A trainee recently observed that psychiatrists frequently seem motivated to protect patients from emotional and internal disruption. He suggested that we often did so by validating their maladaptive perspectives regarding their impaired relationships to society and close attachments. These maneuvers were justified by referring to the need to establish a therapeutic alliance and reduce patients’ suffering.

As an example, he mentioned a patient with alcohol use disorder. The patient came in with complaints that he could not stay sober with his current level of depression. The patient also complained of a family member who was setting limits. To the trainee’s surprise, the patient was not challenged on his perceived victimhood and his fantasy that a sober life should mean a life without negative effect. Instead, the patient was validated in his anger toward the family member. In addition, his medications were adjusted, seemingly confirming to the patient that one could only ask for sobriety once life is empty of pain.

The observation of the trainee reminded us of the three great “untruths” mentioned by Greg Lukianoff and Jonathan Haidt, PhD, in their famous book, “The Coddling of the American Mind.”¹ In the book they warn against the idea of fragility – what doesn’t kill you makes you weaker; emotional reasoning – always trust your feelings; and us-versus-them thinking – life is a battle between good people and evil people. The authors compare these three great untruths with the cognitive distortions of cognitive-behavioral therapy.

We ponder the trainee’s observation that psychiatrists appear to encourage the untruths rather than challenge them. Part of psychiatric and all medical training involves learning nonjudgmental approaches to human suffering and an identification with individual needs over societal demands. Our suspicion is that a nonjudgmental approach to the understanding of the human condition generates a desire to protect patients from a moralistic shaming position. However, we wonder if, at times, psychiatry takes this approach too far.
 

Reconceptualizing shame

Shame can be a toxic presence in the overwhelmed superego of a patient, but it can serve an important role in psychic development and should not be avoided out of hand. We suggest that it can be appropriate for a patient with an alcohol use disorder to feel some shame for the harm caused by their drinking, and we question the limit of psychiatry’s current pursuit of incessant validation. As an extreme example, would modern psychiatry discourage a patient who killed someone while driving in an intoxicated state from feeling remorse and shame?

Modern psychiatry appears to have other examples of the three great untruths on display. In our work, we are often faced with patients who are prematurely placed on disability, an example of fragility. Instead of encouraging patients to return to the workforce, they are “protected” from the emotional difficulty of work. In many patients this results in a decline in functioning and worsening of psychiatric symptoms. We are also confronted with patients who define themselves by how they feel, an example of emotional reasoning. Instead of using our clinical judgments to define and assess symptoms, patients are left to decide for themselves through self-rated scales with questionable validity.2 This can result in patients having their emotional experiences not only validated when inappropriate but can also give emotional reasoning a false sense of medical legitimacy.

Finally, we commonly see patients who endlessly blame family members and others for any life difficulties, a form of us-versus-them thinking. Instead of acknowledging and then integrating life challenges to achieve recovery, patients are affirmed despite clinicians having little evidence on the veracity of the patients’ perspective. As a consequence, patients can be further isolated from their greatest source of support.

In some ways, a mindlessly validating approach in psychiatry is unexpected since the practice of psychiatry would seem to promote the development of strong attachments and resilience. After all, connections to family, employment, social institutions, and even religious worship are associated with vastly better outcomes. Those who have become alienated to these pillars of social cohesion fare much worse. One may deplore the static and at times oppressive nature of these institutions but the empirical experience of practicing psychiatry leads one to a healthy respect for the stabilizing influence they accord for individuals struggling with life’s vicissitudes, unpredictability, and loneliness. Overcoming the fear of responsibility, living up to the demands and expectations of society, and having the strength to overcome difficult emotions should be the standard goals of psychiatric treatment.

From the knowledge gained from working with patients struggling from psychic pain, we wonder how to encourage patients to pursue those adaptive approaches to life. We argue that a stoic emphasis on learning to manage one’s affective and mental response to the inevitable changes of life is key to achieving wisdom and stability in our humble lives. This perspective is a common denominator of multiple different psychotherapies. The goal is to provide patients with the ability to be in a place where they are engaged with the world in a meaningful way that is not overwhelmed by distorted, self-absorbed psychic anguish. This perspective discourages externalization as a relatively low-yield way to understand and overcome one’s problems. One identifies childhood experiences with one’s mother as a source of adult distress not for the purpose of blaming her, but for the purpose of recognizing one’s own childish motivations for making maladaptive decisions as an adult.

For many patients, the goal should be to emphasize an internal locus of control and responsibility. We should also avoid constantly relying on society and government’s role in helping the individual achieve a satisfactory life. We wonder if this endless pursuit of nonjudgment and validation corrupts the doctor-patient interaction. In other words, focusing on medical diagnoses and psychopharmacology may be a counter therapeutic maneuver that compromises a patient’s sense of autonomy and individual responsibility for their own psychic development. Psychotherapy that ends with the patient being able to identify all the traumas that led to their sorrow has simply left the patient in the role of helpless and sorrowful victim. Instead, we should allow patients to proceed to the next step, which is empowerment and transformation. From this angle, the field of psychiatry should be cautious of encouraging movements that promote victimhood and grievance as a meaningful psychic position to take in society.

Mr. Lukianoff and Dr. Haidt use cognitive therapy as an analogy throughout their books for how to confront the great untruths. They perceive those modern forms of thinking as cognitive distortions, which can be remedied using the techniques of cognitive restructuring found in cognitive-behavioral therapy. They encourage us to recognize those maladaptive thoughts, and create more accurate and adaptive ways of viewing the world – a view that would be able to grow from challenges not just survive them; a view referred to as antifragile.3 We believe that those techniques and others would certainly be of assistance in our current times. However, the first step is to recognize our problem – a problem that is not rooted in the DSM, research, or biology but in an exaggerated intention to be patient centered. We should, however, remember that, when a patient has negative schemas, being too patient centered can be encouraging to maladaptive behaviors.

In conclusion, we wonder what modern psychiatry could look like if it made a concerted effort at also treating mental illness by reinforcing the importance of individual agency and responsibility. Modern psychiatry has been so focused on describing biological symptoms needing biological treatments that we sometimes forget that having no symptom (being asymptomatic) is not the only goal. Having a fulfilling and meaningful life, which is resilient to future symptoms is just as important to patients. We seem to have entrenched ourselves so deeply in an overly basic approach of problem-solution and diagnosis-treatment paradigm. However, we don’t need to renege on modern advances to promote the patient’s strength, adaptability, and antifragility. An emphasis on patient growth can complement the medical model. We wonder what effect such an approach would have if the trainee’s patient with alcohol use disorder was instead told: “Given the suffering you have and have caused because of your alcohol use disorder, how do you plan to make changes in your life to help the treatment plan we create together?”

Dr. Lehman is a professor of psychiatry at the University of California, San Diego. He is codirector of all acute and intensive psychiatric treatment at the Veterans Affairs Medical Center in San Diego, where he practices clinical psychiatry. He also is the course director for the UCSD third-year medical student psychiatry clerkship. Dr. Badre is a clinical and forensic psychiatrist in San Diego. He holds teaching positions at UCSD and the University of San Diego. Dr. Badre can be reached at his website, BadreMD.com.

References

1. Lukianoff G, Haidt J. The Coddling of the American Mind: How Good Intentions and Bad Ideas are Setting Up a Generation for Failure. New York: Penguin Books, 2019.

2. Levis B et al. J Clin Epidemiol. 2020 Jun;122:115-128.e1.,

3. Taleb NN. Antifragile: Things That Gain from Disorder. Vol. 3. New York: Random House, 2012.

A trainee recently observed that psychiatrists frequently seem motivated to protect patients from emotional and internal disruption. He suggested that we often did so by validating their maladaptive perspectives regarding their impaired relationships to society and close attachments. These maneuvers were justified by referring to the need to establish a therapeutic alliance and reduce patients’ suffering.

As an example, he mentioned a patient with alcohol use disorder. The patient came in with complaints that he could not stay sober with his current level of depression. The patient also complained of a family member who was setting limits. To the trainee’s surprise, the patient was not challenged on his perceived victimhood and his fantasy that a sober life should mean a life without negative effect. Instead, the patient was validated in his anger toward the family member. In addition, his medications were adjusted, seemingly confirming to the patient that one could only ask for sobriety once life is empty of pain.

The observation of the trainee reminded us of the three great “untruths” mentioned by Greg Lukianoff and Jonathan Haidt, PhD, in their famous book, “The Coddling of the American Mind.”¹ In the book they warn against the idea of fragility – what doesn’t kill you makes you weaker; emotional reasoning – always trust your feelings; and us-versus-them thinking – life is a battle between good people and evil people. The authors compare these three great untruths with the cognitive distortions of cognitive-behavioral therapy.

We ponder the trainee’s observation that psychiatrists appear to encourage the untruths rather than challenge them. Part of psychiatric and all medical training involves learning nonjudgmental approaches to human suffering and an identification with individual needs over societal demands. Our suspicion is that a nonjudgmental approach to the understanding of the human condition generates a desire to protect patients from a moralistic shaming position. However, we wonder if, at times, psychiatry takes this approach too far.
 

Reconceptualizing shame

Shame can be a toxic presence in the overwhelmed superego of a patient, but it can serve an important role in psychic development and should not be avoided out of hand. We suggest that it can be appropriate for a patient with an alcohol use disorder to feel some shame for the harm caused by their drinking, and we question the limit of psychiatry’s current pursuit of incessant validation. As an extreme example, would modern psychiatry discourage a patient who killed someone while driving in an intoxicated state from feeling remorse and shame?

Modern psychiatry appears to have other examples of the three great untruths on display. In our work, we are often faced with patients who are prematurely placed on disability, an example of fragility. Instead of encouraging patients to return to the workforce, they are “protected” from the emotional difficulty of work. In many patients this results in a decline in functioning and worsening of psychiatric symptoms. We are also confronted with patients who define themselves by how they feel, an example of emotional reasoning. Instead of using our clinical judgments to define and assess symptoms, patients are left to decide for themselves through self-rated scales with questionable validity.2 This can result in patients having their emotional experiences not only validated when inappropriate but can also give emotional reasoning a false sense of medical legitimacy.

Finally, we commonly see patients who endlessly blame family members and others for any life difficulties, a form of us-versus-them thinking. Instead of acknowledging and then integrating life challenges to achieve recovery, patients are affirmed despite clinicians having little evidence on the veracity of the patients’ perspective. As a consequence, patients can be further isolated from their greatest source of support.

In some ways, a mindlessly validating approach in psychiatry is unexpected since the practice of psychiatry would seem to promote the development of strong attachments and resilience. After all, connections to family, employment, social institutions, and even religious worship are associated with vastly better outcomes. Those who have become alienated to these pillars of social cohesion fare much worse. One may deplore the static and at times oppressive nature of these institutions but the empirical experience of practicing psychiatry leads one to a healthy respect for the stabilizing influence they accord for individuals struggling with life’s vicissitudes, unpredictability, and loneliness. Overcoming the fear of responsibility, living up to the demands and expectations of society, and having the strength to overcome difficult emotions should be the standard goals of psychiatric treatment.

From the knowledge gained from working with patients struggling from psychic pain, we wonder how to encourage patients to pursue those adaptive approaches to life. We argue that a stoic emphasis on learning to manage one’s affective and mental response to the inevitable changes of life is key to achieving wisdom and stability in our humble lives. This perspective is a common denominator of multiple different psychotherapies. The goal is to provide patients with the ability to be in a place where they are engaged with the world in a meaningful way that is not overwhelmed by distorted, self-absorbed psychic anguish. This perspective discourages externalization as a relatively low-yield way to understand and overcome one’s problems. One identifies childhood experiences with one’s mother as a source of adult distress not for the purpose of blaming her, but for the purpose of recognizing one’s own childish motivations for making maladaptive decisions as an adult.

For many patients, the goal should be to emphasize an internal locus of control and responsibility. We should also avoid constantly relying on society and government’s role in helping the individual achieve a satisfactory life. We wonder if this endless pursuit of nonjudgment and validation corrupts the doctor-patient interaction. In other words, focusing on medical diagnoses and psychopharmacology may be a counter therapeutic maneuver that compromises a patient’s sense of autonomy and individual responsibility for their own psychic development. Psychotherapy that ends with the patient being able to identify all the traumas that led to their sorrow has simply left the patient in the role of helpless and sorrowful victim. Instead, we should allow patients to proceed to the next step, which is empowerment and transformation. From this angle, the field of psychiatry should be cautious of encouraging movements that promote victimhood and grievance as a meaningful psychic position to take in society.

Mr. Lukianoff and Dr. Haidt use cognitive therapy as an analogy throughout their books for how to confront the great untruths. They perceive those modern forms of thinking as cognitive distortions, which can be remedied using the techniques of cognitive restructuring found in cognitive-behavioral therapy. They encourage us to recognize those maladaptive thoughts, and create more accurate and adaptive ways of viewing the world – a view that would be able to grow from challenges not just survive them; a view referred to as antifragile.3 We believe that those techniques and others would certainly be of assistance in our current times. However, the first step is to recognize our problem – a problem that is not rooted in the DSM, research, or biology but in an exaggerated intention to be patient centered. We should, however, remember that, when a patient has negative schemas, being too patient centered can be encouraging to maladaptive behaviors.

In conclusion, we wonder what modern psychiatry could look like if it made a concerted effort at also treating mental illness by reinforcing the importance of individual agency and responsibility. Modern psychiatry has been so focused on describing biological symptoms needing biological treatments that we sometimes forget that having no symptom (being asymptomatic) is not the only goal. Having a fulfilling and meaningful life, which is resilient to future symptoms is just as important to patients. We seem to have entrenched ourselves so deeply in an overly basic approach of problem-solution and diagnosis-treatment paradigm. However, we don’t need to renege on modern advances to promote the patient’s strength, adaptability, and antifragility. An emphasis on patient growth can complement the medical model. We wonder what effect such an approach would have if the trainee’s patient with alcohol use disorder was instead told: “Given the suffering you have and have caused because of your alcohol use disorder, how do you plan to make changes in your life to help the treatment plan we create together?”

