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What role does social media have in GI?
Dear colleagues,
Most of us engage with social media, whether actively tweeting, following friends on Facebook, or discussing TikTok videos with family. Many gastroenterologists leverage social media to build their professional brand and to reach a wider audience. Others remain wary of committing a social media faux paux or worry about patient confidentiality. In this Perspectives column, Dr. Stephen Chris Pappas and Dr. Mohammad Bilal discuss the risks and benefits of social media for the practicing gastroenterologist. Dr. Pappas has a unique perspective as a gastroenterologist who is also trained as a lawyer, and Dr. Bilal speaks from a wealth of experience leading educational activities on social media. We look forward to hearing your thoughts on Twitter @AGA_GIHN and by email at [email protected].
Gyanprakash A. Ketwaroo, MD, MSc, an associate professor of medicine, Yale University, New Haven, Conn., and chief of endoscopy at West Haven (Conn.) VA Medical Center. He is an associate editor for GI & Hepatology News.
Carefully consider the plentiful risks, concerns
BY STEPHEN CHRIS PAPPAS, MD, JD, FAASLD, FACLM
Social media for gastroenterologists comes with benefits accompanied by pesky risks. The risks are pesky like a mosquito bite: An itching bite is annoying, but getting malaria is serious. Managing your unprofessional tweet to salvage your reputation is going to be annoying. Disclosing a patient's identity on social media is going to be serious; you could find yourself fired, fined, reprimanded, and without hospital privileges, as happened recently to a Rhode Island physician. I divide the risks of social media into legal risks (for example, disclosing patient identity or inadvertently creating a doctor-patient relationship), risks of compromising ethical standards (for example, impairing the doctor-patient relationship), and mixed legal/ethics risks (for example, inappropriate Twitter banter disparaging individuals, promotion of “fake news”). Fortunately, these risks are intuitive and can be mitigated by attention to some simple principles.
Disclosing a patient’s identity on social media is clearly in violation of privacy laws and other regulations. Since privacy compliance is drummed into us ad nauseum via annual compliance training, we could ask “how on earth could an inadvertent disclosure of identity occur?” We must remember that sites that are nominally termed “secure” may not be. As a general suggestion, I would regard social media of all types as open public forums with permanent postings. Even limited descriptions of a patient on social media may allow identification of the actual patient. The risk may be highest in smaller communities; in the past I assisted a small-town practitioner manage the fallout from inadvertently identifying a patient on his professional Facebook page by simply saying “I recently managed a 38-year-old pregnant woman with Crohn’s disease ...” That small amount of information allowed some members of his community to identify the specific patient. My suggestion would be to never talk about individual patients on social media. Phrase comments or questions generically; for example, “Crohn’s disease in pregnancy is managed with attention to ...”.
Another legal risk of social media engagement is to unknowingly create a patient-doctor relationship with a duty to treat, opening the door for exposure to malpractice litigation if something goes awry. A patient may interpret a social media interaction as establishing a patient-doctor relationship. While we think we know what defines a doctor-patient relationship, it’s not always clear and varies between jurisdictions. Indeed, a physician-patient relationship may not even be a necessary element of a claim for professional negligence (an issue shared with “curbside” consults). A recent court case in Minnesota ruled that a duty to care is established if “... it is reasonably foreseeable that the third party will rely on the physician’s acts and be harmed by a breach of the standard of care.” That case involved a telephone call, but you could see the standard easily morphing to apply to social media posts. Gastroenterologists should always talk about disease and treatment on social media in generic terms, preferably with appropriate caveats (for example, “Patients with cholestasis and intense itching may be treated with naloxone in selected cases after detailed assessment by a hepatologist”).
Impairing an established doctor-patient relationship by “friending” a patient on your personal Facebook risks a potential compromise of professional ethics, breaking the boundaries between profession and person for the gastroenterologist. The approach by most professional societies is that a “friend” on social media is equal to a friend in the real world; the same legal and ethical standards apply. Doctor-patient friendships may compromise objectivity, lead to preferential but not optimal therapy, and increase the risk of skirting around informed consent among other issues. Being friends on social media is discouraged, but not prohibited, by most professional societies and licensing bodies. In my opinion, that is sound advice. Over a career of more than 40 years, I have had patients who became friends, but only after I had transferred their care to another hepatologist.
More recently with escalating, aggressive, tones for social media communications, GI/hepatology practitioners must be aware of the serious risk of blurring their personal and professional online lives, particularly where Twitter is involved. The rapidity which people seem to want to reply to a tweet, the public and durable natures of a tweet, and the ability to significantly retweet and repost all spell potential disasters for the physician tweeting an inappropriate communication. Separation of personal and professional social media accounts is strongly encouraged but alone is not enough; you are never totally anonymous online. The reality is that a physician will be judged for an inappropriate communication whether it’s found on their professional or personal site. Either posting could result in reputation damage, reprimands, medical license restrictions or revocations, and litigation. Nationally, medical boards now regularly deal with disciplinary actions for inappropriate social media activity. The best preventive measures include pausing before you post, check the veracity of what you are posting, place your post in context, and assess the tone of your post and the tone of the site that you are posting to. A perfect storm for disaster is that the material is not clearly evidence based and could be construed as “fake,” you are personally emotionally charged, and the site you are posting to is a known cauldron of emotion and fake news.
In summary, social media affords benefits in a health care setting but it comes with some baggage. However, the risks of a social media presence are largely instinctive. An initial starting point is pausing to consider, “Would I say/do this in a public venue where everybody could hear/see me?” If there is any concern, don’t post. Subsequently, conduct yourself on social media with meticulous attention to protecting confidentiality, avoiding any impression of creating a doctor-patient relationship, avoiding doctor-friend relationships, being aware of key legal, institutional, and professional society guidance, separating personal and professional activities, and maintaining professionalism.
Dr. Pappas is in the GI and hepatology section of the department of medicine at Baylor College of Medicine, Houston. He has no relevant conflicts of interest to disclose.
References
Attai DJ et al. Semin Hematol. 2017 Oct; 54(4): 198-204.
Bal BS et al. Clin Orthop Relat Res. 2019 Oct; 477(10): 2204-6.
Ekrem, D et al. 20111 Jun 6. https://www.kevinmd.com/2011/06/7-tips-avoid-hipaa-violations-social-media.html
Hallenbeck J. Doctor and Friend. 2005 Jun. https://journalofethics.ama-assn.org/article/doctor-and-friend/2005-06
Moses RE et al. Am J Gastroenterol. 2014 Aug;109(8):1128-32.
Understand its multifaceted importance
BY MOHAMMAD BILAL, MD, FACP
Merriam-Webster’s dictionary defines social media as “forms of electronic communication (such as websites for social networking and microblogging) through which users create online communities to share information, ideas, personal messages, and other content.” Over the last few years, there has been an increase in use of social media by medical professionals. Whether we like it or not, social media is here to stay. Patients use social media to look up information regarding their doctors, medical practices use it to promote the services they offer, institutions share their programs and initiatives, and doctors use it for education, to engage with like-minded colleagues, collaborate, spread awareness, network, and combat medical misinformation. Social media is now rapidly being used by gastroenterologists and hepatologists, as well as majority of professional GI organizations, and hashtags such as “#MedTwitter”, “#GITwitter,” and “#LiverTwitter” have developed into popular academic forums.1 Therefore, the impact of social media in GI is multifaceted and includes its role in medical education, promoting your practice or division, finding collaborations, building your network and establishing mentors and peer-mentors, disseminating your work, and building your brand.2
What is your goal?
Gastroenterologists could have one or more of the goals mentioned above for using social media. Determining the goals for social media use a priori will allow for determining which social media platform will be appropriate for you. Therefore, it is important to understand the users of various social media platforms. In 2017, Facebook was the highest used social media platform in all age groups, whereas Instagram was most popular amongst ages 18-29 years, while Twitter was used more commonly in ages 30-59 years as compared with Instagram. If your goal is to share scientific knowledge and literature with like-minded physicians and interact with leaders in the field, then Twitter may be ideal. If you want to connect with a younger, more diverse audience, Instagram might be a good option. While many physicians may have a Facebook account, this is often reserved for personal use. Many have separated of personal and professional social media use, although they do not need to exist in silos. Defining your goal with social media use will direct you to the best platform to reach your audience.
Medical education
The use of social media especially Twitter for medical education is continuously increasing. Several leaders in the field use “Tweetorials” as a means to educate others. Tweetorials are a collective set of tweets that systematically cover a specialized topic.3 Other educational forums such as @ScopingSundays, @MondayNightIBD, @IBDClub and @GIJournal provide structured platforms for GI focused discussion.4 @MondayNightIBD is also a source for official continued medical education. Other social media educational platforms include “Liver Fellow Network” which has wide variety of educational materials pertaining to hepatology. In addition, there is continuous opportunity to engage with leaders in the field and authors of published studies and guidelines. Several endoscopy educators have dedicated YouTube channels which have endless supply of educational videos.
Networking
As mentioned above, platforms such as #GITwitter and #LiverTwitter have become popular forums for engaging and connecting with like minded colleagues. Social media provides a space to share ideas and build collaborations with colleagues working on similar projects. The concept “#Twitter2Paper” has been proposed which signifies an idea that generated on Twitter and was eventually converted to a manuscript.5
Institutional, divisional, and practice promotion
Social media is a great tool to showcase the clinical, educational and scholarship services and efforts by programs, practices or divisions. During the COVID-19 pandemic, recruitment efforts at all stages were mainly shifted to virtual platforms, and social media was an instrumental way for programs to highlight their culture and initiatives. Prospective applicants can often refer to social media to get a better understanding of what the program offers. Similarly, if a new clinical service is being provided, targeted efforts can be made to ensure that patients are aware of the available services.
Patient education and combating misinformation
Several gastroenterologists also use social media to spread awareness regarding GI diseases. Instagram, Facebook, and TikTok are effective mediums where one can reach a wider audience. It is important for gastroenterologists to provide accurate information since there is a sea of misinformation available on the internet as well. Posts regarding colonoscopy and colon cancer awareness can help alleviate myths regarding role of colonoscopy. In addition, patient advocates use social media to provide peer support to others who deal with challenges related to chronic illnesses such as inflammatory bowel disease.
Sharing your work
Sharing your work on social media can help your work reach a broader audience. Studies have shown that work shared on social media has higher altmetric scores and can also lead to increased citations.
Diversity, equity, and inclusion
Social media offers a platform where one can promote or showcase their support for causes they believe in. The hashtag “#DiversityinGI” has been instrumental in promoting causes pertaining to diversity and inclusion in GI.
Pitfalls
As gastroenterologists continue to use social media, it is important to be mindful of potential pitfalls. The most critical aspect is to always remember that no post should intentionally or unintentionally violate HIPAA. It is advisable to know your institutional and state social media policies.
Social media is beaming with knowledge, education, science and inspiration. There are endless opportunities for professional and personal growth with effective and responsible use of social media. Its never to late to join the conversation.
Dr. Bilal is an assistant professor of medicine at the University of Minnesota, Minneapolis and an advanced endoscopist in the division of gastroenterology at Minneapolis VA Medical Center. He has no relevant conflicts of interest to disclose.
References
1. Mikolajczyk AE et al. Hepatol Commun. 2020 Jul 5;4(8):1229-33.
2. Bilal M and Oxentenko AS. Am J Gastroenterol. 2020 Oct;115(10):1549-52.
3. Breu AC. N Engl J Med. 2019 Sep 19;381(12):1097-8.
4. Bilal M et al. Nat Rev Gastroenterol Hepatol. 2021 Aug;18(8):519-20.
5. Pawlak KM et al. United European Gastroenterol J. 2021 Feb;9(1):129-32.
Dear colleagues,
Most of us engage with social media, whether actively tweeting, following friends on Facebook, or discussing TikTok videos with family. Many gastroenterologists leverage social media to build their professional brand and to reach a wider audience. Others remain wary of committing a social media faux paux or worry about patient confidentiality. In this Perspectives column, Dr. Stephen Chris Pappas and Dr. Mohammad Bilal discuss the risks and benefits of social media for the practicing gastroenterologist. Dr. Pappas has a unique perspective as a gastroenterologist who is also trained as a lawyer, and Dr. Bilal speaks from a wealth of experience leading educational activities on social media. We look forward to hearing your thoughts on Twitter @AGA_GIHN and by email at [email protected].
Gyanprakash A. Ketwaroo, MD, MSc, an associate professor of medicine, Yale University, New Haven, Conn., and chief of endoscopy at West Haven (Conn.) VA Medical Center. He is an associate editor for GI & Hepatology News.
Carefully consider the plentiful risks, concerns
BY STEPHEN CHRIS PAPPAS, MD, JD, FAASLD, FACLM
Social media for gastroenterologists comes with benefits accompanied by pesky risks. The risks are pesky like a mosquito bite: An itching bite is annoying, but getting malaria is serious. Managing your unprofessional tweet to salvage your reputation is going to be annoying. Disclosing a patient's identity on social media is going to be serious; you could find yourself fired, fined, reprimanded, and without hospital privileges, as happened recently to a Rhode Island physician. I divide the risks of social media into legal risks (for example, disclosing patient identity or inadvertently creating a doctor-patient relationship), risks of compromising ethical standards (for example, impairing the doctor-patient relationship), and mixed legal/ethics risks (for example, inappropriate Twitter banter disparaging individuals, promotion of “fake news”). Fortunately, these risks are intuitive and can be mitigated by attention to some simple principles.
Disclosing a patient’s identity on social media is clearly in violation of privacy laws and other regulations. Since privacy compliance is drummed into us ad nauseum via annual compliance training, we could ask “how on earth could an inadvertent disclosure of identity occur?” We must remember that sites that are nominally termed “secure” may not be. As a general suggestion, I would regard social media of all types as open public forums with permanent postings. Even limited descriptions of a patient on social media may allow identification of the actual patient. The risk may be highest in smaller communities; in the past I assisted a small-town practitioner manage the fallout from inadvertently identifying a patient on his professional Facebook page by simply saying “I recently managed a 38-year-old pregnant woman with Crohn’s disease ...” That small amount of information allowed some members of his community to identify the specific patient. My suggestion would be to never talk about individual patients on social media. Phrase comments or questions generically; for example, “Crohn’s disease in pregnancy is managed with attention to ...”.
Another legal risk of social media engagement is to unknowingly create a patient-doctor relationship with a duty to treat, opening the door for exposure to malpractice litigation if something goes awry. A patient may interpret a social media interaction as establishing a patient-doctor relationship. While we think we know what defines a doctor-patient relationship, it’s not always clear and varies between jurisdictions. Indeed, a physician-patient relationship may not even be a necessary element of a claim for professional negligence (an issue shared with “curbside” consults). A recent court case in Minnesota ruled that a duty to care is established if “... it is reasonably foreseeable that the third party will rely on the physician’s acts and be harmed by a breach of the standard of care.” That case involved a telephone call, but you could see the standard easily morphing to apply to social media posts. Gastroenterologists should always talk about disease and treatment on social media in generic terms, preferably with appropriate caveats (for example, “Patients with cholestasis and intense itching may be treated with naloxone in selected cases after detailed assessment by a hepatologist”).
Impairing an established doctor-patient relationship by “friending” a patient on your personal Facebook risks a potential compromise of professional ethics, breaking the boundaries between profession and person for the gastroenterologist. The approach by most professional societies is that a “friend” on social media is equal to a friend in the real world; the same legal and ethical standards apply. Doctor-patient friendships may compromise objectivity, lead to preferential but not optimal therapy, and increase the risk of skirting around informed consent among other issues. Being friends on social media is discouraged, but not prohibited, by most professional societies and licensing bodies. In my opinion, that is sound advice. Over a career of more than 40 years, I have had patients who became friends, but only after I had transferred their care to another hepatologist.
More recently with escalating, aggressive, tones for social media communications, GI/hepatology practitioners must be aware of the serious risk of blurring their personal and professional online lives, particularly where Twitter is involved. The rapidity which people seem to want to reply to a tweet, the public and durable natures of a tweet, and the ability to significantly retweet and repost all spell potential disasters for the physician tweeting an inappropriate communication. Separation of personal and professional social media accounts is strongly encouraged but alone is not enough; you are never totally anonymous online. The reality is that a physician will be judged for an inappropriate communication whether it’s found on their professional or personal site. Either posting could result in reputation damage, reprimands, medical license restrictions or revocations, and litigation. Nationally, medical boards now regularly deal with disciplinary actions for inappropriate social media activity. The best preventive measures include pausing before you post, check the veracity of what you are posting, place your post in context, and assess the tone of your post and the tone of the site that you are posting to. A perfect storm for disaster is that the material is not clearly evidence based and could be construed as “fake,” you are personally emotionally charged, and the site you are posting to is a known cauldron of emotion and fake news.
In summary, social media affords benefits in a health care setting but it comes with some baggage. However, the risks of a social media presence are largely instinctive. An initial starting point is pausing to consider, “Would I say/do this in a public venue where everybody could hear/see me?” If there is any concern, don’t post. Subsequently, conduct yourself on social media with meticulous attention to protecting confidentiality, avoiding any impression of creating a doctor-patient relationship, avoiding doctor-friend relationships, being aware of key legal, institutional, and professional society guidance, separating personal and professional activities, and maintaining professionalism.
Dr. Pappas is in the GI and hepatology section of the department of medicine at Baylor College of Medicine, Houston. He has no relevant conflicts of interest to disclose.
References
Attai DJ et al. Semin Hematol. 2017 Oct; 54(4): 198-204.
Bal BS et al. Clin Orthop Relat Res. 2019 Oct; 477(10): 2204-6.
Ekrem, D et al. 20111 Jun 6. https://www.kevinmd.com/2011/06/7-tips-avoid-hipaa-violations-social-media.html
Hallenbeck J. Doctor and Friend. 2005 Jun. https://journalofethics.ama-assn.org/article/doctor-and-friend/2005-06
Moses RE et al. Am J Gastroenterol. 2014 Aug;109(8):1128-32.
Understand its multifaceted importance
BY MOHAMMAD BILAL, MD, FACP
Merriam-Webster’s dictionary defines social media as “forms of electronic communication (such as websites for social networking and microblogging) through which users create online communities to share information, ideas, personal messages, and other content.” Over the last few years, there has been an increase in use of social media by medical professionals. Whether we like it or not, social media is here to stay. Patients use social media to look up information regarding their doctors, medical practices use it to promote the services they offer, institutions share their programs and initiatives, and doctors use it for education, to engage with like-minded colleagues, collaborate, spread awareness, network, and combat medical misinformation. Social media is now rapidly being used by gastroenterologists and hepatologists, as well as majority of professional GI organizations, and hashtags such as “#MedTwitter”, “#GITwitter,” and “#LiverTwitter” have developed into popular academic forums.1 Therefore, the impact of social media in GI is multifaceted and includes its role in medical education, promoting your practice or division, finding collaborations, building your network and establishing mentors and peer-mentors, disseminating your work, and building your brand.2
What is your goal?
Gastroenterologists could have one or more of the goals mentioned above for using social media. Determining the goals for social media use a priori will allow for determining which social media platform will be appropriate for you. Therefore, it is important to understand the users of various social media platforms. In 2017, Facebook was the highest used social media platform in all age groups, whereas Instagram was most popular amongst ages 18-29 years, while Twitter was used more commonly in ages 30-59 years as compared with Instagram. If your goal is to share scientific knowledge and literature with like-minded physicians and interact with leaders in the field, then Twitter may be ideal. If you want to connect with a younger, more diverse audience, Instagram might be a good option. While many physicians may have a Facebook account, this is often reserved for personal use. Many have separated of personal and professional social media use, although they do not need to exist in silos. Defining your goal with social media use will direct you to the best platform to reach your audience.
