels about the atopic dermatitis and leaves the room.
"Compliment, Discuss, and Suggest" Counseling The use of tight decorative balls on ponytail ties and numerous plastic beads increases the amount of tension and weight on the hair, which may lead to a higher risk for developing traction alopecia.6 It is quite common for children of African descent to wear hair adornments. Proper counseling regarding their use and possible implications is essential.
Compliment: "You're doing a great job controlling the atopic dermatitis, which can cause Janet's scalp to be dry. Also, her hair is beautiful--it looks like you spent a lot of time on her hair. And Janet, I like the color of your barrettes."
Discuss: "Mom, I just noticed that a few areas look tight. Let's look together." (The dermatologist points out areas where the scalp is tented upward due to traction, follicular pustules or papules, or the frontal fringe sign.) "I'm on a mission to #savetheedges because we want Janet to grow up with full edges." (Again, loss of "edges" refers to TA.)
Suggest: "When you do Janet's hair, it's OK if every hair is not in place. In fact, making styles look and feel 1 or 2 weeks old will lessen tension on the scalp. Remove Janet's hair ties to release tension when she is at home and while she's sleeping, if possible. Every minute that the hair is loose really does help."6
The Parent's Perspective
All parents take pride in their children. In some Black communities, mothers are judged by how well they manage and style their children's hair. Some people might even suggest that parents of children with nonstyled, tightly coiled hair are not fit parents. Anthropologist Sylvia Boone, PhD, found that among the Mende tribe in Sierra Leone, "unkempt, 'neglected,' or 'messy' hair implied that a woman either had loose morals or was insane."7
Braids are commonly worn by people of African heritage for a variety of reasons, including ease of manageability, to decrease daily hairstyling time, and as an expression of creativity. Intricate neat hairstyles, despite the risk of pain and TA, are perceived as a sign that the child is cared for and loved.6
FINAL THOUGHTS
Patient-centered communication is associated with the patient trusting the physician, which is especially important in race-discordant physician-patient relationships. A study found that patient-physician race discordance led to shorter visits, a lower rating of patient affect, and less shared decision-making.8 Moreover, in a study of primary care clinicians, implicit bias was found to affect communication patterns and social interactions, impacting patient outcomes. Downstream effects of racial bias resulted in less speaking, smiling, and social comments when interacting with Black patients.9
These findings highlight the need to address interpersonal barriers to effective communication in race-discordant patient-physician dyads. A history of segregated neighborhoods and schools might contribute to structural barriers, resulting in lack of familiarity with cultural norms outside one's culture, which might globally perpetuate poor communication and patient outcomes.
The "compliment, discuss, and suggest" method might lead to more positive physician-patient encounters by having the dermatologist focus on empathetically understanding the patient's perspective.10 Effective communication, understanding cultural hair care practices, and a thorough scalp examination are paramount for patients with tightly coiled hair.11 Early intervention in TA is crucial and involves partnering with patients and parents to amend high-risk hairstyling routines with cultural humility.
People often overestimate what will happen in the next two years and underestimate what will happen in ten. – Bill Gates
The COVID-19 pandemic set in motion a series of innovations catalyzing the digital transformation of the health care landscape.
Telemedicine use exploded over the last 12 months to the point that it has almost become ubiquitous. With that, we saw a rapid proliferation of wearables and remote patient monitoring devices. Thanks to virtual care, care delivery is no longer strictly dependent on having onsite specialists, and care itself is not confined to the boundaries of hospitals or doctors’ offices anymore.
Dr. Sareer Zia
We saw the formation of the digital front door and the emergence of new virtual care sites like virtual urgent care, virtual home health, virtual office visits, virtual hospital at home that allowed clinical care to be delivered safely outside the boundaries of hospitals. Nonclinical public places like gyms, schools, and community centers were being transformed into virtual health care portals that brought care closer to the people.
Inside the hospital, we saw a fusion of traditional inpatient care and virtual care. Onsite hospital teams embraced telemedicine during the pandemic for various reasons; to conserve personal protective equipment (PPE), limit exposure, boost care capacity, improve access to specialists at distant sites, and bring family memberse to “webside” who cannot be at a patient’s bedside.
In clinical trials as well, virtual care is a welcome change. According to one survey1, most trial participants favored the use of telehealth services for clinical trials, as these helped them stay engaged, compliant, monitored, and on track while remaining at home. Furthermore, we are seeing the integration of artificial intelligence (AI) into telehealth, whether it is to aid physicians in clinical decision-making or to generate reminders to help patients with chronic disease management. However, this integration is only beginning to scratch the surface of the combination of two technologies’ real potential.
What’s next?
Based on these trends, it should be no surprise that digital health will become a vital sign for health care organizations.
The next 12 to 24 months will set new standards for digital health and play a significant role in defining the next generation of virtual care. There are projections that global health care industry revenues will exceed $2.6 trillion by 2025, with AI and telehealth playing a prominent role in this growth.2 According to estimates, telehealth itself will be a $175 billion market by 2026 and approximately one in three patient encounters will go virtual.3,4 Moreover, virtual care will continue to make exciting transformations, helping to make quality care accessible to everyone in innovative ways. For example, the University of Cincinnati has recently developed a pilot project using a drone equipped with video technology, artificial intelligence, sensors, and first aid kits to go to hard-to-reach areas to deliver care via telemedicine.5
Smart hospitals
In coming years, we can expect the integration of AI, augmented reality (AR), and virtual reality (VR) into telemedicine at lightning speed – and at a much larger scale – that will enable surgeons from different parts of the globe to perform procedures remotely and more precisely.
AI is already gaining traction in different fields within health care – whether it’s predicting length of stay in the ICU, or assisting in triage decisions, or reading radiological images, to name just a few. The Mayo Clinic is using AI and computer-aided decision-making tools to predict the risk of surgery and potential post-op complications, which could allow even better collaboration between medical and surgical teams. We hear about the “X-ray” vision offered to proceduralists using HoloLens – mixed reality smartglasses – a technology that enables them to perform procedures more precisely. Others project that there will be more sensors and voice recognition tools in the OR that will be used to gather data to develop intelligent algorithms, and to build a safety net for interventionalists that can notify them of potential hazards or accidental sterile field breaches. The insights gained will be used to create best practices and even allow some procedures to be performed outside the traditional OR setting.
Additionally, we are seeing the development of “smart” patient rooms. For example, one health system in Florida is working on deploying Amazon Alexa in 2,500 patient rooms to allow patients to connect more easily to their care team members. In the not-so-distant future, smart hospitals with smart patient rooms and smart ORs equipped with telemedicine, AI, AR, mixed reality, and computer-aided decision-making tools will no longer be an exception.
Smart homes for smart care
Smart homes with technologies like gas detectors, movement sensors, and sleep sensors will continue to evolve. According to one estimate, the global smart home health care market was $8.7 billion in 2019, and is expected to be $96.2 billion by 2030.6
Smart technologies will have applications in fall detection and prevention, evaluation of self-administration of medicine, sleep rhythm monitoring, air quality monitoring for the detection of abnormal gas levels, and identification of things like carbon monoxide poisoning or food spoilage. In coming years, expect to see more virtual medical homes and digital health care complexes. Patients, from the convenience of their homes, might be able to connect to a suite of caregivers, all working collaboratively to provide more coordinated, effective care. The “hospital at home” model that started with six hospitals has already grown to over 100 hospitals across 29 states. The shift from onsite specialists to onscreen specialists will continue, providing greater access to specialized services.
With these emerging trends, it can be anticipated that much acute care will be provided to patients outside the hospital – either under the hospital at home model, via drone technology using telemedicine, through smart devices in smart homes, or via wearables and artificial intelligence. Hence, hospitals’ configuration in the future will be much different and more compact than currently, and many hospitals will be reserved for trauma patients, casualties of natural disasters, higher acuity diseases requiring complex procedures, and other emergencies.
The role of hospitalists has evolved over the years and is still evolving. It should be no surprise if, in the future, we work alongside a digital hospitalist twin to provide better and more personalized care to our patients. Change is uncomfortable but it is inevitable. When COVID hit, we were forced to find innovative ways to deliver care to our patients. One thing is for certain: post-pandemic (AD, or After Disease) we are not going back to a Before COVID (BC) state in terms of virtual care. With the new dawn of digital era, the crucial questions to address will be: What will the future role of a hospitalist look like? How can we leverage technology and embrace our flexibility to adapt to these trends? How can we apply the lessons learned during the pandemic to propel hospital medicine into the future? And is it time to rethink our role and even reclassify ourselves – from hospitalists to Acute Care Experts (ACE) or Primary Acute Care Physicians?
Dr. Zia is a hospitalist, physician advisor, and founder of Virtual Hospitalist - a telemedicine company with a 360-degree care model for hospital patients.
People often overestimate what will happen in the next two years and underestimate what will happen in ten. – Bill Gates
The COVID-19 pandemic set in motion a series of innovations catalyzing the digital transformation of the health care landscape.
Telemedicine use exploded over the last 12 months to the point that it has almost become ubiquitous. With that, we saw a rapid proliferation of wearables and remote patient monitoring devices. Thanks to virtual care, care delivery is no longer strictly dependent on having onsite specialists, and care itself is not confined to the boundaries of hospitals or doctors’ offices anymore.
Dr. Sareer Zia
We saw the formation of the digital front door and the emergence of new virtual care sites like virtual urgent care, virtual home health, virtual office visits, virtual hospital at home that allowed clinical care to be delivered safely outside the boundaries of hospitals. Nonclinical public places like gyms, schools, and community centers were being transformed into virtual health care portals that brought care closer to the people.
Inside the hospital, we saw a fusion of traditional inpatient care and virtual care. Onsite hospital teams embraced telemedicine during the pandemic for various reasons; to conserve personal protective equipment (PPE), limit exposure, boost care capacity, improve access to specialists at distant sites, and bring family memberse to “webside” who cannot be at a patient’s bedside.
In clinical trials as well, virtual care is a welcome change. According to one survey1, most trial participants favored the use of telehealth services for clinical trials, as these helped them stay engaged, compliant, monitored, and on track while remaining at home. Furthermore, we are seeing the integration of artificial intelligence (AI) into telehealth, whether it is to aid physicians in clinical decision-making or to generate reminders to help patients with chronic disease management. However, this integration is only beginning to scratch the surface of the combination of two technologies’ real potential.
What’s next?
Based on these trends, it should be no surprise that digital health will become a vital sign for health care organizations.
The next 12 to 24 months will set new standards for digital health and play a significant role in defining the next generation of virtual care. There are projections that global health care industry revenues will exceed $2.6 trillion by 2025, with AI and telehealth playing a prominent role in this growth.2 According to estimates, telehealth itself will be a $175 billion market by 2026 and approximately one in three patient encounters will go virtual.3,4 Moreover, virtual care will continue to make exciting transformations, helping to make quality care accessible to everyone in innovative ways. For example, the University of Cincinnati has recently developed a pilot project using a drone equipped with video technology, artificial intelligence, sensors, and first aid kits to go to hard-to-reach areas to deliver care via telemedicine.5
Smart hospitals
In coming years, we can expect the integration of AI, augmented reality (AR), and virtual reality (VR) into telemedicine at lightning speed – and at a much larger scale – that will enable surgeons from different parts of the globe to perform procedures remotely and more precisely.
AI is already gaining traction in different fields within health care – whether it’s predicting length of stay in the ICU, or assisting in triage decisions, or reading radiological images, to name just a few. The Mayo Clinic is using AI and computer-aided decision-making tools to predict the risk of surgery and potential post-op complications, which could allow even better collaboration between medical and surgical teams. We hear about the “X-ray” vision offered to proceduralists using HoloLens – mixed reality smartglasses – a technology that enables them to perform procedures more precisely. Others project that there will be more sensors and voice recognition tools in the OR that will be used to gather data to develop intelligent algorithms, and to build a safety net for interventionalists that can notify them of potential hazards or accidental sterile field breaches. The insights gained will be used to create best practices and even allow some procedures to be performed outside the traditional OR setting.
Additionally, we are seeing the development of “smart” patient rooms. For example, one health system in Florida is working on deploying Amazon Alexa in 2,500 patient rooms to allow patients to connect more easily to their care team members. In the not-so-distant future, smart hospitals with smart patient rooms and smart ORs equipped with telemedicine, AI, AR, mixed reality, and computer-aided decision-making tools will no longer be an exception.
Smart homes for smart care
Smart homes with technologies like gas detectors, movement sensors, and sleep sensors will continue to evolve. According to one estimate, the global smart home health care market was $8.7 billion in 2019, and is expected to be $96.2 billion by 2030.6
Smart technologies will have applications in fall detection and prevention, evaluation of self-administration of medicine, sleep rhythm monitoring, air quality monitoring for the detection of abnormal gas levels, and identification of things like carbon monoxide poisoning or food spoilage. In coming years, expect to see more virtual medical homes and digital health care complexes. Patients, from the convenience of their homes, might be able to connect to a suite of caregivers, all working collaboratively to provide more coordinated, effective care. The “hospital at home” model that started with six hospitals has already grown to over 100 hospitals across 29 states. The shift from onsite specialists to onscreen specialists will continue, providing greater access to specialized services.
With these emerging trends, it can be anticipated that much acute care will be provided to patients outside the hospital – either under the hospital at home model, via drone technology using telemedicine, through smart devices in smart homes, or via wearables and artificial intelligence. Hence, hospitals’ configuration in the future will be much different and more compact than currently, and many hospitals will be reserved for trauma patients, casualties of natural disasters, higher acuity diseases requiring complex procedures, and other emergencies.
