Women's Health

In 2024, the Guttmacher Institute reported that eight states enacted or proposed limits on contraceptive access. Currently, more than 19 million women aged 13-44 years in the United States live in “contraceptive deserts” or places that lack access to a full range of birth control methods. About 1.2 million of those women live in counties that don’t have a single health center that has complete birth control services.

Providing contraceptive care in primary care settings has long been deemed a best practice by the Centers for Disease Control and Prevention (CDC). But the percentage of primary care physicians (PCPs) prescribing contraception or offering contraceptive procedures is strikingly low.

 

Only Half of Family Physicians (FPs) Prescribe Contraceptives

Research by Candice Chen, MD, MPH, and colleagues found that while 73.1% of obstetrician-gynecologists (OB/GYNs) and 72.6% of nurse-midwives prescribed the pill, patch, or vaginal ring; only 51% of FPs, 32.4% of pediatricians, and 19.8% of internal medicine physicians did so. And while 92.8% of OB/GYNs provided intrauterine device (IUD) services, only 16.4% of FPs, 2.6% of internists, and 0.6% of pediatricians did so.

One reason primary care is positioned so well to fill contraception gaps is found in the sheer numbers of PCPs. Chen and colleagues found that while the percentage of FPs prescribing contraception was much smaller (51.4%) than the percentage of OB/GYN prescribers (72.6%), the numbers translate to 72,725 FPs prescribing contraceptives, which is nearly double the number of OB/GYNs prescribing them (36,887).

Access to contraception services took a big hit with the COVID-19 pandemic as did access to healthcare in general. And the 2022 Supreme Court ruling that struck down Roe V. Wade has shaken up the landscape for reproductive services with potential consequences for contraceptive access.

 

Why Aren’t More PCPs Offering Contraceptive Services?

Reasons for the relatively low numbers of PCPs prescribing contraceptives include lack of training in residency, health systems’ financial choices, insurance barriers, and expectation by some physicians and many patients that birth control belongs in the OB/GYN sector. Access, patient awareness that PCPs can provide the care, expectations, and options vary by states and regions.

Angeline Ti, MD, an FP who teaches in a residency program at Wellstar Douglasville Medical Center in Douglasville, Georgia, told this news organization that the awareness issue might be the easiest change for PCPs as many patients aren’t aware you can get contraceptive services in primary care.

 

Things PCPs ‘Could Do Tomorrow’

Those physicians who want to add those services might want to start with universal screening, Ti said — having conversations with patients about contraceptive needs and letting them know they don’t have to get those prescriptions from an OB/GYN. The conversations could center on laying out the options and counseling on risks and benefits of various options and providing referrals, if that is the best option. “There are definitely things that you could do tomorrow,” she said.

PCPs should be familiar with the CDC’s Contraceptive Guidance for Health Care Providers and the federal Office of Population Affairs’ Quality Family Planning Recommendations for providers, which offer practice-level information, Ti said.

PCPs should not feel they need to be able to provide same-day contraceptive care to get started. Having nurses and medical assistants and practice managers on board who are passionate about adding the services can also help bring about change with a team approach, she said.

Even when the provider is enthusiastic about providing the care and is trained to do so, however, insurance barriers may exist, Ti acknowledged. For example, at her clinic a common IUD insertion requires prior authorization.

 

Including Other Providers

Julia Strasser, DrPH, MPH, a member of the core faculty at the Fitzhugh Mullan Institute for Health Workforce Equity in Washington, DC, told this news organization that including other clinicians could help expand contraceptive services in primary care. Her research showed that the proportion of the contraception workforce that is made up of advanced practice clinicians and nurse practitioners is increasing, whereas the proportion that includes physicians is either static or declining.

A paper by her team found that although OB/GYNs and nurse-midwives were more likely to prescribe the pill, patch, or ring, the largest numbers of contraception prescribers were FPs (72,725) and advanced practice nurses (70,115).

“We also know that pharmacists can safely prescribe contraception, and some states have authorized this practice, but uptake is low and policies vary by state,” she said. “Some health systems have pharmacists embedded in their practice — for example in federally qualified health centers and others.”

It’s important, she said, not to frame the gaps in contraceptive care as a failure on the part of individual clinicians but rather as: “How can we change some of the system-level factors that have gotten us to this point?”