Medical education
The use of social media especially Twitter for medical education is continuously increasing. Several leaders in the field use “Tweetorials” as a means to educate others. Tweetorials are a collective set of tweets that systematically cover a specialized topic.3 Other educational forums such as @ScopingSundays, @MondayNightIBD, @IBDClub and @GIJournal provide structured platforms for GI focused discussion.4 @MondayNightIBD is also a source for official continued medical education. Other social media educational platforms include “Liver Fellow Network” which has wide variety of educational materials pertaining to hepatology. In addition, there is continuous opportunity to engage with leaders in the field and authors of published studies and guidelines. Several endoscopy educators have dedicated YouTube channels which have endless supply of educational videos.
Networking
As mentioned above, platforms such as #GITwitter and #LiverTwitter have become popular forums for engaging and connecting with like minded colleagues. Social media provides a space to share ideas and build collaborations with colleagues working on similar projects. The concept “#Twitter2Paper” has been proposed which signifies an idea that generated on Twitter and was eventually converted to a manuscript.5
Institutional, divisional, and practice promotion
Social media is a great tool to showcase the clinical, educational and scholarship services and efforts by programs, practices or divisions. During the COVID-19 pandemic, recruitment efforts at all stages were mainly shifted to virtual platforms, and social media was an instrumental way for programs to highlight their culture and initiatives. Prospective applicants can often refer to social media to get a better understanding of what the program offers. Similarly, if a new clinical service is being provided, targeted efforts can be made to ensure that patients are aware of the available services.
Patient education and combating misinformation
Several gastroenterologists also use social media to spread awareness regarding GI diseases. Instagram, Facebook, and TikTok are effective mediums where one can reach a wider audience. It is important for gastroenterologists to provide accurate information since there is a sea of misinformation available on the internet as well. Posts regarding colonoscopy and colon cancer awareness can help alleviate myths regarding role of colonoscopy. In addition, patient advocates use social media to provide peer support to others who deal with challenges related to chronic illnesses such as inflammatory bowel disease.
Sharing your work
Sharing your work on social media can help your work reach a broader audience. Studies have shown that work shared on social media has higher altmetric scores and can also lead to increased citations.
Diversity, equity, and inclusion
Social media offers a platform where one can promote or showcase their support for causes they believe in. The hashtag “#DiversityinGI” has been instrumental in promoting causes pertaining to diversity and inclusion in GI.
Pitfalls
As gastroenterologists continue to use social media, it is important to be mindful of potential pitfalls. The most critical aspect is to always remember that no post should intentionally or unintentionally violate HIPAA. It is advisable to know your institutional and state social media policies.
Social media is beaming with knowledge, education, science and inspiration. There are endless opportunities for professional and personal growth with effective and responsible use of social media. Its never to late to join the conversation.
Dr. Bilal is an assistant professor of medicine at the University of Minnesota, Minneapolis and an advanced endoscopist in the division of gastroenterology at Minneapolis VA Medical Center. He has no relevant conflicts of interest to disclose.
References
1. Mikolajczyk AE et al. Hepatol Commun. 2020 Jul 5;4(8):1229-33.
2. Bilal M and Oxentenko AS. Am J Gastroenterol. 2020 Oct;115(10):1549-52.
3. Breu AC. N Engl J Med. 2019 Sep 19;381(12):1097-8.
4. Bilal M et al. Nat Rev Gastroenterol Hepatol. 2021 Aug;18(8):519-20.
5. Pawlak KM et al. United European Gastroenterol J. 2021 Feb;9(1):129-32.
Dear colleagues,
Most of us engage with social media, whether actively tweeting, following friends on Facebook, or discussing TikTok videos with family. Many gastroenterologists leverage social media to build their professional brand and to reach a wider audience. Others remain wary of committing a social media faux paux or worry about patient confidentiality. In this Perspectives column, Dr. Stephen Chris Pappas and Dr. Mohammad Bilal discuss the risks and benefits of social media for the practicing gastroenterologist. Dr. Pappas has a unique perspective as a gastroenterologist who is also trained as a lawyer, and Dr. Bilal speaks from a wealth of experience leading educational activities on social media. We look forward to hearing your thoughts on Twitter @AGA_GIHN and by email at [email protected].
Gyanprakash A. Ketwaroo, MD, MSc, an associate professor of medicine, Yale University, New Haven, Conn., and chief of endoscopy at West Haven (Conn.) VA Medical Center. He is an associate editor for GI & Hepatology News.
Carefully consider the plentiful risks, concerns
BY STEPHEN CHRIS PAPPAS, MD, JD, FAASLD, FACLM
Social media for gastroenterologists comes with benefits accompanied by pesky risks. The risks are pesky like a mosquito bite: An itching bite is annoying, but getting malaria is serious. Managing your unprofessional tweet to salvage your reputation is going to be annoying. Disclosing a patient's identity on social media is going to be serious; you could find yourself fired, fined, reprimanded, and without hospital privileges, as happened recently to a Rhode Island physician. I divide the risks of social media into legal risks (for example, disclosing patient identity or inadvertently creating a doctor-patient relationship), risks of compromising ethical standards (for example, impairing the doctor-patient relationship), and mixed legal/ethics risks (for example, inappropriate Twitter banter disparaging individuals, promotion of “fake news”). Fortunately, these risks are intuitive and can be mitigated by attention to some simple principles.
Disclosing a patient’s identity on social media is clearly in violation of privacy laws and other regulations. Since privacy compliance is drummed into us ad nauseum via annual compliance training, we could ask “how on earth could an inadvertent disclosure of identity occur?” We must remember that sites that are nominally termed “secure” may not be. As a general suggestion, I would regard social media of all types as open public forums with permanent postings. Even limited descriptions of a patient on social media may allow identification of the actual patient. The risk may be highest in smaller communities; in the past I assisted a small-town practitioner manage the fallout from inadvertently identifying a patient on his professional Facebook page by simply saying “I recently managed a 38-year-old pregnant woman with Crohn’s disease ...” That small amount of information allowed some members of his community to identify the specific patient. My suggestion would be to never talk about individual patients on social media. Phrase comments or questions generically; for example, “Crohn’s disease in pregnancy is managed with attention to ...”.
Another legal risk of social media engagement is to unknowingly create a patient-doctor relationship with a duty to treat, opening the door for exposure to malpractice litigation if something goes awry. A patient may interpret a social media interaction as establishing a patient-doctor relationship. While we think we know what defines a doctor-patient relationship, it’s not always clear and varies between jurisdictions. Indeed, a physician-patient relationship may not even be a necessary element of a claim for professional negligence (an issue shared with “curbside” consults). A recent court case in Minnesota ruled that a duty to care is established if “... it is reasonably foreseeable that the third party will rely on the physician’s acts and be harmed by a breach of the standard of care.” That case involved a telephone call, but you could see the standard easily morphing to apply to social media posts. Gastroenterologists should always talk about disease and treatment on social media in generic terms, preferably with appropriate caveats (for example, “Patients with cholestasis and intense itching may be treated with naloxone in selected cases after detailed assessment by a hepatologist”).
Impairing an established doctor-patient relationship by “friending” a patient on your personal Facebook risks a potential compromise of professional ethics, breaking the boundaries between profession and person for the gastroenterologist. The approach by most professional societies is that a “friend” on social media is equal to a friend in the real world; the same legal and ethical standards apply. Doctor-patient friendships may compromise objectivity, lead to preferential but not optimal therapy, and increase the risk of skirting around informed consent among other issues. Being friends on social media is discouraged, but not prohibited, by most professional societies and licensing bodies. In my opinion, that is sound advice. Over a career of more than 40 years, I have had patients who became friends, but only after I had transferred their care to another hepatologist.
More recently with escalating, aggressive, tones for social media communications, GI/hepatology practitioners must be aware of the serious risk of blurring their personal and professional online lives, particularly where Twitter is involved. The rapidity which people seem to want to reply to a tweet, the public and durable natures of a tweet, and the ability to significantly retweet and repost all spell potential disasters for the physician tweeting an inappropriate communication. Separation of personal and professional social media accounts is strongly encouraged but alone is not enough; you are never totally anonymous online. The reality is that a physician will be judged for an inappropriate communication whether it’s found on their professional or personal site. Either posting could result in reputation damage, reprimands, medical license restrictions or revocations, and litigation. Nationally, medical boards now regularly deal with disciplinary actions for inappropriate social media activity. The best preventive measures include pausing before you post, check the veracity of what you are posting, place your post in context, and assess the tone of your post and the tone of the site that you are posting to. A perfect storm for disaster is that the material is not clearly evidence based and could be construed as “fake,” you are personally emotionally charged, and the site you are posting to is a known cauldron of emotion and fake news.
In summary, social media affords benefits in a health care setting but it comes with some baggage. However, the risks of a social media presence are largely instinctive. An initial starting point is pausing to consider, “Would I say/do this in a public venue where everybody could hear/see me?” If there is any concern, don’t post. Subsequently, conduct yourself on social media with meticulous attention to protecting confidentiality, avoiding any impression of creating a doctor-patient relationship, avoiding doctor-friend relationships, being aware of key legal, institutional, and professional society guidance, separating personal and professional activities, and maintaining professionalism.
Dr. Pappas is in the GI and hepatology section of the department of medicine at Baylor College of Medicine, Houston. He has no relevant conflicts of interest to disclose.
References
Attai DJ et al. Semin Hematol. 2017 Oct; 54(4): 198-204.
Bal BS et al. Clin Orthop Relat Res. 2019 Oct; 477(10): 2204-6.
Ekrem, D et al. 20111 Jun 6. https://www.kevinmd.com/2011/06/7-tips-avoid-hipaa-violations-social-media.html
Hallenbeck J. Doctor and Friend. 2005 Jun. https://journalofethics.ama-assn.org/article/doctor-and-friend/2005-06
Moses RE et al. Am J Gastroenterol. 2014 Aug;109(8):1128-32.
Understand its multifaceted importance
BY MOHAMMAD BILAL, MD, FACP
Merriam-Webster’s dictionary defines social media as “forms of electronic communication (such as websites for social networking and microblogging) through which users create online communities to share information, ideas, personal messages, and other content.” Over the last few years, there has been an increase in use of social media by medical professionals. Whether we like it or not, social media is here to stay. Patients use social media to look up information regarding their doctors, medical practices use it to promote the services they offer, institutions share their programs and initiatives, and doctors use it for education, to engage with like-minded colleagues, collaborate, spread awareness, network, and combat medical misinformation. Social media is now rapidly being used by gastroenterologists and hepatologists, as well as majority of professional GI organizations, and hashtags such as “#MedTwitter”, “#GITwitter,” and “#LiverTwitter” have developed into popular academic forums.1 Therefore, the impact of social media in GI is multifaceted and includes its role in medical education, promoting your practice or division, finding collaborations, building your network and establishing mentors and peer-mentors, disseminating your work, and building your brand.2
What is your goal?
Gastroenterologists could have one or more of the goals mentioned above for using social media. Determining the goals for social media use a priori will allow for determining which social media platform will be appropriate for you. Therefore, it is important to understand the users of various social media platforms. In 2017, Facebook was the highest used social media platform in all age groups, whereas Instagram was most popular amongst ages 18-29 years, while Twitter was used more commonly in ages 30-59 years as compared with Instagram. If your goal is to share scientific knowledge and literature with like-minded physicians and interact with leaders in the field, then Twitter may be ideal. If you want to connect with a younger, more diverse audience, Instagram might be a good option. While many physicians may have a Facebook account, this is often reserved for personal use. Many have separated of personal and professional social media use, although they do not need to exist in silos. Defining your goal with social media use will direct you to the best platform to reach your audience.
Medical education
The use of social media especially Twitter for medical education is continuously increasing. Several leaders in the field use “Tweetorials” as a means to educate others. Tweetorials are a collective set of tweets that systematically cover a specialized topic.3 Other educational forums such as @ScopingSundays, @MondayNightIBD, @IBDClub and @GIJournal provide structured platforms for GI focused discussion.4 @MondayNightIBD is also a source for official continued medical education. Other social media educational platforms include “Liver Fellow Network” which has wide variety of educational materials pertaining to hepatology. In addition, there is continuous opportunity to engage with leaders in the field and authors of published studies and guidelines. Several endoscopy educators have dedicated YouTube channels which have endless supply of educational videos.
Networking
As mentioned above, platforms such as #GITwitter and #LiverTwitter have become popular forums for engaging and connecting with like minded colleagues. Social media provides a space to share ideas and build collaborations with colleagues working on similar projects. The concept “#Twitter2Paper” has been proposed which signifies an idea that generated on Twitter and was eventually converted to a manuscript.5
Institutional, divisional, and practice promotion
Social media is a great tool to showcase the clinical, educational and scholarship services and efforts by programs, practices or divisions. During the COVID-19 pandemic, recruitment efforts at all stages were mainly shifted to virtual platforms, and social media was an instrumental way for programs to highlight their culture and initiatives. Prospective applicants can often refer to social media to get a better understanding of what the program offers. Similarly, if a new clinical service is being provided, targeted efforts can be made to ensure that patients are aware of the available services.
Patient education and combating misinformation
Several gastroenterologists also use social media to spread awareness regarding GI diseases. Instagram, Facebook, and TikTok are effective mediums where one can reach a wider audience. It is important for gastroenterologists to provide accurate information since there is a sea of misinformation available on the internet as well. Posts regarding colonoscopy and colon cancer awareness can help alleviate myths regarding role of colonoscopy. In addition, patient advocates use social media to provide peer support to others who deal with challenges related to chronic illnesses such as inflammatory bowel disease.
Sharing your work
Sharing your work on social media can help your work reach a broader audience. Studies have shown that work shared on social media has higher altmetric scores and can also lead to increased citations.
Diversity, equity, and inclusion
Social media offers a platform where one can promote or showcase their support for causes they believe in. The hashtag “#DiversityinGI” has been instrumental in promoting causes pertaining to diversity and inclusion in GI.
Pitfalls
As gastroenterologists continue to use social media, it is important to be mindful of potential pitfalls. The most critical aspect is to always remember that no post should intentionally or unintentionally violate HIPAA. It is advisable to know your institutional and state social media policies.
Social media is beaming with knowledge, education, science and inspiration. There are endless opportunities for professional and personal growth with effective and responsible use of social media. Its never to late to join the conversation.
Dr. Bilal is an assistant professor of medicine at the University of Minnesota, Minneapolis and an advanced endoscopist in the division of gastroenterology at Minneapolis VA Medical Center. He has no relevant conflicts of interest to disclose.
References
1. Mikolajczyk AE et al. Hepatol Commun. 2020 Jul 5;4(8):1229-33.
2. Bilal M and Oxentenko AS. Am J Gastroenterol. 2020 Oct;115(10):1549-52.
3. Breu AC. N Engl J Med. 2019 Sep 19;381(12):1097-8.
4. Bilal M et al. Nat Rev Gastroenterol Hepatol. 2021 Aug;18(8):519-20.
5. Pawlak KM et al. United European Gastroenterol J. 2021 Feb;9(1):129-32.
How much do we really know about gender dysphoria?
At the risk of losing a digit or two I am going to dip my toes into the murky waters of gender-affirming care, sometimes referred to as trans care. Recently, Moira Szilagyi, MD, PhD, president of the American Academy of Pediatrics, released two statements, one in the Aug. 22, 2022, Wall Street Journal, the other summarized in the Aug. 25, 2022, AAP Daily Briefing, in which she attempts to clarify the academy’s position on gender-affirming care. They were well-worded and heroic attempts to clear the air. I fear these explanations will do little to encourage informed and courteous discussions between those entrenched on either side of a disagreement that is unfortunately being played out on media outlets and state legislatures instead of the offices of primary care physicians and specialists where it belongs.
The current mess is an example of what can happen when there is a paucity of reliable data, a superabundance of emotion, and a system that feeds on instant news and sound bites with little understanding of how science should work.
Some of the turmoil is a response to the notion that in certain situations gender dysphoria may be a condition that can be learned or mimicked from exposure to other gender-dysphoric individuals. Two papers anchor either side of the debate. The first paper was published in 2018 by a then–Brown University health expert who hypothesized the existence of a condition which she labeled “rapid-onset gender dysphoria [ROGD]”. One can imagine that “social contagion” might be considered as one of the potential contributors to this hypothesized condition. Unfortunately, the publication of the paper ignited a firestorm of criticism from a segment of the population that advocates for the transgender community, prompting the university and the online publisher to backpedal and reevaluate the quality of the research on which the paper was based.
One of the concerns voiced at the time of publication was that the research could be used to support the transphobic agenda by some state legislatures hoping to ban gender-affirming care. How large a role the paper played in the current spate of legislation in is unclear. I suspect it has been small. But, one can’t deny the potential exists.
Leaping forward to 2022, the second paper was published in the August issue of Pediatrics, in which the authors attempted to test the ROGD hypothesis and question the inference of social contagion.
The investigators found that in 2017 and 2019 the birth ratios of transgender-diverse (TGD) individuals did not favor assigned female-sex-at-birth (AFAB) individuals. They also discovered that in their sample overall there was a decrease in the percentage of adolescents who self-identified as TGD. Not surprisingly, “bullying victimization and suicidality were higher among TGD youth when compared with their cisgender peers.” The authors concluded that their findings were “incongruent with an ROGD hypothesis that posits social contagion” nor should it be used to restrict access to gender-affirming care.
There you have it. Are we any closer to understanding gender dysphoria and its origins? I don’t think so. The media is somewhat less confused. The NBC News online presence headline on Aug. 3, 2022, reads “‘Social contagion’ isn’t causing more youths to be transgender, study finds.”
My sense is that the general population perceives an increase in the prevalence of gender dysphoria. It is very likely that this perception is primarily a reflection of a more compassionate and educated attitude in a significant portion of the population making it less challenging for gender-dysphoric youth to surface. However, it should not surprise us that some parents and observers are concerned that a percentage of this increased prevalence is the result of social contagion. Nor should it surprise us that some advocates for the trans population feel threatened by this hypothesis.
Neither of these studies really answers the question of whether some cases of gender dysphoria are the result of social contagion. Both were small samples using methodology that has been called into question. The bottom line is that we need more studies and must remain open to considering their results. That’s how science should work.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].
At the risk of losing a digit or two I am going to dip my toes into the murky waters of gender-affirming care, sometimes referred to as trans care. Recently, Moira Szilagyi, MD, PhD, president of the American Academy of Pediatrics, released two statements, one in the Aug. 22, 2022, Wall Street Journal, the other summarized in the Aug. 25, 2022, AAP Daily Briefing, in which she attempts to clarify the academy’s position on gender-affirming care. They were well-worded and heroic attempts to clear the air. I fear these explanations will do little to encourage informed and courteous discussions between those entrenched on either side of a disagreement that is unfortunately being played out on media outlets and state legislatures instead of the offices of primary care physicians and specialists where it belongs.
The current mess is an example of what can happen when there is a paucity of reliable data, a superabundance of emotion, and a system that feeds on instant news and sound bites with little understanding of how science should work.
Some of the turmoil is a response to the notion that in certain situations gender dysphoria may be a condition that can be learned or mimicked from exposure to other gender-dysphoric individuals. Two papers anchor either side of the debate. The first paper was published in 2018 by a then–Brown University health expert who hypothesized the existence of a condition which she labeled “rapid-onset gender dysphoria [ROGD]”. One can imagine that “social contagion” might be considered as one of the potential contributors to this hypothesized condition. Unfortunately, the publication of the paper ignited a firestorm of criticism from a segment of the population that advocates for the transgender community, prompting the university and the online publisher to backpedal and reevaluate the quality of the research on which the paper was based.
One of the concerns voiced at the time of publication was that the research could be used to support the transphobic agenda by some state legislatures hoping to ban gender-affirming care. How large a role the paper played in the current spate of legislation in is unclear. I suspect it has been small. But, one can’t deny the potential exists.