Dr. Lehman is a professor of psychiatry at the University of California, San Diego. He is codirector of all acute and intensive psychiatric treatment at the Veterans Affairs Medical Center in San Diego, where he practices clinical psychiatry. He also is the course director for the UCSD third-year medical student psychiatry clerkship. Dr. Badre is a clinical and forensic psychiatrist in San Diego. He holds teaching positions at UCSD and the University of San Diego. Dr. Badre can be reached at his website, BadreMD.com.

References

1. Lukianoff G, Haidt J. The Coddling of the American Mind: How Good Intentions and Bad Ideas are Setting Up a Generation for Failure. New York: Penguin Books, 2019.

2. Levis B et al. J Clin Epidemiol. 2020 Jun;122:115-128.e1.,

3. Taleb NN. Antifragile: Things That Gain from Disorder. Vol. 3. New York: Random House, 2012.

A trainee recently observed that psychiatrists frequently seem motivated to protect patients from emotional and internal disruption. He suggested that we often did so by validating their maladaptive perspectives regarding their impaired relationships to society and close attachments. These maneuvers were justified by referring to the need to establish a therapeutic alliance and reduce patients’ suffering.

As an example, he mentioned a patient with alcohol use disorder. The patient came in with complaints that he could not stay sober with his current level of depression. The patient also complained of a family member who was setting limits. To the trainee’s surprise, the patient was not challenged on his perceived victimhood and his fantasy that a sober life should mean a life without negative effect. Instead, the patient was validated in his anger toward the family member. In addition, his medications were adjusted, seemingly confirming to the patient that one could only ask for sobriety once life is empty of pain.

The observation of the trainee reminded us of the three great “untruths” mentioned by Greg Lukianoff and Jonathan Haidt, PhD, in their famous book, “The Coddling of the American Mind.”¹ In the book they warn against the idea of fragility – what doesn’t kill you makes you weaker; emotional reasoning – always trust your feelings; and us-versus-them thinking – life is a battle between good people and evil people. The authors compare these three great untruths with the cognitive distortions of cognitive-behavioral therapy.

We ponder the trainee’s observation that psychiatrists appear to encourage the untruths rather than challenge them. Part of psychiatric and all medical training involves learning nonjudgmental approaches to human suffering and an identification with individual needs over societal demands. Our suspicion is that a nonjudgmental approach to the understanding of the human condition generates a desire to protect patients from a moralistic shaming position. However, we wonder if, at times, psychiatry takes this approach too far.
 

Reconceptualizing shame

Shame can be a toxic presence in the overwhelmed superego of a patient, but it can serve an important role in psychic development and should not be avoided out of hand. We suggest that it can be appropriate for a patient with an alcohol use disorder to feel some shame for the harm caused by their drinking, and we question the limit of psychiatry’s current pursuit of incessant validation. As an extreme example, would modern psychiatry discourage a patient who killed someone while driving in an intoxicated state from feeling remorse and shame?

Modern psychiatry appears to have other examples of the three great untruths on display. In our work, we are often faced with patients who are prematurely placed on disability, an example of fragility. Instead of encouraging patients to return to the workforce, they are “protected” from the emotional difficulty of work. In many patients this results in a decline in functioning and worsening of psychiatric symptoms. We are also confronted with patients who define themselves by how they feel, an example of emotional reasoning. Instead of using our clinical judgments to define and assess symptoms, patients are left to decide for themselves through self-rated scales with questionable validity.2 This can result in patients having their emotional experiences not only validated when inappropriate but can also give emotional reasoning a false sense of medical legitimacy.

Finally, we commonly see patients who endlessly blame family members and others for any life difficulties, a form of us-versus-them thinking. Instead of acknowledging and then integrating life challenges to achieve recovery, patients are affirmed despite clinicians having little evidence on the veracity of the patients’ perspective. As a consequence, patients can be further isolated from their greatest source of support.

In some ways, a mindlessly validating approach in psychiatry is unexpected since the practice of psychiatry would seem to promote the development of strong attachments and resilience. After all, connections to family, employment, social institutions, and even religious worship are associated with vastly better outcomes. Those who have become alienated to these pillars of social cohesion fare much worse. One may deplore the static and at times oppressive nature of these institutions but the empirical experience of practicing psychiatry leads one to a healthy respect for the stabilizing influence they accord for individuals struggling with life’s vicissitudes, unpredictability, and loneliness. Overcoming the fear of responsibility, living up to the demands and expectations of society, and having the strength to overcome difficult emotions should be the standard goals of psychiatric treatment.

From the knowledge gained from working with patients struggling from psychic pain, we wonder how to encourage patients to pursue those adaptive approaches to life. We argue that a stoic emphasis on learning to manage one’s affective and mental response to the inevitable changes of life is key to achieving wisdom and stability in our humble lives. This perspective is a common denominator of multiple different psychotherapies. The goal is to provide patients with the ability to be in a place where they are engaged with the world in a meaningful way that is not overwhelmed by distorted, self-absorbed psychic anguish. This perspective discourages externalization as a relatively low-yield way to understand and overcome one’s problems. One identifies childhood experiences with one’s mother as a source of adult distress not for the purpose of blaming her, but for the purpose of recognizing one’s own childish motivations for making maladaptive decisions as an adult.

For many patients, the goal should be to emphasize an internal locus of control and responsibility. We should also avoid constantly relying on society and government’s role in helping the individual achieve a satisfactory life. We wonder if this endless pursuit of nonjudgment and validation corrupts the doctor-patient interaction. In other words, focusing on medical diagnoses and psychopharmacology may be a counter therapeutic maneuver that compromises a patient’s sense of autonomy and individual responsibility for their own psychic development. Psychotherapy that ends with the patient being able to identify all the traumas that led to their sorrow has simply left the patient in the role of helpless and sorrowful victim. Instead, we should allow patients to proceed to the next step, which is empowerment and transformation. From this angle, the field of psychiatry should be cautious of encouraging movements that promote victimhood and grievance as a meaningful psychic position to take in society.

Mr. Lukianoff and Dr. Haidt use cognitive therapy as an analogy throughout their books for how to confront the great untruths. They perceive those modern forms of thinking as cognitive distortions, which can be remedied using the techniques of cognitive restructuring found in cognitive-behavioral therapy. They encourage us to recognize those maladaptive thoughts, and create more accurate and adaptive ways of viewing the world – a view that would be able to grow from challenges not just survive them; a view referred to as antifragile.3 We believe that those techniques and others would certainly be of assistance in our current times. However, the first step is to recognize our problem – a problem that is not rooted in the DSM, research, or biology but in an exaggerated intention to be patient centered. We should, however, remember that, when a patient has negative schemas, being too patient centered can be encouraging to maladaptive behaviors.

In conclusion, we wonder what modern psychiatry could look like if it made a concerted effort at also treating mental illness by reinforcing the importance of individual agency and responsibility. Modern psychiatry has been so focused on describing biological symptoms needing biological treatments that we sometimes forget that having no symptom (being asymptomatic) is not the only goal. Having a fulfilling and meaningful life, which is resilient to future symptoms is just as important to patients. We seem to have entrenched ourselves so deeply in an overly basic approach of problem-solution and diagnosis-treatment paradigm. However, we don’t need to renege on modern advances to promote the patient’s strength, adaptability, and antifragility. An emphasis on patient growth can complement the medical model. We wonder what effect such an approach would have if the trainee’s patient with alcohol use disorder was instead told: “Given the suffering you have and have caused because of your alcohol use disorder, how do you plan to make changes in your life to help the treatment plan we create together?”

Dr. Lehman is a professor of psychiatry at the University of California, San Diego. He is codirector of all acute and intensive psychiatric treatment at the Veterans Affairs Medical Center in San Diego, where he practices clinical psychiatry. He also is the course director for the UCSD third-year medical student psychiatry clerkship. Dr. Badre is a clinical and forensic psychiatrist in San Diego. He holds teaching positions at UCSD and the University of San Diego. Dr. Badre can be reached at his website, BadreMD.com.

References

1. Lukianoff G, Haidt J. The Coddling of the American Mind: How Good Intentions and Bad Ideas are Setting Up a Generation for Failure. New York: Penguin Books, 2019.

2. Levis B et al. J Clin Epidemiol. 2020 Jun;122:115-128.e1.,

3. Taleb NN. Antifragile: Things That Gain from Disorder. Vol. 3. New York: Random House, 2012.

Type 2 diabetes patients who had never used insulin showed sustained remission 10 years after bariatric surgery in a prospective study of 85 patients.

Having diabetes for less than 5 years was also predictive of achieving long-term diabetes remission, Diego Moriconi, MD, of the University of Pisa (Italy) and presenting study investigator, reported at the virtual annual meeting of the European Association for the Study of Diabetes.

“Weight loss was associated with type 2 diabetes remission 1 year after surgery, but it had no impact on the long-term relapse of diabetes,” Dr. Moriconi said.

The findings are important, commented Tina Vilsbøll, MD, DMSc, chief consultant at the Steno Diabetes Centre Copenhagen, who chaired the session. They’re important because they would help “to set the expectations for patients before they have surgery, what to expect in respect to resolution or remission of diabetes.”

If patients were taking insulin, for instance, the take home would seem to be not to expect too much in terms of remission of their diabetes, Dr. Vilsbøll said. She added: “Usually I am not a big fan of [relying on] diabetes duration, because often we know that patients with type 2 diabetes have had diabetes for a long time before they’re actually diagnosed.” However, “it seems to be very important here.”

Dr. Moriconi reported the findings of an observational study that had started in 2006 and recruited individuals about to undergo bariatric surgery for type 2 diabetes. Participants were evaluated before surgery and every 6-12 months after, undergoing various clinical and laboratory investigations, for a period of 10 years.

The majority of the recruited patients (76%) were women. Most (also 76%) had undergone gastric bypass (Roux-en-Y) surgery, and the remainder had undergone sleeve gastrectomy. Both types of surgery were equally as good at getting people into remission, as defined by the American Diabetes Association Standards of Medical Care in Diabetes, Dr. Moriconi said. As such, remission was achieved if the fasting blood glucose fell below 100 mg/dL and the hemoglobin A1c below 5.7%.

In the first year following surgery, 75% of patients had met diabetes remission criteria. This fell to 61% of patients after 5 years, and to 55% at 10 years. At each of these time points, 25% of patients had type 2 diabetes, with 14% relapsing back at 5 years and 20% at 10 years.

Dr. Moriconi pointed out some of the different characteristics of the 47 patients who had achieved diabetes remission at 10 years, compared with the 17 who had “relapsed” back to having type 2 diabetes and the 21 who had remained with type 2 diabetes.

The decrease in body mass index achieved at 10 years was no different between the three groups. However, 1 year after surgery, there had been a significantly greater drop in body in those who achieved remission, compared with those who did not (P = .04).

“Glycemic control improved with time in all the three groups after bariatric surgery, although more markedly so in the remission group,” Dr. Moriconi said.

He highlighted how none of the patients who had achieved remission had used insulin, whereas 12% of those who had relapsed and half (52%) of those who remained with type 2 diabetes had used insulin (P < .0001).

Patients who achieved remission at 1, 5, and 10 years were more likely to have had diabetes for less than 5 years than those who remained with type 2 diabetes. The average duration of diabetes was 2 years in those achieving remission versus 8 years in those who had relapsed and 13 years in those who had remained diabetic (P < .0001).

Logistic regression analysis, which adjusted for all major confounding factors such as age, sex, and type of surgery, showed that only the duration of diabetes and insulin therapy before surgery were the only predictors of long-term diabetes remission.

The study had no commercial funding. Dr. Moriconi and Dr. Vilsbøll had no conflicts of interest to disclose.

SOURCE: Moriconi D. EASD 2020, Oral presentation 120.

Type 2 diabetes patients who had never used insulin showed sustained remission 10 years after bariatric surgery in a prospective study of 85 patients.

Having diabetes for less than 5 years was also predictive of achieving long-term diabetes remission, Diego Moriconi, MD, of the University of Pisa (Italy) and presenting study investigator, reported at the virtual annual meeting of the European Association for the Study of Diabetes.

“Weight loss was associated with type 2 diabetes remission 1 year after surgery, but it had no impact on the long-term relapse of diabetes,” Dr. Moriconi said.

The findings are important, commented Tina Vilsbøll, MD, DMSc, chief consultant at the Steno Diabetes Centre Copenhagen, who chaired the session. They’re important because they would help “to set the expectations for patients before they have surgery, what to expect in respect to resolution or remission of diabetes.”

If patients were taking insulin, for instance, the take home would seem to be not to expect too much in terms of remission of their diabetes, Dr. Vilsbøll said. She added: “Usually I am not a big fan of [relying on] diabetes duration, because often we know that patients with type 2 diabetes have had diabetes for a long time before they’re actually diagnosed.” However, “it seems to be very important here.”

Dr. Moriconi reported the findings of an observational study that had started in 2006 and recruited individuals about to undergo bariatric surgery for type 2 diabetes. Participants were evaluated before surgery and every 6-12 months after, undergoing various clinical and laboratory investigations, for a period of 10 years.

The majority of the recruited patients (76%) were women. Most (also 76%) had undergone gastric bypass (Roux-en-Y) surgery, and the remainder had undergone sleeve gastrectomy. Both types of surgery were equally as good at getting people into remission, as defined by the American Diabetes Association Standards of Medical Care in Diabetes, Dr. Moriconi said. As such, remission was achieved if the fasting blood glucose fell below 100 mg/dL and the hemoglobin A1c below 5.7%.