Yalda Jabbarpour, MD, an FP and director of the Robert Graham Center of the American Academy of Family Physicians, said sometimes it’s the health center’s cost analysis that stands in the way. She gave an example from her own health system.

“The health system doesn’t want to pay for us to have the IUDs stored in our offices and provide that procedure because they feel it’s more cost effective if the OB/GYNs do it.” IUD insertions take more appointment time than the standard appointment, which also goes into the cost analysis. “Even though you’re trained to do it, you can’t necessarily do it when you get to the real world,” Jabbarpour said.

She said the thinking is that while OB/GYNs focus on women, FPs cover all ages and family members, so having the equipment and the storage space is best left to the OB/GYNs. She said that thinking may be short sighted.

“We have good data that the highest number of office visits in the United States actually happen in the family physician’s office,” she said. Not providing the services injects a barrier into the system as women are being referred for a simple procedure to a physician they’ve never seen. “That’s not very patient centered,” Jabbarpour noted.

In systems that refer contraceptive procedures to OB/GYNs, doctors also can’t practice skills they learned in residency and then may not feel comfortable performing the procedures when they enter a health system that offers the procedures in primary care.

 

Number of FPs Prescribing Long-Acting Contraception Growing

Jabbarpour said there has been some improvement in that area in terms of long-acting reversible contraception.

She pointed to a study of recertifying FPs that found that the percent of FPs who offer either IUDs or implants increased from 23.9% in 2018 to 30% in 2022. The share of FPs providing implant insertion increased from 12.9% to 20.8%; those providing IUDs also increased from 22.9% to 25.5% from 2018 to 2022.

FPs also have the advantage of being more widely distributed in rural and remote areas than OB/GYNs, she noted. “They are in almost every county in the United States.”

Jabbarpour said the education must start with health system leaders. If they deem it important to offer these services in primary care, then residency programs will see that their residents must be appropriately trained to provide it.

“Right now, it’s not an expectation of many of the employers that primary care physicians should do this,” she said.

Ti said that expectation should change. The value proposition for all PCPs and health systems, she said, is this: “Most of contraceptive care is well within the scope of primary care providers. This is care that we can do, and it’s care that we should be doing. So why aren’t we doing it?”

Ti, Strasser, and Jabbarpour reported no relevant financial disclosures.

A version of this article appeared on Medscape.com.

In 2024, the Guttmacher Institute reported that eight states enacted or proposed limits on contraceptive access. Currently, more than 19 million women aged 13-44 years in the United States live in “contraceptive deserts” or places that lack access to a full range of birth control methods. About 1.2 million of those women live in counties that don’t have a single health center that has complete birth control services.

Providing contraceptive care in primary care settings has long been deemed a best practice by the Centers for Disease Control and Prevention (CDC). But the percentage of primary care physicians (PCPs) prescribing contraception or offering contraceptive procedures is strikingly low.

 

Only Half of Family Physicians (FPs) Prescribe Contraceptives

Research by Candice Chen, MD, MPH, and colleagues found that while 73.1% of obstetrician-gynecologists (OB/GYNs) and 72.6% of nurse-midwives prescribed the pill, patch, or vaginal ring; only 51% of FPs, 32.4% of pediatricians, and 19.8% of internal medicine physicians did so. And while 92.8% of OB/GYNs provided intrauterine device (IUD) services, only 16.4% of FPs, 2.6% of internists, and 0.6% of pediatricians did so.

One reason primary care is positioned so well to fill contraception gaps is found in the sheer numbers of PCPs. Chen and colleagues found that while the percentage of FPs prescribing contraception was much smaller (51.4%) than the percentage of OB/GYN prescribers (72.6%), the numbers translate to 72,725 FPs prescribing contraceptives, which is nearly double the number of OB/GYNs prescribing them (36,887).

Access to contraception services took a big hit with the COVID-19 pandemic as did access to healthcare in general. And the 2022 Supreme Court ruling that struck down Roe V. Wade has shaken up the landscape for reproductive services with potential consequences for contraceptive access.

 

Why Aren’t More PCPs Offering Contraceptive Services?