Leaping forward to 2022, the second paper was published in the August issue of Pediatrics, in which the authors attempted to test the ROGD hypothesis and question the inference of social contagion.
The investigators found that in 2017 and 2019 the birth ratios of transgender-diverse (TGD) individuals did not favor assigned female-sex-at-birth (AFAB) individuals. They also discovered that in their sample overall there was a decrease in the percentage of adolescents who self-identified as TGD. Not surprisingly, “bullying victimization and suicidality were higher among TGD youth when compared with their cisgender peers.” The authors concluded that their findings were “incongruent with an ROGD hypothesis that posits social contagion” nor should it be used to restrict access to gender-affirming care.
There you have it. Are we any closer to understanding gender dysphoria and its origins? I don’t think so. The media is somewhat less confused. The NBC News online presence headline on Aug. 3, 2022, reads “‘Social contagion’ isn’t causing more youths to be transgender, study finds.”
My sense is that the general population perceives an increase in the prevalence of gender dysphoria. It is very likely that this perception is primarily a reflection of a more compassionate and educated attitude in a significant portion of the population making it less challenging for gender-dysphoric youth to surface. However, it should not surprise us that some parents and observers are concerned that a percentage of this increased prevalence is the result of social contagion. Nor should it surprise us that some advocates for the trans population feel threatened by this hypothesis.
Neither of these studies really answers the question of whether some cases of gender dysphoria are the result of social contagion. Both were small samples using methodology that has been called into question. The bottom line is that we need more studies and must remain open to considering their results. That’s how science should work.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].
At the risk of losing a digit or two I am going to dip my toes into the murky waters of gender-affirming care, sometimes referred to as trans care. Recently, Moira Szilagyi, MD, PhD, president of the American Academy of Pediatrics, released two statements, one in the Aug. 22, 2022, Wall Street Journal, the other summarized in the Aug. 25, 2022, AAP Daily Briefing, in which she attempts to clarify the academy’s position on gender-affirming care. They were well-worded and heroic attempts to clear the air. I fear these explanations will do little to encourage informed and courteous discussions between those entrenched on either side of a disagreement that is unfortunately being played out on media outlets and state legislatures instead of the offices of primary care physicians and specialists where it belongs.
The current mess is an example of what can happen when there is a paucity of reliable data, a superabundance of emotion, and a system that feeds on instant news and sound bites with little understanding of how science should work.
Some of the turmoil is a response to the notion that in certain situations gender dysphoria may be a condition that can be learned or mimicked from exposure to other gender-dysphoric individuals. Two papers anchor either side of the debate. The first paper was published in 2018 by a then–Brown University health expert who hypothesized the existence of a condition which she labeled “rapid-onset gender dysphoria [ROGD]”. One can imagine that “social contagion” might be considered as one of the potential contributors to this hypothesized condition. Unfortunately, the publication of the paper ignited a firestorm of criticism from a segment of the population that advocates for the transgender community, prompting the university and the online publisher to backpedal and reevaluate the quality of the research on which the paper was based.
One of the concerns voiced at the time of publication was that the research could be used to support the transphobic agenda by some state legislatures hoping to ban gender-affirming care. How large a role the paper played in the current spate of legislation in is unclear. I suspect it has been small. But, one can’t deny the potential exists.
Leaping forward to 2022, the second paper was published in the August issue of Pediatrics, in which the authors attempted to test the ROGD hypothesis and question the inference of social contagion.
The investigators found that in 2017 and 2019 the birth ratios of transgender-diverse (TGD) individuals did not favor assigned female-sex-at-birth (AFAB) individuals. They also discovered that in their sample overall there was a decrease in the percentage of adolescents who self-identified as TGD. Not surprisingly, “bullying victimization and suicidality were higher among TGD youth when compared with their cisgender peers.” The authors concluded that their findings were “incongruent with an ROGD hypothesis that posits social contagion” nor should it be used to restrict access to gender-affirming care.
There you have it. Are we any closer to understanding gender dysphoria and its origins? I don’t think so. The media is somewhat less confused. The NBC News online presence headline on Aug. 3, 2022, reads “‘Social contagion’ isn’t causing more youths to be transgender, study finds.”
My sense is that the general population perceives an increase in the prevalence of gender dysphoria. It is very likely that this perception is primarily a reflection of a more compassionate and educated attitude in a significant portion of the population making it less challenging for gender-dysphoric youth to surface. However, it should not surprise us that some parents and observers are concerned that a percentage of this increased prevalence is the result of social contagion. Nor should it surprise us that some advocates for the trans population feel threatened by this hypothesis.
Neither of these studies really answers the question of whether some cases of gender dysphoria are the result of social contagion. Both were small samples using methodology that has been called into question. The bottom line is that we need more studies and must remain open to considering their results. That’s how science should work.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].
TikTok’s impact on adolescent mental health
For younger generations, TikTok is a go-to site for those who like short and catchy video clips. As a social media platform that allows concise video sharing, TikTok has over 1 billion monthly global users. Because of its platform size, a plethora of resources, and influence on media discourse, TikTok is the place for content creators to share visual media. Its cursory, condensed content delivery with videos capped at 1-minute focuses on high-yield information and rapid identification of fundamental points that are both engaging and entertaining.
Currently, on TikTok, 40 billion views are associated with the hashtag #mentalhealth. Content creators and regular users are employing this platform to share their own experiences, opinions, and strategies to overcome their struggles. While it is understandable for creators to share their personal stories that may be abusive, traumatic, or violent, they may not be prepared for their video to “go viral.”
Like any other social media platform, hateful speech such as racism, sexism, or xenophobia can accumulate on TikTok, which may cause more self-harm than self-help. Oversharing about personal strategies may lead to misconceived advice for TikTok viewers, while watching these TikTok videos can have negative mental health effects, even though there are no malicious intentions behind the creators who post these videos.
Hence, public health should pay more attention to the potential health-related implications this platform can create, as the quality of the information and the qualifications of the creators are mostly unrevealed. The concerns include undisclosed conflicts of interest, unchecked spread of misinformation, difficulty identifying source credibility, and excessive false information that viewers must filter through.1,2
Individual TikTok users may follow accounts and interpret these content creators as therapists and the content they see as therapy. They may also believe that a close relationship with the content creator exists when it does not. Specifically, these relationships may be defined as parasocial relationships, which are one-sided relationships where one person (the TikTok viewer) extends emotional energy, interest, and time, and the other party (the content creator) is completely unaware of the other’s existence.3 Additionally, Americans who are uninsured/underinsured may turn to this diluted version of therapy to compensate for the one-on-one or group therapy they need.
While TikTok may seem like a dangerous platform to browse through or post on, its growing influence cannot be underestimated. With 41% of TikTok users between the ages of 16 and 24, this is an ideal platform to disseminate public health information pertaining to this age group (for example, safe sex practices, substance abuse, and mental health issues).4 Because younger generations have incorporated social media into their daily lives, the medical community can harness TikTok’s potential to disseminate accurate information to potential patients for targeted medical education.
For example, Jake Goodman, MD, MBA, and Melissa Shepard, MD, each have more than a million TikTok followers and are notable psychiatrists who post a variety of content ranging from recognizing signs of depression to reducing stigma around mental health. Similarly, Justin Puder, PhD, is a licensed psychologist who advocates for ways to overcome mental health issues. By creating diverse content with appealing strategies, spreading accurate medical knowledge, and answering common medical questions for the public, these ‘mental health influencers’ educate potential patients to create patient-centered interactions.
While there are many pros and cons to social media platforms, it is undeniable that these platforms – such as TikTok – are here to stay. It is crucial for members of the medical community to recognize the outlets that younger generations use to express themselves and to exploit these media channels therapeutically.
Ms. Wong is a fourth-year medical student at the New York Institute of Technology College of Osteopathic Medicine in Old Westbury, N.Y. Dr. Chua is a psychiatrist with the department of child and adolescent psychiatry and behavioral sciences at Children’s Hospital of Philadelphia, and assistant professor of clinical psychiatry at the University of Pennsylvania, also in Philadelphia.
References
1. Gottlieb M and Dyer S. Information and Disinformation: Social Media in the COVID-19 Crisis. Acad Emerg Med. 2020 Jul;27(7):640-1. doi: 10.1111/acem.14036.
2. De Veirman M et al. Front Psychol. 2019;10:2685. doi: 10.3389/fpsyg.2019.02685.
3. Bennett N-K et al. “Parasocial Relationships: The Nature of Celebrity Fascinations.” National Register of Health Service Psychologists. https://www.findapsychologist.org/parasocial-relationships-the-nature-of-celebrity-fascinations/.
4. Eghtesadi M and Florea A. Can J Public Health. 2020 Jun;111(3):389-91. doi: 10.17269/s41997-020-00343-0.
For younger generations, TikTok is a go-to site for those who like short and catchy video clips. As a social media platform that allows concise video sharing, TikTok has over 1 billion monthly global users. Because of its platform size, a plethora of resources, and influence on media discourse, TikTok is the place for content creators to share visual media. Its cursory, condensed content delivery with videos capped at 1-minute focuses on high-yield information and rapid identification of fundamental points that are both engaging and entertaining.
Currently, on TikTok, 40 billion views are associated with the hashtag #mentalhealth. Content creators and regular users are employing this platform to share their own experiences, opinions, and strategies to overcome their struggles. While it is understandable for creators to share their personal stories that may be abusive, traumatic, or violent, they may not be prepared for their video to “go viral.”
Like any other social media platform, hateful speech such as racism, sexism, or xenophobia can accumulate on TikTok, which may cause more self-harm than self-help. Oversharing about personal strategies may lead to misconceived advice for TikTok viewers, while watching these TikTok videos can have negative mental health effects, even though there are no malicious intentions behind the creators who post these videos.
Hence, public health should pay more attention to the potential health-related implications this platform can create, as the quality of the information and the qualifications of the creators are mostly unrevealed. The concerns include undisclosed conflicts of interest, unchecked spread of misinformation, difficulty identifying source credibility, and excessive false information that viewers must filter through.1,2
Individual TikTok users may follow accounts and interpret these content creators as therapists and the content they see as therapy. They may also believe that a close relationship with the content creator exists when it does not. Specifically, these relationships may be defined as parasocial relationships, which are one-sided relationships where one person (the TikTok viewer) extends emotional energy, interest, and time, and the other party (the content creator) is completely unaware of the other’s existence.3 Additionally, Americans who are uninsured/underinsured may turn to this diluted version of therapy to compensate for the one-on-one or group therapy they need.
While TikTok may seem like a dangerous platform to browse through or post on, its growing influence cannot be underestimated. With 41% of TikTok users between the ages of 16 and 24, this is an ideal platform to disseminate public health information pertaining to this age group (for example, safe sex practices, substance abuse, and mental health issues).4 Because younger generations have incorporated social media into their daily lives, the medical community can harness TikTok’s potential to disseminate accurate information to potential patients for targeted medical education.
For example, Jake Goodman, MD, MBA, and Melissa Shepard, MD, each have more than a million TikTok followers and are notable psychiatrists who post a variety of content ranging from recognizing signs of depression to reducing stigma around mental health. Similarly, Justin Puder, PhD, is a licensed psychologist who advocates for ways to overcome mental health issues. By creating diverse content with appealing strategies, spreading accurate medical knowledge, and answering common medical questions for the public, these ‘mental health influencers’ educate potential patients to create patient-centered interactions.
While there are many pros and cons to social media platforms, it is undeniable that these platforms – such as TikTok – are here to stay. It is crucial for members of the medical community to recognize the outlets that younger generations use to express themselves and to exploit these media channels therapeutically.
Ms. Wong is a fourth-year medical student at the New York Institute of Technology College of Osteopathic Medicine in Old Westbury, N.Y. Dr. Chua is a psychiatrist with the department of child and adolescent psychiatry and behavioral sciences at Children’s Hospital of Philadelphia, and assistant professor of clinical psychiatry at the University of Pennsylvania, also in Philadelphia.
References
1. Gottlieb M and Dyer S. Information and Disinformation: Social Media in the COVID-19 Crisis. Acad Emerg Med. 2020 Jul;27(7):640-1. doi: 10.1111/acem.14036.
2. De Veirman M et al. Front Psychol. 2019;10:2685. doi: 10.3389/fpsyg.2019.02685.
3. Bennett N-K et al. “Parasocial Relationships: The Nature of Celebrity Fascinations.” National Register of Health Service Psychologists. https://www.findapsychologist.org/parasocial-relationships-the-nature-of-celebrity-fascinations/.
4. Eghtesadi M and Florea A. Can J Public Health. 2020 Jun;111(3):389-91. doi: 10.17269/s41997-020-00343-0.
For younger generations, TikTok is a go-to site for those who like short and catchy video clips. As a social media platform that allows concise video sharing, TikTok has over 1 billion monthly global users. Because of its platform size, a plethora of resources, and influence on media discourse, TikTok is the place for content creators to share visual media. Its cursory, condensed content delivery with videos capped at 1-minute focuses on high-yield information and rapid identification of fundamental points that are both engaging and entertaining.
Currently, on TikTok, 40 billion views are associated with the hashtag #mentalhealth. Content creators and regular users are employing this platform to share their own experiences, opinions, and strategies to overcome their struggles. While it is understandable for creators to share their personal stories that may be abusive, traumatic, or violent, they may not be prepared for their video to “go viral.”
Like any other social media platform, hateful speech such as racism, sexism, or xenophobia can accumulate on TikTok, which may cause more self-harm than self-help. Oversharing about personal strategies may lead to misconceived advice for TikTok viewers, while watching these TikTok videos can have negative mental health effects, even though there are no malicious intentions behind the creators who post these videos.
Hence, public health should pay more attention to the potential health-related implications this platform can create, as the quality of the information and the qualifications of the creators are mostly unrevealed. The concerns include undisclosed conflicts of interest, unchecked spread of misinformation, difficulty identifying source credibility, and excessive false information that viewers must filter through.1,2
Individual TikTok users may follow accounts and interpret these content creators as therapists and the content they see as therapy. They may also believe that a close relationship with the content creator exists when it does not. Specifically, these relationships may be defined as parasocial relationships, which are one-sided relationships where one person (the TikTok viewer) extends emotional energy, interest, and time, and the other party (the content creator) is completely unaware of the other’s existence.3 Additionally, Americans who are uninsured/underinsured may turn to this diluted version of therapy to compensate for the one-on-one or group therapy they need.
While TikTok may seem like a dangerous platform to browse through or post on, its growing influence cannot be underestimated. With 41% of TikTok users between the ages of 16 and 24, this is an ideal platform to disseminate public health information pertaining to this age group (for example, safe sex practices, substance abuse, and mental health issues).4 Because younger generations have incorporated social media into their daily lives, the medical community can harness TikTok’s potential to disseminate accurate information to potential patients for targeted medical education.
For example, Jake Goodman, MD, MBA, and Melissa Shepard, MD, each have more than a million TikTok followers and are notable psychiatrists who post a variety of content ranging from recognizing signs of depression to reducing stigma around mental health. Similarly, Justin Puder, PhD, is a licensed psychologist who advocates for ways to overcome mental health issues. By creating diverse content with appealing strategies, spreading accurate medical knowledge, and answering common medical questions for the public, these ‘mental health influencers’ educate potential patients to create patient-centered interactions.
While there are many pros and cons to social media platforms, it is undeniable that these platforms – such as TikTok – are here to stay. It is crucial for members of the medical community to recognize the outlets that younger generations use to express themselves and to exploit these media channels therapeutically.
Ms. Wong is a fourth-year medical student at the New York Institute of Technology College of Osteopathic Medicine in Old Westbury, N.Y. Dr. Chua is a psychiatrist with the department of child and adolescent psychiatry and behavioral sciences at Children’s Hospital of Philadelphia, and assistant professor of clinical psychiatry at the University of Pennsylvania, also in Philadelphia.
References
1. Gottlieb M and Dyer S. Information and Disinformation: Social Media in the COVID-19 Crisis. Acad Emerg Med. 2020 Jul;27(7):640-1. doi: 10.1111/acem.14036.
2. De Veirman M et al. Front Psychol. 2019;10:2685. doi: 10.3389/fpsyg.2019.02685.
3. Bennett N-K et al. “Parasocial Relationships: The Nature of Celebrity Fascinations.” National Register of Health Service Psychologists. https://www.findapsychologist.org/parasocial-relationships-the-nature-of-celebrity-fascinations/.
4. Eghtesadi M and Florea A. Can J Public Health. 2020 Jun;111(3):389-91. doi: 10.17269/s41997-020-00343-0.
Preparing for back to school amid monkeypox outbreak and ever-changing COVID landscape
Unlike last school year, there are now vaccines available for all over the age of 6 months, and home rapid antigen tests are more readily available. Additionally, many have now been exposed either by infection or vaccination to the virus.
The CDC has removed the recommendations for maintaining cohorts in the K-12 population. This changing landscape along with differing levels of personal risk make it challenging to counsel families about what to expect in terms of COVID this year.
The best defense that we currently have against COVID is the vaccine. Although it seems that many are susceptible to the virus despite the vaccine, those who have been vaccinated are less susceptible to serious disease, including young children.
As older children may be heading to college, it is important
to encourage them to isolate when they have symptoms, even when they test negative for COVID as we would all like to avoid being sick in general.
Additionally, they should pay attention to the COVID risk level in their area and wear masks, particularly when indoors, as the levels increase. College students should have a plan for where they can isolate when not feeling well. If anyone does test positive for COVID, they should follow the most recent quarantine guidelines, including wearing a well fitted mask when they do begin returning to activities.
Monkeypox
We now have a new health concern for this school year.
Monkeypox has come onto the scene with information changing as rapidly as information previously did for COVID. With this virus, we must particularly counsel those heading away to college to be careful to limit their exposure to this disease.
Dormitories and other congregate settings are high-risk locations for the spread of monkeypox. Particularly, students headed to stay in dormitories should be counseled about avoiding:
- sexual activity with those with lesions consistent with monkeypox;
- sharing eating and drinking utensils; and
- sleeping in the same bed as or sharing bedding or towels with anyone with a diagnosis of or lesions consistent with monkeypox.
Additionally, as with prevention of all infections, it is important to frequently wash hands or use alcohol-based sanitizer before eating, and avoid touching the face after using the restroom.
Guidance for those eligible for vaccines against monkeypox seems to be quickly changing as well.
At the time of this article, CDC guidance recommends the vaccine against monkeypox for:
- those considered to be at high risk for it, including those identified by public health officials as a contact of someone with monkeypox;
- those who are aware that a sexual partner had a diagnosis of monkeypox within the past 2 weeks;
- those with multiple sex partners in the past 2 weeks in an area with known monkeypox; and
- those whose jobs may expose them to monkeypox.
Currently, the CDC recommends the vaccine JYNNEOS, a two-dose vaccine that reaches maximum protection after fourteen days. Ultimately, guidance is likely to continue to quickly change for both COVID-19 and Monkeypox throughout the fall. It is possible that new vaccinations will become available, and families and physicians alike will have many questions.
Primary care offices should ensure that someone is keeping up to date with the latest guidance to share with the office so that physicians may share accurate information with their patients.
Families should be counseled that we anticipate information about monkeypox, particularly related to vaccinations, to continue to change, as it has during all stages of the COVID pandemic.
As always, patients should be reminded to continue regular routine vaccinations, including the annual influenza vaccine.
Dr. Wheat is a family physician at Erie Family Health Center and program director of Northwestern University’s McGaw Family Medicine residency program, both in Chicago. Dr. Wheat serves on the editorial advisory board of Family Practice News. You can contact her at [email protected].
Unlike last school year, there are now vaccines available for all over the age of 6 months, and home rapid antigen tests are more readily available. Additionally, many have now been exposed either by infection or vaccination to the virus.