In the first year following surgery, 75% of patients had met diabetes remission criteria. This fell to 61% of patients after 5 years, and to 55% at 10 years. At each of these time points, 25% of patients had type 2 diabetes, with 14% relapsing back at 5 years and 20% at 10 years.

Dr. Moriconi pointed out some of the different characteristics of the 47 patients who had achieved diabetes remission at 10 years, compared with the 17 who had “relapsed” back to having type 2 diabetes and the 21 who had remained with type 2 diabetes.

The decrease in body mass index achieved at 10 years was no different between the three groups. However, 1 year after surgery, there had been a significantly greater drop in body in those who achieved remission, compared with those who did not (P = .04).

“Glycemic control improved with time in all the three groups after bariatric surgery, although more markedly so in the remission group,” Dr. Moriconi said.

He highlighted how none of the patients who had achieved remission had used insulin, whereas 12% of those who had relapsed and half (52%) of those who remained with type 2 diabetes had used insulin (P < .0001).

Patients who achieved remission at 1, 5, and 10 years were more likely to have had diabetes for less than 5 years than those who remained with type 2 diabetes. The average duration of diabetes was 2 years in those achieving remission versus 8 years in those who had relapsed and 13 years in those who had remained diabetic (P < .0001).

Logistic regression analysis, which adjusted for all major confounding factors such as age, sex, and type of surgery, showed that only the duration of diabetes and insulin therapy before surgery were the only predictors of long-term diabetes remission.

The study had no commercial funding. Dr. Moriconi and Dr. Vilsbøll had no conflicts of interest to disclose.

SOURCE: Moriconi D. EASD 2020, Oral presentation 120.

Type 2 diabetes patients who had never used insulin showed sustained remission 10 years after bariatric surgery in a prospective study of 85 patients.

Having diabetes for less than 5 years was also predictive of achieving long-term diabetes remission, Diego Moriconi, MD, of the University of Pisa (Italy) and presenting study investigator, reported at the virtual annual meeting of the European Association for the Study of Diabetes.

“Weight loss was associated with type 2 diabetes remission 1 year after surgery, but it had no impact on the long-term relapse of diabetes,” Dr. Moriconi said.

The findings are important, commented Tina Vilsbøll, MD, DMSc, chief consultant at the Steno Diabetes Centre Copenhagen, who chaired the session. They’re important because they would help “to set the expectations for patients before they have surgery, what to expect in respect to resolution or remission of diabetes.”

If patients were taking insulin, for instance, the take home would seem to be not to expect too much in terms of remission of their diabetes, Dr. Vilsbøll said. She added: “Usually I am not a big fan of [relying on] diabetes duration, because often we know that patients with type 2 diabetes have had diabetes for a long time before they’re actually diagnosed.” However, “it seems to be very important here.”

Dr. Moriconi reported the findings of an observational study that had started in 2006 and recruited individuals about to undergo bariatric surgery for type 2 diabetes. Participants were evaluated before surgery and every 6-12 months after, undergoing various clinical and laboratory investigations, for a period of 10 years.

The majority of the recruited patients (76%) were women. Most (also 76%) had undergone gastric bypass (Roux-en-Y) surgery, and the remainder had undergone sleeve gastrectomy. Both types of surgery were equally as good at getting people into remission, as defined by the American Diabetes Association Standards of Medical Care in Diabetes, Dr. Moriconi said. As such, remission was achieved if the fasting blood glucose fell below 100 mg/dL and the hemoglobin A1c below 5.7%.

In the first year following surgery, 75% of patients had met diabetes remission criteria. This fell to 61% of patients after 5 years, and to 55% at 10 years. At each of these time points, 25% of patients had type 2 diabetes, with 14% relapsing back at 5 years and 20% at 10 years.

Dr. Moriconi pointed out some of the different characteristics of the 47 patients who had achieved diabetes remission at 10 years, compared with the 17 who had “relapsed” back to having type 2 diabetes and the 21 who had remained with type 2 diabetes.

The decrease in body mass index achieved at 10 years was no different between the three groups. However, 1 year after surgery, there had been a significantly greater drop in body in those who achieved remission, compared with those who did not (P = .04).

“Glycemic control improved with time in all the three groups after bariatric surgery, although more markedly so in the remission group,” Dr. Moriconi said.

He highlighted how none of the patients who had achieved remission had used insulin, whereas 12% of those who had relapsed and half (52%) of those who remained with type 2 diabetes had used insulin (P < .0001).

Patients who achieved remission at 1, 5, and 10 years were more likely to have had diabetes for less than 5 years than those who remained with type 2 diabetes. The average duration of diabetes was 2 years in those achieving remission versus 8 years in those who had relapsed and 13 years in those who had remained diabetic (P < .0001).

Logistic regression analysis, which adjusted for all major confounding factors such as age, sex, and type of surgery, showed that only the duration of diabetes and insulin therapy before surgery were the only predictors of long-term diabetes remission.

The study had no commercial funding. Dr. Moriconi and Dr. Vilsbøll had no conflicts of interest to disclose.

SOURCE: Moriconi D. EASD 2020, Oral presentation 120.

Not only the prevalence, but the impact of nonalcoholic fatty liver disease (NAFLD) is increasing in much of the world, Arun J. Sanyal, MD, said in a virtual presentation at the meeting jointly provided by Rutgers and Global Academy for Medical Education. “It is currently estimated that the number of people living with cirrhosis or with decompensated cirrhosis will increase two- to threefold from 2015 to 2030,” which underlines the public health impact and the need for improved treatment paradigms, he emphasized.

“The thing to remember about NAFLD is that it does not exist in a vacuum,” Dr. Sanyal said. NAFLD is a multisystem disorder. Most patients have concomitant cardiovascular disease, but others may have type 2 diabetes, hypertension, and dyslipidemia, all of which are now accepted as risk factors for nonalcoholic steatohepatitis (NASH), he said.

“What ties these conditions together is metabolic stress leading to systemic inflammation and fibrosis. This is primarily due to diet-induced obesity. If you think about treating all of these competing risks to the patient’s life, the optimal way is to treat the root cause,” he said.

Various options exist to manage the conditions that can lead to NASH, but several of these also appear promising as a treatment of NASH, Dr. Sanyal said. Glucagonlike peptide–1 agonists and sodium-glucose transporter 2 inhibitors have been shown to improve multiple outcomes of interest in type 2 diabetes. However, insulin can cause weight gain at the expense of controlling HbA1C levels, he said.

Bariatric surgery can improve histology, but many patients with advanced fibrosis do not demonstrate improvement in fibrosis. Also, bariatric surgery has its own associated morbidity, including an increased suicide rate across multiple studies, Dr. Sanyal noted.

A new and interesting option is duodenal mucosal resurfacing (DMR) “a novel, minimally invasive outpatient upper-endoscopic procedure,” said Dr. Sanyal. DMR involves use of a catheter to perform a submucosal lift and hydrothermal mucosal ablation, prompting healthy epithelial regrowth, he explained. “The mucosa sloughs off, fresh epithelium grows in, and the hormonal signal from the gut to the rest of the body is restored to a more normal pattern,” he noted.

In the REVITA-2 study of patients with diabetes and NAFLD, the average fat loss was 5.4% in those randomized to DMR vs. 2.4% in sham-procedure patients and represented “quite significant defatting of the liver,” Dr. Sanyal said.

Dr. Sanyal then focused on fatty liver disease. “The first step when you see a patient with fatty liver disease is to see how scarred is the liver, and whether the patient has silent cirrhosis. The more scarred the liver, the greater risk of liver-related outcomes,” he said. The goal of therapy for these patients is to reduce the risk of progression to cirrhosis, he added. Dr. Sanyal recommended evaluating fibrosis using the Fibrosis 4 score (Fib4). “If the Fib4 is less than 1.3, the likelihood of significant scarring in the liver is less than 10%,” he said. On the other hand, a Fib4 greater than 2.67 suggests advanced fibrosis, he noted.

Overall, the goals of treatment for NASH patients are to prevent cirrhosis, reduce decompensation, and prevent hepatocellular carcinoma, said Dr. Sanyal.

“The ideal drug for NASH should also help other end organs, or at least be neutral,” said Dr. Sanyal.

Current frontline therapies for precirrhotic NASH include thiazolidinediones (TZD), farnesoid X receptor (FXR)/fibroblast growth factor 19 (FGF-19), FGF21, thyroxine B-R, and glucagonlike peptide-1. Clinical evidence varies based on different populations, endpoints, assessment methods, and treatment duration, he said.

Looking ahead to the next decade, a NASH management paradigm will likely play out that can be applied in the clinic today, Dr. Sanyal said. First, make an initial assessment of the status of the end organs. Start with a weight-loss regimen; use statins and GLP-1 and SGLT2 inhibitors as needed. Follow and reassess, and if the patient still has disease, progress to targeted therapy for active NASH while continuing to encourage weight loss and healthy living, he said.

“The ultimate proof that what we are doing is working is that we are improving mortality, reducing health care costs, and improving patients’ function and quality of life,” he concluded.

Dr. Sanyal is president of Sanyal Biotechnologies. He also disclosed stock options for Durect, Exhalenz, Galmed, Genfit, Immuton, Indalo, and Tiziana, as well as various relationships with Allergan, AMRA, Astra Zeneca-Medimmune, Birdrock, Boehringer Ingelheim, Bristol Myers, Echosense, GE, Genentech, Gilead, Hemoshear, IFMO, Innovate, Intercept, Lilly, Lipocine, Merck, Novartis, Novo Nordisk, OWL, Pfizer, RedX, Sundise, Tern, and Zydus.

Global Academy for Medical Education and this news organization are owned by the same parent company.

Not only the prevalence, but the impact of nonalcoholic fatty liver disease (NAFLD) is increasing in much of the world, Arun J. Sanyal, MD, said in a virtual presentation at the meeting jointly provided by Rutgers and Global Academy for Medical Education. “It is currently estimated that the number of people living with cirrhosis or with decompensated cirrhosis will increase two- to threefold from 2015 to 2030,” which underlines the public health impact and the need for improved treatment paradigms, he emphasized.

“The thing to remember about NAFLD is that it does not exist in a vacuum,” Dr. Sanyal said. NAFLD is a multisystem disorder. Most patients have concomitant cardiovascular disease, but others may have type 2 diabetes, hypertension, and dyslipidemia, all of which are now accepted as risk factors for nonalcoholic steatohepatitis (NASH), he said.

“What ties these conditions together is metabolic stress leading to systemic inflammation and fibrosis. This is primarily due to diet-induced obesity. If you think about treating all of these competing risks to the patient’s life, the optimal way is to treat the root cause,” he said.

Various options exist to manage the conditions that can lead to NASH, but several of these also appear promising as a treatment of NASH, Dr. Sanyal said. Glucagonlike peptide–1 agonists and sodium-glucose transporter 2 inhibitors have been shown to improve multiple outcomes of interest in type 2 diabetes. However, insulin can cause weight gain at the expense of controlling HbA1C levels, he said.

Bariatric surgery can improve histology, but many patients with advanced fibrosis do not demonstrate improvement in fibrosis. Also, bariatric surgery has its own associated morbidity, including an increased suicide rate across multiple studies, Dr. Sanyal noted.

A new and interesting option is duodenal mucosal resurfacing (DMR) “a novel, minimally invasive outpatient upper-endoscopic procedure,” said Dr. Sanyal. DMR involves use of a catheter to perform a submucosal lift and hydrothermal mucosal ablation, prompting healthy epithelial regrowth, he explained. “The mucosa sloughs off, fresh epithelium grows in, and the hormonal signal from the gut to the rest of the body is restored to a more normal pattern,” he noted.

In the REVITA-2 study of patients with diabetes and NAFLD, the average fat loss was 5.4% in those randomized to DMR vs. 2.4% in sham-procedure patients and represented “quite significant defatting of the liver,” Dr. Sanyal said.

Dr. Sanyal then focused on fatty liver disease. “The first step when you see a patient with fatty liver disease is to see how scarred is the liver, and whether the patient has silent cirrhosis. The more scarred the liver, the greater risk of liver-related outcomes,” he said. The goal of therapy for these patients is to reduce the risk of progression to cirrhosis, he added. Dr. Sanyal recommended evaluating fibrosis using the Fibrosis 4 score (Fib4). “If the Fib4 is less than 1.3, the likelihood of significant scarring in the liver is less than 10%,” he said. On the other hand, a Fib4 greater than 2.67 suggests advanced fibrosis, he noted.

Overall, the goals of treatment for NASH patients are to prevent cirrhosis, reduce decompensation, and prevent hepatocellular carcinoma, said Dr. Sanyal.

“The ideal drug for NASH should also help other end organs, or at least be neutral,” said Dr. Sanyal.

Current frontline therapies for precirrhotic NASH include thiazolidinediones (TZD), farnesoid X receptor (FXR)/fibroblast growth factor 19 (FGF-19), FGF21, thyroxine B-R, and glucagonlike peptide-1. Clinical evidence varies based on different populations, endpoints, assessment methods, and treatment duration, he said.

Looking ahead to the next decade, a NASH management paradigm will likely play out that can be applied in the clinic today, Dr. Sanyal said. First, make an initial assessment of the status of the end organs. Start with a weight-loss regimen; use statins and GLP-1 and SGLT2 inhibitors as needed. Follow and reassess, and if the patient still has disease, progress to targeted therapy for active NASH while continuing to encourage weight loss and healthy living, he said.

“The ultimate proof that what we are doing is working is that we are improving mortality, reducing health care costs, and improving patients’ function and quality of life,” he concluded.