Reasons for the relatively low numbers of PCPs prescribing contraceptives include lack of training in residency, health systems’ financial choices, insurance barriers, and expectation by some physicians and many patients that birth control belongs in the OB/GYN sector. Access, patient awareness that PCPs can provide the care, expectations, and options vary by states and regions.

Angeline Ti, MD, an FP who teaches in a residency program at Wellstar Douglasville Medical Center in Douglasville, Georgia, told this news organization that the awareness issue might be the easiest change for PCPs as many patients aren’t aware you can get contraceptive services in primary care.

 

Things PCPs ‘Could Do Tomorrow’

Those physicians who want to add those services might want to start with universal screening, Ti said — having conversations with patients about contraceptive needs and letting them know they don’t have to get those prescriptions from an OB/GYN. The conversations could center on laying out the options and counseling on risks and benefits of various options and providing referrals, if that is the best option. “There are definitely things that you could do tomorrow,” she said.

PCPs should be familiar with the CDC’s Contraceptive Guidance for Health Care Providers and the federal Office of Population Affairs’ Quality Family Planning Recommendations for providers, which offer practice-level information, Ti said.

PCPs should not feel they need to be able to provide same-day contraceptive care to get started. Having nurses and medical assistants and practice managers on board who are passionate about adding the services can also help bring about change with a team approach, she said.

Even when the provider is enthusiastic about providing the care and is trained to do so, however, insurance barriers may exist, Ti acknowledged. For example, at her clinic a common IUD insertion requires prior authorization.

 

Including Other Providers

Julia Strasser, DrPH, MPH, a member of the core faculty at the Fitzhugh Mullan Institute for Health Workforce Equity in Washington, DC, told this news organization that including other clinicians could help expand contraceptive services in primary care. Her research showed that the proportion of the contraception workforce that is made up of advanced practice clinicians and nurse practitioners is increasing, whereas the proportion that includes physicians is either static or declining.

A paper by her team found that although OB/GYNs and nurse-midwives were more likely to prescribe the pill, patch, or ring, the largest numbers of contraception prescribers were FPs (72,725) and advanced practice nurses (70,115).

“We also know that pharmacists can safely prescribe contraception, and some states have authorized this practice, but uptake is low and policies vary by state,” she said. “Some health systems have pharmacists embedded in their practice — for example in federally qualified health centers and others.”

It’s important, she said, not to frame the gaps in contraceptive care as a failure on the part of individual clinicians but rather as: “How can we change some of the system-level factors that have gotten us to this point?”

Yalda Jabbarpour, MD, an FP and director of the Robert Graham Center of the American Academy of Family Physicians, said sometimes it’s the health center’s cost analysis that stands in the way. She gave an example from her own health system.

“The health system doesn’t want to pay for us to have the IUDs stored in our offices and provide that procedure because they feel it’s more cost effective if the OB/GYNs do it.” IUD insertions take more appointment time than the standard appointment, which also goes into the cost analysis. “Even though you’re trained to do it, you can’t necessarily do it when you get to the real world,” Jabbarpour said.

She said the thinking is that while OB/GYNs focus on women, FPs cover all ages and family members, so having the equipment and the storage space is best left to the OB/GYNs. She said that thinking may be short sighted.

“We have good data that the highest number of office visits in the United States actually happen in the family physician’s office,” she said. Not providing the services injects a barrier into the system as women are being referred for a simple procedure to a physician they’ve never seen. “That’s not very patient centered,” Jabbarpour noted.

In systems that refer contraceptive procedures to OB/GYNs, doctors also can’t practice skills they learned in residency and then may not feel comfortable performing the procedures when they enter a health system that offers the procedures in primary care.

 

Number of FPs Prescribing Long-Acting Contraception Growing

Jabbarpour said there has been some improvement in that area in terms of long-acting reversible contraception.

She pointed to a study of recertifying FPs that found that the percent of FPs who offer either IUDs or implants increased from 23.9% in 2018 to 30% in 2022. The share of FPs providing implant insertion increased from 12.9% to 20.8%; those providing IUDs also increased from 22.9% to 25.5% from 2018 to 2022.

FPs also have the advantage of being more widely distributed in rural and remote areas than OB/GYNs, she noted. “They are in almost every county in the United States.”