The CDC has removed the recommendations for maintaining cohorts in the K-12 population. This changing landscape along with differing levels of personal risk make it challenging to counsel families about what to expect in terms of COVID this year.
The best defense that we currently have against COVID is the vaccine. Although it seems that many are susceptible to the virus despite the vaccine, those who have been vaccinated are less susceptible to serious disease, including young children.
As older children may be heading to college, it is important
to encourage them to isolate when they have symptoms, even when they test negative for COVID as we would all like to avoid being sick in general.
Additionally, they should pay attention to the COVID risk level in their area and wear masks, particularly when indoors, as the levels increase. College students should have a plan for where they can isolate when not feeling well. If anyone does test positive for COVID, they should follow the most recent quarantine guidelines, including wearing a well fitted mask when they do begin returning to activities.
Monkeypox
We now have a new health concern for this school year.
Monkeypox has come onto the scene with information changing as rapidly as information previously did for COVID. With this virus, we must particularly counsel those heading away to college to be careful to limit their exposure to this disease.
Dormitories and other congregate settings are high-risk locations for the spread of monkeypox. Particularly, students headed to stay in dormitories should be counseled about avoiding:
- sexual activity with those with lesions consistent with monkeypox;
- sharing eating and drinking utensils; and
- sleeping in the same bed as or sharing bedding or towels with anyone with a diagnosis of or lesions consistent with monkeypox.
Additionally, as with prevention of all infections, it is important to frequently wash hands or use alcohol-based sanitizer before eating, and avoid touching the face after using the restroom.
Guidance for those eligible for vaccines against monkeypox seems to be quickly changing as well.
At the time of this article, CDC guidance recommends the vaccine against monkeypox for:
- those considered to be at high risk for it, including those identified by public health officials as a contact of someone with monkeypox;
- those who are aware that a sexual partner had a diagnosis of monkeypox within the past 2 weeks;
- those with multiple sex partners in the past 2 weeks in an area with known monkeypox; and
- those whose jobs may expose them to monkeypox.
Currently, the CDC recommends the vaccine JYNNEOS, a two-dose vaccine that reaches maximum protection after fourteen days. Ultimately, guidance is likely to continue to quickly change for both COVID-19 and Monkeypox throughout the fall. It is possible that new vaccinations will become available, and families and physicians alike will have many questions.
Primary care offices should ensure that someone is keeping up to date with the latest guidance to share with the office so that physicians may share accurate information with their patients.
Families should be counseled that we anticipate information about monkeypox, particularly related to vaccinations, to continue to change, as it has during all stages of the COVID pandemic.
As always, patients should be reminded to continue regular routine vaccinations, including the annual influenza vaccine.
Dr. Wheat is a family physician at Erie Family Health Center and program director of Northwestern University’s McGaw Family Medicine residency program, both in Chicago. Dr. Wheat serves on the editorial advisory board of Family Practice News. You can contact her at [email protected].
Unlike last school year, there are now vaccines available for all over the age of 6 months, and home rapid antigen tests are more readily available. Additionally, many have now been exposed either by infection or vaccination to the virus.
The CDC has removed the recommendations for maintaining cohorts in the K-12 population. This changing landscape along with differing levels of personal risk make it challenging to counsel families about what to expect in terms of COVID this year.
The best defense that we currently have against COVID is the vaccine. Although it seems that many are susceptible to the virus despite the vaccine, those who have been vaccinated are less susceptible to serious disease, including young children.
As older children may be heading to college, it is important
to encourage them to isolate when they have symptoms, even when they test negative for COVID as we would all like to avoid being sick in general.
Additionally, they should pay attention to the COVID risk level in their area and wear masks, particularly when indoors, as the levels increase. College students should have a plan for where they can isolate when not feeling well. If anyone does test positive for COVID, they should follow the most recent quarantine guidelines, including wearing a well fitted mask when they do begin returning to activities.
Monkeypox
We now have a new health concern for this school year.
Monkeypox has come onto the scene with information changing as rapidly as information previously did for COVID. With this virus, we must particularly counsel those heading away to college to be careful to limit their exposure to this disease.
Dormitories and other congregate settings are high-risk locations for the spread of monkeypox. Particularly, students headed to stay in dormitories should be counseled about avoiding:
- sexual activity with those with lesions consistent with monkeypox;
- sharing eating and drinking utensils; and
- sleeping in the same bed as or sharing bedding or towels with anyone with a diagnosis of or lesions consistent with monkeypox.
Additionally, as with prevention of all infections, it is important to frequently wash hands or use alcohol-based sanitizer before eating, and avoid touching the face after using the restroom.
Guidance for those eligible for vaccines against monkeypox seems to be quickly changing as well.
At the time of this article, CDC guidance recommends the vaccine against monkeypox for:
- those considered to be at high risk for it, including those identified by public health officials as a contact of someone with monkeypox;
- those who are aware that a sexual partner had a diagnosis of monkeypox within the past 2 weeks;
- those with multiple sex partners in the past 2 weeks in an area with known monkeypox; and
- those whose jobs may expose them to monkeypox.
Currently, the CDC recommends the vaccine JYNNEOS, a two-dose vaccine that reaches maximum protection after fourteen days. Ultimately, guidance is likely to continue to quickly change for both COVID-19 and Monkeypox throughout the fall. It is possible that new vaccinations will become available, and families and physicians alike will have many questions.
Primary care offices should ensure that someone is keeping up to date with the latest guidance to share with the office so that physicians may share accurate information with their patients.
Families should be counseled that we anticipate information about monkeypox, particularly related to vaccinations, to continue to change, as it has during all stages of the COVID pandemic.
As always, patients should be reminded to continue regular routine vaccinations, including the annual influenza vaccine.
Dr. Wheat is a family physician at Erie Family Health Center and program director of Northwestern University’s McGaw Family Medicine residency program, both in Chicago. Dr. Wheat serves on the editorial advisory board of Family Practice News. You can contact her at [email protected].
Use of antidotes in pregnancy and lactation
The human pregnancy data reported for these 16 agents are very limited as only 8 of the drugs have this data. However, the 8 reports indicated that the use of these drugs was highly important for the mother and did not cause embryo/fetal harm.
- Acetylcysteine
The need for this antidote in a pregnant or lactating woman is most likely a rare requirement. However, the need for this agent does occur in women who have taken a potentially hepatic toxic dose of acetaminophen (e.g., Tylenol).
- Black widow spider antivenin
Only three reports of the use of this agent in a pregnant woman have been located. In each case, the symptoms from the spider bite did not respond to other therapies but did within 1 hour to the antivenin. There was no fetal harm in these cases.
- Deferasirox
This agent is an oral iron-chelating agent used for the treatment of chronic iron overload. Five case reports have described its use without causing any fetal harm.
- Deferoxamine
This agent has been used in more than 65 pregnancies for acute iron overdose or for transfusion-dependent thalassemia. No reports have observed adverse human developmental effects.
- Digoxin immune FAB (ovine)
Several reports have described the use of this agent in pregnancy. No fetal harm has been observed, but none of the reports involved exposure during organogenesis. However, in cases of digoxin overdose, the maternal benefits of therapy should take priority over the embryo/fetus.
- Dimercaprol
Although the limited animal data suggest low risk, there are no reports of the use of this drug in human organogenesis. The absence of data prevents an assessment of the embryo-fetal risk, but the maternal benefit and indirect embryo-fetal benefit appears to outweigh that risk.
- Edetate calcium disodium
This agent is used to treat acute or chronic lead poisoning. It is compatible in pregnancy because the maternal and possibly the embryo-fetal benefit appears to outweigh any unknown direct or indirect risks.
- Flumazenil
The use of this drug in the third trimester has been reported in two cases. Because the drug is indicated to reverse the effects of benzodiazepines on the central nervous system, the maternal benefit should far outweigh the unknown embryo-fetal risk.
- Glucagon
The embryo-fetal risks appear to be very low. Apparently, the drug does not cross the placenta.
- Glucarpidase
This drug is indicated for the treatment of methotrexate toxicity. There are no reports describing the use of this drug in pregnancy or during breastfeeding.
- Idarucizumab
This agent is a humanized monoclonal antibody fragment that is indicated for the reversal of the anticoagulant effects of dabigatran. No reports describing its use in human or animal pregnancy have been located. However, the maternal benefit appears to be high and probably outweighs the unknown risk to the embryo/fetus.
- Lanthanum carbonate
There are no human pregnancy or lactation data. It is used to reduce blood levels of phosphate in people with kidney disease.
- Pralidoxime
This agent relieves the paralysis of the muscles of respiration caused by an organophosphate pesticide or related compound. The human pregnancy experience is limited to two cases, one at 36 weeks and the other at 16 weeks, both of which delivered normal infants.
- Sapropterin
Four reports have described the use of sapropterin to lower blood phenylalanine levels in 31 pregnancies. There were no embryo-fetal adverse effects attributable to the drug.
- Sevelamer
Sevelamer is used to control high blood levels of phosphorus in people with chronic kidney disease who are on dialysis. There are no human pregnancy or breastfeeding data.
- Succimer
This drug is a heavy metal–chelating agent that is indicated for the treatment of lead poisoning in pediatric patients. The drug was teratogenic in rats and mice. Two reports described the use of the drug in two pregnant women for lead poisoning. It has also been used as an antidote for the treatment of arsenic, mercury, and cadmium poisoning in adults, but there have been no reports of this use in pregnant patients.
Mr. Briggs, now retired, was a clinical professor of pharmacy at the University of California, San Francisco, and adjunct professor of pharmacy at the University of Southern California, Los Angeles, as well as at Washington State University, Spokane. Mr. Briggs said he had no relevant financial disclosures. Email him at [email protected].
The human pregnancy data reported for these 16 agents are very limited as only 8 of the drugs have this data. However, the 8 reports indicated that the use of these drugs was highly important for the mother and did not cause embryo/fetal harm.
- Acetylcysteine
The need for this antidote in a pregnant or lactating woman is most likely a rare requirement. However, the need for this agent does occur in women who have taken a potentially hepatic toxic dose of acetaminophen (e.g., Tylenol).
- Black widow spider antivenin
Only three reports of the use of this agent in a pregnant woman have been located. In each case, the symptoms from the spider bite did not respond to other therapies but did within 1 hour to the antivenin. There was no fetal harm in these cases.
- Deferasirox
This agent is an oral iron-chelating agent used for the treatment of chronic iron overload. Five case reports have described its use without causing any fetal harm.
- Deferoxamine
This agent has been used in more than 65 pregnancies for acute iron overdose or for transfusion-dependent thalassemia. No reports have observed adverse human developmental effects.
- Digoxin immune FAB (ovine)
Several reports have described the use of this agent in pregnancy. No fetal harm has been observed, but none of the reports involved exposure during organogenesis. However, in cases of digoxin overdose, the maternal benefits of therapy should take priority over the embryo/fetus.
- Dimercaprol
Although the limited animal data suggest low risk, there are no reports of the use of this drug in human organogenesis. The absence of data prevents an assessment of the embryo-fetal risk, but the maternal benefit and indirect embryo-fetal benefit appears to outweigh that risk.
- Edetate calcium disodium
This agent is used to treat acute or chronic lead poisoning. It is compatible in pregnancy because the maternal and possibly the embryo-fetal benefit appears to outweigh any unknown direct or indirect risks.
- Flumazenil
The use of this drug in the third trimester has been reported in two cases. Because the drug is indicated to reverse the effects of benzodiazepines on the central nervous system, the maternal benefit should far outweigh the unknown embryo-fetal risk.
- Glucagon
The embryo-fetal risks appear to be very low. Apparently, the drug does not cross the placenta.
- Glucarpidase
This drug is indicated for the treatment of methotrexate toxicity. There are no reports describing the use of this drug in pregnancy or during breastfeeding.
- Idarucizumab
This agent is a humanized monoclonal antibody fragment that is indicated for the reversal of the anticoagulant effects of dabigatran. No reports describing its use in human or animal pregnancy have been located. However, the maternal benefit appears to be high and probably outweighs the unknown risk to the embryo/fetus.
- Lanthanum carbonate
There are no human pregnancy or lactation data. It is used to reduce blood levels of phosphate in people with kidney disease.
- Pralidoxime
This agent relieves the paralysis of the muscles of respiration caused by an organophosphate pesticide or related compound. The human pregnancy experience is limited to two cases, one at 36 weeks and the other at 16 weeks, both of which delivered normal infants.
- Sapropterin
Four reports have described the use of sapropterin to lower blood phenylalanine levels in 31 pregnancies. There were no embryo-fetal adverse effects attributable to the drug.
- Sevelamer
Sevelamer is used to control high blood levels of phosphorus in people with chronic kidney disease who are on dialysis. There are no human pregnancy or breastfeeding data.
- Succimer
This drug is a heavy metal–chelating agent that is indicated for the treatment of lead poisoning in pediatric patients. The drug was teratogenic in rats and mice. Two reports described the use of the drug in two pregnant women for lead poisoning. It has also been used as an antidote for the treatment of arsenic, mercury, and cadmium poisoning in adults, but there have been no reports of this use in pregnant patients.
Mr. Briggs, now retired, was a clinical professor of pharmacy at the University of California, San Francisco, and adjunct professor of pharmacy at the University of Southern California, Los Angeles, as well as at Washington State University, Spokane. Mr. Briggs said he had no relevant financial disclosures. Email him at [email protected].
The human pregnancy data reported for these 16 agents are very limited as only 8 of the drugs have this data. However, the 8 reports indicated that the use of these drugs was highly important for the mother and did not cause embryo/fetal harm.
- Acetylcysteine
The need for this antidote in a pregnant or lactating woman is most likely a rare requirement. However, the need for this agent does occur in women who have taken a potentially hepatic toxic dose of acetaminophen (e.g., Tylenol).
- Black widow spider antivenin
Only three reports of the use of this agent in a pregnant woman have been located. In each case, the symptoms from the spider bite did not respond to other therapies but did within 1 hour to the antivenin. There was no fetal harm in these cases.
- Deferasirox
This agent is an oral iron-chelating agent used for the treatment of chronic iron overload. Five case reports have described its use without causing any fetal harm.
- Deferoxamine
This agent has been used in more than 65 pregnancies for acute iron overdose or for transfusion-dependent thalassemia. No reports have observed adverse human developmental effects.
- Digoxin immune FAB (ovine)
Several reports have described the use of this agent in pregnancy. No fetal harm has been observed, but none of the reports involved exposure during organogenesis. However, in cases of digoxin overdose, the maternal benefits of therapy should take priority over the embryo/fetus.
- Dimercaprol
Although the limited animal data suggest low risk, there are no reports of the use of this drug in human organogenesis. The absence of data prevents an assessment of the embryo-fetal risk, but the maternal benefit and indirect embryo-fetal benefit appears to outweigh that risk.
- Edetate calcium disodium
This agent is used to treat acute or chronic lead poisoning. It is compatible in pregnancy because the maternal and possibly the embryo-fetal benefit appears to outweigh any unknown direct or indirect risks.
- Flumazenil
The use of this drug in the third trimester has been reported in two cases. Because the drug is indicated to reverse the effects of benzodiazepines on the central nervous system, the maternal benefit should far outweigh the unknown embryo-fetal risk.
- Glucagon
The embryo-fetal risks appear to be very low. Apparently, the drug does not cross the placenta.
- Glucarpidase
This drug is indicated for the treatment of methotrexate toxicity. There are no reports describing the use of this drug in pregnancy or during breastfeeding.
- Idarucizumab
This agent is a humanized monoclonal antibody fragment that is indicated for the reversal of the anticoagulant effects of dabigatran. No reports describing its use in human or animal pregnancy have been located. However, the maternal benefit appears to be high and probably outweighs the unknown risk to the embryo/fetus.
- Lanthanum carbonate
There are no human pregnancy or lactation data. It is used to reduce blood levels of phosphate in people with kidney disease.
- Pralidoxime
This agent relieves the paralysis of the muscles of respiration caused by an organophosphate pesticide or related compound. The human pregnancy experience is limited to two cases, one at 36 weeks and the other at 16 weeks, both of which delivered normal infants.
- Sapropterin
Four reports have described the use of sapropterin to lower blood phenylalanine levels in 31 pregnancies. There were no embryo-fetal adverse effects attributable to the drug.
- Sevelamer
Sevelamer is used to control high blood levels of phosphorus in people with chronic kidney disease who are on dialysis. There are no human pregnancy or breastfeeding data.
- Succimer
This drug is a heavy metal–chelating agent that is indicated for the treatment of lead poisoning in pediatric patients. The drug was teratogenic in rats and mice. Two reports described the use of the drug in two pregnant women for lead poisoning. It has also been used as an antidote for the treatment of arsenic, mercury, and cadmium poisoning in adults, but there have been no reports of this use in pregnant patients.
Mr. Briggs, now retired, was a clinical professor of pharmacy at the University of California, San Francisco, and adjunct professor of pharmacy at the University of Southern California, Los Angeles, as well as at Washington State University, Spokane. Mr. Briggs said he had no relevant financial disclosures. Email him at [email protected].
‘I missed it’: Coping with medical error
Thursday night
It was 9 o’clock at night when my phone rang. I didn’t recognize the number but decided to answer it anyway. It was my doctor.
“Chase, I got your labs back and you have a critically low level. I spoke with someone at the hospital, I think I know what is happening, but I need you to go to the pharmacy right now and get a medicine.” She explained further and as I listened electric currents ran through my thighs until I could barely feel my legs.
“I’m so sorry, Chase. I missed it. It was low the last time we did your labs 9 months ago, and I missed it.”
In disbelief, I continued to listen as she instructed me about the next steps I was to take and prepared me for what was to come the next day.
“If you notice any changes overnight, go straight to the ED.”
My chest tingled and I could barely breathe. My mind struggled to comprehend what was happening. I looked at my husband sitting close by on the couch. He looked concerned. I tuned back in and heard her say: “Is your husband there? Can I talk to him?”
“Yes,” is all I could manage, and I handed him the phone. I sat while he listened and asked his questions. My breathing came back under my control, my legs felt wiry, and restlessness set in. “I have to get out of here,” I thought. “I have to go and pick up this medicine.”
Monday afternoon
I am sitting across from a PGY3 resident I have been treating since his intern year, as part of his treatment plan for managing a chronic mental illness that began in medical school. Earlier in the day, I received an urgent message from him requesting an emergency appointment.
Within a few minutes of sitting down, the story from his weekend call shift tumbled out of him. His speech became pressured, and his eyes welled with tears as he recounted in detail the steps he had taken to care for a very sick patient overnight.
“I missed it.” The dam broke and he sat sobbing in front of me, his body trembling.
I sat silently across from him. Willing him to breathe.
In time, his breathing came back under his control, and he slowly regained his composure. He continued: “I got the imaging, and I missed a bleed.”
Failure and shame
I can recall memorable moments from my training when I came to understand that what I initially perceived to be a mistake was instead part of the work. An example from our practice involves a patient whom I was comanaging with her primary care provider (PCP). She was not doing well following a critical work event. When I met with her after the event, she admitted having thoughts of suicide, refused a voluntary inpatient admission, and would not have met criteria for an involuntary admission. My hands were tied.
Together we created a plan to keep her safe, which included paging her PCP after hours if needed. I told her PCP before leaving that night that he might hear from her and that if she reached out, she would require hospitalization.
I arrived at work the following day, and her PCP shared with me that our patient had overdosed on medication, paged him, and was admitted to the unit.
He seemed forlorn.
I was both relieved by the news and confused by his reaction. I had hoped that she would choose a higher level of care than what we could provide her as an outpatient. I said: “This is good. She followed the plan.”
Her overdose was, of course, not part of the plan. She was struggling with several internal conflicts, including having mixed feelings about coming into the hospital; but, when the critical moment happened and she was faced with a decision to call for help or possibly die, she chose to call her PCP and have him paged as we had talked about.