Dr. Sanyal is president of Sanyal Biotechnologies. He also disclosed stock options for Durect, Exhalenz, Galmed, Genfit, Immuton, Indalo, and Tiziana, as well as various relationships with Allergan, AMRA, Astra Zeneca-Medimmune, Birdrock, Boehringer Ingelheim, Bristol Myers, Echosense, GE, Genentech, Gilead, Hemoshear, IFMO, Innovate, Intercept, Lilly, Lipocine, Merck, Novartis, Novo Nordisk, OWL, Pfizer, RedX, Sundise, Tern, and Zydus.

Global Academy for Medical Education and this news organization are owned by the same parent company.

Not only the prevalence, but the impact of nonalcoholic fatty liver disease (NAFLD) is increasing in much of the world, Arun J. Sanyal, MD, said in a virtual presentation at the meeting jointly provided by Rutgers and Global Academy for Medical Education. “It is currently estimated that the number of people living with cirrhosis or with decompensated cirrhosis will increase two- to threefold from 2015 to 2030,” which underlines the public health impact and the need for improved treatment paradigms, he emphasized.

“The thing to remember about NAFLD is that it does not exist in a vacuum,” Dr. Sanyal said. NAFLD is a multisystem disorder. Most patients have concomitant cardiovascular disease, but others may have type 2 diabetes, hypertension, and dyslipidemia, all of which are now accepted as risk factors for nonalcoholic steatohepatitis (NASH), he said.

“What ties these conditions together is metabolic stress leading to systemic inflammation and fibrosis. This is primarily due to diet-induced obesity. If you think about treating all of these competing risks to the patient’s life, the optimal way is to treat the root cause,” he said.

Various options exist to manage the conditions that can lead to NASH, but several of these also appear promising as a treatment of NASH, Dr. Sanyal said. Glucagonlike peptide–1 agonists and sodium-glucose transporter 2 inhibitors have been shown to improve multiple outcomes of interest in type 2 diabetes. However, insulin can cause weight gain at the expense of controlling HbA1C levels, he said.

Bariatric surgery can improve histology, but many patients with advanced fibrosis do not demonstrate improvement in fibrosis. Also, bariatric surgery has its own associated morbidity, including an increased suicide rate across multiple studies, Dr. Sanyal noted.

A new and interesting option is duodenal mucosal resurfacing (DMR) “a novel, minimally invasive outpatient upper-endoscopic procedure,” said Dr. Sanyal. DMR involves use of a catheter to perform a submucosal lift and hydrothermal mucosal ablation, prompting healthy epithelial regrowth, he explained. “The mucosa sloughs off, fresh epithelium grows in, and the hormonal signal from the gut to the rest of the body is restored to a more normal pattern,” he noted.

In the REVITA-2 study of patients with diabetes and NAFLD, the average fat loss was 5.4% in those randomized to DMR vs. 2.4% in sham-procedure patients and represented “quite significant defatting of the liver,” Dr. Sanyal said.

Dr. Sanyal then focused on fatty liver disease. “The first step when you see a patient with fatty liver disease is to see how scarred is the liver, and whether the patient has silent cirrhosis. The more scarred the liver, the greater risk of liver-related outcomes,” he said. The goal of therapy for these patients is to reduce the risk of progression to cirrhosis, he added. Dr. Sanyal recommended evaluating fibrosis using the Fibrosis 4 score (Fib4). “If the Fib4 is less than 1.3, the likelihood of significant scarring in the liver is less than 10%,” he said. On the other hand, a Fib4 greater than 2.67 suggests advanced fibrosis, he noted.

Overall, the goals of treatment for NASH patients are to prevent cirrhosis, reduce decompensation, and prevent hepatocellular carcinoma, said Dr. Sanyal.

“The ideal drug for NASH should also help other end organs, or at least be neutral,” said Dr. Sanyal.

Current frontline therapies for precirrhotic NASH include thiazolidinediones (TZD), farnesoid X receptor (FXR)/fibroblast growth factor 19 (FGF-19), FGF21, thyroxine B-R, and glucagonlike peptide-1. Clinical evidence varies based on different populations, endpoints, assessment methods, and treatment duration, he said.

Looking ahead to the next decade, a NASH management paradigm will likely play out that can be applied in the clinic today, Dr. Sanyal said. First, make an initial assessment of the status of the end organs. Start with a weight-loss regimen; use statins and GLP-1 and SGLT2 inhibitors as needed. Follow and reassess, and if the patient still has disease, progress to targeted therapy for active NASH while continuing to encourage weight loss and healthy living, he said.

“The ultimate proof that what we are doing is working is that we are improving mortality, reducing health care costs, and improving patients’ function and quality of life,” he concluded.

Dr. Sanyal is president of Sanyal Biotechnologies. He also disclosed stock options for Durect, Exhalenz, Galmed, Genfit, Immuton, Indalo, and Tiziana, as well as various relationships with Allergan, AMRA, Astra Zeneca-Medimmune, Birdrock, Boehringer Ingelheim, Bristol Myers, Echosense, GE, Genentech, Gilead, Hemoshear, IFMO, Innovate, Intercept, Lilly, Lipocine, Merck, Novartis, Novo Nordisk, OWL, Pfizer, RedX, Sundise, Tern, and Zydus.

Global Academy for Medical Education and this news organization are owned by the same parent company.

States have begun preparing to distribute a COVID-19 vaccine if one is approved, a CDC official said today.

The CDC released guidance for states on Sept. 16 titled COVID-19 Vaccination Program Interim Playbook for Jurisdiction Operations. The document discusses vaccine ordering, storage, and handling and says that states should submit their plans for vaccine distribution to the agency by Oct. 16.

“Every jurisdiction is heavily involved right now in their plan development,” CDC official Janell Routh, MD, told the Advisory Committee on Immunization Practices during its Sept. 22 meeting. “It was really impressive to me that, even though the playbook only went out last week, states and jurisdictions have been thinking about this for quite some time.”

However, one committee member suggested that setting a deadline before more safety, efficacy, and storage information is known may be premature.

“I cannot imagine that we will actually know the final storage requirements for this vaccine by Oct. 16, which makes me a little concerned about finalizing state plans,” said Helen “Keipp” Talbot, MD, MPH, associate professor of medicine at Vanderbilt University Medical Center in Nashville, Tenn. “We also don’t know the best populations yet when it comes to efficacy and safety.”

Dr. Routh said the CDC is asking states to plan on the basis of assumptions. “We know those plans will constantly be improving, changing, as we learn more information,” Dr. Routh said. States agreed to return a plan 30 days after the playbook was released, which is how the Oct. 16 deadline was established, she said.

States are encouraged to think broadly. Plans may include contingencies for a product that requires ultracold storage or for distributing more than one vaccine product, Dr. Routh said.

“One goal is to be ready on the first day that we can actually distribute vaccine,” Nancy Messonnier, MD, director of the National Center for Immunization and Respiratory Diseases, said during the meeting. “Our colleagues in Operation Warp Speed say that they expect there will be vaccine as early as November, and therefore we need to be ready so there is no delay in distributing that vaccine. And that phase, that early phase, is really close upon us.”

Many states have already developed plans, and the CDC is providing technical assistance as needed to monitor the plans regularly, Dr. Routh said.
 

Key issues identified

From holding pilot meetings with five jurisdictions, officials learned that public confidence in the vaccine is among states’ greatest concerns, Dr. Routh said. In addition, distribution is resource intensive, and social distancing adds logistical complexity.

Specific guidance on whom to vaccinate in the early stages will smooth the process, officials suggested during the pilot meetings. For the first several weeks, vaccine doses may be limited to priority populations, such as health care workers.

“This interim playbook is a living document,” Dr. Routh emphasized. “We definitely plan to update the content regularly as we learn more information about what vaccines and when they will be released.”

During the early stages of COVID-19 vaccination, officials plan to implement an enhanced monitoring program in which vaccine recipients would complete surveys about adverse events, in addition to the traditional vaccine safety monitoring programs that already exist, officials said.
 

A version of this article originally appeared on Medscape.com.

States have begun preparing to distribute a COVID-19 vaccine if one is approved, a CDC official said today.

The CDC released guidance for states on Sept. 16 titled COVID-19 Vaccination Program Interim Playbook for Jurisdiction Operations. The document discusses vaccine ordering, storage, and handling and says that states should submit their plans for vaccine distribution to the agency by Oct. 16.

“Every jurisdiction is heavily involved right now in their plan development,” CDC official Janell Routh, MD, told the Advisory Committee on Immunization Practices during its Sept. 22 meeting. “It was really impressive to me that, even though the playbook only went out last week, states and jurisdictions have been thinking about this for quite some time.”

However, one committee member suggested that setting a deadline before more safety, efficacy, and storage information is known may be premature.

“I cannot imagine that we will actually know the final storage requirements for this vaccine by Oct. 16, which makes me a little concerned about finalizing state plans,” said Helen “Keipp” Talbot, MD, MPH, associate professor of medicine at Vanderbilt University Medical Center in Nashville, Tenn. “We also don’t know the best populations yet when it comes to efficacy and safety.”

Dr. Routh said the CDC is asking states to plan on the basis of assumptions. “We know those plans will constantly be improving, changing, as we learn more information,” Dr. Routh said. States agreed to return a plan 30 days after the playbook was released, which is how the Oct. 16 deadline was established, she said.

States are encouraged to think broadly. Plans may include contingencies for a product that requires ultracold storage or for distributing more than one vaccine product, Dr. Routh said.

“One goal is to be ready on the first day that we can actually distribute vaccine,” Nancy Messonnier, MD, director of the National Center for Immunization and Respiratory Diseases, said during the meeting. “Our colleagues in Operation Warp Speed say that they expect there will be vaccine as early as November, and therefore we need to be ready so there is no delay in distributing that vaccine. And that phase, that early phase, is really close upon us.”

Many states have already developed plans, and the CDC is providing technical assistance as needed to monitor the plans regularly, Dr. Routh said.
 

Key issues identified

From holding pilot meetings with five jurisdictions, officials learned that public confidence in the vaccine is among states’ greatest concerns, Dr. Routh said. In addition, distribution is resource intensive, and social distancing adds logistical complexity.

Specific guidance on whom to vaccinate in the early stages will smooth the process, officials suggested during the pilot meetings. For the first several weeks, vaccine doses may be limited to priority populations, such as health care workers.

“This interim playbook is a living document,” Dr. Routh emphasized. “We definitely plan to update the content regularly as we learn more information about what vaccines and when they will be released.”

During the early stages of COVID-19 vaccination, officials plan to implement an enhanced monitoring program in which vaccine recipients would complete surveys about adverse events, in addition to the traditional vaccine safety monitoring programs that already exist, officials said.
 

A version of this article originally appeared on Medscape.com.

States have begun preparing to distribute a COVID-19 vaccine if one is approved, a CDC official said today.

The CDC released guidance for states on Sept. 16 titled COVID-19 Vaccination Program Interim Playbook for Jurisdiction Operations. The document discusses vaccine ordering, storage, and handling and says that states should submit their plans for vaccine distribution to the agency by Oct. 16.

“Every jurisdiction is heavily involved right now in their plan development,” CDC official Janell Routh, MD, told the Advisory Committee on Immunization Practices during its Sept. 22 meeting. “It was really impressive to me that, even though the playbook only went out last week, states and jurisdictions have been thinking about this for quite some time.”

However, one committee member suggested that setting a deadline before more safety, efficacy, and storage information is known may be premature.

“I cannot imagine that we will actually know the final storage requirements for this vaccine by Oct. 16, which makes me a little concerned about finalizing state plans,” said Helen “Keipp” Talbot, MD, MPH, associate professor of medicine at Vanderbilt University Medical Center in Nashville, Tenn. “We also don’t know the best populations yet when it comes to efficacy and safety.”

Dr. Routh said the CDC is asking states to plan on the basis of assumptions. “We know those plans will constantly be improving, changing, as we learn more information,” Dr. Routh said. States agreed to return a plan 30 days after the playbook was released, which is how the Oct. 16 deadline was established, she said.

States are encouraged to think broadly. Plans may include contingencies for a product that requires ultracold storage or for distributing more than one vaccine product, Dr. Routh said.

“One goal is to be ready on the first day that we can actually distribute vaccine,” Nancy Messonnier, MD, director of the National Center for Immunization and Respiratory Diseases, said during the meeting. “Our colleagues in Operation Warp Speed say that they expect there will be vaccine as early as November, and therefore we need to be ready so there is no delay in distributing that vaccine. And that phase, that early phase, is really close upon us.”

Many states have already developed plans, and the CDC is providing technical assistance as needed to monitor the plans regularly, Dr. Routh said.
 

Key issues identified

From holding pilot meetings with five jurisdictions, officials learned that public confidence in the vaccine is among states’ greatest concerns, Dr. Routh said. In addition, distribution is resource intensive, and social distancing adds logistical complexity.

Specific guidance on whom to vaccinate in the early stages will smooth the process, officials suggested during the pilot meetings. For the first several weeks, vaccine doses may be limited to priority populations, such as health care workers.

“This interim playbook is a living document,” Dr. Routh emphasized. “We definitely plan to update the content regularly as we learn more information about what vaccines and when they will be released.”

During the early stages of COVID-19 vaccination, officials plan to implement an enhanced monitoring program in which vaccine recipients would complete surveys about adverse events, in addition to the traditional vaccine safety monitoring programs that already exist, officials said.
 

A version of this article originally appeared on Medscape.com.

The punch biopsies were consistent with lichen planopilaris, an idiopathic, immune-mediated scarring alopecia that largely affects women between the ages of 40 and 70 years. In this variant of lichen planus, T cells target hair bulbs and cause destruction with scarring and permanent hair loss. Distribution may be patchy or may be more concentrated on the crown or involve the frontal scalp—a subtype called frontal fibrosing alopecia. Early recognition and intervention may save hair follicles and minimize disease severity.