Jabbarpour said the education must start with health system leaders. If they deem it important to offer these services in primary care, then residency programs will see that their residents must be appropriately trained to provide it.

“Right now, it’s not an expectation of many of the employers that primary care physicians should do this,” she said.

Ti said that expectation should change. The value proposition for all PCPs and health systems, she said, is this: “Most of contraceptive care is well within the scope of primary care providers. This is care that we can do, and it’s care that we should be doing. So why aren’t we doing it?”

Ti, Strasser, and Jabbarpour reported no relevant financial disclosures.

A version of this article appeared on Medscape.com.

In 2024, the Guttmacher Institute reported that eight states enacted or proposed limits on contraceptive access. Currently, more than 19 million women aged 13-44 years in the United States live in “contraceptive deserts” or places that lack access to a full range of birth control methods. About 1.2 million of those women live in counties that don’t have a single health center that has complete birth control services.

Providing contraceptive care in primary care settings has long been deemed a best practice by the Centers for Disease Control and Prevention (CDC). But the percentage of primary care physicians (PCPs) prescribing contraception or offering contraceptive procedures is strikingly low.

 

Only Half of Family Physicians (FPs) Prescribe Contraceptives

Research by Candice Chen, MD, MPH, and colleagues found that while 73.1% of obstetrician-gynecologists (OB/GYNs) and 72.6% of nurse-midwives prescribed the pill, patch, or vaginal ring; only 51% of FPs, 32.4% of pediatricians, and 19.8% of internal medicine physicians did so. And while 92.8% of OB/GYNs provided intrauterine device (IUD) services, only 16.4% of FPs, 2.6% of internists, and 0.6% of pediatricians did so.

One reason primary care is positioned so well to fill contraception gaps is found in the sheer numbers of PCPs. Chen and colleagues found that while the percentage of FPs prescribing contraception was much smaller (51.4%) than the percentage of OB/GYN prescribers (72.6%), the numbers translate to 72,725 FPs prescribing contraceptives, which is nearly double the number of OB/GYNs prescribing them (36,887).

Access to contraception services took a big hit with the COVID-19 pandemic as did access to healthcare in general. And the 2022 Supreme Court ruling that struck down Roe V. Wade has shaken up the landscape for reproductive services with potential consequences for contraceptive access.

 

Why Aren’t More PCPs Offering Contraceptive Services?

Reasons for the relatively low numbers of PCPs prescribing contraceptives include lack of training in residency, health systems’ financial choices, insurance barriers, and expectation by some physicians and many patients that birth control belongs in the OB/GYN sector. Access, patient awareness that PCPs can provide the care, expectations, and options vary by states and regions.

Angeline Ti, MD, an FP who teaches in a residency program at Wellstar Douglasville Medical Center in Douglasville, Georgia, told this news organization that the awareness issue might be the easiest change for PCPs as many patients aren’t aware you can get contraceptive services in primary care.

 

Things PCPs ‘Could Do Tomorrow’

Those physicians who want to add those services might want to start with universal screening, Ti said — having conversations with patients about contraceptive needs and letting them know they don’t have to get those prescriptions from an OB/GYN. The conversations could center on laying out the options and counseling on risks and benefits of various options and providing referrals, if that is the best option. “There are definitely things that you could do tomorrow,” she said.

PCPs should be familiar with the CDC’s Contraceptive Guidance for Health Care Providers and the federal Office of Population Affairs’ Quality Family Planning Recommendations for providers, which offer practice-level information, Ti said.

PCPs should not feel they need to be able to provide same-day contraceptive care to get started. Having nurses and medical assistants and practice managers on board who are passionate about adding the services can also help bring about change with a team approach, she said.

Even when the provider is enthusiastic about providing the care and is trained to do so, however, insurance barriers may exist, Ti acknowledged. For example, at her clinic a common IUD insertion requires prior authorization.

 

Including Other Providers

Julia Strasser, DrPH, MPH, a member of the core faculty at the Fitzhugh Mullan Institute for Health Workforce Equity in Washington, DC, told this news organization that including other clinicians could help expand contraceptive services in primary care. Her research showed that the proportion of the contraception workforce that is made up of advanced practice clinicians and nurse practitioners is increasing, whereas the proportion that includes physicians is either static or declining.