I looked at her PCP. “You helped get her to where she needed to be.”
In the years of working side by side with medically trained colleagues, I have time and again needed to reframe for them that what they perceive to be a “failure” or a “crisis” is often a catalyst for change. The patient I comanaged with the PCP was a highly skilled caregiver and, as such, had been having a hard time asking for help. The hospitalization that her PCP facilitated allowed her to receive the care she needed and created an opportunity for family and friends to show up for her. Their support fed her, and she only made gains from that point on.
My training had taught me that respecting a patient’s autonomy was of the utmost importance. This instills confidence in patients as the authority in their lives. For a clinician to do this, a certain amount of helplessness must be tolerated. As I became better at identifying these moments of helplessness, feelings of failure and shame transformed.
Medical error
Sitting across from the PGY3 resident who I had met with weekly for the past 3 years, I thought about his error.
I thought about my phone call 4 nights earlier. My doctor was called at home by a lab technician, who never met their patients but was simply following protocol and alerted my doctor to the worsening number that she should have been aware of 9 months earlier.
Just like my doctor’s lapse of attention, my patient’s error was not a moment of helplessness to be tolerated. These were mistakes, and there was no way around it.
“People make mistakes.” I said simply.
We sat silently for a time.
I don’t remember who broke the silence. The conversation that followed was centered on our humanity and our capability for both compassion and fallibility. Afterward, I wondered who my doctor confided in and hoped she had a similar conversation.
Dr. Levesque is a clinical psychologist and clinical assistant professor of psychiatry at the Geisel School of Medicine at Dartmouth, Hanover, N.H., where she also serves on the Committee for a Respectful Learning Environment.
A version of this article first appeared on Medscape.com.
Thursday night
It was 9 o’clock at night when my phone rang. I didn’t recognize the number but decided to answer it anyway. It was my doctor.
“Chase, I got your labs back and you have a critically low level. I spoke with someone at the hospital, I think I know what is happening, but I need you to go to the pharmacy right now and get a medicine.” She explained further and as I listened electric currents ran through my thighs until I could barely feel my legs.
“I’m so sorry, Chase. I missed it. It was low the last time we did your labs 9 months ago, and I missed it.”
In disbelief, I continued to listen as she instructed me about the next steps I was to take and prepared me for what was to come the next day.
“If you notice any changes overnight, go straight to the ED.”
My chest tingled and I could barely breathe. My mind struggled to comprehend what was happening. I looked at my husband sitting close by on the couch. He looked concerned. I tuned back in and heard her say: “Is your husband there? Can I talk to him?”
“Yes,” is all I could manage, and I handed him the phone. I sat while he listened and asked his questions. My breathing came back under my control, my legs felt wiry, and restlessness set in. “I have to get out of here,” I thought. “I have to go and pick up this medicine.”
Monday afternoon
I am sitting across from a PGY3 resident I have been treating since his intern year, as part of his treatment plan for managing a chronic mental illness that began in medical school. Earlier in the day, I received an urgent message from him requesting an emergency appointment.
Within a few minutes of sitting down, the story from his weekend call shift tumbled out of him. His speech became pressured, and his eyes welled with tears as he recounted in detail the steps he had taken to care for a very sick patient overnight.
“I missed it.” The dam broke and he sat sobbing in front of me, his body trembling.
I sat silently across from him. Willing him to breathe.
In time, his breathing came back under his control, and he slowly regained his composure. He continued: “I got the imaging, and I missed a bleed.”
Failure and shame
I can recall memorable moments from my training when I came to understand that what I initially perceived to be a mistake was instead part of the work. An example from our practice involves a patient whom I was comanaging with her primary care provider (PCP). She was not doing well following a critical work event. When I met with her after the event, she admitted having thoughts of suicide, refused a voluntary inpatient admission, and would not have met criteria for an involuntary admission. My hands were tied.
Together we created a plan to keep her safe, which included paging her PCP after hours if needed. I told her PCP before leaving that night that he might hear from her and that if she reached out, she would require hospitalization.
I arrived at work the following day, and her PCP shared with me that our patient had overdosed on medication, paged him, and was admitted to the unit.
He seemed forlorn.
I was both relieved by the news and confused by his reaction. I had hoped that she would choose a higher level of care than what we could provide her as an outpatient. I said: “This is good. She followed the plan.”
Her overdose was, of course, not part of the plan. She was struggling with several internal conflicts, including having mixed feelings about coming into the hospital; but, when the critical moment happened and she was faced with a decision to call for help or possibly die, she chose to call her PCP and have him paged as we had talked about.
I looked at her PCP. “You helped get her to where she needed to be.”
In the years of working side by side with medically trained colleagues, I have time and again needed to reframe for them that what they perceive to be a “failure” or a “crisis” is often a catalyst for change. The patient I comanaged with the PCP was a highly skilled caregiver and, as such, had been having a hard time asking for help. The hospitalization that her PCP facilitated allowed her to receive the care she needed and created an opportunity for family and friends to show up for her. Their support fed her, and she only made gains from that point on.
My training had taught me that respecting a patient’s autonomy was of the utmost importance. This instills confidence in patients as the authority in their lives. For a clinician to do this, a certain amount of helplessness must be tolerated. As I became better at identifying these moments of helplessness, feelings of failure and shame transformed.
Medical error
Sitting across from the PGY3 resident who I had met with weekly for the past 3 years, I thought about his error.
I thought about my phone call 4 nights earlier. My doctor was called at home by a lab technician, who never met their patients but was simply following protocol and alerted my doctor to the worsening number that she should have been aware of 9 months earlier.
Just like my doctor’s lapse of attention, my patient’s error was not a moment of helplessness to be tolerated. These were mistakes, and there was no way around it.
“People make mistakes.” I said simply.
We sat silently for a time.
I don’t remember who broke the silence. The conversation that followed was centered on our humanity and our capability for both compassion and fallibility. Afterward, I wondered who my doctor confided in and hoped she had a similar conversation.
Dr. Levesque is a clinical psychologist and clinical assistant professor of psychiatry at the Geisel School of Medicine at Dartmouth, Hanover, N.H., where she also serves on the Committee for a Respectful Learning Environment.
A version of this article first appeared on Medscape.com.
Thursday night
It was 9 o’clock at night when my phone rang. I didn’t recognize the number but decided to answer it anyway. It was my doctor.
“Chase, I got your labs back and you have a critically low level. I spoke with someone at the hospital, I think I know what is happening, but I need you to go to the pharmacy right now and get a medicine.” She explained further and as I listened electric currents ran through my thighs until I could barely feel my legs.
“I’m so sorry, Chase. I missed it. It was low the last time we did your labs 9 months ago, and I missed it.”
In disbelief, I continued to listen as she instructed me about the next steps I was to take and prepared me for what was to come the next day.
“If you notice any changes overnight, go straight to the ED.”
My chest tingled and I could barely breathe. My mind struggled to comprehend what was happening. I looked at my husband sitting close by on the couch. He looked concerned. I tuned back in and heard her say: “Is your husband there? Can I talk to him?”
“Yes,” is all I could manage, and I handed him the phone. I sat while he listened and asked his questions. My breathing came back under my control, my legs felt wiry, and restlessness set in. “I have to get out of here,” I thought. “I have to go and pick up this medicine.”
Monday afternoon
I am sitting across from a PGY3 resident I have been treating since his intern year, as part of his treatment plan for managing a chronic mental illness that began in medical school. Earlier in the day, I received an urgent message from him requesting an emergency appointment.
Within a few minutes of sitting down, the story from his weekend call shift tumbled out of him. His speech became pressured, and his eyes welled with tears as he recounted in detail the steps he had taken to care for a very sick patient overnight.
“I missed it.” The dam broke and he sat sobbing in front of me, his body trembling.
I sat silently across from him. Willing him to breathe.
In time, his breathing came back under his control, and he slowly regained his composure. He continued: “I got the imaging, and I missed a bleed.”
Failure and shame
I can recall memorable moments from my training when I came to understand that what I initially perceived to be a mistake was instead part of the work. An example from our practice involves a patient whom I was comanaging with her primary care provider (PCP). She was not doing well following a critical work event. When I met with her after the event, she admitted having thoughts of suicide, refused a voluntary inpatient admission, and would not have met criteria for an involuntary admission. My hands were tied.
Together we created a plan to keep her safe, which included paging her PCP after hours if needed. I told her PCP before leaving that night that he might hear from her and that if she reached out, she would require hospitalization.
I arrived at work the following day, and her PCP shared with me that our patient had overdosed on medication, paged him, and was admitted to the unit.
He seemed forlorn.
I was both relieved by the news and confused by his reaction. I had hoped that she would choose a higher level of care than what we could provide her as an outpatient. I said: “This is good. She followed the plan.”
Her overdose was, of course, not part of the plan. She was struggling with several internal conflicts, including having mixed feelings about coming into the hospital; but, when the critical moment happened and she was faced with a decision to call for help or possibly die, she chose to call her PCP and have him paged as we had talked about.
I looked at her PCP. “You helped get her to where she needed to be.”
In the years of working side by side with medically trained colleagues, I have time and again needed to reframe for them that what they perceive to be a “failure” or a “crisis” is often a catalyst for change. The patient I comanaged with the PCP was a highly skilled caregiver and, as such, had been having a hard time asking for help. The hospitalization that her PCP facilitated allowed her to receive the care she needed and created an opportunity for family and friends to show up for her. Their support fed her, and she only made gains from that point on.
My training had taught me that respecting a patient’s autonomy was of the utmost importance. This instills confidence in patients as the authority in their lives. For a clinician to do this, a certain amount of helplessness must be tolerated. As I became better at identifying these moments of helplessness, feelings of failure and shame transformed.
Medical error
Sitting across from the PGY3 resident who I had met with weekly for the past 3 years, I thought about his error.
I thought about my phone call 4 nights earlier. My doctor was called at home by a lab technician, who never met their patients but was simply following protocol and alerted my doctor to the worsening number that she should have been aware of 9 months earlier.
Just like my doctor’s lapse of attention, my patient’s error was not a moment of helplessness to be tolerated. These were mistakes, and there was no way around it.
“People make mistakes.” I said simply.
We sat silently for a time.
I don’t remember who broke the silence. The conversation that followed was centered on our humanity and our capability for both compassion and fallibility. Afterward, I wondered who my doctor confided in and hoped she had a similar conversation.
Dr. Levesque is a clinical psychologist and clinical assistant professor of psychiatry at the Geisel School of Medicine at Dartmouth, Hanover, N.H., where she also serves on the Committee for a Respectful Learning Environment.
A version of this article first appeared on Medscape.com.
Exercise limitations in COPD – not everyone needs more inhalers
Chronic obstructive pulmonary disease (COPD) is defined by airway obstruction and alveolar damage caused by exposure to noxious air particles. The physiologic results include varying degrees of gas-exchange abnormality and mechanical respiratory limitation, often in the form of dynamic hyperinflation. There’s a third major contributor, though – skeletal muscle deconditioning. Only one of these abnormalities responds to inhalers.
When your patients with COPD report dyspnea or exercise intolerance, what do you do? Do you attempt to determine its character to pinpoint its origin? Do you quiz them about their baseline activity levels to quantify their conditioning? I bet you get right to the point and order a cardiopulmonary exercise test (CPET). That way you’ll be able to tease out all the contributors. Nah. Most likely you add an inhaler before continuing to rush through your COPD quality metrics: Vaccines? Check. Lung cancer screening? Check. Smoking cessation? Check.
The physiology of dyspnea and exercise limitation in COPD has been extensively studied. Work-of-breathing, dynamic hyperinflation, and gas-exchange inefficiencies interact with each other in complex ways to produce symptoms. The presence of deconditioning simply magnifies the existing abnormalities within the respiratory system by creating more strain at lower work rates. Acute exacerbations (AECOPD) and oral corticosteroids further aggravate skeletal muscle dysfunction.
The Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (GOLD) Report directs clinicians to use inhalers to manage dyspnea. If they’re already on one inhaler, they get another. This continues until they’re stabilized on a long-acting beta-agonist (LABA), long-acting muscarinic antagonist (LAMA), and an inhaled corticosteroid (ICS). The GOLD report also advises pulmonary rehabilitation for any patient with grade B through D disease. Unfortunately, the pulmonary rehabilitation recommendation is buried in the text and doesn’t appear within the popularized pharmacologic algorithms in the report’s figures.
The data for adding inhalers on top of each other to reduce AECOPD and improve overall quality of life (QOL) are good. However, although GOLD tells us to keep adding inhalers for the dyspneic patient with COPD, the authors acknowledge that this hasn’t been systematically tested. The difference? A statement doesn’t require the same formal, rigorous scientific analysis known as the GRADE approach. Using this kind of analysis, a recent clinical practice guideline by the American Thoracic Society found no benefit in dyspnea or respiratory QOL with step-up from inhaler monotherapy.
Inhalers won’t do anything for gas-exchange inefficiencies and deconditioning, at least not directly. A recent CPET study from the CanCOLD network found ventilatory inefficiency in 23% of GOLD 1 and 26% of GOLD 2-4 COPD patients. The numbers were higher for those who reported dyspnea. Skeletal muscle dysfunction rates are equally high.
Thus, dyspnea and exercise intolerance are major determinants of QOL in COPD, but inhalers will only get you so far. At a minimum, make sure you get an activity/exercise history from your patients with COPD. For those who are sedentary, provide an exercise prescription (really, it’s not that hard to do). If dyspnea persists despite LABA or LAMA monotherapy, clarify the complaint before doubling down. Finally, try to get the patient into a good pulmonary rehabilitation program. They’ll thank you afterwards.
Dr. Holley is Associate Professor, department of medicine, Uniformed Services University of the Health Sciences and Program Director, Pulmonary and Critical Care Medical Fellowship, department of medicine, Walter Reed National Military Medical Center, both in Bethesda, Md. He reported receiving research grants from Fisher-Paykel and receiving income from the American College of Chest Physicians.
A version of this article first appeared on Medscape.com.
Chronic obstructive pulmonary disease (COPD) is defined by airway obstruction and alveolar damage caused by exposure to noxious air particles. The physiologic results include varying degrees of gas-exchange abnormality and mechanical respiratory limitation, often in the form of dynamic hyperinflation. There’s a third major contributor, though – skeletal muscle deconditioning. Only one of these abnormalities responds to inhalers.
When your patients with COPD report dyspnea or exercise intolerance, what do you do? Do you attempt to determine its character to pinpoint its origin? Do you quiz them about their baseline activity levels to quantify their conditioning? I bet you get right to the point and order a cardiopulmonary exercise test (CPET). That way you’ll be able to tease out all the contributors. Nah. Most likely you add an inhaler before continuing to rush through your COPD quality metrics: Vaccines? Check. Lung cancer screening? Check. Smoking cessation? Check.
The physiology of dyspnea and exercise limitation in COPD has been extensively studied. Work-of-breathing, dynamic hyperinflation, and gas-exchange inefficiencies interact with each other in complex ways to produce symptoms. The presence of deconditioning simply magnifies the existing abnormalities within the respiratory system by creating more strain at lower work rates. Acute exacerbations (AECOPD) and oral corticosteroids further aggravate skeletal muscle dysfunction.
The Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (GOLD) Report directs clinicians to use inhalers to manage dyspnea. If they’re already on one inhaler, they get another. This continues until they’re stabilized on a long-acting beta-agonist (LABA), long-acting muscarinic antagonist (LAMA), and an inhaled corticosteroid (ICS). The GOLD report also advises pulmonary rehabilitation for any patient with grade B through D disease. Unfortunately, the pulmonary rehabilitation recommendation is buried in the text and doesn’t appear within the popularized pharmacologic algorithms in the report’s figures.
The data for adding inhalers on top of each other to reduce AECOPD and improve overall quality of life (QOL) are good. However, although GOLD tells us to keep adding inhalers for the dyspneic patient with COPD, the authors acknowledge that this hasn’t been systematically tested. The difference? A statement doesn’t require the same formal, rigorous scientific analysis known as the GRADE approach. Using this kind of analysis, a recent clinical practice guideline by the American Thoracic Society found no benefit in dyspnea or respiratory QOL with step-up from inhaler monotherapy.
Inhalers won’t do anything for gas-exchange inefficiencies and deconditioning, at least not directly. A recent CPET study from the CanCOLD network found ventilatory inefficiency in 23% of GOLD 1 and 26% of GOLD 2-4 COPD patients. The numbers were higher for those who reported dyspnea. Skeletal muscle dysfunction rates are equally high.
Thus, dyspnea and exercise intolerance are major determinants of QOL in COPD, but inhalers will only get you so far. At a minimum, make sure you get an activity/exercise history from your patients with COPD. For those who are sedentary, provide an exercise prescription (really, it’s not that hard to do). If dyspnea persists despite LABA or LAMA monotherapy, clarify the complaint before doubling down. Finally, try to get the patient into a good pulmonary rehabilitation program. They’ll thank you afterwards.
Dr. Holley is Associate Professor, department of medicine, Uniformed Services University of the Health Sciences and Program Director, Pulmonary and Critical Care Medical Fellowship, department of medicine, Walter Reed National Military Medical Center, both in Bethesda, Md. He reported receiving research grants from Fisher-Paykel and receiving income from the American College of Chest Physicians.
A version of this article first appeared on Medscape.com.
Chronic obstructive pulmonary disease (COPD) is defined by airway obstruction and alveolar damage caused by exposure to noxious air particles. The physiologic results include varying degrees of gas-exchange abnormality and mechanical respiratory limitation, often in the form of dynamic hyperinflation. There’s a third major contributor, though – skeletal muscle deconditioning. Only one of these abnormalities responds to inhalers.
When your patients with COPD report dyspnea or exercise intolerance, what do you do? Do you attempt to determine its character to pinpoint its origin? Do you quiz them about their baseline activity levels to quantify their conditioning? I bet you get right to the point and order a cardiopulmonary exercise test (CPET). That way you’ll be able to tease out all the contributors. Nah. Most likely you add an inhaler before continuing to rush through your COPD quality metrics: Vaccines? Check. Lung cancer screening? Check. Smoking cessation? Check.
The physiology of dyspnea and exercise limitation in COPD has been extensively studied. Work-of-breathing, dynamic hyperinflation, and gas-exchange inefficiencies interact with each other in complex ways to produce symptoms. The presence of deconditioning simply magnifies the existing abnormalities within the respiratory system by creating more strain at lower work rates. Acute exacerbations (AECOPD) and oral corticosteroids further aggravate skeletal muscle dysfunction.
The Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (GOLD) Report directs clinicians to use inhalers to manage dyspnea. If they’re already on one inhaler, they get another. This continues until they’re stabilized on a long-acting beta-agonist (LABA), long-acting muscarinic antagonist (LAMA), and an inhaled corticosteroid (ICS). The GOLD report also advises pulmonary rehabilitation for any patient with grade B through D disease. Unfortunately, the pulmonary rehabilitation recommendation is buried in the text and doesn’t appear within the popularized pharmacologic algorithms in the report’s figures.
The data for adding inhalers on top of each other to reduce AECOPD and improve overall quality of life (QOL) are good. However, although GOLD tells us to keep adding inhalers for the dyspneic patient with COPD, the authors acknowledge that this hasn’t been systematically tested. The difference? A statement doesn’t require the same formal, rigorous scientific analysis known as the GRADE approach. Using this kind of analysis, a recent clinical practice guideline by the American Thoracic Society found no benefit in dyspnea or respiratory QOL with step-up from inhaler monotherapy.
Inhalers won’t do anything for gas-exchange inefficiencies and deconditioning, at least not directly. A recent CPET study from the CanCOLD network found ventilatory inefficiency in 23% of GOLD 1 and 26% of GOLD 2-4 COPD patients. The numbers were higher for those who reported dyspnea. Skeletal muscle dysfunction rates are equally high.