The differential diagnosis includes traction alopecia, discoid lupus erythematosus, alopecia areata, centrifugal cicatricial alopecia, and folliculitis decalvans. The diagnosis may be confirmed with a scalp biopsy of actively inflamed follicles. Biopsy of scarred areas is likely to be nonspecific and unhelpful.

Treatment is targeted at slowing progression and symptom management. First-line therapy often includes potent corticosteroids (intralesional, topical, or systemic). Longer courses of steroid-sparing agents may be considered, including hydroxychloroquine, tacrolimus, ciclosporin, methotrexate, or acitretin. Hair styling and coloring, as well as hairpieces, often are used to conceal patches of hair loss. Hair transplantation is expensive but can be used to increase hair density in scarred areas once disease is controlled.

In this case, the patient was started on clobetasol solution 0.05% to be applied nightly to affected areas of the scalp. This treatment helped with the itching, but the inflammation and hair loss continued to worsen after 2 months. At that point, hydroxychloroquine 200 mg bid was added to the regimen, and hair loss and associated symptoms stopped. The patient remained on this therapy for 16 months. The hydroxychloroquine was then stopped, and the patient was advised to use the topical clobetasol, as needed.

‌

Text courtesy of Tristan Reynolds, DO, Maine Dartmouth Family Medicine Residency, and Jonathan Karnes, MD, medical director, MDFMR Dermatology Services, Augusta, ME. Photos courtesy of Jonathan Karnes, MD (copyright retained).

The punch biopsies were consistent with lichen planopilaris, an idiopathic, immune-mediated scarring alopecia that largely affects women between the ages of 40 and 70 years. In this variant of lichen planus, T cells target hair bulbs and cause destruction with scarring and permanent hair loss. Distribution may be patchy or may be more concentrated on the crown or involve the frontal scalp—a subtype called frontal fibrosing alopecia. Early recognition and intervention may save hair follicles and minimize disease severity.

The differential diagnosis includes traction alopecia, discoid lupus erythematosus, alopecia areata, centrifugal cicatricial alopecia, and folliculitis decalvans. The diagnosis may be confirmed with a scalp biopsy of actively inflamed follicles. Biopsy of scarred areas is likely to be nonspecific and unhelpful.

Treatment is targeted at slowing progression and symptom management. First-line therapy often includes potent corticosteroids (intralesional, topical, or systemic). Longer courses of steroid-sparing agents may be considered, including hydroxychloroquine, tacrolimus, ciclosporin, methotrexate, or acitretin. Hair styling and coloring, as well as hairpieces, often are used to conceal patches of hair loss. Hair transplantation is expensive but can be used to increase hair density in scarred areas once disease is controlled.

In this case, the patient was started on clobetasol solution 0.05% to be applied nightly to affected areas of the scalp. This treatment helped with the itching, but the inflammation and hair loss continued to worsen after 2 months. At that point, hydroxychloroquine 200 mg bid was added to the regimen, and hair loss and associated symptoms stopped. The patient remained on this therapy for 16 months. The hydroxychloroquine was then stopped, and the patient was advised to use the topical clobetasol, as needed.

‌

Text courtesy of Tristan Reynolds, DO, Maine Dartmouth Family Medicine Residency, and Jonathan Karnes, MD, medical director, MDFMR Dermatology Services, Augusta, ME. Photos courtesy of Jonathan Karnes, MD (copyright retained).

The punch biopsies were consistent with lichen planopilaris, an idiopathic, immune-mediated scarring alopecia that largely affects women between the ages of 40 and 70 years. In this variant of lichen planus, T cells target hair bulbs and cause destruction with scarring and permanent hair loss. Distribution may be patchy or may be more concentrated on the crown or involve the frontal scalp—a subtype called frontal fibrosing alopecia. Early recognition and intervention may save hair follicles and minimize disease severity.

The differential diagnosis includes traction alopecia, discoid lupus erythematosus, alopecia areata, centrifugal cicatricial alopecia, and folliculitis decalvans. The diagnosis may be confirmed with a scalp biopsy of actively inflamed follicles. Biopsy of scarred areas is likely to be nonspecific and unhelpful.

Treatment is targeted at slowing progression and symptom management. First-line therapy often includes potent corticosteroids (intralesional, topical, or systemic). Longer courses of steroid-sparing agents may be considered, including hydroxychloroquine, tacrolimus, ciclosporin, methotrexate, or acitretin. Hair styling and coloring, as well as hairpieces, often are used to conceal patches of hair loss. Hair transplantation is expensive but can be used to increase hair density in scarred areas once disease is controlled.

In this case, the patient was started on clobetasol solution 0.05% to be applied nightly to affected areas of the scalp. This treatment helped with the itching, but the inflammation and hair loss continued to worsen after 2 months. At that point, hydroxychloroquine 200 mg bid was added to the regimen, and hair loss and associated symptoms stopped. The patient remained on this therapy for 16 months. The hydroxychloroquine was then stopped, and the patient was advised to use the topical clobetasol, as needed.

‌

Text courtesy of Tristan Reynolds, DO, Maine Dartmouth Family Medicine Residency, and Jonathan Karnes, MD, medical director, MDFMR Dermatology Services, Augusta, ME. Photos courtesy of Jonathan Karnes, MD (copyright retained).

Physicians with difficult patient scenarios regularly bring their questions to the AGA Community (https://community.gastro.org) to seek advice from colleagues about therapy and disease management options, best practices, and diagnoses. The upgraded networking platform now features a newsfeed for difficult patient scenarios and regularly scheduled Roundtable discussions with experts in the field.

In case you missed it, here are some clinical discussions and Roundtables in the newsfeed this month:
 

• Patient case: Crohn’s patient with three different strictures (https://community.gastro.org/posts/22491)
• Patient case: Alcoholic hepatitis and positive anti-smooth muscle antibody (https://community.gastro.org/posts/22407)
• COVID-19: The importance of preparedness in independent GI practices (https://community.gastro.org/posts/22340)
• Patient case: Crohn’s patient with no tissue (https://community.gastro.org/posts/22472)

Roundtables (https://community.gastro.org/discussions/)

• Roadmap for the future of colorectal cancer screening in the U.S.
• Windows on Clinical GI lecture series: NAFLD, Crohn’s disease and gastroparesis

View all upcoming Roundtables in the community at https://community.gastro.org/discussions.

Physicians with difficult patient scenarios regularly bring their questions to the AGA Community (https://community.gastro.org) to seek advice from colleagues about therapy and disease management options, best practices, and diagnoses. The upgraded networking platform now features a newsfeed for difficult patient scenarios and regularly scheduled Roundtable discussions with experts in the field.

In case you missed it, here are some clinical discussions and Roundtables in the newsfeed this month:
 

• Patient case: Crohn’s patient with three different strictures (https://community.gastro.org/posts/22491)
• Patient case: Alcoholic hepatitis and positive anti-smooth muscle antibody (https://community.gastro.org/posts/22407)
• COVID-19: The importance of preparedness in independent GI practices (https://community.gastro.org/posts/22340)
• Patient case: Crohn’s patient with no tissue (https://community.gastro.org/posts/22472)

Roundtables (https://community.gastro.org/discussions/)

• Roadmap for the future of colorectal cancer screening in the U.S.
• Windows on Clinical GI lecture series: NAFLD, Crohn’s disease and gastroparesis

View all upcoming Roundtables in the community at https://community.gastro.org/discussions.

Physicians with difficult patient scenarios regularly bring their questions to the AGA Community (https://community.gastro.org) to seek advice from colleagues about therapy and disease management options, best practices, and diagnoses. The upgraded networking platform now features a newsfeed for difficult patient scenarios and regularly scheduled Roundtable discussions with experts in the field.

In case you missed it, here are some clinical discussions and Roundtables in the newsfeed this month:
 

• Patient case: Crohn’s patient with three different strictures (https://community.gastro.org/posts/22491)
• Patient case: Alcoholic hepatitis and positive anti-smooth muscle antibody (https://community.gastro.org/posts/22407)
• COVID-19: The importance of preparedness in independent GI practices (https://community.gastro.org/posts/22340)
• Patient case: Crohn’s patient with no tissue (https://community.gastro.org/posts/22472)

Roundtables (https://community.gastro.org/discussions/)

• Roadmap for the future of colorectal cancer screening in the U.S.
• Windows on Clinical GI lecture series: NAFLD, Crohn’s disease and gastroparesis

View all upcoming Roundtables in the community at https://community.gastro.org/discussions.

Gastroenterology is proud to announce the release of a special collection of colorectal cancer articles. This curated collection includes some of the top colorectal cancer research published over the last 3 years with new research being added to the collection as it’s published.

View the special collection on Gastroenterology’s website, which is designed to help you quickly scan recent colorectal cancer research and easily navigate to studies of interest. Recent articles include:
 

• Use of Artificial Intelligence-Based Analytics From Live Colonoscopies to Optimize the Quality of the Colonoscopy Examination in Real Time: Proof of Concept
• Risk Factors for Early-Onset Colorectal Cancer
• Causes of Post-Colonoscopy Colorectal Cancers Based on World Endoscopy Organization System of Analysis

To view all of Gastroenterology’s curated article collections, please visit gastro.org/GastroCollections.

[email protected]

Gastroenterology is proud to announce the release of a special collection of colorectal cancer articles. This curated collection includes some of the top colorectal cancer research published over the last 3 years with new research being added to the collection as it’s published.

View the special collection on Gastroenterology’s website, which is designed to help you quickly scan recent colorectal cancer research and easily navigate to studies of interest. Recent articles include:
 

• Use of Artificial Intelligence-Based Analytics From Live Colonoscopies to Optimize the Quality of the Colonoscopy Examination in Real Time: Proof of Concept
• Risk Factors for Early-Onset Colorectal Cancer
• Causes of Post-Colonoscopy Colorectal Cancers Based on World Endoscopy Organization System of Analysis

To view all of Gastroenterology’s curated article collections, please visit gastro.org/GastroCollections.

[email protected]

Gastroenterology is proud to announce the release of a special collection of colorectal cancer articles. This curated collection includes some of the top colorectal cancer research published over the last 3 years with new research being added to the collection as it’s published.

View the special collection on Gastroenterology’s website, which is designed to help you quickly scan recent colorectal cancer research and easily navigate to studies of interest. Recent articles include:
 

• Use of Artificial Intelligence-Based Analytics From Live Colonoscopies to Optimize the Quality of the Colonoscopy Examination in Real Time: Proof of Concept
• Risk Factors for Early-Onset Colorectal Cancer
• Causes of Post-Colonoscopy Colorectal Cancers Based on World Endoscopy Organization System of Analysis

To view all of Gastroenterology’s curated article collections, please visit gastro.org/GastroCollections.

[email protected]

The search engine giants, Dr. Google or Dr. Bing, are visited by most of our patients before seeking medical help. In 1976, medical student Tom Ferguson, MD, first coined the term e-Patient. It means a health consumer who uses the Internet to gather information about a medical condition for themselves or on behalf of family and friends and uses electronic communication tools to cope with medical conditions. Dr. Ferguson described e-Patients as “empowered medical consumers.”¹

During the COVID-19 pandemic, social media and networking platforms – such as Facebook, Twitter, Instagram, Snapchat, YouTube, WhatsApp, online health support groups – are used increasingly by e-Patients to gather critical health information. Health care providers often take a conflicted stand on the use of social media. Though we want our patients to read about their illnesses and make informed choices, we often get frustrated by misdiagnoses, misinformation, and disinformation that comes with it.

According to a study investigating the differential diffusion of news stories distributed on Twitter from 2006 to 2017, fake news was considered more novel than true news, and people were more likely to share novel information.² Bots accelerated the spread of true and fake news at the same rate, implying that fake news spreads more than the truth because humans, not robots, are more likely to spread it. Social media has promoted some of the best health campaigns, like public cancer awareness, the ALS Ice Bucket Challenge, World Heart Day, and others. At the same time, it has also provided a platform for antivaccination activists, dangerous and unproven alternative cancer therapies, weight loss pills, and nutrition plans.

According to a Pew Research Center survey, 72% of adult Internet users had searched online for information about a range of health issues of their own or for others in the past 12 months.³ A survey from 2019-2020 showed that those who relied on social media for news were among the least knowledgeable about key facts during the COVID-19 outbreak.⁴ About 74% of public posts about COVID-19 were linked to news organizations, while just 1% linked to health and science sites.⁵ While social media has emerged as one of the most significant health information sources, it famously has only a few safeguards in place against medical misinformation. Requiring responsibility and regulations for accurate or evidence-based information walks a thin line on infringing freedom of speech. Medical misinformation related to COVID-19 has become as contagious as the virus itself.

In February 2020, the World Health Organization warned that a massive ‘Infodemic’ had accompanied the COVID-19 outbreak, with an overabundance of information, some accurate and some not, making it difficult for people to find reliable sources and trustworthy information.⁶ The Black immunity myth, groups opposing vaccines, campaigns against 5G mobile phone networks, suggestions that SARS-CoV-2 was an engineered bioweapon, and online rumors leading to mob attacks in India and mass poisonings in Iran are some of the misleading health information that has circulated related to COVID-19.

In the Web 2.0 era, in which credible health information comes packaged with divisive and misleading information, social media’s full impact on health care, health outcomes, and mental health has yet to be explored. Social networks and media sharing networks have recently announced initiatives to stop misinformation and disinformation by fact-checking, flagging, issuing warnings, and deleting misinformation or misleading content. Providing links to more and correct information and partnering with health and science organizations can also encourage the spread of verifiable information.

While we have yet to see if social media safeguards are adequate, the medical community needs to proactively educate patients on the appropriate use of social media for health information, e-Health literacy, and media health literacy. Like health care providers evaluating scientific papers, we need to cultivate e-Patients’ ability to seek, evaluate, understand, and convey health information from electronic sources. Although the measurement and training tools for e-Health and media health literacy are still scarce, a good place to start could be to have simple conversations with patients. Encouraging patients to critically analyze online information, use credible social media sources, and recognizing the warnings, red flags, and links on unreliable information are some of the discussions worth considering. Equally important is to discourage patients from changing health behaviors or practices based on unverified social media resources and discussing the possible impact of medical misinformation.