The role of hospitalists has evolved over the years and is still evolving. It should be no surprise if, in the future, we work alongside a digital hospitalist twin to provide better and more personalized care to our patients. Change is uncomfortable but it is inevitable. When COVID hit, we were forced to find innovative ways to deliver care to our patients. One thing is for certain: post-pandemic (AD, or After Disease) we are not going back to a Before COVID (BC) state in terms of virtual care. With the new dawn of digital era, the crucial questions to address will be: What will the future role of a hospitalist look like? How can we leverage technology and embrace our flexibility to adapt to these trends? How can we apply the lessons learned during the pandemic to propel hospital medicine into the future? And is it time to rethink our role and even reclassify ourselves – from hospitalists to Acute Care Experts (ACE) or Primary Acute Care Physicians?
Dr. Zia is a hospitalist, physician advisor, and founder of Virtual Hospitalist - a telemedicine company with a 360-degree care model for hospital patients.
People often overestimate what will happen in the next two years and underestimate what will happen in ten. – Bill Gates
The COVID-19 pandemic set in motion a series of innovations catalyzing the digital transformation of the health care landscape.
Telemedicine use exploded over the last 12 months to the point that it has almost become ubiquitous. With that, we saw a rapid proliferation of wearables and remote patient monitoring devices. Thanks to virtual care, care delivery is no longer strictly dependent on having onsite specialists, and care itself is not confined to the boundaries of hospitals or doctors’ offices anymore.
Dr. Sareer Zia
We saw the formation of the digital front door and the emergence of new virtual care sites like virtual urgent care, virtual home health, virtual office visits, virtual hospital at home that allowed clinical care to be delivered safely outside the boundaries of hospitals. Nonclinical public places like gyms, schools, and community centers were being transformed into virtual health care portals that brought care closer to the people.
Inside the hospital, we saw a fusion of traditional inpatient care and virtual care. Onsite hospital teams embraced telemedicine during the pandemic for various reasons; to conserve personal protective equipment (PPE), limit exposure, boost care capacity, improve access to specialists at distant sites, and bring family memberse to “webside” who cannot be at a patient’s bedside.
In clinical trials as well, virtual care is a welcome change. According to one survey1, most trial participants favored the use of telehealth services for clinical trials, as these helped them stay engaged, compliant, monitored, and on track while remaining at home. Furthermore, we are seeing the integration of artificial intelligence (AI) into telehealth, whether it is to aid physicians in clinical decision-making or to generate reminders to help patients with chronic disease management. However, this integration is only beginning to scratch the surface of the combination of two technologies’ real potential.
What’s next?
Based on these trends, it should be no surprise that digital health will become a vital sign for health care organizations.
The next 12 to 24 months will set new standards for digital health and play a significant role in defining the next generation of virtual care. There are projections that global health care industry revenues will exceed $2.6 trillion by 2025, with AI and telehealth playing a prominent role in this growth.2 According to estimates, telehealth itself will be a $175 billion market by 2026 and approximately one in three patient encounters will go virtual.3,4 Moreover, virtual care will continue to make exciting transformations, helping to make quality care accessible to everyone in innovative ways. For example, the University of Cincinnati has recently developed a pilot project using a drone equipped with video technology, artificial intelligence, sensors, and first aid kits to go to hard-to-reach areas to deliver care via telemedicine.5
Smart hospitals
In coming years, we can expect the integration of AI, augmented reality (AR), and virtual reality (VR) into telemedicine at lightning speed – and at a much larger scale – that will enable surgeons from different parts of the globe to perform procedures remotely and more precisely.
AI is already gaining traction in different fields within health care – whether it’s predicting length of stay in the ICU, or assisting in triage decisions, or reading radiological images, to name just a few. The Mayo Clinic is using AI and computer-aided decision-making tools to predict the risk of surgery and potential post-op complications, which could allow even better collaboration between medical and surgical teams. We hear about the “X-ray” vision offered to proceduralists using HoloLens – mixed reality smartglasses – a technology that enables them to perform procedures more precisely. Others project that there will be more sensors and voice recognition tools in the OR that will be used to gather data to develop intelligent algorithms, and to build a safety net for interventionalists that can notify them of potential hazards or accidental sterile field breaches. The insights gained will be used to create best practices and even allow some procedures to be performed outside the traditional OR setting.
Additionally, we are seeing the development of “smart” patient rooms. For example, one health system in Florida is working on deploying Amazon Alexa in 2,500 patient rooms to allow patients to connect more easily to their care team members. In the not-so-distant future, smart hospitals with smart patient rooms and smart ORs equipped with telemedicine, AI, AR, mixed reality, and computer-aided decision-making tools will no longer be an exception.
Smart homes for smart care
Smart homes with technologies like gas detectors, movement sensors, and sleep sensors will continue to evolve. According to one estimate, the global smart home health care market was $8.7 billion in 2019, and is expected to be $96.2 billion by 2030.6
Smart technologies will have applications in fall detection and prevention, evaluation of self-administration of medicine, sleep rhythm monitoring, air quality monitoring for the detection of abnormal gas levels, and identification of things like carbon monoxide poisoning or food spoilage. In coming years, expect to see more virtual medical homes and digital health care complexes. Patients, from the convenience of their homes, might be able to connect to a suite of caregivers, all working collaboratively to provide more coordinated, effective care. The “hospital at home” model that started with six hospitals has already grown to over 100 hospitals across 29 states. The shift from onsite specialists to onscreen specialists will continue, providing greater access to specialized services.
With these emerging trends, it can be anticipated that much acute care will be provided to patients outside the hospital – either under the hospital at home model, via drone technology using telemedicine, through smart devices in smart homes, or via wearables and artificial intelligence. Hence, hospitals’ configuration in the future will be much different and more compact than currently, and many hospitals will be reserved for trauma patients, casualties of natural disasters, higher acuity diseases requiring complex procedures, and other emergencies.
The role of hospitalists has evolved over the years and is still evolving. It should be no surprise if, in the future, we work alongside a digital hospitalist twin to provide better and more personalized care to our patients. Change is uncomfortable but it is inevitable. When COVID hit, we were forced to find innovative ways to deliver care to our patients. One thing is for certain: post-pandemic (AD, or After Disease) we are not going back to a Before COVID (BC) state in terms of virtual care. With the new dawn of digital era, the crucial questions to address will be: What will the future role of a hospitalist look like? How can we leverage technology and embrace our flexibility to adapt to these trends? How can we apply the lessons learned during the pandemic to propel hospital medicine into the future? And is it time to rethink our role and even reclassify ourselves – from hospitalists to Acute Care Experts (ACE) or Primary Acute Care Physicians?
Dr. Zia is a hospitalist, physician advisor, and founder of Virtual Hospitalist - a telemedicine company with a 360-degree care model for hospital patients.
A Elbow and forearm with erythematous, well-demarcated, pink plaques with mild micaceous scale in a 42-year-old White woman.
B Elbow and forearm with violaceous, well-demarcated plaques with micaceous scale and hyperpigmented patches around the active plaques in a 58-year-old Black man.
Epidemiology Psoriasis prevalence in the United States has been estimated at 3.7%.1-3 If broken down by race or ethnicity, the prevalence of psoriasis varies: 2.5% to 3.7% in White adults1-4; 1.3% to 2% in Black adults1-4; 1.6% in Hispanics/ other adults1-3; 1% in children overall; 0.29% in White children1,5; and 0.06% in Black children.1,5
Key clinical features in people with darker skin tones include:
plaques that may appear more violaceous in color instead of pink or erythematous
higher body surface area of involvement4 and thicker, more scaly plaques6
increased likelihood of postinflammatory hyperpigmentation (PIH).
Worth noting Although individuals of all skin tones may experience the psychosocial impact of psoriasis, quality-of-life measures have been found to be worse in those with skin of color (SOC) compared to White patients.1,4 This may be due to the lingering PIH and hypopigmentation that occurs even after inflammatory plaques are treated. Of course, lack of access to care contributes to greater disease burden and more devastating psychological impact.
Health disparity highlight Psoriasis may be underreported and underdiagnosed in individuals with SOC, as factors contributing to health care disparities may play a role, such as access to health care in general,1,7 and access to clinicians proficient in diagnosing cutaneous diseases in SOC may be delayed.8
Biologic medications are used less often in Black patients than in White patients, despite biologic medications being very efficacious for treatment of psoriasis.1,9,10
References
Kaufman BP, Alexis AF. Psoriasis in skin of color: insights into the epidemiology, clinical presentation, genetics, quality-of-life impact, and treatment of psoriasis in non-white racial/ethnic groups. Am J Clin Dermatol. 2018;19:405-423.
Rachakonda TD, Schupp CW, Armstrong AW. Psoriasis prevalence among adults in the United States. J Am Acad Dermatol. 2014;70:512-516.
Helmick CG, Lee-Han H, Hirsch SC, et al. Prevalence of psoriasis among adults in the U.S.: 2003-2006 and 2009-2010 National Health and Nutrition Examination Surveys. Am J Prev Med. 2014;47:37-45.
Gelfand JM, Stern RS, Nijsten T, et al. The prevalence of psoriasis in African Americans: results from a population-based study. J Am Acad Dermatol. 2005;52:23-26.
Wu JJ, Black MH, Smith N, et al. Low prevalence of psoriasis among children and adolescents in a large multiethnic cohort in southern California. J Am Acad Dermatol. 2011;65:957-964.
Davis SA, Narahari S, Feldman SR, et al. Top dermatologic conditions in patients of color: an analysis of nationally representative data. J Drugs Dermatol. 2012;11:466-473.
Alexis AF, Blackcloud P. Psoriasis in skin of color: epidemiology, genetics, clinical presentation, and treatment nuances. J Clin Aesthet Dermatol. 2014;7:16-24.
Mundluru SN, Ramalingam ND, Tran HN. Addressing internal medicine residents’ discomfort with basic dermatology in persons of color in the primary care clinic. Am J Med Qual. 2019;34:513-513.
Kerr GS, Qaiyumi S, Richards J, et al. Psoriasis and psoriatic arthritis in African-American patients—the need to measure disease burden. Clin Rheumatol. 2015;34:1753-1759.
Takeshita J, Gelfand JM, Li P, et al. Psoriasis in the US Medicare population: prevalence, treatment, and factors associated with biologic use. J Invest Dermatol. 2015;135:2955-2963.
A Elbow and forearm with erythematous, well-demarcated, pink plaques with mild micaceous scale in a 42-year-old White woman.
B Elbow and forearm with violaceous, well-demarcated plaques with micaceous scale and hyperpigmented patches around the active plaques in a 58-year-old Black man.
Epidemiology Psoriasis prevalence in the United States has been estimated at 3.7%.1-3 If broken down by race or ethnicity, the prevalence of psoriasis varies: 2.5% to 3.7% in White adults1-4; 1.3% to 2% in Black adults1-4; 1.6% in Hispanics/ other adults1-3; 1% in children overall; 0.29% in White children1,5; and 0.06% in Black children.1,5
Key clinical features in people with darker skin tones include:
plaques that may appear more violaceous in color instead of pink or erythematous
higher body surface area of involvement4 and thicker, more scaly plaques6
increased likelihood of postinflammatory hyperpigmentation (PIH).
Worth noting Although individuals of all skin tones may experience the psychosocial impact of psoriasis, quality-of-life measures have been found to be worse in those with skin of color (SOC) compared to White patients.1,4 This may be due to the lingering PIH and hypopigmentation that occurs even after inflammatory plaques are treated. Of course, lack of access to care contributes to greater disease burden and more devastating psychological impact.
Health disparity highlight Psoriasis may be underreported and underdiagnosed in individuals with SOC, as factors contributing to health care disparities may play a role, such as access to health care in general,1,7 and access to clinicians proficient in diagnosing cutaneous diseases in SOC may be delayed.8
Biologic medications are used less often in Black patients than in White patients, despite biologic medications being very efficacious for treatment of psoriasis.1,9,10
Photographs courtesy of Richard P. Usatine, MD.
The Comparison
A Elbow and forearm with erythematous, well-demarcated, pink plaques with mild micaceous scale in a 42-year-old White woman.
B Elbow and forearm with violaceous, well-demarcated plaques with micaceous scale and hyperpigmented patches around the active plaques in a 58-year-old Black man.
Epidemiology Psoriasis prevalence in the United States has been estimated at 3.7%.1-3 If broken down by race or ethnicity, the prevalence of psoriasis varies: 2.5% to 3.7% in White adults1-4; 1.3% to 2% in Black adults1-4; 1.6% in Hispanics/ other adults1-3; 1% in children overall; 0.29% in White children1,5; and 0.06% in Black children.1,5
Key clinical features in people with darker skin tones include:
plaques that may appear more violaceous in color instead of pink or erythematous
higher body surface area of involvement4 and thicker, more scaly plaques6
increased likelihood of postinflammatory hyperpigmentation (PIH).
Worth noting Although individuals of all skin tones may experience the psychosocial impact of psoriasis, quality-of-life measures have been found to be worse in those with skin of color (SOC) compared to White patients.1,4 This may be due to the lingering PIH and hypopigmentation that occurs even after inflammatory plaques are treated. Of course, lack of access to care contributes to greater disease burden and more devastating psychological impact.
Health disparity highlight Psoriasis may be underreported and underdiagnosed in individuals with SOC, as factors contributing to health care disparities may play a role, such as access to health care in general,1,7 and access to clinicians proficient in diagnosing cutaneous diseases in SOC may be delayed.8
Biologic medications are used less often in Black patients than in White patients, despite biologic medications being very efficacious for treatment of psoriasis.1,9,10
References
Kaufman BP, Alexis AF. Psoriasis in skin of color: insights into the epidemiology, clinical presentation, genetics, quality-of-life impact, and treatment of psoriasis in non-white racial/ethnic groups. Am J Clin Dermatol. 2018;19:405-423.
Rachakonda TD, Schupp CW, Armstrong AW. Psoriasis prevalence among adults in the United States. J Am Acad Dermatol. 2014;70:512-516.