Thus, dyspnea and exercise intolerance are major determinants of QOL in COPD, but inhalers will only get you so far. At a minimum, make sure you get an activity/exercise history from your patients with COPD. For those who are sedentary, provide an exercise prescription (really, it’s not that hard to do). If dyspnea persists despite LABA or LAMA monotherapy, clarify the complaint before doubling down. Finally, try to get the patient into a good pulmonary rehabilitation program. They’ll thank you afterwards.
Dr. Holley is Associate Professor, department of medicine, Uniformed Services University of the Health Sciences and Program Director, Pulmonary and Critical Care Medical Fellowship, department of medicine, Walter Reed National Military Medical Center, both in Bethesda, Md. He reported receiving research grants from Fisher-Paykel and receiving income from the American College of Chest Physicians.
A version of this article first appeared on Medscape.com.
Understanding the relationship between life satisfaction and cognitive decline
Every day, we depend on our working memory, spatial cognition, and processing speed abilities to optimize productivity, interpersonal interactions, and psychological wellbeing. These cognitive functioning indices relate closely with academic and work performance, managing emotions, physical fitness, and a sense of fulfillment in personal and work relationships. They are linked intimately to complex cognitive skills (van Dijk et al., 2020). It is thus imperative to identify modifiable predictors of cognitive functioning in the brain to protect against aging-related cognitive decline and maximize the quality of life.
A decline in life satisfaction can worsen cognitive functioning over long periods via lifestyle factors (e.g., suboptimal diet and nutrition, lack of exercise) (Ratigan et al., 2016). Inadequate engagement in these health-enhancing pursuits could build up inflammation in EF-linked brain areas, thus negatively impacting cognitive functioning in adulthood (Grant et al., 2009). Possible pathways include long-term wear and tear of the hypothalamic-pituitary axis and brain regions linked to executive functioning (Zainal and Newman, 2022a). These processes may deteriorate working memory, spatial cognition, and processing speed across time.
Similarly, it is plausible that a reduction in cognitive functioning may lead to a long-term decrease in life satisfaction. Working memory, processing speed, spatial cognition, and related capacities are essential to meaningful activities and feelings of gratification in personal and professional relationships and other spheres of health throughout life (Baumeister et al., 2007). These cognitive functioning markers safeguard against reduced life satisfaction by facilitating effective problem-solving, and choices (Swanson and Fung, 2016). For example, stronger working memory, processing speed, and related domains coincided with better tolerance for stress and trading off immediate rewards for long-term values and life goals (Hofmann et al., 2012). Therefore, reduction in cognitive functioning abilities could precede a future decline in life satisfaction.
Nonetheless, the literature on this topic has several limitations. Most of the studies have been cross-sectional (i.e., across a single time-point) and thus do not permit inferences between cause and effect (e.g., Toh et al., 2020). Also, most studies used statistical methods that did not differentiate between between-person (trait-like individual differences) and within-person (state-like) relations. Distinguishing within- and between-person relations is necessary because they may vary in magnitude and direction. The preceding theories emphasize change-to-future change relations within persons rather than between persons (Wright and Woods, 2020).
Clinical implications
Our recent work (Zainal and Newman, 2022b) added to the literature by using an advanced statistical method to determine the relations between change in life satisfaction and future change in cognitive functioning domains within persons. The choice of an advanced statistical technique minimizes biases due to the passage of time and assessment unreliability. It also adjusts for between-person effects (Klopack and Wickrama, 2020). Improving understanding of the within-person factors leading to the deterioration of cognitive functioning and life satisfaction is crucial given the rising rates of psychiatric and neurocognitive illnesses (Cui et al., 2020). Identifying these changeable risk factors can optimize prevention, early detection, and treatment approaches.
Specifically, we analyzed the publicly available Swedish Adoption/Twin Study of Aging (SATSA) dataset (Petkus et al., 2017). Their dataset comprised 520 middle- to older-aged twin adults without dementia. Participants provided data across 23 years with five time points. Each time lag ranged from 3 to 11 years. The analyses demonstrated that greater decreases in life satisfaction predicted larger future declines in processing speed, verbal working memory, and spatial cognition. Moreover, declines in verbal working memory and processing speed predicted a reduction in life satisfaction. However, change in spatial awareness did not predict change in life satisfaction.
Our study offers multiple theoretical perspectives. Scar theories propose that decreased life satisfaction and related mental health problems can compromise working memory, processing speed, and spatial cognition in the long term. This scarring process occurs through the buildup of allostatic load, such as increased biomarkers of chronic stress (e.g., cortisol) and inflammation (e.g., interleukin-6, C-reactive protein) (Fancourt and Steptoe, 2020; Zainal and Newman, 2021a). Also, findings suggest the importance of executive functioning domains to attain desired milestones and aspirations to enhance a sense of fulfillment (Baddeley, 2013; Toh and Yang, 2020). Reductions in these cognitive functioning capacities could, over time, adversely affect the ability to engage in daily living activities and manage negative moods.
Limitations of our study include the lack of a multiple-assessment approach to measuring diverse cognitive functioning domains. Also, the absence of cognitive self-reports is a shortcoming since perceived cognitive difficulties might not align with performance on cognitive tests. Relatedly, future studies should administer cognitive tests that parallel and transfer to everyday tasks. However, our study’s strengths include the robust findings across different intervals between study waves, advanced statistics, and the large sample size.
If future studies replicate a similar pattern of results, the clinical applications of this study merit attention. Mindfulness-based interventions can promote working memory, sustained awareness, and spatial cognition or protect against cognitive decline (Jha et al., 2019; Zainal and Newman, 2021b). Further, clinical science can profit from exploring cognitive-behavioral therapies to improve adults’ cognitive function or life satisfaction (Sok et al., 2021).
Dr. Zainal recently accepted a 2-year postdoctoral research associate position at Harvard Medical School, Boston, starting in summer 2022. She received her Ph.D. from Pennsylvania State University, University Park, and completed a predoctoral clinical fellowship at the HMS-affiliated Massachusetts General Hospital – Cognitive Behavioral Scientist Track. Her research interests focus on how executive functioning, social cognition, and cognitive-behavioral strategies link to the etiology, maintenance, and treatment of anxiety and depressive disorders. Dr. Newman is a professor of psychology and psychiatry, and the director of the Center for the Treatment of Anxiety and Depression, at Pennsylvania State University. She has conducted basic and applied research on anxiety disorders and depression and has published over 200 papers on these topics.
Sources
Baddeley A. Working memory and emotion: Ruminations on a theory of depression. Rev Gen Psychol. 2013;17(1):20-7. doi: 10.1037/a0030029.
Baumeister RF et al. “Self-regulation and the executive function: The self as controlling agent,” in Social Psychology: Handbook of Basic Principles, 2nd ed. (pp. 516-39). The Guilford Press: New York, 2007.
Cui L et al. Prevalence of alzheimer’s disease and parkinson’s disease in China: An updated systematical analysis. Front Aging Neurosci. 2020 Dec 21;12:603854. doi: 10.3389/fnagi.2020.603854.
Fancourt D and Steptoe A. The longitudinal relationship between changes in wellbeing and inflammatory markers: Are associations independent of depression? Brain Behav Immun. 2020 Jan;83:146-52. doi: 10.1016/j.bbi.2019.10.004.
Grant N et al. The relationship between life satisfaction and health behavior: A cross-cultural analysis of young adults. Int J Behav Med. 2009;16(3):259-68. doi: 10.1007/s12529-009-9032-x.
Hofmann W et al. Executive functions and self-regulation. Trends Cogn Sci. 2012 Mar;16(3):174-80. doi: 10.1016/j.tics.2012.01.006.
Jha AP et al. Bolstering cognitive resilience via train-the-trainer delivery of mindfulness training in applied high-demand settings. Mindfulness. 2019;11(3):683-97. doi: 10.1007/s12671-019-01284-7.
Klopack ET and Wickrama K. Modeling latent change score analysis and extensions in Mplus: A practical guide for researchers. Struct Equ Modeling. 2020;27(1):97-110. doi: 10.1080/10705511.2018.1562929.
Petkus AJ et al. Temporal dynamics of cognitive performance and anxiety across older adulthood. Psychol Aging. 2017 May;32(3):278-92. doi: 10.1037/pag0000164.
Ratigan A et al. Sex differences in the association of physical function and cognitive function with life satisfaction in older age: The Rancho Bernardo Study. Maturitas. 2016 Jul;89:29-35. doi: 10.1016/j.maturitas.2016.04.007.
Sok S et al. Effects of cognitive/exercise dual-task program on the cognitive function, health status, depression, and life satisfaction of the elderly living in the community. Int J Environ Res Public Health. 2021 Jul 24;18(15):7848. doi: 10.3390/ijerph18157848.
Swanson HL and Fung W. Working memory components and problem-solving accuracy: Are there multiple pathways? J Educ Psychol. 2016;108(8):1153-77. doi: 10.1037/edu0000116.
Toh WX and Yang H. Executive function moderates the effect of reappraisal on life satisfaction: A latent variable analysis. Emotion. 2020;22(3):554-71. doi: 10.1037/emo0000907.
Toh WX et al. Executive function and subjective wellbeing in middle and late adulthood. J Gerontol B Psychol Sci Soc Sci. 2020 Jun 2;75(6):e69-e77. doi: 10.1093/geronb/gbz006.
van Dijk DM, et al. Cognitive functioning, sleep quality, and work performance in non-clinical burnout: The role of working memory. PLoS One. 2020 Apr 23;15(4):e0231906. doi: 10.1371/journal.pone.0231906.
Wright AGC and Woods WC. Personalized models of psychopathology. Annu Rev Clin Psychol. 2020 May 7;16:49-74. doi: 10.1146/annurev-clinpsy-102419-125032.
Zainal NH and Newman MG. (2021a). Depression and worry symptoms predict future executive functioning impairment via inflammation. Psychol Med. 2021 Mar 3;1-11. doi: 10.1017/S0033291721000398.
Zainal NH and Newman MG. (2021b). Mindfulness enhances cognitive functioning: A meta-analysis of 111 randomized controlled trials. PsyArXiv Preprints. 2021 May 11. doi: 10.31234/osf.io/vzxw7.
Zainal NH and Newman MG. (2022a). Inflammation mediates depression and generalized anxiety symptoms predicting executive function impairment after 18 years. J Affect Disord. 2022 Jan 1;296:465-75. doi: 10.1016/j.jad.2021.08.077.
Zainal NH and Newman MG. (2022b). Life satisfaction prevents decline in working memory, spatial cognition, and processing speed: Latent change score analyses across 23 years. Eur Psychiatry. 2022 Apr 19;65(1):1-55. doi: 10.1192/j.eurpsy.2022.19.
Every day, we depend on our working memory, spatial cognition, and processing speed abilities to optimize productivity, interpersonal interactions, and psychological wellbeing. These cognitive functioning indices relate closely with academic and work performance, managing emotions, physical fitness, and a sense of fulfillment in personal and work relationships. They are linked intimately to complex cognitive skills (van Dijk et al., 2020). It is thus imperative to identify modifiable predictors of cognitive functioning in the brain to protect against aging-related cognitive decline and maximize the quality of life.
A decline in life satisfaction can worsen cognitive functioning over long periods via lifestyle factors (e.g., suboptimal diet and nutrition, lack of exercise) (Ratigan et al., 2016). Inadequate engagement in these health-enhancing pursuits could build up inflammation in EF-linked brain areas, thus negatively impacting cognitive functioning in adulthood (Grant et al., 2009). Possible pathways include long-term wear and tear of the hypothalamic-pituitary axis and brain regions linked to executive functioning (Zainal and Newman, 2022a). These processes may deteriorate working memory, spatial cognition, and processing speed across time.
Similarly, it is plausible that a reduction in cognitive functioning may lead to a long-term decrease in life satisfaction. Working memory, processing speed, spatial cognition, and related capacities are essential to meaningful activities and feelings of gratification in personal and professional relationships and other spheres of health throughout life (Baumeister et al., 2007). These cognitive functioning markers safeguard against reduced life satisfaction by facilitating effective problem-solving, and choices (Swanson and Fung, 2016). For example, stronger working memory, processing speed, and related domains coincided with better tolerance for stress and trading off immediate rewards for long-term values and life goals (Hofmann et al., 2012). Therefore, reduction in cognitive functioning abilities could precede a future decline in life satisfaction.
Nonetheless, the literature on this topic has several limitations. Most of the studies have been cross-sectional (i.e., across a single time-point) and thus do not permit inferences between cause and effect (e.g., Toh et al., 2020). Also, most studies used statistical methods that did not differentiate between between-person (trait-like individual differences) and within-person (state-like) relations. Distinguishing within- and between-person relations is necessary because they may vary in magnitude and direction. The preceding theories emphasize change-to-future change relations within persons rather than between persons (Wright and Woods, 2020).
Clinical implications
Our recent work (Zainal and Newman, 2022b) added to the literature by using an advanced statistical method to determine the relations between change in life satisfaction and future change in cognitive functioning domains within persons. The choice of an advanced statistical technique minimizes biases due to the passage of time and assessment unreliability. It also adjusts for between-person effects (Klopack and Wickrama, 2020). Improving understanding of the within-person factors leading to the deterioration of cognitive functioning and life satisfaction is crucial given the rising rates of psychiatric and neurocognitive illnesses (Cui et al., 2020). Identifying these changeable risk factors can optimize prevention, early detection, and treatment approaches.
Specifically, we analyzed the publicly available Swedish Adoption/Twin Study of Aging (SATSA) dataset (Petkus et al., 2017). Their dataset comprised 520 middle- to older-aged twin adults without dementia. Participants provided data across 23 years with five time points. Each time lag ranged from 3 to 11 years. The analyses demonstrated that greater decreases in life satisfaction predicted larger future declines in processing speed, verbal working memory, and spatial cognition. Moreover, declines in verbal working memory and processing speed predicted a reduction in life satisfaction. However, change in spatial awareness did not predict change in life satisfaction.
Our study offers multiple theoretical perspectives. Scar theories propose that decreased life satisfaction and related mental health problems can compromise working memory, processing speed, and spatial cognition in the long term. This scarring process occurs through the buildup of allostatic load, such as increased biomarkers of chronic stress (e.g., cortisol) and inflammation (e.g., interleukin-6, C-reactive protein) (Fancourt and Steptoe, 2020; Zainal and Newman, 2021a). Also, findings suggest the importance of executive functioning domains to attain desired milestones and aspirations to enhance a sense of fulfillment (Baddeley, 2013; Toh and Yang, 2020). Reductions in these cognitive functioning capacities could, over time, adversely affect the ability to engage in daily living activities and manage negative moods.
Limitations of our study include the lack of a multiple-assessment approach to measuring diverse cognitive functioning domains. Also, the absence of cognitive self-reports is a shortcoming since perceived cognitive difficulties might not align with performance on cognitive tests. Relatedly, future studies should administer cognitive tests that parallel and transfer to everyday tasks. However, our study’s strengths include the robust findings across different intervals between study waves, advanced statistics, and the large sample size.
If future studies replicate a similar pattern of results, the clinical applications of this study merit attention. Mindfulness-based interventions can promote working memory, sustained awareness, and spatial cognition or protect against cognitive decline (Jha et al., 2019; Zainal and Newman, 2021b). Further, clinical science can profit from exploring cognitive-behavioral therapies to improve adults’ cognitive function or life satisfaction (Sok et al., 2021).
Dr. Zainal recently accepted a 2-year postdoctoral research associate position at Harvard Medical School, Boston, starting in summer 2022. She received her Ph.D. from Pennsylvania State University, University Park, and completed a predoctoral clinical fellowship at the HMS-affiliated Massachusetts General Hospital – Cognitive Behavioral Scientist Track. Her research interests focus on how executive functioning, social cognition, and cognitive-behavioral strategies link to the etiology, maintenance, and treatment of anxiety and depressive disorders. Dr. Newman is a professor of psychology and psychiatry, and the director of the Center for the Treatment of Anxiety and Depression, at Pennsylvania State University. She has conducted basic and applied research on anxiety disorders and depression and has published over 200 papers on these topics.
Sources
Baddeley A. Working memory and emotion: Ruminations on a theory of depression. Rev Gen Psychol. 2013;17(1):20-7. doi: 10.1037/a0030029.
Baumeister RF et al. “Self-regulation and the executive function: The self as controlling agent,” in Social Psychology: Handbook of Basic Principles, 2nd ed. (pp. 516-39). The Guilford Press: New York, 2007.
Cui L et al. Prevalence of alzheimer’s disease and parkinson’s disease in China: An updated systematical analysis. Front Aging Neurosci. 2020 Dec 21;12:603854. doi: 10.3389/fnagi.2020.603854.
Fancourt D and Steptoe A. The longitudinal relationship between changes in wellbeing and inflammatory markers: Are associations independent of depression? Brain Behav Immun. 2020 Jan;83:146-52. doi: 10.1016/j.bbi.2019.10.004.
Grant N et al. The relationship between life satisfaction and health behavior: A cross-cultural analysis of young adults. Int J Behav Med. 2009;16(3):259-68. doi: 10.1007/s12529-009-9032-x.
Hofmann W et al. Executive functions and self-regulation. Trends Cogn Sci. 2012 Mar;16(3):174-80. doi: 10.1016/j.tics.2012.01.006.
Jha AP et al. Bolstering cognitive resilience via train-the-trainer delivery of mindfulness training in applied high-demand settings. Mindfulness. 2019;11(3):683-97. doi: 10.1007/s12671-019-01284-7.
Klopack ET and Wickrama K. Modeling latent change score analysis and extensions in Mplus: A practical guide for researchers. Struct Equ Modeling. 2020;27(1):97-110. doi: 10.1080/10705511.2018.1562929.
Petkus AJ et al. Temporal dynamics of cognitive performance and anxiety across older adulthood. Psychol Aging. 2017 May;32(3):278-92. doi: 10.1037/pag0000164.
Ratigan A et al. Sex differences in the association of physical function and cognitive function with life satisfaction in older age: The Rancho Bernardo Study. Maturitas. 2016 Jul;89:29-35. doi: 10.1016/j.maturitas.2016.04.007.
Sok S et al. Effects of cognitive/exercise dual-task program on the cognitive function, health status, depression, and life satisfaction of the elderly living in the community. Int J Environ Res Public Health. 2021 Jul 24;18(15):7848. doi: 10.3390/ijerph18157848.
Swanson HL and Fung W. Working memory components and problem-solving accuracy: Are there multiple pathways? J Educ Psychol. 2016;108(8):1153-77. doi: 10.1037/edu0000116.
Toh WX and Yang H. Executive function moderates the effect of reappraisal on life satisfaction: A latent variable analysis. Emotion. 2020;22(3):554-71. doi: 10.1037/emo0000907.
Toh WX et al. Executive function and subjective wellbeing in middle and late adulthood. J Gerontol B Psychol Sci Soc Sci. 2020 Jun 2;75(6):e69-e77. doi: 10.1093/geronb/gbz006.
van Dijk DM, et al. Cognitive functioning, sleep quality, and work performance in non-clinical burnout: The role of working memory. PLoS One. 2020 Apr 23;15(4):e0231906. doi: 10.1371/journal.pone.0231906.
Wright AGC and Woods WC. Personalized models of psychopathology. Annu Rev Clin Psychol. 2020 May 7;16:49-74. doi: 10.1146/annurev-clinpsy-102419-125032.
Zainal NH and Newman MG. (2021a). Depression and worry symptoms predict future executive functioning impairment via inflammation. Psychol Med. 2021 Mar 3;1-11. doi: 10.1017/S0033291721000398.
Zainal NH and Newman MG. (2021b). Mindfulness enhances cognitive functioning: A meta-analysis of 111 randomized controlled trials. PsyArXiv Preprints. 2021 May 11. doi: 10.31234/osf.io/vzxw7.