A practical approach for e-Patients could be to ask the Five Ws, considered fundamental in information gathering: Who, What, Why, When, and Where.^7,8

• Who runs the website? Examine the authors, sponsors, and sources. Federal agencies’ website addresses end in “.gov,” educational institutions maintain “.edu,” large professional or nonprofit organizations often use “.org,” and commercial websites use “.com.”
• What is offered, and What is the evidence? Does it provide unbelievable solutions or quick, miracle cures?
• Why was the site created? Is the mission or goal to inform, explain, or sell health or medical products? Check details on “About This Site” or “About Us.”
• When was the information written or the webpage last updated?
• Where are the privacy policies? Is your privacy protected?

The anonymity of sources, sponsors, financial interests, or the lack of medical credentials and reputable medical research, the use of testimonials as evidence, outdated or incomplete information, and emotional or exaggerated language should raise suspicion about the reliability of the information. Tools like the online tutorial and a checklist from the National Institute of Health’s National Library of Medicine can also be offered to e-Patients to learn how to evaluate health information online.^9,10

Online health support groups widely used by patients can be an additional layer of support but can also be a source of misinformation. Since they have fewer gatekeepers than traditional face-to-face communication, keeping a check on the credibility of the information can be difficult. Support groups affiliated with local hospitals or national organizations, or those endorsed by well-known scientific societies, can be encouraged instead of less credible sources. Some online support groups, run by non–health care professionals but with experienced and reliable scientific panels, can be useful resources. However, patients must check for the credibility and reliability of the information.

Lastly, just as hospitalists take a social history of our patients, we could also ask for a “social media history” to understand patients’ sources of health information. We can then guide them toward more credible sources to make them truly empowered medical consumers.
 

Dr. Saigal is a hospitalist and clinical assistant professor of medicine in the division of hospital medicine at the Ohio State University Wexner Medical Center, Columbus.

References

1. Nelson R. Informatics: Empowering ePatients to drive health care reform - part I. Online J Issues Nurs. 2016 Sep 13;21(3):9.

2. Vosoughi S et al. The spread of true and false news online. Science. 2012;359(6380):1146-51.

3. Fox S. The social life of health information. Pew Research Center: Fact Tank. 2014 Jan 15. Accessed 2020 Jul 31.

4. Mitchel A, Jurkowitz M, Oliphant JB, Shearer E. Americans Who Mainly Get Their News on Social Media Are Less Engaged, Less Knowledgeable. Pew Research Center: Journalism & Media. 2020 Jul 30. Accessed 2020 Jul 31.

5. Stocking G, Matsa KE, Khuzam M. As COVID-19 Emerged in U.S., Facebook Posts About It Appeared in a Wide Range of Public Pages, Groups Pew Research Center: Journalism & Media. 2020 Jun 24. Accessed 2020 Jul 31.

6. Munich Security Conference. World Health Organization. 2020 Feb 15. Accessed 2020 Jul 31.

7. Levin-Zamir D, Bertschi I. Media health literacy, eHealth literacy, and the role of the social environment in context. Int J Environ Res Public Health. 2018 Aug 3;15(8):1643.

8. Online Health Information: Is It Reliable? National Institute on Aging, National Institutes of Health. 2018 Oct 31. Accessed 2020 Aug 10.

9. How To Evaluate Health Information on the Internet: Questions and Answers. Office of Dietary Supplements, National Institutes of Health. 2011 Jun 24. Accessed 2020 Aug 10.

10. Evaluating Internet Health Information: A Tutorial From the National Library of Medicine. Medline Plus. 2020 Mar 6. Accessed 2020 Aug 10.
 

The search engine giants, Dr. Google or Dr. Bing, are visited by most of our patients before seeking medical help. In 1976, medical student Tom Ferguson, MD, first coined the term e-Patient. It means a health consumer who uses the Internet to gather information about a medical condition for themselves or on behalf of family and friends and uses electronic communication tools to cope with medical conditions. Dr. Ferguson described e-Patients as “empowered medical consumers.”¹

During the COVID-19 pandemic, social media and networking platforms – such as Facebook, Twitter, Instagram, Snapchat, YouTube, WhatsApp, online health support groups – are used increasingly by e-Patients to gather critical health information. Health care providers often take a conflicted stand on the use of social media. Though we want our patients to read about their illnesses and make informed choices, we often get frustrated by misdiagnoses, misinformation, and disinformation that comes with it.

According to a study investigating the differential diffusion of news stories distributed on Twitter from 2006 to 2017, fake news was considered more novel than true news, and people were more likely to share novel information.² Bots accelerated the spread of true and fake news at the same rate, implying that fake news spreads more than the truth because humans, not robots, are more likely to spread it. Social media has promoted some of the best health campaigns, like public cancer awareness, the ALS Ice Bucket Challenge, World Heart Day, and others. At the same time, it has also provided a platform for antivaccination activists, dangerous and unproven alternative cancer therapies, weight loss pills, and nutrition plans.

According to a Pew Research Center survey, 72% of adult Internet users had searched online for information about a range of health issues of their own or for others in the past 12 months.³ A survey from 2019-2020 showed that those who relied on social media for news were among the least knowledgeable about key facts during the COVID-19 outbreak.⁴ About 74% of public posts about COVID-19 were linked to news organizations, while just 1% linked to health and science sites.⁵ While social media has emerged as one of the most significant health information sources, it famously has only a few safeguards in place against medical misinformation. Requiring responsibility and regulations for accurate or evidence-based information walks a thin line on infringing freedom of speech. Medical misinformation related to COVID-19 has become as contagious as the virus itself.

In February 2020, the World Health Organization warned that a massive ‘Infodemic’ had accompanied the COVID-19 outbreak, with an overabundance of information, some accurate and some not, making it difficult for people to find reliable sources and trustworthy information.⁶ The Black immunity myth, groups opposing vaccines, campaigns against 5G mobile phone networks, suggestions that SARS-CoV-2 was an engineered bioweapon, and online rumors leading to mob attacks in India and mass poisonings in Iran are some of the misleading health information that has circulated related to COVID-19.

In the Web 2.0 era, in which credible health information comes packaged with divisive and misleading information, social media’s full impact on health care, health outcomes, and mental health has yet to be explored. Social networks and media sharing networks have recently announced initiatives to stop misinformation and disinformation by fact-checking, flagging, issuing warnings, and deleting misinformation or misleading content. Providing links to more and correct information and partnering with health and science organizations can also encourage the spread of verifiable information.

While we have yet to see if social media safeguards are adequate, the medical community needs to proactively educate patients on the appropriate use of social media for health information, e-Health literacy, and media health literacy. Like health care providers evaluating scientific papers, we need to cultivate e-Patients’ ability to seek, evaluate, understand, and convey health information from electronic sources. Although the measurement and training tools for e-Health and media health literacy are still scarce, a good place to start could be to have simple conversations with patients. Encouraging patients to critically analyze online information, use credible social media sources, and recognizing the warnings, red flags, and links on unreliable information are some of the discussions worth considering. Equally important is to discourage patients from changing health behaviors or practices based on unverified social media resources and discussing the possible impact of medical misinformation.

A practical approach for e-Patients could be to ask the Five Ws, considered fundamental in information gathering: Who, What, Why, When, and Where.^7,8

• Who runs the website? Examine the authors, sponsors, and sources. Federal agencies’ website addresses end in “.gov,” educational institutions maintain “.edu,” large professional or nonprofit organizations often use “.org,” and commercial websites use “.com.”
• What is offered, and What is the evidence? Does it provide unbelievable solutions or quick, miracle cures?
• Why was the site created? Is the mission or goal to inform, explain, or sell health or medical products? Check details on “About This Site” or “About Us.”
• When was the information written or the webpage last updated?
• Where are the privacy policies? Is your privacy protected?

The anonymity of sources, sponsors, financial interests, or the lack of medical credentials and reputable medical research, the use of testimonials as evidence, outdated or incomplete information, and emotional or exaggerated language should raise suspicion about the reliability of the information. Tools like the online tutorial and a checklist from the National Institute of Health’s National Library of Medicine can also be offered to e-Patients to learn how to evaluate health information online.^9,10

Online health support groups widely used by patients can be an additional layer of support but can also be a source of misinformation. Since they have fewer gatekeepers than traditional face-to-face communication, keeping a check on the credibility of the information can be difficult. Support groups affiliated with local hospitals or national organizations, or those endorsed by well-known scientific societies, can be encouraged instead of less credible sources. Some online support groups, run by non–health care professionals but with experienced and reliable scientific panels, can be useful resources. However, patients must check for the credibility and reliability of the information.

Lastly, just as hospitalists take a social history of our patients, we could also ask for a “social media history” to understand patients’ sources of health information. We can then guide them toward more credible sources to make them truly empowered medical consumers.
 

Dr. Saigal is a hospitalist and clinical assistant professor of medicine in the division of hospital medicine at the Ohio State University Wexner Medical Center, Columbus.

References

1. Nelson R. Informatics: Empowering ePatients to drive health care reform - part I. Online J Issues Nurs. 2016 Sep 13;21(3):9.

2. Vosoughi S et al. The spread of true and false news online. Science. 2012;359(6380):1146-51.

3. Fox S. The social life of health information. Pew Research Center: Fact Tank. 2014 Jan 15. Accessed 2020 Jul 31.

4. Mitchel A, Jurkowitz M, Oliphant JB, Shearer E. Americans Who Mainly Get Their News on Social Media Are Less Engaged, Less Knowledgeable. Pew Research Center: Journalism & Media. 2020 Jul 30. Accessed 2020 Jul 31.

5. Stocking G, Matsa KE, Khuzam M. As COVID-19 Emerged in U.S., Facebook Posts About It Appeared in a Wide Range of Public Pages, Groups Pew Research Center: Journalism & Media. 2020 Jun 24. Accessed 2020 Jul 31.

6. Munich Security Conference. World Health Organization. 2020 Feb 15. Accessed 2020 Jul 31.

7. Levin-Zamir D, Bertschi I. Media health literacy, eHealth literacy, and the role of the social environment in context. Int J Environ Res Public Health. 2018 Aug 3;15(8):1643.

8. Online Health Information: Is It Reliable? National Institute on Aging, National Institutes of Health. 2018 Oct 31. Accessed 2020 Aug 10.

9. How To Evaluate Health Information on the Internet: Questions and Answers. Office of Dietary Supplements, National Institutes of Health. 2011 Jun 24. Accessed 2020 Aug 10.

10. Evaluating Internet Health Information: A Tutorial From the National Library of Medicine. Medline Plus. 2020 Mar 6. Accessed 2020 Aug 10.
 

The search engine giants, Dr. Google or Dr. Bing, are visited by most of our patients before seeking medical help. In 1976, medical student Tom Ferguson, MD, first coined the term e-Patient. It means a health consumer who uses the Internet to gather information about a medical condition for themselves or on behalf of family and friends and uses electronic communication tools to cope with medical conditions. Dr. Ferguson described e-Patients as “empowered medical consumers.”¹

During the COVID-19 pandemic, social media and networking platforms – such as Facebook, Twitter, Instagram, Snapchat, YouTube, WhatsApp, online health support groups – are used increasingly by e-Patients to gather critical health information. Health care providers often take a conflicted stand on the use of social media. Though we want our patients to read about their illnesses and make informed choices, we often get frustrated by misdiagnoses, misinformation, and disinformation that comes with it.

According to a study investigating the differential diffusion of news stories distributed on Twitter from 2006 to 2017, fake news was considered more novel than true news, and people were more likely to share novel information.² Bots accelerated the spread of true and fake news at the same rate, implying that fake news spreads more than the truth because humans, not robots, are more likely to spread it. Social media has promoted some of the best health campaigns, like public cancer awareness, the ALS Ice Bucket Challenge, World Heart Day, and others. At the same time, it has also provided a platform for antivaccination activists, dangerous and unproven alternative cancer therapies, weight loss pills, and nutrition plans.

According to a Pew Research Center survey, 72% of adult Internet users had searched online for information about a range of health issues of their own or for others in the past 12 months.³ A survey from 2019-2020 showed that those who relied on social media for news were among the least knowledgeable about key facts during the COVID-19 outbreak.⁴ About 74% of public posts about COVID-19 were linked to news organizations, while just 1% linked to health and science sites.⁵ While social media has emerged as one of the most significant health information sources, it famously has only a few safeguards in place against medical misinformation. Requiring responsibility and regulations for accurate or evidence-based information walks a thin line on infringing freedom of speech. Medical misinformation related to COVID-19 has become as contagious as the virus itself.

In February 2020, the World Health Organization warned that a massive ‘Infodemic’ had accompanied the COVID-19 outbreak, with an overabundance of information, some accurate and some not, making it difficult for people to find reliable sources and trustworthy information.⁶ The Black immunity myth, groups opposing vaccines, campaigns against 5G mobile phone networks, suggestions that SARS-CoV-2 was an engineered bioweapon, and online rumors leading to mob attacks in India and mass poisonings in Iran are some of the misleading health information that has circulated related to COVID-19.

In the Web 2.0 era, in which credible health information comes packaged with divisive and misleading information, social media’s full impact on health care, health outcomes, and mental health has yet to be explored. Social networks and media sharing networks have recently announced initiatives to stop misinformation and disinformation by fact-checking, flagging, issuing warnings, and deleting misinformation or misleading content. Providing links to more and correct information and partnering with health and science organizations can also encourage the spread of verifiable information.