A paper by her team found that although OB/GYNs and nurse-midwives were more likely to prescribe the pill, patch, or ring, the largest numbers of contraception prescribers were FPs (72,725) and advanced practice nurses (70,115).

“We also know that pharmacists can safely prescribe contraception, and some states have authorized this practice, but uptake is low and policies vary by state,” she said. “Some health systems have pharmacists embedded in their practice — for example in federally qualified health centers and others.”

It’s important, she said, not to frame the gaps in contraceptive care as a failure on the part of individual clinicians but rather as: “How can we change some of the system-level factors that have gotten us to this point?”

Yalda Jabbarpour, MD, an FP and director of the Robert Graham Center of the American Academy of Family Physicians, said sometimes it’s the health center’s cost analysis that stands in the way. She gave an example from her own health system.

“The health system doesn’t want to pay for us to have the IUDs stored in our offices and provide that procedure because they feel it’s more cost effective if the OB/GYNs do it.” IUD insertions take more appointment time than the standard appointment, which also goes into the cost analysis. “Even though you’re trained to do it, you can’t necessarily do it when you get to the real world,” Jabbarpour said.

She said the thinking is that while OB/GYNs focus on women, FPs cover all ages and family members, so having the equipment and the storage space is best left to the OB/GYNs. She said that thinking may be short sighted.

“We have good data that the highest number of office visits in the United States actually happen in the family physician’s office,” she said. Not providing the services injects a barrier into the system as women are being referred for a simple procedure to a physician they’ve never seen. “That’s not very patient centered,” Jabbarpour noted.

In systems that refer contraceptive procedures to OB/GYNs, doctors also can’t practice skills they learned in residency and then may not feel comfortable performing the procedures when they enter a health system that offers the procedures in primary care.

 

Number of FPs Prescribing Long-Acting Contraception Growing

Jabbarpour said there has been some improvement in that area in terms of long-acting reversible contraception.

She pointed to a study of recertifying FPs that found that the percent of FPs who offer either IUDs or implants increased from 23.9% in 2018 to 30% in 2022. The share of FPs providing implant insertion increased from 12.9% to 20.8%; those providing IUDs also increased from 22.9% to 25.5% from 2018 to 2022.

FPs also have the advantage of being more widely distributed in rural and remote areas than OB/GYNs, she noted. “They are in almost every county in the United States.”

Jabbarpour said the education must start with health system leaders. If they deem it important to offer these services in primary care, then residency programs will see that their residents must be appropriately trained to provide it.

“Right now, it’s not an expectation of many of the employers that primary care physicians should do this,” she said.

Ti said that expectation should change. The value proposition for all PCPs and health systems, she said, is this: “Most of contraceptive care is well within the scope of primary care providers. This is care that we can do, and it’s care that we should be doing. So why aren’t we doing it?”

Ti, Strasser, and Jabbarpour reported no relevant financial disclosures.

A version of this article appeared on Medscape.com.

Could an artificial intelligence (AI)–driven tool that mines medical records for suspected cases of osteoporosis be so successful that it becomes a potential liability? Yes, according to Christopher White, PhD, executive director of Maridulu Budyari Gumal, the Sydney Partnership for Health, Education, Research, and Enterprise, a research translation center in Liverpool, Australia.

In a thought-provoking presentation at the Endocrine Society’s AI in Healthcare Virtual Summit, White described the results after his fracture liaison team at Prince of Wales Hospital in Randwick, Australia, tried to plug the “osteoporosis treatment gap” by mining medical records to identify patients with the disorder.

 

‘Be Careful What You Wish For’

White and colleagues developed a robust standalone database over 20 years that informed fracture risk among patients with osteoporosis in Sydney. The database included all relevant clinical information, as well as bone density measurements, on about 30,000 patients and could be interrogated for randomized controlled trial recruitment.

However, a “crisis” occurred around 2011, when the team received a recruitment request for the first head-to-head comparison of alendronate with romosozumab. “We had numerous postmenopausal women in the age range with the required bone density, but we hadn’t captured the severity of their vertebral fracture or how many they actually had,” White told the this news organization. For recruitment into the study, participants must have had at least two moderate or severe vertebral fractures or a proximal vertebral fracture that was sustained between 3 and 24 months before recruitment.