Zainal NH and Newman MG. (2022a). Inflammation mediates depression and generalized anxiety symptoms predicting executive function impairment after 18 years. J Affect Disord. 2022 Jan 1;296:465-75. doi: 10.1016/j.jad.2021.08.077.
Zainal NH and Newman MG. (2022b). Life satisfaction prevents decline in working memory, spatial cognition, and processing speed: Latent change score analyses across 23 years. Eur Psychiatry. 2022 Apr 19;65(1):1-55. doi: 10.1192/j.eurpsy.2022.19.
Every day, we depend on our working memory, spatial cognition, and processing speed abilities to optimize productivity, interpersonal interactions, and psychological wellbeing. These cognitive functioning indices relate closely with academic and work performance, managing emotions, physical fitness, and a sense of fulfillment in personal and work relationships. They are linked intimately to complex cognitive skills (van Dijk et al., 2020). It is thus imperative to identify modifiable predictors of cognitive functioning in the brain to protect against aging-related cognitive decline and maximize the quality of life.
A decline in life satisfaction can worsen cognitive functioning over long periods via lifestyle factors (e.g., suboptimal diet and nutrition, lack of exercise) (Ratigan et al., 2016). Inadequate engagement in these health-enhancing pursuits could build up inflammation in EF-linked brain areas, thus negatively impacting cognitive functioning in adulthood (Grant et al., 2009). Possible pathways include long-term wear and tear of the hypothalamic-pituitary axis and brain regions linked to executive functioning (Zainal and Newman, 2022a). These processes may deteriorate working memory, spatial cognition, and processing speed across time.
Similarly, it is plausible that a reduction in cognitive functioning may lead to a long-term decrease in life satisfaction. Working memory, processing speed, spatial cognition, and related capacities are essential to meaningful activities and feelings of gratification in personal and professional relationships and other spheres of health throughout life (Baumeister et al., 2007). These cognitive functioning markers safeguard against reduced life satisfaction by facilitating effective problem-solving, and choices (Swanson and Fung, 2016). For example, stronger working memory, processing speed, and related domains coincided with better tolerance for stress and trading off immediate rewards for long-term values and life goals (Hofmann et al., 2012). Therefore, reduction in cognitive functioning abilities could precede a future decline in life satisfaction.
Nonetheless, the literature on this topic has several limitations. Most of the studies have been cross-sectional (i.e., across a single time-point) and thus do not permit inferences between cause and effect (e.g., Toh et al., 2020). Also, most studies used statistical methods that did not differentiate between between-person (trait-like individual differences) and within-person (state-like) relations. Distinguishing within- and between-person relations is necessary because they may vary in magnitude and direction. The preceding theories emphasize change-to-future change relations within persons rather than between persons (Wright and Woods, 2020).
Clinical implications
Our recent work (Zainal and Newman, 2022b) added to the literature by using an advanced statistical method to determine the relations between change in life satisfaction and future change in cognitive functioning domains within persons. The choice of an advanced statistical technique minimizes biases due to the passage of time and assessment unreliability. It also adjusts for between-person effects (Klopack and Wickrama, 2020). Improving understanding of the within-person factors leading to the deterioration of cognitive functioning and life satisfaction is crucial given the rising rates of psychiatric and neurocognitive illnesses (Cui et al., 2020). Identifying these changeable risk factors can optimize prevention, early detection, and treatment approaches.
Specifically, we analyzed the publicly available Swedish Adoption/Twin Study of Aging (SATSA) dataset (Petkus et al., 2017). Their dataset comprised 520 middle- to older-aged twin adults without dementia. Participants provided data across 23 years with five time points. Each time lag ranged from 3 to 11 years. The analyses demonstrated that greater decreases in life satisfaction predicted larger future declines in processing speed, verbal working memory, and spatial cognition. Moreover, declines in verbal working memory and processing speed predicted a reduction in life satisfaction. However, change in spatial awareness did not predict change in life satisfaction.
Our study offers multiple theoretical perspectives. Scar theories propose that decreased life satisfaction and related mental health problems can compromise working memory, processing speed, and spatial cognition in the long term. This scarring process occurs through the buildup of allostatic load, such as increased biomarkers of chronic stress (e.g., cortisol) and inflammation (e.g., interleukin-6, C-reactive protein) (Fancourt and Steptoe, 2020; Zainal and Newman, 2021a). Also, findings suggest the importance of executive functioning domains to attain desired milestones and aspirations to enhance a sense of fulfillment (Baddeley, 2013; Toh and Yang, 2020). Reductions in these cognitive functioning capacities could, over time, adversely affect the ability to engage in daily living activities and manage negative moods.
Limitations of our study include the lack of a multiple-assessment approach to measuring diverse cognitive functioning domains. Also, the absence of cognitive self-reports is a shortcoming since perceived cognitive difficulties might not align with performance on cognitive tests. Relatedly, future studies should administer cognitive tests that parallel and transfer to everyday tasks. However, our study’s strengths include the robust findings across different intervals between study waves, advanced statistics, and the large sample size.
If future studies replicate a similar pattern of results, the clinical applications of this study merit attention. Mindfulness-based interventions can promote working memory, sustained awareness, and spatial cognition or protect against cognitive decline (Jha et al., 2019; Zainal and Newman, 2021b). Further, clinical science can profit from exploring cognitive-behavioral therapies to improve adults’ cognitive function or life satisfaction (Sok et al., 2021).
Dr. Zainal recently accepted a 2-year postdoctoral research associate position at Harvard Medical School, Boston, starting in summer 2022. She received her Ph.D. from Pennsylvania State University, University Park, and completed a predoctoral clinical fellowship at the HMS-affiliated Massachusetts General Hospital – Cognitive Behavioral Scientist Track. Her research interests focus on how executive functioning, social cognition, and cognitive-behavioral strategies link to the etiology, maintenance, and treatment of anxiety and depressive disorders. Dr. Newman is a professor of psychology and psychiatry, and the director of the Center for the Treatment of Anxiety and Depression, at Pennsylvania State University. She has conducted basic and applied research on anxiety disorders and depression and has published over 200 papers on these topics.
Sources
Baddeley A. Working memory and emotion: Ruminations on a theory of depression. Rev Gen Psychol. 2013;17(1):20-7. doi: 10.1037/a0030029.
Baumeister RF et al. “Self-regulation and the executive function: The self as controlling agent,” in Social Psychology: Handbook of Basic Principles, 2nd ed. (pp. 516-39). The Guilford Press: New York, 2007.
Cui L et al. Prevalence of alzheimer’s disease and parkinson’s disease in China: An updated systematical analysis. Front Aging Neurosci. 2020 Dec 21;12:603854. doi: 10.3389/fnagi.2020.603854.
Fancourt D and Steptoe A. The longitudinal relationship between changes in wellbeing and inflammatory markers: Are associations independent of depression? Brain Behav Immun. 2020 Jan;83:146-52. doi: 10.1016/j.bbi.2019.10.004.
Grant N et al. The relationship between life satisfaction and health behavior: A cross-cultural analysis of young adults. Int J Behav Med. 2009;16(3):259-68. doi: 10.1007/s12529-009-9032-x.
Hofmann W et al. Executive functions and self-regulation. Trends Cogn Sci. 2012 Mar;16(3):174-80. doi: 10.1016/j.tics.2012.01.006.
Jha AP et al. Bolstering cognitive resilience via train-the-trainer delivery of mindfulness training in applied high-demand settings. Mindfulness. 2019;11(3):683-97. doi: 10.1007/s12671-019-01284-7.
Klopack ET and Wickrama K. Modeling latent change score analysis and extensions in Mplus: A practical guide for researchers. Struct Equ Modeling. 2020;27(1):97-110. doi: 10.1080/10705511.2018.1562929.
Petkus AJ et al. Temporal dynamics of cognitive performance and anxiety across older adulthood. Psychol Aging. 2017 May;32(3):278-92. doi: 10.1037/pag0000164.
Ratigan A et al. Sex differences in the association of physical function and cognitive function with life satisfaction in older age: The Rancho Bernardo Study. Maturitas. 2016 Jul;89:29-35. doi: 10.1016/j.maturitas.2016.04.007.
Sok S et al. Effects of cognitive/exercise dual-task program on the cognitive function, health status, depression, and life satisfaction of the elderly living in the community. Int J Environ Res Public Health. 2021 Jul 24;18(15):7848. doi: 10.3390/ijerph18157848.
Swanson HL and Fung W. Working memory components and problem-solving accuracy: Are there multiple pathways? J Educ Psychol. 2016;108(8):1153-77. doi: 10.1037/edu0000116.
Toh WX and Yang H. Executive function moderates the effect of reappraisal on life satisfaction: A latent variable analysis. Emotion. 2020;22(3):554-71. doi: 10.1037/emo0000907.
Toh WX et al. Executive function and subjective wellbeing in middle and late adulthood. J Gerontol B Psychol Sci Soc Sci. 2020 Jun 2;75(6):e69-e77. doi: 10.1093/geronb/gbz006.
van Dijk DM, et al. Cognitive functioning, sleep quality, and work performance in non-clinical burnout: The role of working memory. PLoS One. 2020 Apr 23;15(4):e0231906. doi: 10.1371/journal.pone.0231906.
Wright AGC and Woods WC. Personalized models of psychopathology. Annu Rev Clin Psychol. 2020 May 7;16:49-74. doi: 10.1146/annurev-clinpsy-102419-125032.
Zainal NH and Newman MG. (2021a). Depression and worry symptoms predict future executive functioning impairment via inflammation. Psychol Med. 2021 Mar 3;1-11. doi: 10.1017/S0033291721000398.
Zainal NH and Newman MG. (2021b). Mindfulness enhances cognitive functioning: A meta-analysis of 111 randomized controlled trials. PsyArXiv Preprints. 2021 May 11. doi: 10.31234/osf.io/vzxw7.
Zainal NH and Newman MG. (2022a). Inflammation mediates depression and generalized anxiety symptoms predicting executive function impairment after 18 years. J Affect Disord. 2022 Jan 1;296:465-75. doi: 10.1016/j.jad.2021.08.077.
Zainal NH and Newman MG. (2022b). Life satisfaction prevents decline in working memory, spatial cognition, and processing speed: Latent change score analyses across 23 years. Eur Psychiatry. 2022 Apr 19;65(1):1-55. doi: 10.1192/j.eurpsy.2022.19.
Reliably solving complex problems
The James Webb Space Telescope (JWST) is an engineering marvel. Costing over $10 billion, it should be. The project cost overrun was 900%. The launch was delayed by more than a decade. The Human Genome Project from 1990 to 2003 was completed slightly ahead of schedule and for less than the $4-$5 billion original estimates. This HGP success story is partly because of private entrepreneurial involvement. The Superconducting Super Collider in Texas spent $2 billion but never got off the ground. Successfully shepherding huge public projects like these involves the art of politics and management as well as science.
Whatever the earlier missteps, the JWST project is now performing above expectations. It has launched, taken up residence a million miles from Earth, deployed its mirrors (a process that had more than 300 possible single points of failure, any one of which would reduce the thing to scrap metal), and been calibrated. The JWST has even been dented by a micrometeoroid – sort of like a parking lot ding on the door of your brand new car. The first images are visually amazing and producing new scientific insights. This is a pinnacle of scientific achievement.
What characteristics enable such an achievement? How do we foster those same characteristics in the practice of medicine and medical research? Will the success of the JWST increase and restore the public’s trust in science and scientists?
After all the bickering over vaccines and masks for the past 2+ years, medical science could use a boost. The gravitas of scientists, and indeed all experts, has diminished over the 5 decades since humans walked on the moon. It has been harmed by mercenary scientists who sought to sow doubt about whether smoking caused cancer and whether fossil fuels created climate change. No proof was needed, just doubt.
The trust in science has also been harmed by the vast amount of published medical research that is wrong. An effort was made 20 years ago to rid research of the bias of taking money from drug companies. To my observation, that change produced only a small benefit that has been overwhelmed by the unintended harms. The large, well-funded academic labs of full-time researchers have been replaced with unfunded, undertrained, and inadequately supported part-time junior faculty trying to publish enough articles to be promoted. In my opinion, this change is worse than funding from Big Pharma. (Disclosure – I worked in industry prior to graduate school.)
The pressure to publish reduces skepticism, so more incorrect data are published. The small size of these amateur studies produces unconvincing conclusions that feed an industry of meta-analysis that tries to overcome the deficiencies of the individual studies. This fragmented, biased approach is not how you build, launch, deploy, and operate the JWST, which requires very high reliability.
This approach is not working well for pediatrics either. I look at the history of the recommended workup of the febrile young infant from the 1980s until today. I see constant changes to the guidelines but no real progress toward a validated, evidence-based approach. A similar history is behind treatment of neonatal hyperbilirubinemia. In the 1994 publication, there was a movement toward being less aggressive. The 2004 and 2009 editions increased the frequency of screening and phototherapy. Now, the 2022 guidelines have moved in the direction we were headed in the 1990s. The workup of infants and children with possible urinary tract infections has undergone a similar trajectory. So has the screening for neonatal herpes infections. The practice changes are more like Brownian motion than real progress. This inconsistency has led me to be skeptical of the process the American Academy of Pediatrics uses to create guidelines.
Part of solving complex problems is allowing all stakeholders’ voices to be heard. On Jan. 28, 1986, seconds after liftoff, the space shuttle Challenger exploded. In the aftermath, it was determined that some engineers had expressed concern about the very cold weather that morning. The rubber in the O-ring would not be as flexible as designed. Their objection was not listened to. The O-ring failed, the fuel tank exploded, and the ship and crew were lost. It is a lesson many engineers of my generation took to heart. Do not suppress voices.
For example, 1 year ago (September 2021), the Royal Australian and New Zealand College of Psychiatrists published a position statement, “Recognising and addressing the mental health needs of people experiencing gender dysphoria/gender incongruence.” The statement expressed concern about the marked increase in incidence of rapid-onset gender dysphoria and therefore urged more thorough assessment by psychiatry before embarking on puberty-blocking therapies. The RANZCP position is at variance with recent trends in the United States. The topic was censored at the 2021 AAP national conference. Lately, I have heard the words disinformation and homophobic used to describe my RANZCP colleagues. I have been comparing AAP, Britain’s National Institute for Health and Care Excellence, and Royal Children’s Hospital Melbourne guidelines for 20 years. The variation is enlightening. I do not know the correct answer to treating gender dysphoria, but I know suppressing viewpoints and debate leads to exploding spaceships.
Dr. Powell is a retired pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at [email protected].
The James Webb Space Telescope (JWST) is an engineering marvel. Costing over $10 billion, it should be. The project cost overrun was 900%. The launch was delayed by more than a decade. The Human Genome Project from 1990 to 2003 was completed slightly ahead of schedule and for less than the $4-$5 billion original estimates. This HGP success story is partly because of private entrepreneurial involvement. The Superconducting Super Collider in Texas spent $2 billion but never got off the ground. Successfully shepherding huge public projects like these involves the art of politics and management as well as science.
Whatever the earlier missteps, the JWST project is now performing above expectations. It has launched, taken up residence a million miles from Earth, deployed its mirrors (a process that had more than 300 possible single points of failure, any one of which would reduce the thing to scrap metal), and been calibrated. The JWST has even been dented by a micrometeoroid – sort of like a parking lot ding on the door of your brand new car. The first images are visually amazing and producing new scientific insights. This is a pinnacle of scientific achievement.
What characteristics enable such an achievement? How do we foster those same characteristics in the practice of medicine and medical research? Will the success of the JWST increase and restore the public’s trust in science and scientists?
After all the bickering over vaccines and masks for the past 2+ years, medical science could use a boost. The gravitas of scientists, and indeed all experts, has diminished over the 5 decades since humans walked on the moon. It has been harmed by mercenary scientists who sought to sow doubt about whether smoking caused cancer and whether fossil fuels created climate change. No proof was needed, just doubt.
The trust in science has also been harmed by the vast amount of published medical research that is wrong. An effort was made 20 years ago to rid research of the bias of taking money from drug companies. To my observation, that change produced only a small benefit that has been overwhelmed by the unintended harms. The large, well-funded academic labs of full-time researchers have been replaced with unfunded, undertrained, and inadequately supported part-time junior faculty trying to publish enough articles to be promoted. In my opinion, this change is worse than funding from Big Pharma. (Disclosure – I worked in industry prior to graduate school.)
The pressure to publish reduces skepticism, so more incorrect data are published. The small size of these amateur studies produces unconvincing conclusions that feed an industry of meta-analysis that tries to overcome the deficiencies of the individual studies. This fragmented, biased approach is not how you build, launch, deploy, and operate the JWST, which requires very high reliability.
This approach is not working well for pediatrics either. I look at the history of the recommended workup of the febrile young infant from the 1980s until today. I see constant changes to the guidelines but no real progress toward a validated, evidence-based approach. A similar history is behind treatment of neonatal hyperbilirubinemia. In the 1994 publication, there was a movement toward being less aggressive. The 2004 and 2009 editions increased the frequency of screening and phototherapy. Now, the 2022 guidelines have moved in the direction we were headed in the 1990s. The workup of infants and children with possible urinary tract infections has undergone a similar trajectory. So has the screening for neonatal herpes infections. The practice changes are more like Brownian motion than real progress. This inconsistency has led me to be skeptical of the process the American Academy of Pediatrics uses to create guidelines.
Part of solving complex problems is allowing all stakeholders’ voices to be heard. On Jan. 28, 1986, seconds after liftoff, the space shuttle Challenger exploded. In the aftermath, it was determined that some engineers had expressed concern about the very cold weather that morning. The rubber in the O-ring would not be as flexible as designed. Their objection was not listened to. The O-ring failed, the fuel tank exploded, and the ship and crew were lost. It is a lesson many engineers of my generation took to heart. Do not suppress voices.
For example, 1 year ago (September 2021), the Royal Australian and New Zealand College of Psychiatrists published a position statement, “Recognising and addressing the mental health needs of people experiencing gender dysphoria/gender incongruence.” The statement expressed concern about the marked increase in incidence of rapid-onset gender dysphoria and therefore urged more thorough assessment by psychiatry before embarking on puberty-blocking therapies. The RANZCP position is at variance with recent trends in the United States. The topic was censored at the 2021 AAP national conference. Lately, I have heard the words disinformation and homophobic used to describe my RANZCP colleagues. I have been comparing AAP, Britain’s National Institute for Health and Care Excellence, and Royal Children’s Hospital Melbourne guidelines for 20 years. The variation is enlightening. I do not know the correct answer to treating gender dysphoria, but I know suppressing viewpoints and debate leads to exploding spaceships.
Dr. Powell is a retired pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at [email protected].
The James Webb Space Telescope (JWST) is an engineering marvel. Costing over $10 billion, it should be. The project cost overrun was 900%. The launch was delayed by more than a decade. The Human Genome Project from 1990 to 2003 was completed slightly ahead of schedule and for less than the $4-$5 billion original estimates. This HGP success story is partly because of private entrepreneurial involvement. The Superconducting Super Collider in Texas spent $2 billion but never got off the ground. Successfully shepherding huge public projects like these involves the art of politics and management as well as science.
Whatever the earlier missteps, the JWST project is now performing above expectations. It has launched, taken up residence a million miles from Earth, deployed its mirrors (a process that had more than 300 possible single points of failure, any one of which would reduce the thing to scrap metal), and been calibrated. The JWST has even been dented by a micrometeoroid – sort of like a parking lot ding on the door of your brand new car. The first images are visually amazing and producing new scientific insights. This is a pinnacle of scientific achievement.
What characteristics enable such an achievement? How do we foster those same characteristics in the practice of medicine and medical research? Will the success of the JWST increase and restore the public’s trust in science and scientists?