While we have yet to see if social media safeguards are adequate, the medical community needs to proactively educate patients on the appropriate use of social media for health information, e-Health literacy, and media health literacy. Like health care providers evaluating scientific papers, we need to cultivate e-Patients’ ability to seek, evaluate, understand, and convey health information from electronic sources. Although the measurement and training tools for e-Health and media health literacy are still scarce, a good place to start could be to have simple conversations with patients. Encouraging patients to critically analyze online information, use credible social media sources, and recognizing the warnings, red flags, and links on unreliable information are some of the discussions worth considering. Equally important is to discourage patients from changing health behaviors or practices based on unverified social media resources and discussing the possible impact of medical misinformation.

A practical approach for e-Patients could be to ask the Five Ws, considered fundamental in information gathering: Who, What, Why, When, and Where.^7,8

• Who runs the website? Examine the authors, sponsors, and sources. Federal agencies’ website addresses end in “.gov,” educational institutions maintain “.edu,” large professional or nonprofit organizations often use “.org,” and commercial websites use “.com.”
• What is offered, and What is the evidence? Does it provide unbelievable solutions or quick, miracle cures?
• Why was the site created? Is the mission or goal to inform, explain, or sell health or medical products? Check details on “About This Site” or “About Us.”
• When was the information written or the webpage last updated?
• Where are the privacy policies? Is your privacy protected?

The anonymity of sources, sponsors, financial interests, or the lack of medical credentials and reputable medical research, the use of testimonials as evidence, outdated or incomplete information, and emotional or exaggerated language should raise suspicion about the reliability of the information. Tools like the online tutorial and a checklist from the National Institute of Health’s National Library of Medicine can also be offered to e-Patients to learn how to evaluate health information online.^9,10

Online health support groups widely used by patients can be an additional layer of support but can also be a source of misinformation. Since they have fewer gatekeepers than traditional face-to-face communication, keeping a check on the credibility of the information can be difficult. Support groups affiliated with local hospitals or national organizations, or those endorsed by well-known scientific societies, can be encouraged instead of less credible sources. Some online support groups, run by non–health care professionals but with experienced and reliable scientific panels, can be useful resources. However, patients must check for the credibility and reliability of the information.

Lastly, just as hospitalists take a social history of our patients, we could also ask for a “social media history” to understand patients’ sources of health information. We can then guide them toward more credible sources to make them truly empowered medical consumers.
 

Dr. Saigal is a hospitalist and clinical assistant professor of medicine in the division of hospital medicine at the Ohio State University Wexner Medical Center, Columbus.

References

1. Nelson R. Informatics: Empowering ePatients to drive health care reform - part I. Online J Issues Nurs. 2016 Sep 13;21(3):9.

2. Vosoughi S et al. The spread of true and false news online. Science. 2012;359(6380):1146-51.

3. Fox S. The social life of health information. Pew Research Center: Fact Tank. 2014 Jan 15. Accessed 2020 Jul 31.

4. Mitchel A, Jurkowitz M, Oliphant JB, Shearer E. Americans Who Mainly Get Their News on Social Media Are Less Engaged, Less Knowledgeable. Pew Research Center: Journalism & Media. 2020 Jul 30. Accessed 2020 Jul 31.

5. Stocking G, Matsa KE, Khuzam M. As COVID-19 Emerged in U.S., Facebook Posts About It Appeared in a Wide Range of Public Pages, Groups Pew Research Center: Journalism & Media. 2020 Jun 24. Accessed 2020 Jul 31.

6. Munich Security Conference. World Health Organization. 2020 Feb 15. Accessed 2020 Jul 31.

7. Levin-Zamir D, Bertschi I. Media health literacy, eHealth literacy, and the role of the social environment in context. Int J Environ Res Public Health. 2018 Aug 3;15(8):1643.

8. Online Health Information: Is It Reliable? National Institute on Aging, National Institutes of Health. 2018 Oct 31. Accessed 2020 Aug 10.

9. How To Evaluate Health Information on the Internet: Questions and Answers. Office of Dietary Supplements, National Institutes of Health. 2011 Jun 24. Accessed 2020 Aug 10.

10. Evaluating Internet Health Information: A Tutorial From the National Library of Medicine. Medline Plus. 2020 Mar 6. Accessed 2020 Aug 10.
 

Monitor antidrug antibodies for their impact on drug clearance to maximize treatment outcomes in rheumatology patients treated with biologics, Niels Vande Casteele, PharmD, PhD, said in a virtual presentation at the annual Perspectives in Rheumatic Diseases held by Global Academy for Medical Education.

Antidrug antibodies (ADAb) are associated with impaired drug efficacy and safety, he noted. Furthermore, he indicated that when ADAb bind to the drug, they can either block the activity of the drug directly and/or may cause the formation of complexes, leading to accelerated drug clearance and reduced drug exposure.

Dr. Vande Casteele, assistant professor in the department of medicine at the University of California, San Diego, outlined factors that contribute to immunogenicity, which occurs when the body reacts to neoantigens, or when there is a breakdown in immune tolerance, he said.

Genetics can play a key role in the risk for immunogenicity, as can the route of administration, dose, treatment duration, and concomitant diseases or medications, he explained.

In addition, product-related factors including sequence variation, glycosylation, host cells, contaminants and processing impurities, formulation, and handling and storage issues can impact immunogenicity, he noted.

For example, Dr. Vande Casteele cited a study in which the proportion of infliximab-treated patients with positive ADAbs was substantially higher among those receiving the drug intravenously, compared with those receiving it subcutaneously. As for treatment dosing, data on patients treated with infliximab have shown that maintenance therapy is associated with lower rates of immunogenicity, compared to episodic therapy, he said.

In terms of genetics, Dr. Vande Casteele cited a study published in January in Gastroenterology showing the presence of the HLA-DQA1*05 allele, carried by approximately 40% of the European population, significantly increased the rate of immunogenicity to infliximab and adalimumab in patients with Crohn’s disease (hazard ratio, 1.90).
 

Therapeutic drug monitoring and overcoming immunogenicity

Dr. Vande Casteele also reviewed how to measure ADAbs. “Antidrug antibody units and concentrations can differ across assays,” he said.

In clinical practice, “the majority of patients at the time of secondary loss of response will present with low drug exposure, and that is when you measure antidrug antibodies,” he said.

In rheumatology patients, the presence of ADAbs against anti–tumor necrosis factor monoclonal antibodies conveys a risk for treatment discontinuation, as well as “a risk of development of hypersensitivity reactions in all immune-mediated inflammatory diseases,” Dr. Vande Casteele said.

However, “the combined use of anti–tumor necrosis factor monoclonal antibodies and disease-modifying antirheumatic drugs reduces the development of antibodies and subsequent risks,” he noted.

For therapeutic drug monitoring in patients with a secondary loss of response, “first, look at the trough concentration,” Dr. Vande Casteele said. “If it is optimal, then ADAbs are probably inconsequential.” If the trough is low or undetectable, examine ADAbs, he added. To manage ADAbs, data support the use of drug dose escalation in some cases. However, “you may be able to overcome the antidrug antibodies in some patients with dose escalation, but this is not always a cost-effective strategy in the long term,” and some patients fail a drug despite adequate drug concentration, which may mean they are failing the mechanism, and not because of pharmacokinetic-related issues, he said.

Dr. Vande Casteele cited a post hoc analysis of the TAXIT trial, published in Gastroenterology. It was the first prospective study to look at proactive therapeutic drug monitoring in patients with inflammatory bowel diseases treated with maintenance infliximab. This post hoc analysis showed that ADAbs were overcome with dose escalation in nearly 50% of patients in the lowest two ADAb quartiles at the start of the trial, and although ADAb were masked by dose escalation in the highest two quartiles, measurement with a drug-sensitive assay showed that ADAb never disappeared, he said.

Another strategy to try to overcome immunogenicity is to add an immunomodulator, Dr. Vande Casteele said. He cited a recent study published in Rheumatology showing that the effect of methotrexate was mediated through immunogenicity for immunogenic compounds such as adalimumab.

Importantly, there is a risk for immunogenicity across agents, he noted. “Patients who are antibody positive to the prior anti-TNF are at a higher risk of developing antibodies to subsequent anti-TNFs.”

Dr. Vande Casteele reported receiving research grants from R-Biopharm; grants and personal fees from Takeda and UCB; and personal fees from Alimentiv (formerly Robarts Clinical Trials), Celltrion, and Prometheus. Global Academy for Medical Education and this news organization are owned by the same parent company.

Monitor antidrug antibodies for their impact on drug clearance to maximize treatment outcomes in rheumatology patients treated with biologics, Niels Vande Casteele, PharmD, PhD, said in a virtual presentation at the annual Perspectives in Rheumatic Diseases held by Global Academy for Medical Education.

Antidrug antibodies (ADAb) are associated with impaired drug efficacy and safety, he noted. Furthermore, he indicated that when ADAb bind to the drug, they can either block the activity of the drug directly and/or may cause the formation of complexes, leading to accelerated drug clearance and reduced drug exposure.

Dr. Vande Casteele, assistant professor in the department of medicine at the University of California, San Diego, outlined factors that contribute to immunogenicity, which occurs when the body reacts to neoantigens, or when there is a breakdown in immune tolerance, he said.

Genetics can play a key role in the risk for immunogenicity, as can the route of administration, dose, treatment duration, and concomitant diseases or medications, he explained.

In addition, product-related factors including sequence variation, glycosylation, host cells, contaminants and processing impurities, formulation, and handling and storage issues can impact immunogenicity, he noted.

For example, Dr. Vande Casteele cited a study in which the proportion of infliximab-treated patients with positive ADAbs was substantially higher among those receiving the drug intravenously, compared with those receiving it subcutaneously. As for treatment dosing, data on patients treated with infliximab have shown that maintenance therapy is associated with lower rates of immunogenicity, compared to episodic therapy, he said.

In terms of genetics, Dr. Vande Casteele cited a study published in January in Gastroenterology showing the presence of the HLA-DQA1*05 allele, carried by approximately 40% of the European population, significantly increased the rate of immunogenicity to infliximab and adalimumab in patients with Crohn’s disease (hazard ratio, 1.90).
 

Therapeutic drug monitoring and overcoming immunogenicity

Dr. Vande Casteele also reviewed how to measure ADAbs. “Antidrug antibody units and concentrations can differ across assays,” he said.

In clinical practice, “the majority of patients at the time of secondary loss of response will present with low drug exposure, and that is when you measure antidrug antibodies,” he said.

In rheumatology patients, the presence of ADAbs against anti–tumor necrosis factor monoclonal antibodies conveys a risk for treatment discontinuation, as well as “a risk of development of hypersensitivity reactions in all immune-mediated inflammatory diseases,” Dr. Vande Casteele said.

However, “the combined use of anti–tumor necrosis factor monoclonal antibodies and disease-modifying antirheumatic drugs reduces the development of antibodies and subsequent risks,” he noted.

For therapeutic drug monitoring in patients with a secondary loss of response, “first, look at the trough concentration,” Dr. Vande Casteele said. “If it is optimal, then ADAbs are probably inconsequential.” If the trough is low or undetectable, examine ADAbs, he added. To manage ADAbs, data support the use of drug dose escalation in some cases. However, “you may be able to overcome the antidrug antibodies in some patients with dose escalation, but this is not always a cost-effective strategy in the long term,” and some patients fail a drug despite adequate drug concentration, which may mean they are failing the mechanism, and not because of pharmacokinetic-related issues, he said.

Dr. Vande Casteele cited a post hoc analysis of the TAXIT trial, published in Gastroenterology. It was the first prospective study to look at proactive therapeutic drug monitoring in patients with inflammatory bowel diseases treated with maintenance infliximab. This post hoc analysis showed that ADAbs were overcome with dose escalation in nearly 50% of patients in the lowest two ADAb quartiles at the start of the trial, and although ADAb were masked by dose escalation in the highest two quartiles, measurement with a drug-sensitive assay showed that ADAb never disappeared, he said.

Another strategy to try to overcome immunogenicity is to add an immunomodulator, Dr. Vande Casteele said. He cited a recent study published in Rheumatology showing that the effect of methotrexate was mediated through immunogenicity for immunogenic compounds such as adalimumab.

Importantly, there is a risk for immunogenicity across agents, he noted. “Patients who are antibody positive to the prior anti-TNF are at a higher risk of developing antibodies to subsequent anti-TNFs.”

Dr. Vande Casteele reported receiving research grants from R-Biopharm; grants and personal fees from Takeda and UCB; and personal fees from Alimentiv (formerly Robarts Clinical Trials), Celltrion, and Prometheus. Global Academy for Medical Education and this news organization are owned by the same parent company.

Monitor antidrug antibodies for their impact on drug clearance to maximize treatment outcomes in rheumatology patients treated with biologics, Niels Vande Casteele, PharmD, PhD, said in a virtual presentation at the annual Perspectives in Rheumatic Diseases held by Global Academy for Medical Education.

Antidrug antibodies (ADAb) are associated with impaired drug efficacy and safety, he noted. Furthermore, he indicated that when ADAb bind to the drug, they can either block the activity of the drug directly and/or may cause the formation of complexes, leading to accelerated drug clearance and reduced drug exposure.

Dr. Vande Casteele, assistant professor in the department of medicine at the University of California, San Diego, outlined factors that contribute to immunogenicity, which occurs when the body reacts to neoantigens, or when there is a breakdown in immune tolerance, he said.

Genetics can play a key role in the risk for immunogenicity, as can the route of administration, dose, treatment duration, and concomitant diseases or medications, he explained.

In addition, product-related factors including sequence variation, glycosylation, host cells, contaminants and processing impurities, formulation, and handling and storage issues can impact immunogenicity, he noted.