Helmick CG, Lee-Han H, Hirsch SC, et al. Prevalence of psoriasis among adults in the U.S.: 2003-2006 and 2009-2010 National Health and Nutrition Examination Surveys. Am J Prev Med. 2014;47:37-45.
Gelfand JM, Stern RS, Nijsten T, et al. The prevalence of psoriasis in African Americans: results from a population-based study. J Am Acad Dermatol. 2005;52:23-26.
Wu JJ, Black MH, Smith N, et al. Low prevalence of psoriasis among children and adolescents in a large multiethnic cohort in southern California. J Am Acad Dermatol. 2011;65:957-964.
Davis SA, Narahari S, Feldman SR, et al. Top dermatologic conditions in patients of color: an analysis of nationally representative data. J Drugs Dermatol. 2012;11:466-473.
Alexis AF, Blackcloud P. Psoriasis in skin of color: epidemiology, genetics, clinical presentation, and treatment nuances. J Clin Aesthet Dermatol. 2014;7:16-24.
Mundluru SN, Ramalingam ND, Tran HN. Addressing internal medicine residents’ discomfort with basic dermatology in persons of color in the primary care clinic. Am J Med Qual. 2019;34:513-513.
Kerr GS, Qaiyumi S, Richards J, et al. Psoriasis and psoriatic arthritis in African-American patients—the need to measure disease burden. Clin Rheumatol. 2015;34:1753-1759.
Takeshita J, Gelfand JM, Li P, et al. Psoriasis in the US Medicare population: prevalence, treatment, and factors associated with biologic use. J Invest Dermatol. 2015;135:2955-2963.
References
Kaufman BP, Alexis AF. Psoriasis in skin of color: insights into the epidemiology, clinical presentation, genetics, quality-of-life impact, and treatment of psoriasis in non-white racial/ethnic groups. Am J Clin Dermatol. 2018;19:405-423.
Rachakonda TD, Schupp CW, Armstrong AW. Psoriasis prevalence among adults in the United States. J Am Acad Dermatol. 2014;70:512-516.
Helmick CG, Lee-Han H, Hirsch SC, et al. Prevalence of psoriasis among adults in the U.S.: 2003-2006 and 2009-2010 National Health and Nutrition Examination Surveys. Am J Prev Med. 2014;47:37-45.
Gelfand JM, Stern RS, Nijsten T, et al. The prevalence of psoriasis in African Americans: results from a population-based study. J Am Acad Dermatol. 2005;52:23-26.
Wu JJ, Black MH, Smith N, et al. Low prevalence of psoriasis among children and adolescents in a large multiethnic cohort in southern California. J Am Acad Dermatol. 2011;65:957-964.
Davis SA, Narahari S, Feldman SR, et al. Top dermatologic conditions in patients of color: an analysis of nationally representative data. J Drugs Dermatol. 2012;11:466-473.
Alexis AF, Blackcloud P. Psoriasis in skin of color: epidemiology, genetics, clinical presentation, and treatment nuances. J Clin Aesthet Dermatol. 2014;7:16-24.
Mundluru SN, Ramalingam ND, Tran HN. Addressing internal medicine residents’ discomfort with basic dermatology in persons of color in the primary care clinic. Am J Med Qual. 2019;34:513-513.
Kerr GS, Qaiyumi S, Richards J, et al. Psoriasis and psoriatic arthritis in African-American patients—the need to measure disease burden. Clin Rheumatol. 2015;34:1753-1759.
Takeshita J, Gelfand JM, Li P, et al. Psoriasis in the US Medicare population: prevalence, treatment, and factors associated with biologic use. J Invest Dermatol. 2015;135:2955-2963.
Medical admissions for adolescents with restrictive eating disorders more than doubled at one hospital during the first 12 months of the COVID-19 pandemic, relative to the average number of admissions in prior years, a new study shows.
Doctors are seeing similar increases across the United States and in other countries.
Providers and health care systems “may need to rapidly adapt in response to increasing demands for care during the COVID-19 pandemic,” the researchers said in their study, which was published online in Pediatrics.
To assess whether admission patterns among adolescents with restrictive eating disorders changed during the pandemic, Alana K. Otto, MD, MPH, with the division of adolescent medicine at the University of Michigan, Ann Arbor, and colleagues reviewed the charts of patients admitted to C.S. Mott Children’s Hospital, also in Ann Arbor.
Their analysis included 297 admissions among 248 patients aged 10-23 years between March 1, 2017, and March 31, 2021. Patients had an average age of about 15 years. Approximately 90% were female, and most had a diagnosis of anorexia nervosa or atypical anorexia nervosa.
Indications for medical admission included physiological instability (for example, heart rate less than 50 beats per minute while awake or blood pressure less than 90/40 mm Hg), electrolyte derangements, and acute medical complications of malnutrition such as syncope. Other possible indications included uncontrolled purging, body mass index less than 75% of the median for age and sex, acute food refusal, and failure of outpatient treatment.
Eating disorder–related admissions per month were stable prior to the pandemic. Admissions then decreased in April 2020, but subsequently increased significantly throughout the study period. In all, there were 125 admissions between April 1, 2020, and March 31, 2021. During the previous 3 years, the average number of admissions per year was 56.
Patients’ insurance status was one factor that differed before and during the pandemic. Prepandemic, about 20% of admissions were for adolescents with public insurance. During the pandemic, however, the proportion with public insurance was approximately 9%, the researchers noted. Other characteristics were generally similar.
The study was retrospective and relatively small and only looked at patients with restrictive eating disorders who were severely ill and admitted for medical stabilization. It does not reflect adolescents with eating disorders in different settings, the authors noted.
Primary care pediatricians should be familiar with indications for medical admission, such as severe bradycardia, as outlined by the Society for Adolescent Health and Medicine, they said.
Consistent trends
Unfortunately, the trend seems consistent across the nation, said Michaela M. Voss, MD, director of the the Eating Disorders Center at Children’s Mercy in Kansas City, Mo. “Our outpatient setting went from availability to get in immediately to a 6-month wait list.”
As in Michigan, Dr. Voss noted a drop in admissions as lockdowns started, followed by a spike in treatment demand that has not let up.
Dr. Voss described two of the more common presentations. In one, parents might note that their child had been getting into healthy eating and exercise before the pandemic and seemed fine. “But then COVID came, the lockdown happened, and they became overly obsessed with those things,” Dr. Voss said.
In the other presentation, kids with anxiety, depression, or OCD who lost access to their usual coping strategies and outlets developed eating disorders during the pandemic. “They focused on one of the few things they could during the lockdown, which was their own body, and then their anxiety, depression, [obsessive-compulsive disorder], and other mental health comorbidities presented as an eating disorder,” Dr. Voss said.
The increasing need for treatment over the course of the pandemic may reflect the time that it has taken for the disorders to develop, as well as the time that it takes parents to recognize the problem.
Not only are doctors seeing more cases, but patients are arriving sicker than usual, Dr. Voss said.
Major medical concerns for patients in starvation mode center on the heart, brain, and bones. In addition, refeeding syndrome poses an extreme risk, Dr. Voss noted.
The Academy for Eating Disorders has created a guide to help doctors recognize and manage risks for patients with eating disorders, which may be useful for primary care providers while they are trying to get a patient into more intensive treatment, Dr. Voss suggested. The American Academy of Pediatrics recently published a clinical report on the identification and management of eating disorders in children and adolescents.
Dr. Jennifer Leah Goetz
At Johns Hopkins Hospital Children’s Center in Baltimore, “we have seen a pretty remarkable increase in the number of eating disorders in the child and adolescent space since COVID,” said Jennifer Leah Goetz, MD, a psychiatrist and medical director of the child and adolescent inpatient unit. “We have seen increasing numbers of kids presenting for acute medical stabilization and refeeding and for specific treatment for the eating disorder.”
It could be that, for people with a genetic predisposition to eating disorders, a confluence of factors related to the pandemic unmasked it. For example, children may have spent more time looking at themselves on virtual meeting platforms, which could stir lingering body image and appearance-related concerns in those who are vulnerable. And some teens who were not able to participate in athletics as usual started to watch what they eat more closely, Dr. Goetz said.
A treatment bottleneck
Patients with eating disorders “can be quite ill from a psychiatric and general medical perspective,” Dr. Goetz said. “Most psychiatrists are not particularly comfortable with the medical complications, and most internists or pediatricians are not particularly comfortable with the psychiatric complications. You end up with a patient population that can only see a really highly specialized group of individuals for care. And it is a problem. It was a problem before the pandemic, and it has been really exacerbated by what we have been going through with COVID.”
Dr. Natalie Muth
Natalie Muth, MD, MPH, RDN, a pediatrician at Children’s Primary Care Medical Group La Costa in Carlsbad, Calif., has also noticed the increase in eating disorders since COVID.
In-patient colleagues “have longer wait lists and more severe cases than they have ever seen previously,” said Dr. Muth, who chairs the American Academy of Pediatrics Section on Obesity and is an adjunct assistant professor at the University of California, Los Angeles. “In primary care, we are all having to better educate and prepare ourselves for identifying and managing patients with eating disorders.”
That could mean connecting with mental health professionals, registered dietitians, and higher levels of care. But that may be a challenge. “Accessing these resources has been more difficult due to the increasing incidence of eating disorders recently,” Dr. Muth said.
Dr. Voss acknowledged that childhood obesity is another concern for pediatricians. “However, there are appropriate and healthy and safe ways to address that,” she said. A patient with overweight or obesity who loses weight may not be doing so in a healthy way.
Clinicians should wonder if a patient’s weight is decreasing too fast. And they should ask patients questions that could help identify a problem, such as: What are they doing to cause the weight loss? Why do they want to lose the weight?
Dr. Voss added that eating disorders “do not discriminate.” While there may be a perception that all patients with eating disorders are White, upper middle–class females who are thin, “that is not the case,” Dr. Voss said. They “come in all genders, all races, all weight classes, and all ages,” she said, “and we see that variety.”
In general, there may be a need to shift how weight is discussed in clinics and society more broadly, Dr. Goetz said. Weight is an incredibly personal thing, and everyone’s genetics, metabolism, and life circumstances vary. At the same time, body mass index is not necessarily the best measure of a person’s health.
Asking a child, teen, or even an adult to go on a diet is not a benign intervention, Dr. Goetz noted. In addition, dieting is unlikely to help in the long term.
Emerging from lockdown, pressure to lose “COVID pounds” is a dangerous message for people with eating disorders, Dr. Goetz said. It also could be a dangerous message for people without eating disorders. “There are so many more interesting things about each one of us than our weight,” she added.
The study authors, Dr. Voss, Dr. Goetz, and Dr. Muth had no relevant disclosures.
Medical admissions for adolescents with restrictive eating disorders more than doubled at one hospital during the first 12 months of the COVID-19 pandemic, relative to the average number of admissions in prior years, a new study shows.
Doctors are seeing similar increases across the United States and in other countries.
Providers and health care systems “may need to rapidly adapt in response to increasing demands for care during the COVID-19 pandemic,” the researchers said in their study, which was published online in Pediatrics.
To assess whether admission patterns among adolescents with restrictive eating disorders changed during the pandemic, Alana K. Otto, MD, MPH, with the division of adolescent medicine at the University of Michigan, Ann Arbor, and colleagues reviewed the charts of patients admitted to C.S. Mott Children’s Hospital, also in Ann Arbor.
Their analysis included 297 admissions among 248 patients aged 10-23 years between March 1, 2017, and March 31, 2021. Patients had an average age of about 15 years. Approximately 90% were female, and most had a diagnosis of anorexia nervosa or atypical anorexia nervosa.
Indications for medical admission included physiological instability (for example, heart rate less than 50 beats per minute while awake or blood pressure less than 90/40 mm Hg), electrolyte derangements, and acute medical complications of malnutrition such as syncope. Other possible indications included uncontrolled purging, body mass index less than 75% of the median for age and sex, acute food refusal, and failure of outpatient treatment.
Eating disorder–related admissions per month were stable prior to the pandemic. Admissions then decreased in April 2020, but subsequently increased significantly throughout the study period. In all, there were 125 admissions between April 1, 2020, and March 31, 2021. During the previous 3 years, the average number of admissions per year was 56.
Patients’ insurance status was one factor that differed before and during the pandemic. Prepandemic, about 20% of admissions were for adolescents with public insurance. During the pandemic, however, the proportion with public insurance was approximately 9%, the researchers noted. Other characteristics were generally similar.
The study was retrospective and relatively small and only looked at patients with restrictive eating disorders who were severely ill and admitted for medical stabilization. It does not reflect adolescents with eating disorders in different settings, the authors noted.
Primary care pediatricians should be familiar with indications for medical admission, such as severe bradycardia, as outlined by the Society for Adolescent Health and Medicine, they said.
Consistent trends
Unfortunately, the trend seems consistent across the nation, said Michaela M. Voss, MD, director of the the Eating Disorders Center at Children’s Mercy in Kansas City, Mo. “Our outpatient setting went from availability to get in immediately to a 6-month wait list.”
As in Michigan, Dr. Voss noted a drop in admissions as lockdowns started, followed by a spike in treatment demand that has not let up.
Dr. Voss described two of the more common presentations. In one, parents might note that their child had been getting into healthy eating and exercise before the pandemic and seemed fine. “But then COVID came, the lockdown happened, and they became overly obsessed with those things,” Dr. Voss said.
In the other presentation, kids with anxiety, depression, or OCD who lost access to their usual coping strategies and outlets developed eating disorders during the pandemic. “They focused on one of the few things they could during the lockdown, which was their own body, and then their anxiety, depression, [obsessive-compulsive disorder], and other mental health comorbidities presented as an eating disorder,” Dr. Voss said.
The increasing need for treatment over the course of the pandemic may reflect the time that it has taken for the disorders to develop, as well as the time that it takes parents to recognize the problem.
Not only are doctors seeing more cases, but patients are arriving sicker than usual, Dr. Voss said.