White turned to his hospital’s mainframe, which had coding data and time intervals for patients who were admitted with vertebral or hip fractures. He calculated how many patients who met the study criteria had been discharged and how many of those he thought he’d be able to capture through the mainframe. He was confident he would have enough, but he was wrong. He underrecruited and could not participate in the trial.

Determined not to wind up in a similar situation in the future, he investigated and found that other centers were struggling with similar problems. This led to a collaboration with four investigators who were using AI and Advanced Encryption Standard (AES) coding to identify patients at risk for osteoporotic fractures. White, meanwhile, had developed a natural language processing tool called XRAIT that also identified patients at fracture risk. A study comparing the two electronic search programs, which screen medical records for fractures, found that both reliably identified patients who had had a fracture. White and his colleagues concluded that hybrid tools combining XRAIT and AES would likely improve the identification of patients with osteoporosis who would require follow-up or might participate in future trials.

Those patients were not being identified sooner for multiple reasons, White explained. Sometimes, the radiologist would report osteoporosis, but it wouldn’t get coded. Or, in the emergency department, a patient with a fracture would be treated and then sent home, and the possibility of osteoporosis wasn’t reported.

“As we went deeper and deeper with our tools into the medical record, we found more and more patients who hadn’t been coded or reported but who actually had osteoporosis,” White said. “It was incredibly prevalent.”

But the number of patients identified was more than the hospital could comfortably handle.

Ironically, he added, “To my relief and probably not to the benefit of the patients, there was a system upgrade of the radiology reporting system, which was incompatible with the natural language processing technology that I had installed. The AI was turned off at that point, but I had a look over the edge and into the mine pit.”

“The lesson learned,” White told this news organization, is “If you mine the medical record for unidentified patients before you know what to do with the output, you create a medico-legal minefield. You need to be careful what you wish for with technology, because it may actually come true.”

 

Grappling With the Treatment Gap

An (over)abundance of patients is likely contributing to the “osteoporosis treatment gap” that Australia’s fracture liaison services, which handle many of these patients, are grappling with. One recent meta-analysis showed that not all eligible patients are treated and that not all patients who are treated actually start treatment. Another study showed that only a minority of patients — anywhere between 20% and 40% — who start are still persisting at about 3 years, White said.

Various types of fracture liaison services exist, he noted. The model that has been shown to best promote adherence is the one requiring clinicians to “identify, educate [usually, the primary care physician], evaluate, start treatment, continue treatment, and follow-up at 12 months for to confirm that there is adherence.”

What’s happening now, he said, is that the technology is identifying a high number of vertebral crush fractures, and there’s no education or evaluation. “The radiologist just refers the patient to a primary care physician and hopes for the best. AI isn’t contributing to solving the treatment gap problem; it’s amplifying it. It’s ahead of the ability of organizations to accommodate the findings.”

Solutions, he said, would require support at the top of health systems and organizations, and funding to proceed; data surveys concentrating on vertical integration of the medical record to follow patients wherever they are — eg, hospital, primary care — in their health journeys; a workflow with synchronous diagnosis and treatment planning, delivery, monitoring, and payment; and clinical and community champions advocating and “leading the charge in health tech.”

Furthermore, he advised, organizations need to be “very, very careful with safety and security — that is, managing the digital risks.”

“Oscar Wilde said there are two tragedies in life: One is not getting what one wants, and the other is getting it,” White concluded. “In my career, we’ve moved on from not knowing how to treat osteoporosis to knowing how to treat it. And that is both an asset and a liability.”

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

Could an artificial intelligence (AI)–driven tool that mines medical records for suspected cases of osteoporosis be so successful that it becomes a potential liability? Yes, according to Christopher White, PhD, executive director of Maridulu Budyari Gumal, the Sydney Partnership for Health, Education, Research, and Enterprise, a research translation center in Liverpool, Australia.

In a thought-provoking presentation at the Endocrine Society’s AI in Healthcare Virtual Summit, White described the results after his fracture liaison team at Prince of Wales Hospital in Randwick, Australia, tried to plug the “osteoporosis treatment gap” by mining medical records to identify patients with the disorder.