For example, Dr. Vande Casteele cited a study in which the proportion of infliximab-treated patients with positive ADAbs was substantially higher among those receiving the drug intravenously, compared with those receiving it subcutaneously. As for treatment dosing, data on patients treated with infliximab have shown that maintenance therapy is associated with lower rates of immunogenicity, compared to episodic therapy, he said.

In terms of genetics, Dr. Vande Casteele cited a study published in January in Gastroenterology showing the presence of the HLA-DQA1*05 allele, carried by approximately 40% of the European population, significantly increased the rate of immunogenicity to infliximab and adalimumab in patients with Crohn’s disease (hazard ratio, 1.90).
 

Therapeutic drug monitoring and overcoming immunogenicity

Dr. Vande Casteele also reviewed how to measure ADAbs. “Antidrug antibody units and concentrations can differ across assays,” he said.

In clinical practice, “the majority of patients at the time of secondary loss of response will present with low drug exposure, and that is when you measure antidrug antibodies,” he said.

In rheumatology patients, the presence of ADAbs against anti–tumor necrosis factor monoclonal antibodies conveys a risk for treatment discontinuation, as well as “a risk of development of hypersensitivity reactions in all immune-mediated inflammatory diseases,” Dr. Vande Casteele said.

However, “the combined use of anti–tumor necrosis factor monoclonal antibodies and disease-modifying antirheumatic drugs reduces the development of antibodies and subsequent risks,” he noted.

For therapeutic drug monitoring in patients with a secondary loss of response, “first, look at the trough concentration,” Dr. Vande Casteele said. “If it is optimal, then ADAbs are probably inconsequential.” If the trough is low or undetectable, examine ADAbs, he added. To manage ADAbs, data support the use of drug dose escalation in some cases. However, “you may be able to overcome the antidrug antibodies in some patients with dose escalation, but this is not always a cost-effective strategy in the long term,” and some patients fail a drug despite adequate drug concentration, which may mean they are failing the mechanism, and not because of pharmacokinetic-related issues, he said.

Dr. Vande Casteele cited a post hoc analysis of the TAXIT trial, published in Gastroenterology. It was the first prospective study to look at proactive therapeutic drug monitoring in patients with inflammatory bowel diseases treated with maintenance infliximab. This post hoc analysis showed that ADAbs were overcome with dose escalation in nearly 50% of patients in the lowest two ADAb quartiles at the start of the trial, and although ADAb were masked by dose escalation in the highest two quartiles, measurement with a drug-sensitive assay showed that ADAb never disappeared, he said.

Another strategy to try to overcome immunogenicity is to add an immunomodulator, Dr. Vande Casteele said. He cited a recent study published in Rheumatology showing that the effect of methotrexate was mediated through immunogenicity for immunogenic compounds such as adalimumab.

Importantly, there is a risk for immunogenicity across agents, he noted. “Patients who are antibody positive to the prior anti-TNF are at a higher risk of developing antibodies to subsequent anti-TNFs.”

Dr. Vande Casteele reported receiving research grants from R-Biopharm; grants and personal fees from Takeda and UCB; and personal fees from Alimentiv (formerly Robarts Clinical Trials), Celltrion, and Prometheus. Global Academy for Medical Education and this news organization are owned by the same parent company.

Whether they realize it or not, dermatologists play a key role in the physical transformation of transgender patients, according to Doris Day, MD.

While clinical management of this patient population has historically been limited to experts in mental health, endocrinology, and select surgeons with experience in sex reassignment surgery, “what dermatologists provide on an aesthetic level through noninvasive or minimally invasive procedures can have a big impact in helping that transformation,” Dr. Day, of the department of dermatology at New York University Langone Health, said during the virtual annual Masters of Aesthetics Symposium. “But, we have to go through a transformation of sorts as well as we care for these patients, because we need to help them in the way that best matches their needs. We need to know about their mental health and the medicines they’re taking as well as their goals for their outcomes. If they’re working with surgeons for sex reassignment, we should have discussions with those clinicians as well.”

Gender-affirming hormone therapy is the primary medical intervention sought by transgender people, she said. This allows the acquisition of secondary sex characteristics more aligned with their gender identity. Feminizing hormone therapy affects the skin by reducing sebaceous gland activity, “which can lead to fewer acne breakouts and smaller pores but also cause drier skin,” Dr. Day said. “We can slow down the growth of body and facial hair and we can perform hair removal treatments. We see decreased male-pattern scalp hair loss, and we see smoother skin as the fat under the skin becomes thicker and the pores become smaller. We can also have increased pigment production, which is always a good thing.”

In a 2016 survey of 327 transgender individuals led by Dr. Day’s mentee, Brian A. Ginsberg, MD, and published in the Journal of the American Academy of Dermatology, most transgender women indicated that their face was most important to have changed, while for men it was the chest. Hair removal was the most common women’s facial procedure, followed by surgery then injectables, mostly performed by plastic surgeons.

Limitations of hormone therapy include the fact that it can take 2 or more years for associated changes to fully develop. “At least here in New York, patients want everything in a New York minute, so that’s always an issue,” she said. “We often recommend that patients wait at least 2 years after beginning hormone therapy before considering drastic feminization surgeries, but there are many options we have for them while they’re waiting for that. Even with hormone therapy, the bone structure of the face is unaffected, so we need to be artistic in creating a more feminized balance in order to help them physically match their gender to their identity.”

Noninvasive aesthetic procedures can compound the effects of hormone therapy, in addition to offering physical transformation beyond hormone therapy. She recalled assisting one of her patients transform from male to female. Over a period of 2 years, Dr. Day added Botox then Juvederm Voluma to the patient’s cheeks and chin, “and she started her transformation to a more feminized gender matching identity,” she said. Next came a hair transplant and the injection of more Voluma and fillers in the lips and cheeks on an as-needed basis.

“During one visit, I felt that we could still do more,” Dr. Day recalled. “She looked at me and said, ‘Actually, I feel so happy. This looks like me as I imagined I would look in my mind.’ I realized that my vision for her wasn’t the same as her vision for herself. She was thrilled with her transformation. I realized that as we see these patients, for all we learn about the science of gender transformation, the emotional aspects of our vision of what we can accomplish for our patients versus their vision of what their happiness level is may not entirely match. We have to be careful to help them celebrate their version of their femininity or masculinity, rather than trying to have our patients match what we think we can accomplish for them with our own sense of what femininity or masculinity is.”

Over time, Dr. Day said, the patient’s acne scars improved with fillers and microneedling treatments, and with the hormone therapy. “As we softened her appearance and as she made changes like the earrings that she wore and the hair style that she chose, she was in line with what her perception of her femininity was,” she said. “Little by little we’ve been watching her grow into her new self. It’s been a beautiful transformation. I was honored to be able to share in that journey with her.”

Dr. Day reported having no relevant financial disclosures.

[email protected]

Whether they realize it or not, dermatologists play a key role in the physical transformation of transgender patients, according to Doris Day, MD.

While clinical management of this patient population has historically been limited to experts in mental health, endocrinology, and select surgeons with experience in sex reassignment surgery, “what dermatologists provide on an aesthetic level through noninvasive or minimally invasive procedures can have a big impact in helping that transformation,” Dr. Day, of the department of dermatology at New York University Langone Health, said during the virtual annual Masters of Aesthetics Symposium. “But, we have to go through a transformation of sorts as well as we care for these patients, because we need to help them in the way that best matches their needs. We need to know about their mental health and the medicines they’re taking as well as their goals for their outcomes. If they’re working with surgeons for sex reassignment, we should have discussions with those clinicians as well.”

Gender-affirming hormone therapy is the primary medical intervention sought by transgender people, she said. This allows the acquisition of secondary sex characteristics more aligned with their gender identity. Feminizing hormone therapy affects the skin by reducing sebaceous gland activity, “which can lead to fewer acne breakouts and smaller pores but also cause drier skin,” Dr. Day said. “We can slow down the growth of body and facial hair and we can perform hair removal treatments. We see decreased male-pattern scalp hair loss, and we see smoother skin as the fat under the skin becomes thicker and the pores become smaller. We can also have increased pigment production, which is always a good thing.”

In a 2016 survey of 327 transgender individuals led by Dr. Day’s mentee, Brian A. Ginsberg, MD, and published in the Journal of the American Academy of Dermatology, most transgender women indicated that their face was most important to have changed, while for men it was the chest. Hair removal was the most common women’s facial procedure, followed by surgery then injectables, mostly performed by plastic surgeons.

Limitations of hormone therapy include the fact that it can take 2 or more years for associated changes to fully develop. “At least here in New York, patients want everything in a New York minute, so that’s always an issue,” she said. “We often recommend that patients wait at least 2 years after beginning hormone therapy before considering drastic feminization surgeries, but there are many options we have for them while they’re waiting for that. Even with hormone therapy, the bone structure of the face is unaffected, so we need to be artistic in creating a more feminized balance in order to help them physically match their gender to their identity.”

Noninvasive aesthetic procedures can compound the effects of hormone therapy, in addition to offering physical transformation beyond hormone therapy. She recalled assisting one of her patients transform from male to female. Over a period of 2 years, Dr. Day added Botox then Juvederm Voluma to the patient’s cheeks and chin, “and she started her transformation to a more feminized gender matching identity,” she said. Next came a hair transplant and the injection of more Voluma and fillers in the lips and cheeks on an as-needed basis.

“During one visit, I felt that we could still do more,” Dr. Day recalled. “She looked at me and said, ‘Actually, I feel so happy. This looks like me as I imagined I would look in my mind.’ I realized that my vision for her wasn’t the same as her vision for herself. She was thrilled with her transformation. I realized that as we see these patients, for all we learn about the science of gender transformation, the emotional aspects of our vision of what we can accomplish for our patients versus their vision of what their happiness level is may not entirely match. We have to be careful to help them celebrate their version of their femininity or masculinity, rather than trying to have our patients match what we think we can accomplish for them with our own sense of what femininity or masculinity is.”

Over time, Dr. Day said, the patient’s acne scars improved with fillers and microneedling treatments, and with the hormone therapy. “As we softened her appearance and as she made changes like the earrings that she wore and the hair style that she chose, she was in line with what her perception of her femininity was,” she said. “Little by little we’ve been watching her grow into her new self. It’s been a beautiful transformation. I was honored to be able to share in that journey with her.”

Dr. Day reported having no relevant financial disclosures.

[email protected]

Whether they realize it or not, dermatologists play a key role in the physical transformation of transgender patients, according to Doris Day, MD.

While clinical management of this patient population has historically been limited to experts in mental health, endocrinology, and select surgeons with experience in sex reassignment surgery, “what dermatologists provide on an aesthetic level through noninvasive or minimally invasive procedures can have a big impact in helping that transformation,” Dr. Day, of the department of dermatology at New York University Langone Health, said during the virtual annual Masters of Aesthetics Symposium. “But, we have to go through a transformation of sorts as well as we care for these patients, because we need to help them in the way that best matches their needs. We need to know about their mental health and the medicines they’re taking as well as their goals for their outcomes. If they’re working with surgeons for sex reassignment, we should have discussions with those clinicians as well.”

Gender-affirming hormone therapy is the primary medical intervention sought by transgender people, she said. This allows the acquisition of secondary sex characteristics more aligned with their gender identity. Feminizing hormone therapy affects the skin by reducing sebaceous gland activity, “which can lead to fewer acne breakouts and smaller pores but also cause drier skin,” Dr. Day said. “We can slow down the growth of body and facial hair and we can perform hair removal treatments. We see decreased male-pattern scalp hair loss, and we see smoother skin as the fat under the skin becomes thicker and the pores become smaller. We can also have increased pigment production, which is always a good thing.”

In a 2016 survey of 327 transgender individuals led by Dr. Day’s mentee, Brian A. Ginsberg, MD, and published in the Journal of the American Academy of Dermatology, most transgender women indicated that their face was most important to have changed, while for men it was the chest. Hair removal was the most common women’s facial procedure, followed by surgery then injectables, mostly performed by plastic surgeons.

Limitations of hormone therapy include the fact that it can take 2 or more years for associated changes to fully develop. “At least here in New York, patients want everything in a New York minute, so that’s always an issue,” she said. “We often recommend that patients wait at least 2 years after beginning hormone therapy before considering drastic feminization surgeries, but there are many options we have for them while they’re waiting for that. Even with hormone therapy, the bone structure of the face is unaffected, so we need to be artistic in creating a more feminized balance in order to help them physically match their gender to their identity.”

Noninvasive aesthetic procedures can compound the effects of hormone therapy, in addition to offering physical transformation beyond hormone therapy. She recalled assisting one of her patients transform from male to female. Over a period of 2 years, Dr. Day added Botox then Juvederm Voluma to the patient’s cheeks and chin, “and she started her transformation to a more feminized gender matching identity,” she said. Next came a hair transplant and the injection of more Voluma and fillers in the lips and cheeks on an as-needed basis.

“During one visit, I felt that we could still do more,” Dr. Day recalled. “She looked at me and said, ‘Actually, I feel so happy. This looks like me as I imagined I would look in my mind.’ I realized that my vision for her wasn’t the same as her vision for herself. She was thrilled with her transformation. I realized that as we see these patients, for all we learn about the science of gender transformation, the emotional aspects of our vision of what we can accomplish for our patients versus their vision of what their happiness level is may not entirely match. We have to be careful to help them celebrate their version of their femininity or masculinity, rather than trying to have our patients match what we think we can accomplish for them with our own sense of what femininity or masculinity is.”

Over time, Dr. Day said, the patient’s acne scars improved with fillers and microneedling treatments, and with the hormone therapy. “As we softened her appearance and as she made changes like the earrings that she wore and the hair style that she chose, she was in line with what her perception of her femininity was,” she said. “Little by little we’ve been watching her grow into her new self. It’s been a beautiful transformation. I was honored to be able to share in that journey with her.”

Dr. Day reported having no relevant financial disclosures.

[email protected]