Major medical concerns for patients in starvation mode center on the heart, brain, and bones. In addition, refeeding syndrome poses an extreme risk, Dr. Voss noted.
The Academy for Eating Disorders has created a guide to help doctors recognize and manage risks for patients with eating disorders, which may be useful for primary care providers while they are trying to get a patient into more intensive treatment, Dr. Voss suggested. The American Academy of Pediatrics recently published a clinical report on the identification and management of eating disorders in children and adolescents.
Dr. Jennifer Leah Goetz
At Johns Hopkins Hospital Children’s Center in Baltimore, “we have seen a pretty remarkable increase in the number of eating disorders in the child and adolescent space since COVID,” said Jennifer Leah Goetz, MD, a psychiatrist and medical director of the child and adolescent inpatient unit. “We have seen increasing numbers of kids presenting for acute medical stabilization and refeeding and for specific treatment for the eating disorder.”
It could be that, for people with a genetic predisposition to eating disorders, a confluence of factors related to the pandemic unmasked it. For example, children may have spent more time looking at themselves on virtual meeting platforms, which could stir lingering body image and appearance-related concerns in those who are vulnerable. And some teens who were not able to participate in athletics as usual started to watch what they eat more closely, Dr. Goetz said.
A treatment bottleneck
Patients with eating disorders “can be quite ill from a psychiatric and general medical perspective,” Dr. Goetz said. “Most psychiatrists are not particularly comfortable with the medical complications, and most internists or pediatricians are not particularly comfortable with the psychiatric complications. You end up with a patient population that can only see a really highly specialized group of individuals for care. And it is a problem. It was a problem before the pandemic, and it has been really exacerbated by what we have been going through with COVID.”
Dr. Natalie Muth
Natalie Muth, MD, MPH, RDN, a pediatrician at Children’s Primary Care Medical Group La Costa in Carlsbad, Calif., has also noticed the increase in eating disorders since COVID.
In-patient colleagues “have longer wait lists and more severe cases than they have ever seen previously,” said Dr. Muth, who chairs the American Academy of Pediatrics Section on Obesity and is an adjunct assistant professor at the University of California, Los Angeles. “In primary care, we are all having to better educate and prepare ourselves for identifying and managing patients with eating disorders.”
That could mean connecting with mental health professionals, registered dietitians, and higher levels of care. But that may be a challenge. “Accessing these resources has been more difficult due to the increasing incidence of eating disorders recently,” Dr. Muth said.
Dr. Voss acknowledged that childhood obesity is another concern for pediatricians. “However, there are appropriate and healthy and safe ways to address that,” she said. A patient with overweight or obesity who loses weight may not be doing so in a healthy way.
Clinicians should wonder if a patient’s weight is decreasing too fast. And they should ask patients questions that could help identify a problem, such as: What are they doing to cause the weight loss? Why do they want to lose the weight?
Dr. Voss added that eating disorders “do not discriminate.” While there may be a perception that all patients with eating disorders are White, upper middle–class females who are thin, “that is not the case,” Dr. Voss said. They “come in all genders, all races, all weight classes, and all ages,” she said, “and we see that variety.”
In general, there may be a need to shift how weight is discussed in clinics and society more broadly, Dr. Goetz said. Weight is an incredibly personal thing, and everyone’s genetics, metabolism, and life circumstances vary. At the same time, body mass index is not necessarily the best measure of a person’s health.
Asking a child, teen, or even an adult to go on a diet is not a benign intervention, Dr. Goetz noted. In addition, dieting is unlikely to help in the long term.
Emerging from lockdown, pressure to lose “COVID pounds” is a dangerous message for people with eating disorders, Dr. Goetz said. It also could be a dangerous message for people without eating disorders. “There are so many more interesting things about each one of us than our weight,” she added.
The study authors, Dr. Voss, Dr. Goetz, and Dr. Muth had no relevant disclosures.
Medical admissions for adolescents with restrictive eating disorders more than doubled at one hospital during the first 12 months of the COVID-19 pandemic, relative to the average number of admissions in prior years, a new study shows.
Doctors are seeing similar increases across the United States and in other countries.
Providers and health care systems “may need to rapidly adapt in response to increasing demands for care during the COVID-19 pandemic,” the researchers said in their study, which was published online in Pediatrics.
To assess whether admission patterns among adolescents with restrictive eating disorders changed during the pandemic, Alana K. Otto, MD, MPH, with the division of adolescent medicine at the University of Michigan, Ann Arbor, and colleagues reviewed the charts of patients admitted to C.S. Mott Children’s Hospital, also in Ann Arbor.
Their analysis included 297 admissions among 248 patients aged 10-23 years between March 1, 2017, and March 31, 2021. Patients had an average age of about 15 years. Approximately 90% were female, and most had a diagnosis of anorexia nervosa or atypical anorexia nervosa.
Indications for medical admission included physiological instability (for example, heart rate less than 50 beats per minute while awake or blood pressure less than 90/40 mm Hg), electrolyte derangements, and acute medical complications of malnutrition such as syncope. Other possible indications included uncontrolled purging, body mass index less than 75% of the median for age and sex, acute food refusal, and failure of outpatient treatment.
Eating disorder–related admissions per month were stable prior to the pandemic. Admissions then decreased in April 2020, but subsequently increased significantly throughout the study period. In all, there were 125 admissions between April 1, 2020, and March 31, 2021. During the previous 3 years, the average number of admissions per year was 56.
Patients’ insurance status was one factor that differed before and during the pandemic. Prepandemic, about 20% of admissions were for adolescents with public insurance. During the pandemic, however, the proportion with public insurance was approximately 9%, the researchers noted. Other characteristics were generally similar.
The study was retrospective and relatively small and only looked at patients with restrictive eating disorders who were severely ill and admitted for medical stabilization. It does not reflect adolescents with eating disorders in different settings, the authors noted.
Primary care pediatricians should be familiar with indications for medical admission, such as severe bradycardia, as outlined by the Society for Adolescent Health and Medicine, they said.
Consistent trends
Unfortunately, the trend seems consistent across the nation, said Michaela M. Voss, MD, director of the the Eating Disorders Center at Children’s Mercy in Kansas City, Mo. “Our outpatient setting went from availability to get in immediately to a 6-month wait list.”
As in Michigan, Dr. Voss noted a drop in admissions as lockdowns started, followed by a spike in treatment demand that has not let up.
Dr. Voss described two of the more common presentations. In one, parents might note that their child had been getting into healthy eating and exercise before the pandemic and seemed fine. “But then COVID came, the lockdown happened, and they became overly obsessed with those things,” Dr. Voss said.
In the other presentation, kids with anxiety, depression, or OCD who lost access to their usual coping strategies and outlets developed eating disorders during the pandemic. “They focused on one of the few things they could during the lockdown, which was their own body, and then their anxiety, depression, [obsessive-compulsive disorder], and other mental health comorbidities presented as an eating disorder,” Dr. Voss said.
The increasing need for treatment over the course of the pandemic may reflect the time that it has taken for the disorders to develop, as well as the time that it takes parents to recognize the problem.
Not only are doctors seeing more cases, but patients are arriving sicker than usual, Dr. Voss said.
Major medical concerns for patients in starvation mode center on the heart, brain, and bones. In addition, refeeding syndrome poses an extreme risk, Dr. Voss noted.
The Academy for Eating Disorders has created a guide to help doctors recognize and manage risks for patients with eating disorders, which may be useful for primary care providers while they are trying to get a patient into more intensive treatment, Dr. Voss suggested. The American Academy of Pediatrics recently published a clinical report on the identification and management of eating disorders in children and adolescents.
Dr. Jennifer Leah Goetz
At Johns Hopkins Hospital Children’s Center in Baltimore, “we have seen a pretty remarkable increase in the number of eating disorders in the child and adolescent space since COVID,” said Jennifer Leah Goetz, MD, a psychiatrist and medical director of the child and adolescent inpatient unit. “We have seen increasing numbers of kids presenting for acute medical stabilization and refeeding and for specific treatment for the eating disorder.”
It could be that, for people with a genetic predisposition to eating disorders, a confluence of factors related to the pandemic unmasked it. For example, children may have spent more time looking at themselves on virtual meeting platforms, which could stir lingering body image and appearance-related concerns in those who are vulnerable. And some teens who were not able to participate in athletics as usual started to watch what they eat more closely, Dr. Goetz said.
A treatment bottleneck
Patients with eating disorders “can be quite ill from a psychiatric and general medical perspective,” Dr. Goetz said. “Most psychiatrists are not particularly comfortable with the medical complications, and most internists or pediatricians are not particularly comfortable with the psychiatric complications. You end up with a patient population that can only see a really highly specialized group of individuals for care. And it is a problem. It was a problem before the pandemic, and it has been really exacerbated by what we have been going through with COVID.”
Dr. Natalie Muth
Natalie Muth, MD, MPH, RDN, a pediatrician at Children’s Primary Care Medical Group La Costa in Carlsbad, Calif., has also noticed the increase in eating disorders since COVID.
In-patient colleagues “have longer wait lists and more severe cases than they have ever seen previously,” said Dr. Muth, who chairs the American Academy of Pediatrics Section on Obesity and is an adjunct assistant professor at the University of California, Los Angeles. “In primary care, we are all having to better educate and prepare ourselves for identifying and managing patients with eating disorders.”
That could mean connecting with mental health professionals, registered dietitians, and higher levels of care. But that may be a challenge. “Accessing these resources has been more difficult due to the increasing incidence of eating disorders recently,” Dr. Muth said.
Dr. Voss acknowledged that childhood obesity is another concern for pediatricians. “However, there are appropriate and healthy and safe ways to address that,” she said. A patient with overweight or obesity who loses weight may not be doing so in a healthy way.
Clinicians should wonder if a patient’s weight is decreasing too fast. And they should ask patients questions that could help identify a problem, such as: What are they doing to cause the weight loss? Why do they want to lose the weight?
Dr. Voss added that eating disorders “do not discriminate.” While there may be a perception that all patients with eating disorders are White, upper middle–class females who are thin, “that is not the case,” Dr. Voss said. They “come in all genders, all races, all weight classes, and all ages,” she said, “and we see that variety.”
In general, there may be a need to shift how weight is discussed in clinics and society more broadly, Dr. Goetz said. Weight is an incredibly personal thing, and everyone’s genetics, metabolism, and life circumstances vary. At the same time, body mass index is not necessarily the best measure of a person’s health.
Asking a child, teen, or even an adult to go on a diet is not a benign intervention, Dr. Goetz noted. In addition, dieting is unlikely to help in the long term.
Emerging from lockdown, pressure to lose “COVID pounds” is a dangerous message for people with eating disorders, Dr. Goetz said. It also could be a dangerous message for people without eating disorders. “There are so many more interesting things about each one of us than our weight,” she added.
The study authors, Dr. Voss, Dr. Goetz, and Dr. Muth had no relevant disclosures.
Consumers should stop using certain brands of spray-on sunscreen products made by Johnson & Johnson. The company has issued a voluntary recall after finding low levels of benzene, a known cancer-causing agent, in some samples.
Benzene is not an ingredient of sunscreen, and should not be present in these products. The levels detected were low and would not be expected to have an adverse effect on health, but the company says it is recalling the products anyway “out of an abundance of caution.”
The sunscreen products that have been recalled are:
These products were distributed nationwide through a variety of retail stores. Consumers should stop using these products and throw them away, the company said.
At the same time, it emphasized the importance of using alternative sunscreen products to protect the skin from excessive sun exposure, which can lead to skin cancer including melanoma.
Johnson & Johnson has launched an investigation into how benzene got into these products.
One of the company’s other spray sunscreen products, Neutrogena Wet Skin, was not included in the recall.
Recently, benzene was found in 78 widely-used sunscreen products in tests conducted by the online pharmacy and laboratory Valisure. Most of the products were aerosol sprays, and the company called on the Food and Drug Administration to recall them all.
That petition suggested that the finding of benzene was the result of contamination somewhere in the manufacturing process.
“This isn’t a sunscreen issue, it’s a manufacturing issue,” said Adam Friedman, MD, professor and chief of dermatology at George Washington University. “We don’t want those things to be blurred.”
There is a risk that people take away the wrong message from these findings.
“People already have ambivalence about sunscreen, and this is just going to make that worse,” Dr. Friedman said in an interview.
He pointed out that benzene is present in car exhaust, second-hand smoke, and elsewhere. Inhalation exposure has been the primary focus of toxicology investigations, as has exposure from things such as contaminated drinking water – not via topical application. “We don’t know how effectively [benzene] gets through the skin, if it gets absorbed systemically, and how that then behaves downstream,” he noted.
On the other hand, ultraviolet radiation is a well-established carcinogen. Avoiding an effective preventive measure such as sunscreen could prove more harmful than exposure to trace amounts of benzene, he said.
A version of this article first appeared on WebMD.com.
Consumers should stop using certain brands of spray-on sunscreen products made by Johnson & Johnson. The company has issued a voluntary recall after finding low levels of benzene, a known cancer-causing agent, in some samples.
Benzene is not an ingredient of sunscreen, and should not be present in these products. The levels detected were low and would not be expected to have an adverse effect on health, but the company says it is recalling the products anyway “out of an abundance of caution.”
The sunscreen products that have been recalled are:
These products were distributed nationwide through a variety of retail stores. Consumers should stop using these products and throw them away, the company said.
At the same time, it emphasized the importance of using alternative sunscreen products to protect the skin from excessive sun exposure, which can lead to skin cancer including melanoma.
Johnson & Johnson has launched an investigation into how benzene got into these products.
One of the company’s other spray sunscreen products, Neutrogena Wet Skin, was not included in the recall.
Recently, benzene was found in 78 widely-used sunscreen products in tests conducted by the online pharmacy and laboratory Valisure. Most of the products were aerosol sprays, and the company called on the Food and Drug Administration to recall them all.