After all the bickering over vaccines and masks for the past 2+ years, medical science could use a boost. The gravitas of scientists, and indeed all experts, has diminished over the 5 decades since humans walked on the moon. It has been harmed by mercenary scientists who sought to sow doubt about whether smoking caused cancer and whether fossil fuels created climate change. No proof was needed, just doubt.
The trust in science has also been harmed by the vast amount of published medical research that is wrong. An effort was made 20 years ago to rid research of the bias of taking money from drug companies. To my observation, that change produced only a small benefit that has been overwhelmed by the unintended harms. The large, well-funded academic labs of full-time researchers have been replaced with unfunded, undertrained, and inadequately supported part-time junior faculty trying to publish enough articles to be promoted. In my opinion, this change is worse than funding from Big Pharma. (Disclosure – I worked in industry prior to graduate school.)
The pressure to publish reduces skepticism, so more incorrect data are published. The small size of these amateur studies produces unconvincing conclusions that feed an industry of meta-analysis that tries to overcome the deficiencies of the individual studies. This fragmented, biased approach is not how you build, launch, deploy, and operate the JWST, which requires very high reliability.
This approach is not working well for pediatrics either. I look at the history of the recommended workup of the febrile young infant from the 1980s until today. I see constant changes to the guidelines but no real progress toward a validated, evidence-based approach. A similar history is behind treatment of neonatal hyperbilirubinemia. In the 1994 publication, there was a movement toward being less aggressive. The 2004 and 2009 editions increased the frequency of screening and phototherapy. Now, the 2022 guidelines have moved in the direction we were headed in the 1990s. The workup of infants and children with possible urinary tract infections has undergone a similar trajectory. So has the screening for neonatal herpes infections. The practice changes are more like Brownian motion than real progress. This inconsistency has led me to be skeptical of the process the American Academy of Pediatrics uses to create guidelines.
Part of solving complex problems is allowing all stakeholders’ voices to be heard. On Jan. 28, 1986, seconds after liftoff, the space shuttle Challenger exploded. In the aftermath, it was determined that some engineers had expressed concern about the very cold weather that morning. The rubber in the O-ring would not be as flexible as designed. Their objection was not listened to. The O-ring failed, the fuel tank exploded, and the ship and crew were lost. It is a lesson many engineers of my generation took to heart. Do not suppress voices.
For example, 1 year ago (September 2021), the Royal Australian and New Zealand College of Psychiatrists published a position statement, “Recognising and addressing the mental health needs of people experiencing gender dysphoria/gender incongruence.” The statement expressed concern about the marked increase in incidence of rapid-onset gender dysphoria and therefore urged more thorough assessment by psychiatry before embarking on puberty-blocking therapies. The RANZCP position is at variance with recent trends in the United States. The topic was censored at the 2021 AAP national conference. Lately, I have heard the words disinformation and homophobic used to describe my RANZCP colleagues. I have been comparing AAP, Britain’s National Institute for Health and Care Excellence, and Royal Children’s Hospital Melbourne guidelines for 20 years. The variation is enlightening. I do not know the correct answer to treating gender dysphoria, but I know suppressing viewpoints and debate leads to exploding spaceships.
Dr. Powell is a retired pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at [email protected].
Estrogen replacement therapy in endometrial cancer survivors
In the United States, uterine cancer is the fourth most common cancer among women, behind breast, lung/bronchus, and colorectal cancer. There are expected to be almost 66,000 new cases of uterine cancer in 2022.1 The majority of uterine cancers are endometrioid in histology and tend to be low grade, diagnosed at an early stage, and have a good prognosis. While our molecular understanding of endometrial cancers (EC) has changed significantly in recent years, low-grade endometrioid adenocarcinomas have historically been described as type 1 ECs. Type 1 ECs are typically caused by excess estrogen exposure (often unopposed or lacking progesterone protection) and are preceded by endometrial hyperplasia. Excess estrogen can come from exogenous sources (such as unopposed estrogen replacement therapy or tamoxifen, a commonly used treatment in estrogen receptor–positive breast cancer that acts as an estrogen agonist in the endometrium in postmenopausal patients) or endogenous ones (such as obesity).
Peripheral adipose tissue converts androgens into estrogens; paired with the decreased levels of sex hormone–binding globulin seen in obesity, there is more unbound or free serum estrogen (specifically estradiol) in obese women. Estrogen acts on the endometrium to cause proliferation and, if unopposed or imbalanced in relation to progesterone exposure, can ultimately lead to hyperplasia and malignancy.
If excess and unopposed estrogen exposure are major risk factors for the development of EC, is it safe to consider estrogen replacement therapy (ERT) in patients after EC treatment?
The short answer is the data are limited, but in a patient with a history of low-risk early-stage EC who undergoes appropriate counseling, it is likely safe to consider ERT.
Among EC survivors, there has been only one prospective randomized controlled trial that assessed the effect of recurrence rate and survival in women on ERT after EC treatment.2 Patients with stage I or occult stage II endometrial adenocarcinoma treated with at least a total hysterectomy and bilateral salpingo-oophorectomy were randomized to ERT versus placebo for 3 years of treatment, with therapy starting once recovered and within 20 weeks after surgery. Trial participation required an indication for ERT, such as vasomotor symptoms, vaginal atrophy, or increased risk of cardiovascular disease or osteoporosis.
The trial accrued 1,236 patients, falling short of its goal of 2,108 patients after enrollment decreased following the publication of the Women’s Health Initiative results in 2002. This publication prompted a review of the ERT study protocol that found that between decreased accrual and lower than expected recurrence rate, goal accrual would be impossible. Of those enrolled, participants were overwhelmingly white (84%-85%), 41-70 years old (80%-82%), and had stage IA or IB disease (88%). Median follow-up was almost 3 years.
Twenty-six (2.1%) patients experienced cancer recurrence, with similar rates in both groups. Three-year progression-free and overall survival were high overall among all study participants (94.8% and 96.5%). Unfortunately, because the study was closed early, definitive conclusions about the noninferiority of ERT versus placebo regarding oncologic outcomes in early-stage endometrial adenocarcinoma could not be made.
A subsequent meta-analysis looked at the effect of hormone therapy (HT) on recurrence rate in EC survivors.3 Five observational studies were included along with the previously discussed randomized controlled trial. Among 1,975 participants across six studies, there were cancer recurrences in 19 of 896 (2.1%) HT users and 64 of 1,079 (5.9%) controls. HT did not negatively affect cancer recurrence or overall survival. There was significant heterogeneity between studies as to dosing, duration, and type of HT given (some used estrogen-only replacement, others used estrogen and progesterone replacement, and some used both estrogen only and the combination of estrogen and progesterone replacement). Among the five nonrandomized studies included, a protective effect of combined HT on EC recurrence was noted. One study included patients with stage III disease, but only four patients received HT in this cohort.
Given the data we have, ERT does not appear to significantly affect oncologic outcomes in low-risk, early-stage EC survivors. We do not have data to support this same assertion in more advanced, high-risk disease. Before initiation of any ERT in an EC survivor, there should be a detailed discussion to weigh the risks and benefits of starting therapy. The goal of treatment should be to use the lowest dose of ERT possible to treat symptoms, with planned surveillance visits for symptom check-in and assessment of readiness to start tapering treatment.
Footnote: vaginal estrogen therapy
There are no randomized trials assessing the safety of vaginal estrogen preparations or their effect on oncologic outcomes in EC survivors. Observational data from the Women’s Health Initiative showed no increased risk of endometrial cancer in patients who used vaginal estrogen with an intact uterus.4 A recently published retrospective study among 244 gynecologic cancer survivors found low rates of disease recurrence and adverse outcomes among women who used vaginal estrogen for genitourinary symptoms.5 Among EC survivors, the incidence of recurrence was 2.4% for patients with stage I/II disease and 4.3% for stage III/IV disease, with a median follow-up of 80.2 months. While there appears to be some systemic absorption with vaginal estrogen use, this can be quite challenging to measure because of the current sensitivity of serum estradiol and estrone assays. Given the significantly lower serum levels with vaginal estrogen preparations compared with ERT, vaginal estrogen use appears to be safe in EC survivors.
Dr. Tucker is assistant professor of gynecologic oncology at the University of North Carolina at Chapel Hill.
References
1. Cancer Stat Facts: Uterine Cancer. National Cancer Institute: Surveillance, Epidemiology, and End Results Program. Accessed 12 Aug. 2022. https://seer.cancer.gov/statfacts/html/corp.html.
2. Barakat RR et al. J Clin Oncol. 2006;24(4):587-92.
3. Shim SH et al. Eur J Cancer. 2014;50(9):1628-37.
4. Crandall CJ et al. Menopause. 2018 Jan;25(1):11-20.
5. Chambers LM et al. Int J Gynecol Cancer. 2020 Apr;30(4):515-24.
In the United States, uterine cancer is the fourth most common cancer among women, behind breast, lung/bronchus, and colorectal cancer. There are expected to be almost 66,000 new cases of uterine cancer in 2022.1 The majority of uterine cancers are endometrioid in histology and tend to be low grade, diagnosed at an early stage, and have a good prognosis. While our molecular understanding of endometrial cancers (EC) has changed significantly in recent years, low-grade endometrioid adenocarcinomas have historically been described as type 1 ECs. Type 1 ECs are typically caused by excess estrogen exposure (often unopposed or lacking progesterone protection) and are preceded by endometrial hyperplasia. Excess estrogen can come from exogenous sources (such as unopposed estrogen replacement therapy or tamoxifen, a commonly used treatment in estrogen receptor–positive breast cancer that acts as an estrogen agonist in the endometrium in postmenopausal patients) or endogenous ones (such as obesity).
Peripheral adipose tissue converts androgens into estrogens; paired with the decreased levels of sex hormone–binding globulin seen in obesity, there is more unbound or free serum estrogen (specifically estradiol) in obese women. Estrogen acts on the endometrium to cause proliferation and, if unopposed or imbalanced in relation to progesterone exposure, can ultimately lead to hyperplasia and malignancy.
If excess and unopposed estrogen exposure are major risk factors for the development of EC, is it safe to consider estrogen replacement therapy (ERT) in patients after EC treatment?
The short answer is the data are limited, but in a patient with a history of low-risk early-stage EC who undergoes appropriate counseling, it is likely safe to consider ERT.
Among EC survivors, there has been only one prospective randomized controlled trial that assessed the effect of recurrence rate and survival in women on ERT after EC treatment.2 Patients with stage I or occult stage II endometrial adenocarcinoma treated with at least a total hysterectomy and bilateral salpingo-oophorectomy were randomized to ERT versus placebo for 3 years of treatment, with therapy starting once recovered and within 20 weeks after surgery. Trial participation required an indication for ERT, such as vasomotor symptoms, vaginal atrophy, or increased risk of cardiovascular disease or osteoporosis.
The trial accrued 1,236 patients, falling short of its goal of 2,108 patients after enrollment decreased following the publication of the Women’s Health Initiative results in 2002. This publication prompted a review of the ERT study protocol that found that between decreased accrual and lower than expected recurrence rate, goal accrual would be impossible. Of those enrolled, participants were overwhelmingly white (84%-85%), 41-70 years old (80%-82%), and had stage IA or IB disease (88%). Median follow-up was almost 3 years.
Twenty-six (2.1%) patients experienced cancer recurrence, with similar rates in both groups. Three-year progression-free and overall survival were high overall among all study participants (94.8% and 96.5%). Unfortunately, because the study was closed early, definitive conclusions about the noninferiority of ERT versus placebo regarding oncologic outcomes in early-stage endometrial adenocarcinoma could not be made.
A subsequent meta-analysis looked at the effect of hormone therapy (HT) on recurrence rate in EC survivors.3 Five observational studies were included along with the previously discussed randomized controlled trial. Among 1,975 participants across six studies, there were cancer recurrences in 19 of 896 (2.1%) HT users and 64 of 1,079 (5.9%) controls. HT did not negatively affect cancer recurrence or overall survival. There was significant heterogeneity between studies as to dosing, duration, and type of HT given (some used estrogen-only replacement, others used estrogen and progesterone replacement, and some used both estrogen only and the combination of estrogen and progesterone replacement). Among the five nonrandomized studies included, a protective effect of combined HT on EC recurrence was noted. One study included patients with stage III disease, but only four patients received HT in this cohort.
Given the data we have, ERT does not appear to significantly affect oncologic outcomes in low-risk, early-stage EC survivors. We do not have data to support this same assertion in more advanced, high-risk disease. Before initiation of any ERT in an EC survivor, there should be a detailed discussion to weigh the risks and benefits of starting therapy. The goal of treatment should be to use the lowest dose of ERT possible to treat symptoms, with planned surveillance visits for symptom check-in and assessment of readiness to start tapering treatment.
Footnote: vaginal estrogen therapy
There are no randomized trials assessing the safety of vaginal estrogen preparations or their effect on oncologic outcomes in EC survivors. Observational data from the Women’s Health Initiative showed no increased risk of endometrial cancer in patients who used vaginal estrogen with an intact uterus.4 A recently published retrospective study among 244 gynecologic cancer survivors found low rates of disease recurrence and adverse outcomes among women who used vaginal estrogen for genitourinary symptoms.5 Among EC survivors, the incidence of recurrence was 2.4% for patients with stage I/II disease and 4.3% for stage III/IV disease, with a median follow-up of 80.2 months. While there appears to be some systemic absorption with vaginal estrogen use, this can be quite challenging to measure because of the current sensitivity of serum estradiol and estrone assays. Given the significantly lower serum levels with vaginal estrogen preparations compared with ERT, vaginal estrogen use appears to be safe in EC survivors.
Dr. Tucker is assistant professor of gynecologic oncology at the University of North Carolina at Chapel Hill.
References
1. Cancer Stat Facts: Uterine Cancer. National Cancer Institute: Surveillance, Epidemiology, and End Results Program. Accessed 12 Aug. 2022. https://seer.cancer.gov/statfacts/html/corp.html.
2. Barakat RR et al. J Clin Oncol. 2006;24(4):587-92.
3. Shim SH et al. Eur J Cancer. 2014;50(9):1628-37.
4. Crandall CJ et al. Menopause. 2018 Jan;25(1):11-20.
5. Chambers LM et al. Int J Gynecol Cancer. 2020 Apr;30(4):515-24.
In the United States, uterine cancer is the fourth most common cancer among women, behind breast, lung/bronchus, and colorectal cancer. There are expected to be almost 66,000 new cases of uterine cancer in 2022.1 The majority of uterine cancers are endometrioid in histology and tend to be low grade, diagnosed at an early stage, and have a good prognosis. While our molecular understanding of endometrial cancers (EC) has changed significantly in recent years, low-grade endometrioid adenocarcinomas have historically been described as type 1 ECs. Type 1 ECs are typically caused by excess estrogen exposure (often unopposed or lacking progesterone protection) and are preceded by endometrial hyperplasia. Excess estrogen can come from exogenous sources (such as unopposed estrogen replacement therapy or tamoxifen, a commonly used treatment in estrogen receptor–positive breast cancer that acts as an estrogen agonist in the endometrium in postmenopausal patients) or endogenous ones (such as obesity).
Peripheral adipose tissue converts androgens into estrogens; paired with the decreased levels of sex hormone–binding globulin seen in obesity, there is more unbound or free serum estrogen (specifically estradiol) in obese women. Estrogen acts on the endometrium to cause proliferation and, if unopposed or imbalanced in relation to progesterone exposure, can ultimately lead to hyperplasia and malignancy.
If excess and unopposed estrogen exposure are major risk factors for the development of EC, is it safe to consider estrogen replacement therapy (ERT) in patients after EC treatment?
The short answer is the data are limited, but in a patient with a history of low-risk early-stage EC who undergoes appropriate counseling, it is likely safe to consider ERT.
Among EC survivors, there has been only one prospective randomized controlled trial that assessed the effect of recurrence rate and survival in women on ERT after EC treatment.2 Patients with stage I or occult stage II endometrial adenocarcinoma treated with at least a total hysterectomy and bilateral salpingo-oophorectomy were randomized to ERT versus placebo for 3 years of treatment, with therapy starting once recovered and within 20 weeks after surgery. Trial participation required an indication for ERT, such as vasomotor symptoms, vaginal atrophy, or increased risk of cardiovascular disease or osteoporosis.
The trial accrued 1,236 patients, falling short of its goal of 2,108 patients after enrollment decreased following the publication of the Women’s Health Initiative results in 2002. This publication prompted a review of the ERT study protocol that found that between decreased accrual and lower than expected recurrence rate, goal accrual would be impossible. Of those enrolled, participants were overwhelmingly white (84%-85%), 41-70 years old (80%-82%), and had stage IA or IB disease (88%). Median follow-up was almost 3 years.
Twenty-six (2.1%) patients experienced cancer recurrence, with similar rates in both groups. Three-year progression-free and overall survival were high overall among all study participants (94.8% and 96.5%). Unfortunately, because the study was closed early, definitive conclusions about the noninferiority of ERT versus placebo regarding oncologic outcomes in early-stage endometrial adenocarcinoma could not be made.
A subsequent meta-analysis looked at the effect of hormone therapy (HT) on recurrence rate in EC survivors.3 Five observational studies were included along with the previously discussed randomized controlled trial. Among 1,975 participants across six studies, there were cancer recurrences in 19 of 896 (2.1%) HT users and 64 of 1,079 (5.9%) controls. HT did not negatively affect cancer recurrence or overall survival. There was significant heterogeneity between studies as to dosing, duration, and type of HT given (some used estrogen-only replacement, others used estrogen and progesterone replacement, and some used both estrogen only and the combination of estrogen and progesterone replacement). Among the five nonrandomized studies included, a protective effect of combined HT on EC recurrence was noted. One study included patients with stage III disease, but only four patients received HT in this cohort.
Given the data we have, ERT does not appear to significantly affect oncologic outcomes in low-risk, early-stage EC survivors. We do not have data to support this same assertion in more advanced, high-risk disease. Before initiation of any ERT in an EC survivor, there should be a detailed discussion to weigh the risks and benefits of starting therapy. The goal of treatment should be to use the lowest dose of ERT possible to treat symptoms, with planned surveillance visits for symptom check-in and assessment of readiness to start tapering treatment.
Footnote: vaginal estrogen therapy
There are no randomized trials assessing the safety of vaginal estrogen preparations or their effect on oncologic outcomes in EC survivors. Observational data from the Women’s Health Initiative showed no increased risk of endometrial cancer in patients who used vaginal estrogen with an intact uterus.4 A recently published retrospective study among 244 gynecologic cancer survivors found low rates of disease recurrence and adverse outcomes among women who used vaginal estrogen for genitourinary symptoms.5 Among EC survivors, the incidence of recurrence was 2.4% for patients with stage I/II disease and 4.3% for stage III/IV disease, with a median follow-up of 80.2 months. While there appears to be some systemic absorption with vaginal estrogen use, this can be quite challenging to measure because of the current sensitivity of serum estradiol and estrone assays. Given the significantly lower serum levels with vaginal estrogen preparations compared with ERT, vaginal estrogen use appears to be safe in EC survivors.
Dr. Tucker is assistant professor of gynecologic oncology at the University of North Carolina at Chapel Hill.
References
1. Cancer Stat Facts: Uterine Cancer. National Cancer Institute: Surveillance, Epidemiology, and End Results Program. Accessed 12 Aug. 2022. https://seer.cancer.gov/statfacts/html/corp.html.
2. Barakat RR et al. J Clin Oncol. 2006;24(4):587-92.
3. Shim SH et al. Eur J Cancer. 2014;50(9):1628-37.
4. Crandall CJ et al. Menopause. 2018 Jan;25(1):11-20.
5. Chambers LM et al. Int J Gynecol Cancer. 2020 Apr;30(4):515-24.