That petition suggested that the finding of benzene was the result of contamination somewhere in the manufacturing process.
“This isn’t a sunscreen issue, it’s a manufacturing issue,” said Adam Friedman, MD, professor and chief of dermatology at George Washington University. “We don’t want those things to be blurred.”
There is a risk that people take away the wrong message from these findings.
“People already have ambivalence about sunscreen, and this is just going to make that worse,” Dr. Friedman said in an interview.
He pointed out that benzene is present in car exhaust, second-hand smoke, and elsewhere. Inhalation exposure has been the primary focus of toxicology investigations, as has exposure from things such as contaminated drinking water – not via topical application. “We don’t know how effectively [benzene] gets through the skin, if it gets absorbed systemically, and how that then behaves downstream,” he noted.
On the other hand, ultraviolet radiation is a well-established carcinogen. Avoiding an effective preventive measure such as sunscreen could prove more harmful than exposure to trace amounts of benzene, he said.
A version of this article first appeared on WebMD.com.
Consumers should stop using certain brands of spray-on sunscreen products made by Johnson & Johnson. The company has issued a voluntary recall after finding low levels of benzene, a known cancer-causing agent, in some samples.
Benzene is not an ingredient of sunscreen, and should not be present in these products. The levels detected were low and would not be expected to have an adverse effect on health, but the company says it is recalling the products anyway “out of an abundance of caution.”
The sunscreen products that have been recalled are:
These products were distributed nationwide through a variety of retail stores. Consumers should stop using these products and throw them away, the company said.
At the same time, it emphasized the importance of using alternative sunscreen products to protect the skin from excessive sun exposure, which can lead to skin cancer including melanoma.
Johnson & Johnson has launched an investigation into how benzene got into these products.
One of the company’s other spray sunscreen products, Neutrogena Wet Skin, was not included in the recall.
Recently, benzene was found in 78 widely-used sunscreen products in tests conducted by the online pharmacy and laboratory Valisure. Most of the products were aerosol sprays, and the company called on the Food and Drug Administration to recall them all.
That petition suggested that the finding of benzene was the result of contamination somewhere in the manufacturing process.
“This isn’t a sunscreen issue, it’s a manufacturing issue,” said Adam Friedman, MD, professor and chief of dermatology at George Washington University. “We don’t want those things to be blurred.”
There is a risk that people take away the wrong message from these findings.
“People already have ambivalence about sunscreen, and this is just going to make that worse,” Dr. Friedman said in an interview.
He pointed out that benzene is present in car exhaust, second-hand smoke, and elsewhere. Inhalation exposure has been the primary focus of toxicology investigations, as has exposure from things such as contaminated drinking water – not via topical application. “We don’t know how effectively [benzene] gets through the skin, if it gets absorbed systemically, and how that then behaves downstream,” he noted.
On the other hand, ultraviolet radiation is a well-established carcinogen. Avoiding an effective preventive measure such as sunscreen could prove more harmful than exposure to trace amounts of benzene, he said.
A version of this article first appeared on WebMD.com.
The historical mistreatment of Black bodies in gynecologic care has bled into present day inequities—from surgeries performed on enslaved Black women and sterilization of low-income Black women under federally funded programs, to higher rates of adverse health-related outcomes among Black women compared with their non-Black counterparts.1-3 Not only is the foundation of gynecology imperfect, so too is its current-day structure.
It is not enough to identify and describe racial inequities in health care; action plans to provide equitable care are called for. In this report, we aim to 1) contextualize the data on disparities in minimally invasive gynecologic surgery, specifically hysterectomy and myomectomy candidates and postsurgical outcomes, and 2) provide recommendations to close racial gaps in gynecologic treatment for more equitable experiences for minority women.
Black women and uterine fibroids
Uterine leiomyomas, or fibroids, are not only the most common benign pelvic tumor but they also cause a significant medical and financial burden in the United States, with estimated direct costs of $4.1 ̶ 9.4 billion.4 Fibroids can affect fertility and cause pain, bulk symptoms, heavy bleeding, anemia requiring blood transfusion, and poor pregnancy outcomes. The burden of disease for uterine fibroids is greatest for Black women. While race is a social construct, women with African ancestry (who we tend to identify as having darker skin) have disproportionately higher rates of uterine fibroids. Black women experience symptoms at a younger age, spanning more of their reproductive years compared with their non-Black counterparts and their disease is often more severe compared with White women.5
The incidence of fibroids is 2 to 3 times higher in Black women compared with White women.5 According to ultrasound-based studies, the prevalence of fibroids among women aged 18 to 30 years was 26% among Black and 7% among White asymptomatic women.6 Earlier onset and more severe symptoms mean that there is a larger potential for impact on fertility for Black women. This coupled with the historical context of mistreatment of Black bodies makes the need for personalized medicine and culturally sensitive care critical. The disproportionately higher rates of uterine fibroids in Black women has been attributed to many factors, including socioeconomic status, health-care access, genetics, and lifestyle and environmental exposures, but the underlying causes of racial/ethnic differences remain unclear.7 Amazingly little data exist not only on patient preferences for management approach but also on the influence of genetic and epigenetic mediators and environmental factors that may play a role in fibroid development to guide optimal management and treatment outcomes for Black women with uterine fibroids.8
Inequitable management of uterine fibroids
Although tumor size, location, and patient risk factors are used to determine the best treatment approach, the American College of Obstetricians and Gynecologists (ACOG) guidelines suggest that the use of alternative treatments to surgery should be first-line management instead of hysterectomy for most benign conditions.9 Conservative management will often help alleviate symptoms, slow the growth of fibroid(s), or bridge women to menopause, and treatment options include hormonal contraception, gonadotropin-releasing hormone agonists, hysteroscopic resection, uterine artery embolization, magnetic resonance-guided focused ultrasound, and myomectomy.
The rate of conservative management prior to hysterectomy varies by setting, reflecting potential bias in treatment decisions. Some medical settings have reported a 29% alternative management rate prior to hysterectomy, while others report much higher rates.10 A study using patient data from Kaiser Permanente Northern California (KPNC) showed that, within a large, diverse, and integrated health care system, more than 80% of patients received alternative treatments before undergoing hysterectomy; for those with symptomatic leiomyomas, 74.1% used alternative treatments prior to hysterectomy, and in logistic regression there was not a difference by race.11 Nationally, Black women are more likely to have hysterectomy or myomectomy compared with a nonsurgical uterine-sparing therapy.12,13
With about 600,000 cases per year within the United States, the hysterectomy is the most frequently performed benign gynecologic surgery.14 The most common indication is for “symptomatic fibroid uterus.” The approach to decision making for route of hysterectomy involves multiple patient and surgeon factors, including history of vaginal delivery, body mass index, history of previous surgery, uterine size, informed patient preference, and surgeon volume.15-17 ACOG recommends a minimally invasive hysterectomy (MIH) whenever feasible given its benefits in postoperative pain, recovery time, and blood loss. Myomectomy, particularly among women in their reproductive years desiring management of leiomyomas, is a uterine-sparing procedure versus hysterectomy. Minimally invasive myomectomy (MIM), compared with an open abdominal route, provides for lower drop in hemoglobin levels, shorter hospital stay, less adhesion formation, and decreased postoperative pain.18
Racial variations in hysterectomy rates persist overall and according to hysterectomy type. Black women are 2 to 3 times more likely to undergo hysterectomy for leiomyomas than other racial groups.19 These differences in rates have been shown to persist even when burden of disease is the same. One study found that Black women had increased odds of hysterectomy compared with their White counterparts even when there was no difference in mean fibroid volume by race,20 calling into question provider bias. Even in a universal insurance setting, Black patients have been found to have higher rates of open hysterectomies.21 Previous studies found that, despite growing frequency of laparoscopic and robotic-assisted hysterectomies, patients of a minority race had decreased odds of undergoing a MIH compared with their White counterparts.22
While little data exist on route of myomectomy by race, a recent study found minority women were more likely to undergo abdominal myomectomy compared with White women; Black women were twice as likely to undergo abdominal myomectomy (adjusted odds ratio [aOR], 1.9; 95% confidence interval [CI], 1.7–2.0), Asian American women were more than twice as likely (aOR, 2.3; 95% CI, 1.8–2.8), and Hispanic American women were 50% more likely to undergo abdominal myomectomy (aOR, 1.5; 95% CI, 1.2–1.9) when compared with White women.23 These differences remained after controlling for potential confounders, and there appeared to be an interaction between race and fibroid weight such that racial bias alone may not explain the differences.
Finally, Black women have higher perioperative complication rates compared with non-Black women. Postoperative complications including blood transfusion after myomectomy have been shown to be twice as high among Black women compared with White women. However, once uterine size, comorbidities, and fibroid number were controlled, race was not associated with higher complications. Black women, compared with White women, have been found to have 50% increased odds of morbidity after an abdominal myomectomy.24
Continue to: How to ensure that BIPOC women get the best management...
How to ensure that BIPOC women get the best management
Eliminating disparities and providing equitable and patient-centered care for Black, Indigenous, and people of color (BIPOC) womenwill require research, education, training, and targeted quality improvement initiatives.
Research into fibroids and comparative treatment outcomes
Uterine fibroids, despite their major public health impact, remain understudied. With Black women carrying the highest fibroid prevalence and severity burden, especially in their childbearing years, it is imperative that research efforts be focused on outcomes by race and ethnicity. Given the significant economic impact of fibroids, more efforts should be directed toward primary prevention of fibroid formation as well as secondary prevention and limitation of fibroid growth by affordable, effective, and safe means. For example, Bratka and colleagues researched the role of vitamin D in inhibiting growth of leiomyoma cells in animal models.25Other innovative forms of management under investigation include aromatase inhibitors, green tea, cabergoline, elagolix, paricalcitol, and epigallocatechin gallate.26 Considerations such as stress, diet, and environmental risk factors have yet to be investigated in large studies.
Research contributing to evidence-based guidelines that address the needs of different patient populations affected by uterine fibroids is critical.8 Additionally, research conducted by Black women about Black women should be prioritized. In March 2021, the Stephanie Tubbs Jones Uterine Fibroid Research and Education Act of 2021 was introduced to fund $150 million in research supported by the National Institutes of Health (NIH). This is an opportunity to develop a research database to inform evidence-based culturally informed care regarding fertility counseling, medical management, and optimal surgical approach, as well as to award funding to minority researchers. There are disparities in distribution of funds from the NIH to minority researchers. Under-represented minorities are awarded fewer NIH grants compared with their counterparts despite initiatives to increase funding. Furthermore, in 2011, Black applicants for NIH funding were two-thirds as likely as White applicants to receive grants from 2000 ̶ 2006, even when accounting for publication record and training.27 Funding BIPOC researchers fuels diversity-driven investigation and can be useful in the charge to increase fibroid research.
Education and training: Changing the work force
Achieving equity requires change in provider work force. In a study of trends across multiple specialties including obstetrics and gynecology, Blacks and Latinx are more under-represented in 2016 than in 1990 across all specialties except for Black women in obstetrics and gynecology.28 It is well documented that under-represented minorities are more likely to engage in practice, research, service, and mentorship activities aligned with their identity.29 As a higher proportion of under-represented minority obstetricians and gynecologists practice in medically underserved areas,30 this presents a unique opportunity for gynecologists to improve care for and increase research involvement among BIPOC women.
Increasing BIPOC representation in medical and health care institutions and practices is not enough, however, to achieve health equity. Data from the Association of American Medical Colleges demonstrate that between 1978 and 2017 the total number of full-time obstetrics and gynecology faculty rose nearly fourfold from 1,688 to 6,347; however, the greatest rise in proportion of faculty who were nontenured was among women who were under-represented minorities.31 Additionally, there are disparities in wage by race even after controlling for hours worked and state of residence.32 Medical and academic centers and health care institutions and practices should proactively and systematically engage in the recruitment and retention of under-represented minority physicians and people in leadership roles. This will involve creating safe and inclusive work environments, with equal pay and promotion structures.
Quality initiatives to address provider bias
Provider bias should be addressed in clinical decision making and counseling of patients. Studies focused on ultrasonography have shown an estimated cumulative incidence of fibroids by age 50 of greater than 80% for Black women and nearly 70% for White women.5 Due to the prevalence and burden of fibroids among Black women there may be a provider bias in approach to management. Addressing this bias requires quality improvement efforts and investigation into patient and provider factors in management of fibroids. Black women have been a vulnerable population in medicine due to instances of mistreatment, and often times mistrust can play a role in how a patient views his or her care decisions. A patient-centered strategy allows patient factors such as age, uterine size, and cultural background to be considered such that a provider can tailor an approach that is best for the patient. Previous minority women focus groups have demonstrated that women have a strong desire for elective treatment;33 therefore, providers should listen openly to patients about their values and their perspectives on how fibroids affect their lives. Provider bias toward surgical volume, incentive for surgery, and implicit bias need to be addressed at every institution to work toward equitable and cost-effective care.
Integrated health care systems like Southern and Northern California Permanente Medical Group, using quality initiatives, have increased their minimally invasive surgery rates. Southern California Permanente Medical Group reached a 78% rate of MIH in a system of more than 350 surgeons performing benign indication hysterectomies as reported in 2011.34 Similarly, a study within KPNC, an institution with an MIH rate greater than 95%,35 found that racial disparities in route of MIH were eliminated through a quality improvement initiative described in detail in 2018 (FIGURE and TABLE).36
Conclusions
There are recognized successes in the gynecology field’s efforts to address racial disparities. Prior studies provide insight into opportunities to improve care in medical management of leiomyomas, minimally invasive route of hysterectomy and myomectomy, postsurgical outcomes, and institutional leadership. Particularly, when systemwide approaches are taken in the delivery of health care it is possible to significantly diminish racial disparities in gynecology.35 Much work remains to be done for our health care systems to provide equitable care.
References
Ojanuga D. The medical ethics of the ‘father of gynaecology,’ Dr J Marion Sims. J Med Ethics. 1993;19:28-31. doi: 10.1136/jme.19.1.28.
Borrero S, Zite N, Creinin MD. Federally funded sterilization: time to rethink policy? Am J Public Health. 2012;102:1822-1825.
Eaglehouse YL, Georg MW, Shriver CD, et al. Racial differences in time to breast cancer surgery and overall survival in the US Military Health System. JAMA Surg. 2019;154:e185113. doi: 10.1001/jamasurg.2018.5113.
Soliman AM, Yang H, Du EX, et al. The direct and indirect costs of uterine fibroid tumors: a systematic review of the literature between 2000 and 2013. Am J Obstet Gynecol. 2015;213:141-160.
Baird DD, Dunson DB, Hill MC, et al. High cumulative incidence of uterine leiomyoma in black and white women: ultrasound evidence. Am J Obstet Gynecol. 2003;188:100-107.
Marshall LM, Spiegelman D, Barbieri RL, et al. Variation in the incidence of uterine leiomyoma among premenopausal women by age and race. Obstet Gynecol. 1997;90:967-973. doi: 10.1016/s0029-7844(97)00534-6.
Styer AK, Rueda BR. The epidemiology and genetics of uterine leiomyoma. Best Pract Res Clin Obstet Gynaecol. 2016;34:3-12. doi: 10.1016/j.bpobgyn.2015.11.018.
Al-Hendy A, Myers ER, Stewart E. Uterine fibroids: burden and unmet medical need. Semin Reprod Med. 2017;35:473-480. doi: 10.1055/s-0037-1607264.
American College of Obstetricians and Gynecologists. ACOG practice bulletin. Alternatives to hysterectomy in the management of leiomyomas. Obstet Gynecol. 2008;112(2 pt 1):387-400.
Corona LE, Swenson CW, Sheetz KH, et al. Use of other treatments before hysterectomy for benign conditions in a statewide hospital collaborative. Am J Obstet Gynecol. 2015;212:304.e1-e7. doi: 10.1016/j.ajog.2014.11.031.
Nguyen NT, Merchant M, Ritterman Weintraub ML, et al. Alternative treatment utilization before hysterectomy for benign gynecologic conditions at a large integrated health system. J Minim Invasive Gynecol. 2019;26:847-855. doi: 10.1016/j.jmig.2018.08.013.
Laughlin-Tommaso SK, Jacoby VL, Myers ER. Disparities in fibroid incidence, prognosis, and management. Obstet Gynecol Clin North Am. 2017;44:81-94. doi: 10.1016/j.ogc.2016.11.007.
Borah BJ, Laughlin-Tommaso SK, Myers ER, et al. Association between patient characteristics and treatment procedure among patients with uterine leiomyomas. Obstet Gynecol. 2016;127:67-77.
Whiteman MK, Hillis SD, Jamieson DJ, et al. Inpatient hysterectomy surveillance in the United States, 2000-2004. Am J Obstet Gynecol. 2008;198:34.e1-e7. doi:10.1016/j.ajog.2007.05.039.
Bardens D, Solomayer E, Baum S, et al. The impact of the body mass index (BMI) on laparoscopic hysterectomy for benign disease. Arch Gynecol Obstet. 2014;289:803-807. doi: 10.1007/s00404-013-3050-2.
Seracchioli R, Venturoli S, Vianello F, et al. Total laparoscopic hysterectomy compared with abdominal hysterectomy in the presence of a large uterus. J Am Assoc Gynecol Laparosc. 2002;9:333-338. doi: 10.1016/s1074-3804(05)60413.
Boyd LR, Novetsky AP, Curtin JP. Effect of surgical volume on route of hysterectomy and short-term morbidity. Obstet Gynecol. 2010;116:909-915. doi: 10.1097/AOG.0b013e3181f395d9.
Jin C, Hu Y, Chen XC, et al. Laparoscopic versus open myomectomy—a meta-analysis of randomized controlled trials. Eur J Obstet Gynecol Reprod Biol. 2009;145:14-21. doi: 10.1016/j.ejogrb.2009.03.009.
Wechter ME, Stewart EA, Myers ER, et al. Leiomyoma-related hospitalization and surgery: prevalence and predicted growth based on population trends. Am J Obstet Gynecol. 2011;205:492.e1-e5. doi: 10.1016/j.ajog.2011.07.008.
Bower JK, Schreiner PJ, Sternfeld B, et al. Black-White differences in hysterectomy prevalence: the CARDIA study. Am J Public Health. 2009;99:300-307. doi: 10.2105/AJPH.2008.133702.
Ranjit A, Sharma M, Romano A, et al. Does universal insurance mitigate racial differences in minimally invasive hysterectomy?J Minim Invasive Gynecol. 2017;24. doi:10.1016/j.jmig.2017.03.016.
Pollack LM, Olsen MA, Gehlert SJ, et al. Racial/ethnic disparities/differences in hysterectomy route in women likely eligible for minimally invasive surgery. J Minim Invasive Gynecol. 2020;27:1167-1177.e2. doi:10.1016/j.jmig.2019.09.003.
Stentz NC, Cooney LG, Sammel MD, et al. Association of patient race with surgical practice and perioperative morbidity after myomectomy. Obstet Gynecol. 2018;132:291-297. doi: 10.1097/AOG.0000000000002738.
Roth TM, Gustilo-Ashby T, Barber MD, et al. Effects of race and clinical factors on short-term outcomes of abdominal myomectomy. Obstet Gynecol. 2003;101(5 pt 1):881-884. doi: 10.1016/s0029-7844(03)00015-2.
Bratka S, Diamond JS, Al-Hendy A, et al. The role of vitamin D in uterine fibroid biology. Fertil Steril. 2015;104:698-706. doi: 10.1016/j.fertnstert.2015.05.031.
Ciebiera M, Łukaszuk K, Męczekalski B, et al. Alternative oral agents in prophylaxis and therapy of uterine fibroids—an up-to-date review. Int J Mol Sci. 2017;18:2586. doi:10.3390/ijms18122586.
Lett LA, Orji WU, Sebro R. Declining racial and ethnic representation in clinical academic medicine: a longitudinal study of 16 US medical specialties. PLoS One. 2018;13:e0207274. doi: 10.1371/journal.pone.0207274.
Sánchez JP, Poll-Hunter N, Stern N, et al. Balancing two cultures: American Indian/Alaska Native medical students’ perceptions of academic medicine careers. J Community Health. 2016;41:871-880.
Rayburn WF, Xierali IM, Castillo-Page L, et al. Racial and ethnic differences between obstetrician-gynecologists and other adult medical specialists. Obstet Gynecol. 2016;127:148-152. doi: 10.1097/AOG.0000000000001184.
Esters D, Xierali IM, Nivet MA, et al. The rise of nontenured faculty in obstetrics and gynecology by sex and underrepresented in medicine status. Obstet Gynecol. 2019;134 suppl 1:34S-39S. doi: 10.1097/AOG.0000000000003484.
Ly DP, Seabury SA, Jena AB. Differences in incomes of physicians in the United States by race and sex: observational study. BMJ. 2016;I2923. doi:10.1136/bmj.i2923.
Groff JY, Mullen PD, Byrd T, et al. Decision making, beliefs, and attitudes toward hysterectomy: a focus group study with medically underserved women in Texas. J Womens Health Gend Based Med. 2000;9 suppl 2:S39-50. doi: 10.1089/152460900318759.
Andryjowicz E, Wray T. Regional expansion of minimally invasive surgery for hysterectomy: implementation and methodology in a large multispecialty group. Perm J. 2011;15:42-46.
Zaritsky E, Ojo A, Tucker LY, et al. Racial disparities in route of hysterectomy for benign indications within an integrated health care system. JAMA Netw Open. 2019;2:e1917004. doi: 10.1001/jamanetworkopen.2019.17004.
Abel MK, Kho KA, Walter A, et al. Measuring quality in minimally invasive gynecologic surgery: what, how, and why? J Minim Invasive Gynecol. 2019;26:321-326. doi: 10.1016/j.jmig.2018.11.013.
Author and Disclosure Information
Dr. Zaritsky is Minimally Invasive Gynecologic Surgeon and Assistant Residency Program Director, Kaiser Permanente Northern California, Oakland Medical Center.
Dr. Ojo is a Chief Resident in Obstetrics & Gynecology, Kaiser Permanente Northern California.
Dr. Ritterman Weintraub is Senior Research Project ManagerGraduate Medical Education, Kaiser Permanente Northern California.
Dr. Raine-Bennett isSenior Staff Physician and Senior Research Scientist in Division of Research, Obstetrics & Gynecology, Kaiser Permanente Northern California.
The authors report no financial relationships relevant to this article.
Dr. Zaritsky is Minimally Invasive Gynecologic Surgeon and Assistant Residency Program Director, Kaiser Permanente Northern California, Oakland Medical Center.
Dr. Ojo is a Chief Resident in Obstetrics & Gynecology, Kaiser Permanente Northern California.
Dr. Ritterman Weintraub is Senior Research Project ManagerGraduate Medical Education, Kaiser Permanente Northern California.
Dr. Raine-Bennett isSenior Staff Physician and Senior Research Scientist in Division of Research, Obstetrics & Gynecology, Kaiser Permanente Northern California.
The authors report no financial relationships relevant to this article.
Author and Disclosure Information
Dr. Zaritsky is Minimally Invasive Gynecologic Surgeon and Assistant Residency Program Director, Kaiser Permanente Northern California, Oakland Medical Center.
Dr. Ojo is a Chief Resident in Obstetrics & Gynecology, Kaiser Permanente Northern California.
Dr. Ritterman Weintraub is Senior Research Project ManagerGraduate Medical Education, Kaiser Permanente Northern California.
Dr. Raine-Bennett isSenior Staff Physician and Senior Research Scientist in Division of Research, Obstetrics & Gynecology, Kaiser Permanente Northern California.
The authors report no financial relationships relevant to this article.
The historical mistreatment of Black bodies in gynecologic care has bled into present day inequities—from surgeries performed on enslaved Black women and sterilization of low-income Black women under federally funded programs, to higher rates of adverse health-related outcomes among Black women compared with their non-Black counterparts.1-3 Not only is the foundation of gynecology imperfect, so too is its current-day structure.
It is not enough to identify and describe racial inequities in health care; action plans to provide equitable care are called for. In this report, we aim to 1) contextualize the data on disparities in minimally invasive gynecologic surgery, specifically hysterectomy and myomectomy candidates and postsurgical outcomes, and 2) provide recommendations to close racial gaps in gynecologic treatment for more equitable experiences for minority women.
Black women and uterine fibroids
Uterine leiomyomas, or fibroids, are not only the most common benign pelvic tumor but they also cause a significant medical and financial burden in the United States, with estimated direct costs of $4.1 ̶ 9.4 billion.4 Fibroids can affect fertility and cause pain, bulk symptoms, heavy bleeding, anemia requiring blood transfusion, and poor pregnancy outcomes. The burden of disease for uterine fibroids is greatest for Black women. While race is a social construct, women with African ancestry (who we tend to identify as having darker skin) have disproportionately higher rates of uterine fibroids. Black women experience symptoms at a younger age, spanning more of their reproductive years compared with their non-Black counterparts and their disease is often more severe compared with White women.5
The incidence of fibroids is 2 to 3 times higher in Black women compared with White women.5 According to ultrasound-based studies, the prevalence of fibroids among women aged 18 to 30 years was 26% among Black and 7% among White asymptomatic women.6 Earlier onset and more severe symptoms mean that there is a larger potential for impact on fertility for Black women. This coupled with the historical context of mistreatment of Black bodies makes the need for personalized medicine and culturally sensitive care critical. The disproportionately higher rates of uterine fibroids in Black women has been attributed to many factors, including socioeconomic status, health-care access, genetics, and lifestyle and environmental exposures, but the underlying causes of racial/ethnic differences remain unclear.7 Amazingly little data exist not only on patient preferences for management approach but also on the influence of genetic and epigenetic mediators and environmental factors that may play a role in fibroid development to guide optimal management and treatment outcomes for Black women with uterine fibroids.8
Inequitable management of uterine fibroids
Although tumor size, location, and patient risk factors are used to determine the best treatment approach, the American College of Obstetricians and Gynecologists (ACOG) guidelines suggest that the use of alternative treatments to surgery should be first-line management instead of hysterectomy for most benign conditions.9 Conservative management will often help alleviate symptoms, slow the growth of fibroid(s), or bridge women to menopause, and treatment options include hormonal contraception, gonadotropin-releasing hormone agonists, hysteroscopic resection, uterine artery embolization, magnetic resonance-guided focused ultrasound, and myomectomy.
The rate of conservative management prior to hysterectomy varies by setting, reflecting potential bias in treatment decisions. Some medical settings have reported a 29% alternative management rate prior to hysterectomy, while others report much higher rates.10 A study using patient data from Kaiser Permanente Northern California (KPNC) showed that, within a large, diverse, and integrated health care system, more than 80% of patients received alternative treatments before undergoing hysterectomy; for those with symptomatic leiomyomas, 74.1% used alternative treatments prior to hysterectomy, and in logistic regression there was not a difference by race.11 Nationally, Black women are more likely to have hysterectomy or myomectomy compared with a nonsurgical uterine-sparing therapy.12,13
With about 600,000 cases per year within the United States, the hysterectomy is the most frequently performed benign gynecologic surgery.14 The most common indication is for “symptomatic fibroid uterus.” The approach to decision making for route of hysterectomy involves multiple patient and surgeon factors, including history of vaginal delivery, body mass index, history of previous surgery, uterine size, informed patient preference, and surgeon volume.15-17 ACOG recommends a minimally invasive hysterectomy (MIH) whenever feasible given its benefits in postoperative pain, recovery time, and blood loss. Myomectomy, particularly among women in their reproductive years desiring management of leiomyomas, is a uterine-sparing procedure versus hysterectomy. Minimally invasive myomectomy (MIM), compared with an open abdominal route, provides for lower drop in hemoglobin levels, shorter hospital stay, less adhesion formation, and decreased postoperative pain.18
Racial variations in hysterectomy rates persist overall and according to hysterectomy type. Black women are 2 to 3 times more likely to undergo hysterectomy for leiomyomas than other racial groups.19 These differences in rates have been shown to persist even when burden of disease is the same. One study found that Black women had increased odds of hysterectomy compared with their White counterparts even when there was no difference in mean fibroid volume by race,20 calling into question provider bias. Even in a universal insurance setting, Black patients have been found to have higher rates of open hysterectomies.21 Previous studies found that, despite growing frequency of laparoscopic and robotic-assisted hysterectomies, patients of a minority race had decreased odds of undergoing a MIH compared with their White counterparts.22
While little data exist on route of myomectomy by race, a recent study found minority women were more likely to undergo abdominal myomectomy compared with White women; Black women were twice as likely to undergo abdominal myomectomy (adjusted odds ratio [aOR], 1.9; 95% confidence interval [CI], 1.7–2.0), Asian American women were more than twice as likely (aOR, 2.3; 95% CI, 1.8–2.8), and Hispanic American women were 50% more likely to undergo abdominal myomectomy (aOR, 1.5; 95% CI, 1.2–1.9) when compared with White women.23 These differences remained after controlling for potential confounders, and there appeared to be an interaction between race and fibroid weight such that racial bias alone may not explain the differences.
Finally, Black women have higher perioperative complication rates compared with non-Black women. Postoperative complications including blood transfusion after myomectomy have been shown to be twice as high among Black women compared with White women. However, once uterine size, comorbidities, and fibroid number were controlled, race was not associated with higher complications. Black women, compared with White women, have been found to have 50% increased odds of morbidity after an abdominal myomectomy.24
Continue to: How to ensure that BIPOC women get the best management...
How to ensure that BIPOC women get the best management
Eliminating disparities and providing equitable and patient-centered care for Black, Indigenous, and people of color (BIPOC) womenwill require research, education, training, and targeted quality improvement initiatives.
Research into fibroids and comparative treatment outcomes
Uterine fibroids, despite their major public health impact, remain understudied. With Black women carrying the highest fibroid prevalence and severity burden, especially in their childbearing years, it is imperative that research efforts be focused on outcomes by race and ethnicity. Given the significant economic impact of fibroids, more efforts should be directed toward primary prevention of fibroid formation as well as secondary prevention and limitation of fibroid growth by affordable, effective, and safe means. For example, Bratka and colleagues researched the role of vitamin D in inhibiting growth of leiomyoma cells in animal models.25Other innovative forms of management under investigation include aromatase inhibitors, green tea, cabergoline, elagolix, paricalcitol, and epigallocatechin gallate.26 Considerations such as stress, diet, and environmental risk factors have yet to be investigated in large studies.
Research contributing to evidence-based guidelines that address the needs of different patient populations affected by uterine fibroids is critical.8 Additionally, research conducted by Black women about Black women should be prioritized. In March 2021, the Stephanie Tubbs Jones Uterine Fibroid Research and Education Act of 2021 was introduced to fund $150 million in research supported by the National Institutes of Health (NIH). This is an opportunity to develop a research database to inform evidence-based culturally informed care regarding fertility counseling, medical management, and optimal surgical approach, as well as to award funding to minority researchers. There are disparities in distribution of funds from the NIH to minority researchers. Under-represented minorities are awarded fewer NIH grants compared with their counterparts despite initiatives to increase funding. Furthermore, in 2011, Black applicants for NIH funding were two-thirds as likely as White applicants to receive grants from 2000 ̶ 2006, even when accounting for publication record and training.27 Funding BIPOC researchers fuels diversity-driven investigation and can be useful in the charge to increase fibroid research.
Education and training: Changing the work force
Achieving equity requires change in provider work force. In a study of trends across multiple specialties including obstetrics and gynecology, Blacks and Latinx are more under-represented in 2016 than in 1990 across all specialties except for Black women in obstetrics and gynecology.28 It is well documented that under-represented minorities are more likely to engage in practice, research, service, and mentorship activities aligned with their identity.29 As a higher proportion of under-represented minority obstetricians and gynecologists practice in medically underserved areas,30 this presents a unique opportunity for gynecologists to improve care for and increase research involvement among BIPOC women.
Increasing BIPOC representation in medical and health care institutions and practices is not enough, however, to achieve health equity. Data from the Association of American Medical Colleges demonstrate that between 1978 and 2017 the total number of full-time obstetrics and gynecology faculty rose nearly fourfold from 1,688 to 6,347; however, the greatest rise in proportion of faculty who were nontenured was among women who were under-represented minorities.31 Additionally, there are disparities in wage by race even after controlling for hours worked and state of residence.32 Medical and academic centers and health care institutions and practices should proactively and systematically engage in the recruitment and retention of under-represented minority physicians and people in leadership roles. This will involve creating safe and inclusive work environments, with equal pay and promotion structures.
Quality initiatives to address provider bias
Provider bias should be addressed in clinical decision making and counseling of patients. Studies focused on ultrasonography have shown an estimated cumulative incidence of fibroids by age 50 of greater than 80% for Black women and nearly 70% for White women.5 Due to the prevalence and burden of fibroids among Black women there may be a provider bias in approach to management. Addressing this bias requires quality improvement efforts and investigation into patient and provider factors in management of fibroids. Black women have been a vulnerable population in medicine due to instances of mistreatment, and often times mistrust can play a role in how a patient views his or her care decisions. A patient-centered strategy allows patient factors such as age, uterine size, and cultural background to be considered such that a provider can tailor an approach that is best for the patient. Previous minority women focus groups have demonstrated that women have a strong desire for elective treatment;33 therefore, providers should listen openly to patients about their values and their perspectives on how fibroids affect their lives. Provider bias toward surgical volume, incentive for surgery, and implicit bias need to be addressed at every institution to work toward equitable and cost-effective care.
Integrated health care systems like Southern and Northern California Permanente Medical Group, using quality initiatives, have increased their minimally invasive surgery rates. Southern California Permanente Medical Group reached a 78% rate of MIH in a system of more than 350 surgeons performing benign indication hysterectomies as reported in 2011.34 Similarly, a study within KPNC, an institution with an MIH rate greater than 95%,35 found that racial disparities in route of MIH were eliminated through a quality improvement initiative described in detail in 2018 (FIGURE and TABLE).36
Conclusions
There are recognized successes in the gynecology field’s efforts to address racial disparities. Prior studies provide insight into opportunities to improve care in medical management of leiomyomas, minimally invasive route of hysterectomy and myomectomy, postsurgical outcomes, and institutional leadership. Particularly, when systemwide approaches are taken in the delivery of health care it is possible to significantly diminish racial disparities in gynecology.35 Much work remains to be done for our health care systems to provide equitable care.
The historical mistreatment of Black bodies in gynecologic care has bled into present day inequities—from surgeries performed on enslaved Black women and sterilization of low-income Black women under federally funded programs, to higher rates of adverse health-related outcomes among Black women compared with their non-Black counterparts.1-3 Not only is the foundation of gynecology imperfect, so too is its current-day structure.
It is not enough to identify and describe racial inequities in health care; action plans to provide equitable care are called for. In this report, we aim to 1) contextualize the data on disparities in minimally invasive gynecologic surgery, specifically hysterectomy and myomectomy candidates and postsurgical outcomes, and 2) provide recommendations to close racial gaps in gynecologic treatment for more equitable experiences for minority women.
Black women and uterine fibroids
Uterine leiomyomas, or fibroids, are not only the most common benign pelvic tumor but they also cause a significant medical and financial burden in the United States, with estimated direct costs of $4.1 ̶ 9.4 billion.4 Fibroids can affect fertility and cause pain, bulk symptoms, heavy bleeding, anemia requiring blood transfusion, and poor pregnancy outcomes. The burden of disease for uterine fibroids is greatest for Black women. While race is a social construct, women with African ancestry (who we tend to identify as having darker skin) have disproportionately higher rates of uterine fibroids. Black women experience symptoms at a younger age, spanning more of their reproductive years compared with their non-Black counterparts and their disease is often more severe compared with White women.5
The incidence of fibroids is 2 to 3 times higher in Black women compared with White women.5 According to ultrasound-based studies, the prevalence of fibroids among women aged 18 to 30 years was 26% among Black and 7% among White asymptomatic women.6 Earlier onset and more severe symptoms mean that there is a larger potential for impact on fertility for Black women. This coupled with the historical context of mistreatment of Black bodies makes the need for personalized medicine and culturally sensitive care critical. The disproportionately higher rates of uterine fibroids in Black women has been attributed to many factors, including socioeconomic status, health-care access, genetics, and lifestyle and environmental exposures, but the underlying causes of racial/ethnic differences remain unclear.7 Amazingly little data exist not only on patient preferences for management approach but also on the influence of genetic and epigenetic mediators and environmental factors that may play a role in fibroid development to guide optimal management and treatment outcomes for Black women with uterine fibroids.8
Inequitable management of uterine fibroids
Although tumor size, location, and patient risk factors are used to determine the best treatment approach, the American College of Obstetricians and Gynecologists (ACOG) guidelines suggest that the use of alternative treatments to surgery should be first-line management instead of hysterectomy for most benign conditions.9 Conservative management will often help alleviate symptoms, slow the growth of fibroid(s), or bridge women to menopause, and treatment options include hormonal contraception, gonadotropin-releasing hormone agonists, hysteroscopic resection, uterine artery embolization, magnetic resonance-guided focused ultrasound, and myomectomy.
The rate of conservative management prior to hysterectomy varies by setting, reflecting potential bias in treatment decisions. Some medical settings have reported a 29% alternative management rate prior to hysterectomy, while others report much higher rates.10 A study using patient data from Kaiser Permanente Northern California (KPNC) showed that, within a large, diverse, and integrated health care system, more than 80% of patients received alternative treatments before undergoing hysterectomy; for those with symptomatic leiomyomas, 74.1% used alternative treatments prior to hysterectomy, and in logistic regression there was not a difference by race.11 Nationally, Black women are more likely to have hysterectomy or myomectomy compared with a nonsurgical uterine-sparing therapy.12,13
With about 600,000 cases per year within the United States, the hysterectomy is the most frequently performed benign gynecologic surgery.14 The most common indication is for “symptomatic fibroid uterus.” The approach to decision making for route of hysterectomy involves multiple patient and surgeon factors, including history of vaginal delivery, body mass index, history of previous surgery, uterine size, informed patient preference, and surgeon volume.15-17 ACOG recommends a minimally invasive hysterectomy (MIH) whenever feasible given its benefits in postoperative pain, recovery time, and blood loss. Myomectomy, particularly among women in their reproductive years desiring management of leiomyomas, is a uterine-sparing procedure versus hysterectomy. Minimally invasive myomectomy (MIM), compared with an open abdominal route, provides for lower drop in hemoglobin levels, shorter hospital stay, less adhesion formation, and decreased postoperative pain.18
Racial variations in hysterectomy rates persist overall and according to hysterectomy type. Black women are 2 to 3 times more likely to undergo hysterectomy for leiomyomas than other racial groups.19 These differences in rates have been shown to persist even when burden of disease is the same. One study found that Black women had increased odds of hysterectomy compared with their White counterparts even when there was no difference in mean fibroid volume by race,20 calling into question provider bias. Even in a universal insurance setting, Black patients have been found to have higher rates of open hysterectomies.21 Previous studies found that, despite growing frequency of laparoscopic and robotic-assisted hysterectomies, patients of a minority race had decreased odds of undergoing a MIH compared with their White counterparts.22
While little data exist on route of myomectomy by race, a recent study found minority women were more likely to undergo abdominal myomectomy compared with White women; Black women were twice as likely to undergo abdominal myomectomy (adjusted odds ratio [aOR], 1.9; 95% confidence interval [CI], 1.7–2.0), Asian American women were more than twice as likely (aOR, 2.3; 95% CI, 1.8–2.8), and Hispanic American women were 50% more likely to undergo abdominal myomectomy (aOR, 1.5; 95% CI, 1.2–1.9) when compared with White women.23 These differences remained after controlling for potential confounders, and there appeared to be an interaction between race and fibroid weight such that racial bias alone may not explain the differences.
Finally, Black women have higher perioperative complication rates compared with non-Black women. Postoperative complications including blood transfusion after myomectomy have been shown to be twice as high among Black women compared with White women. However, once uterine size, comorbidities, and fibroid number were controlled, race was not associated with higher complications. Black women, compared with White women, have been found to have 50% increased odds of morbidity after an abdominal myomectomy.24
Continue to: How to ensure that BIPOC women get the best management...
How to ensure that BIPOC women get the best management
Eliminating disparities and providing equitable and patient-centered care for Black, Indigenous, and people of color (BIPOC) womenwill require research, education, training, and targeted quality improvement initiatives.
Research into fibroids and comparative treatment outcomes
Uterine fibroids, despite their major public health impact, remain understudied. With Black women carrying the highest fibroid prevalence and severity burden, especially in their childbearing years, it is imperative that research efforts be focused on outcomes by race and ethnicity. Given the significant economic impact of fibroids, more efforts should be directed toward primary prevention of fibroid formation as well as secondary prevention and limitation of fibroid growth by affordable, effective, and safe means. For example, Bratka and colleagues researched the role of vitamin D in inhibiting growth of leiomyoma cells in animal models.25Other innovative forms of management under investigation include aromatase inhibitors, green tea, cabergoline, elagolix, paricalcitol, and epigallocatechin gallate.26 Considerations such as stress, diet, and environmental risk factors have yet to be investigated in large studies.
Research contributing to evidence-based guidelines that address the needs of different patient populations affected by uterine fibroids is critical.8 Additionally, research conducted by Black women about Black women should be prioritized. In March 2021, the Stephanie Tubbs Jones Uterine Fibroid Research and Education Act of 2021 was introduced to fund $150 million in research supported by the National Institutes of Health (NIH). This is an opportunity to develop a research database to inform evidence-based culturally informed care regarding fertility counseling, medical management, and optimal surgical approach, as well as to award funding to minority researchers. There are disparities in distribution of funds from the NIH to minority researchers. Under-represented minorities are awarded fewer NIH grants compared with their counterparts despite initiatives to increase funding. Furthermore, in 2011, Black applicants for NIH funding were two-thirds as likely as White applicants to receive grants from 2000 ̶ 2006, even when accounting for publication record and training.27 Funding BIPOC researchers fuels diversity-driven investigation and can be useful in the charge to increase fibroid research.
Education and training: Changing the work force
Achieving equity requires change in provider work force. In a study of trends across multiple specialties including obstetrics and gynecology, Blacks and Latinx are more under-represented in 2016 than in 1990 across all specialties except for Black women in obstetrics and gynecology.28 It is well documented that under-represented minorities are more likely to engage in practice, research, service, and mentorship activities aligned with their identity.29 As a higher proportion of under-represented minority obstetricians and gynecologists practice in medically underserved areas,30 this presents a unique opportunity for gynecologists to improve care for and increase research involvement among BIPOC women.
Increasing BIPOC representation in medical and health care institutions and practices is not enough, however, to achieve health equity. Data from the Association of American Medical Colleges demonstrate that between 1978 and 2017 the total number of full-time obstetrics and gynecology faculty rose nearly fourfold from 1,688 to 6,347; however, the greatest rise in proportion of faculty who were nontenured was among women who were under-represented minorities.31 Additionally, there are disparities in wage by race even after controlling for hours worked and state of residence.32 Medical and academic centers and health care institutions and practices should proactively and systematically engage in the recruitment and retention of under-represented minority physicians and people in leadership roles. This will involve creating safe and inclusive work environments, with equal pay and promotion structures.
Quality initiatives to address provider bias
Provider bias should be addressed in clinical decision making and counseling of patients. Studies focused on ultrasonography have shown an estimated cumulative incidence of fibroids by age 50 of greater than 80% for Black women and nearly 70% for White women.5 Due to the prevalence and burden of fibroids among Black women there may be a provider bias in approach to management. Addressing this bias requires quality improvement efforts and investigation into patient and provider factors in management of fibroids. Black women have been a vulnerable population in medicine due to instances of mistreatment, and often times mistrust can play a role in how a patient views his or her care decisions. A patient-centered strategy allows patient factors such as age, uterine size, and cultural background to be considered such that a provider can tailor an approach that is best for the patient. Previous minority women focus groups have demonstrated that women have a strong desire for elective treatment;33 therefore, providers should listen openly to patients about their values and their perspectives on how fibroids affect their lives. Provider bias toward surgical volume, incentive for surgery, and implicit bias need to be addressed at every institution to work toward equitable and cost-effective care.
Integrated health care systems like Southern and Northern California Permanente Medical Group, using quality initiatives, have increased their minimally invasive surgery rates. Southern California Permanente Medical Group reached a 78% rate of MIH in a system of more than 350 surgeons performing benign indication hysterectomies as reported in 2011.34 Similarly, a study within KPNC, an institution with an MIH rate greater than 95%,35 found that racial disparities in route of MIH were eliminated through a quality improvement initiative described in detail in 2018 (FIGURE and TABLE).36
Conclusions
There are recognized successes in the gynecology field’s efforts to address racial disparities. Prior studies provide insight into opportunities to improve care in medical management of leiomyomas, minimally invasive route of hysterectomy and myomectomy, postsurgical outcomes, and institutional leadership. Particularly, when systemwide approaches are taken in the delivery of health care it is possible to significantly diminish racial disparities in gynecology.35 Much work remains to be done for our health care systems to provide equitable care.
References
Ojanuga D. The medical ethics of the ‘father of gynaecology,’ Dr J Marion Sims. J Med Ethics. 1993;19:28-31. doi: 10.1136/jme.19.1.28.
Borrero S, Zite N, Creinin MD. Federally funded sterilization: time to rethink policy? Am J Public Health. 2012;102:1822-1825.
Eaglehouse YL, Georg MW, Shriver CD, et al. Racial differences in time to breast cancer surgery and overall survival in the US Military Health System. JAMA Surg. 2019;154:e185113. doi: 10.1001/jamasurg.2018.5113.
Soliman AM, Yang H, Du EX, et al. The direct and indirect costs of uterine fibroid tumors: a systematic review of the literature between 2000 and 2013. Am J Obstet Gynecol. 2015;213:141-160.
Baird DD, Dunson DB, Hill MC, et al. High cumulative incidence of uterine leiomyoma in black and white women: ultrasound evidence. Am J Obstet Gynecol. 2003;188:100-107.
Marshall LM, Spiegelman D, Barbieri RL, et al. Variation in the incidence of uterine leiomyoma among premenopausal women by age and race. Obstet Gynecol. 1997;90:967-973. doi: 10.1016/s0029-7844(97)00534-6.
Styer AK, Rueda BR. The epidemiology and genetics of uterine leiomyoma. Best Pract Res Clin Obstet Gynaecol. 2016;34:3-12. doi: 10.1016/j.bpobgyn.2015.11.018.
Al-Hendy A, Myers ER, Stewart E. Uterine fibroids: burden and unmet medical need. Semin Reprod Med. 2017;35:473-480. doi: 10.1055/s-0037-1607264.
American College of Obstetricians and Gynecologists. ACOG practice bulletin. Alternatives to hysterectomy in the management of leiomyomas. Obstet Gynecol. 2008;112(2 pt 1):387-400.
Corona LE, Swenson CW, Sheetz KH, et al. Use of other treatments before hysterectomy for benign conditions in a statewide hospital collaborative. Am J Obstet Gynecol. 2015;212:304.e1-e7. doi: 10.1016/j.ajog.2014.11.031.
Nguyen NT, Merchant M, Ritterman Weintraub ML, et al. Alternative treatment utilization before hysterectomy for benign gynecologic conditions at a large integrated health system. J Minim Invasive Gynecol. 2019;26:847-855. doi: 10.1016/j.jmig.2018.08.013.
Laughlin-Tommaso SK, Jacoby VL, Myers ER. Disparities in fibroid incidence, prognosis, and management. Obstet Gynecol Clin North Am. 2017;44:81-94. doi: 10.1016/j.ogc.2016.11.007.
Borah BJ, Laughlin-Tommaso SK, Myers ER, et al. Association between patient characteristics and treatment procedure among patients with uterine leiomyomas. Obstet Gynecol. 2016;127:67-77.
Whiteman MK, Hillis SD, Jamieson DJ, et al. Inpatient hysterectomy surveillance in the United States, 2000-2004. Am J Obstet Gynecol. 2008;198:34.e1-e7. doi:10.1016/j.ajog.2007.05.039.
Bardens D, Solomayer E, Baum S, et al. The impact of the body mass index (BMI) on laparoscopic hysterectomy for benign disease. Arch Gynecol Obstet. 2014;289:803-807. doi: 10.1007/s00404-013-3050-2.
Seracchioli R, Venturoli S, Vianello F, et al. Total laparoscopic hysterectomy compared with abdominal hysterectomy in the presence of a large uterus. J Am Assoc Gynecol Laparosc. 2002;9:333-338. doi: 10.1016/s1074-3804(05)60413.
Boyd LR, Novetsky AP, Curtin JP. Effect of surgical volume on route of hysterectomy and short-term morbidity. Obstet Gynecol. 2010;116:909-915. doi: 10.1097/AOG.0b013e3181f395d9.
Jin C, Hu Y, Chen XC, et al. Laparoscopic versus open myomectomy—a meta-analysis of randomized controlled trials. Eur J Obstet Gynecol Reprod Biol. 2009;145:14-21. doi: 10.1016/j.ejogrb.2009.03.009.
Wechter ME, Stewart EA, Myers ER, et al. Leiomyoma-related hospitalization and surgery: prevalence and predicted growth based on population trends. Am J Obstet Gynecol. 2011;205:492.e1-e5. doi: 10.1016/j.ajog.2011.07.008.
Bower JK, Schreiner PJ, Sternfeld B, et al. Black-White differences in hysterectomy prevalence: the CARDIA study. Am J Public Health. 2009;99:300-307. doi: 10.2105/AJPH.2008.133702.
Ranjit A, Sharma M, Romano A, et al. Does universal insurance mitigate racial differences in minimally invasive hysterectomy?J Minim Invasive Gynecol. 2017;24. doi:10.1016/j.jmig.2017.03.016.
Pollack LM, Olsen MA, Gehlert SJ, et al. Racial/ethnic disparities/differences in hysterectomy route in women likely eligible for minimally invasive surgery. J Minim Invasive Gynecol. 2020;27:1167-1177.e2. doi:10.1016/j.jmig.2019.09.003.
Stentz NC, Cooney LG, Sammel MD, et al. Association of patient race with surgical practice and perioperative morbidity after myomectomy. Obstet Gynecol. 2018;132:291-297. doi: 10.1097/AOG.0000000000002738.
Roth TM, Gustilo-Ashby T, Barber MD, et al. Effects of race and clinical factors on short-term outcomes of abdominal myomectomy. Obstet Gynecol. 2003;101(5 pt 1):881-884. doi: 10.1016/s0029-7844(03)00015-2.
Bratka S, Diamond JS, Al-Hendy A, et al. The role of vitamin D in uterine fibroid biology. Fertil Steril. 2015;104:698-706. doi: 10.1016/j.fertnstert.2015.05.031.
Ciebiera M, Łukaszuk K, Męczekalski B, et al. Alternative oral agents in prophylaxis and therapy of uterine fibroids—an up-to-date review. Int J Mol Sci. 2017;18:2586. doi:10.3390/ijms18122586.
Lett LA, Orji WU, Sebro R. Declining racial and ethnic representation in clinical academic medicine: a longitudinal study of 16 US medical specialties. PLoS One. 2018;13:e0207274. doi: 10.1371/journal.pone.0207274.
Sánchez JP, Poll-Hunter N, Stern N, et al. Balancing two cultures: American Indian/Alaska Native medical students’ perceptions of academic medicine careers. J Community Health. 2016;41:871-880.
Rayburn WF, Xierali IM, Castillo-Page L, et al. Racial and ethnic differences between obstetrician-gynecologists and other adult medical specialists. Obstet Gynecol. 2016;127:148-152. doi: 10.1097/AOG.0000000000001184.
Esters D, Xierali IM, Nivet MA, et al. The rise of nontenured faculty in obstetrics and gynecology by sex and underrepresented in medicine status. Obstet Gynecol. 2019;134 suppl 1:34S-39S. doi: 10.1097/AOG.0000000000003484.
Ly DP, Seabury SA, Jena AB. Differences in incomes of physicians in the United States by race and sex: observational study. BMJ. 2016;I2923. doi:10.1136/bmj.i2923.
Groff JY, Mullen PD, Byrd T, et al. Decision making, beliefs, and attitudes toward hysterectomy: a focus group study with medically underserved women in Texas. J Womens Health Gend Based Med. 2000;9 suppl 2:S39-50. doi: 10.1089/152460900318759.
Andryjowicz E, Wray T. Regional expansion of minimally invasive surgery for hysterectomy: implementation and methodology in a large multispecialty group. Perm J. 2011;15:42-46.
Zaritsky E, Ojo A, Tucker LY, et al. Racial disparities in route of hysterectomy for benign indications within an integrated health care system. JAMA Netw Open. 2019;2:e1917004. doi: 10.1001/jamanetworkopen.2019.17004.
Abel MK, Kho KA, Walter A, et al. Measuring quality in minimally invasive gynecologic surgery: what, how, and why? J Minim Invasive Gynecol. 2019;26:321-326. doi: 10.1016/j.jmig.2018.11.013.
References
Ojanuga D. The medical ethics of the ‘father of gynaecology,’ Dr J Marion Sims. J Med Ethics. 1993;19:28-31. doi: 10.1136/jme.19.1.28.
Borrero S, Zite N, Creinin MD. Federally funded sterilization: time to rethink policy? Am J Public Health. 2012;102:1822-1825.
Eaglehouse YL, Georg MW, Shriver CD, et al. Racial differences in time to breast cancer surgery and overall survival in the US Military Health System. JAMA Surg. 2019;154:e185113. doi: 10.1001/jamasurg.2018.5113.
Soliman AM, Yang H, Du EX, et al. The direct and indirect costs of uterine fibroid tumors: a systematic review of the literature between 2000 and 2013. Am J Obstet Gynecol. 2015;213:141-160.
Baird DD, Dunson DB, Hill MC, et al. High cumulative incidence of uterine leiomyoma in black and white women: ultrasound evidence. Am J Obstet Gynecol. 2003;188:100-107.
Marshall LM, Spiegelman D, Barbieri RL, et al. Variation in the incidence of uterine leiomyoma among premenopausal women by age and race. Obstet Gynecol. 1997;90:967-973. doi: 10.1016/s0029-7844(97)00534-6.
Styer AK, Rueda BR. The epidemiology and genetics of uterine leiomyoma. Best Pract Res Clin Obstet Gynaecol. 2016;34:3-12. doi: 10.1016/j.bpobgyn.2015.11.018.
Al-Hendy A, Myers ER, Stewart E. Uterine fibroids: burden and unmet medical need. Semin Reprod Med. 2017;35:473-480. doi: 10.1055/s-0037-1607264.
American College of Obstetricians and Gynecologists. ACOG practice bulletin. Alternatives to hysterectomy in the management of leiomyomas. Obstet Gynecol. 2008;112(2 pt 1):387-400.
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