 

‘Be Careful What You Wish For’

White and colleagues developed a robust standalone database over 20 years that informed fracture risk among patients with osteoporosis in Sydney. The database included all relevant clinical information, as well as bone density measurements, on about 30,000 patients and could be interrogated for randomized controlled trial recruitment.

However, a “crisis” occurred around 2011, when the team received a recruitment request for the first head-to-head comparison of alendronate with romosozumab. “We had numerous postmenopausal women in the age range with the required bone density, but we hadn’t captured the severity of their vertebral fracture or how many they actually had,” White told the this news organization. For recruitment into the study, participants must have had at least two moderate or severe vertebral fractures or a proximal vertebral fracture that was sustained between 3 and 24 months before recruitment.

White turned to his hospital’s mainframe, which had coding data and time intervals for patients who were admitted with vertebral or hip fractures. He calculated how many patients who met the study criteria had been discharged and how many of those he thought he’d be able to capture through the mainframe. He was confident he would have enough, but he was wrong. He underrecruited and could not participate in the trial.

Determined not to wind up in a similar situation in the future, he investigated and found that other centers were struggling with similar problems. This led to a collaboration with four investigators who were using AI and Advanced Encryption Standard (AES) coding to identify patients at risk for osteoporotic fractures. White, meanwhile, had developed a natural language processing tool called XRAIT that also identified patients at fracture risk. A study comparing the two electronic search programs, which screen medical records for fractures, found that both reliably identified patients who had had a fracture. White and his colleagues concluded that hybrid tools combining XRAIT and AES would likely improve the identification of patients with osteoporosis who would require follow-up or might participate in future trials.

Those patients were not being identified sooner for multiple reasons, White explained. Sometimes, the radiologist would report osteoporosis, but it wouldn’t get coded. Or, in the emergency department, a patient with a fracture would be treated and then sent home, and the possibility of osteoporosis wasn’t reported.

“As we went deeper and deeper with our tools into the medical record, we found more and more patients who hadn’t been coded or reported but who actually had osteoporosis,” White said. “It was incredibly prevalent.”

But the number of patients identified was more than the hospital could comfortably handle.

Ironically, he added, “To my relief and probably not to the benefit of the patients, there was a system upgrade of the radiology reporting system, which was incompatible with the natural language processing technology that I had installed. The AI was turned off at that point, but I had a look over the edge and into the mine pit.”

“The lesson learned,” White told this news organization, is “If you mine the medical record for unidentified patients before you know what to do with the output, you create a medico-legal minefield. You need to be careful what you wish for with technology, because it may actually come true.”

 

Grappling With the Treatment Gap

An (over)abundance of patients is likely contributing to the “osteoporosis treatment gap” that Australia’s fracture liaison services, which handle many of these patients, are grappling with. One recent meta-analysis showed that not all eligible patients are treated and that not all patients who are treated actually start treatment. Another study showed that only a minority of patients — anywhere between 20% and 40% — who start are still persisting at about 3 years, White said.

Various types of fracture liaison services exist, he noted. The model that has been shown to best promote adherence is the one requiring clinicians to “identify, educate [usually, the primary care physician], evaluate, start treatment, continue treatment, and follow-up at 12 months for to confirm that there is adherence.”

What’s happening now, he said, is that the technology is identifying a high number of vertebral crush fractures, and there’s no education or evaluation. “The radiologist just refers the patient to a primary care physician and hopes for the best. AI isn’t contributing to solving the treatment gap problem; it’s amplifying it. It’s ahead of the ability of organizations to accommodate the findings.”

Solutions, he said, would require support at the top of health systems and organizations, and funding to proceed; data surveys concentrating on vertical integration of the medical record to follow patients wherever they are — eg, hospital, primary care — in their health journeys; a workflow with synchronous diagnosis and treatment planning, delivery, monitoring, and payment; and clinical and community champions advocating and “leading the charge in health tech.”

Furthermore, he advised, organizations need to be “very, very careful with safety and security — that is, managing the digital risks.”

“Oscar Wilde said there are two tragedies in life: One is not getting what one wants, and the other is getting it,” White concluded. “In my career, we’ve moved on from not knowing how to treat osteoporosis to knowing how to treat it. And that is both an asset and a liability.”

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

Could an artificial intelligence (AI)–driven tool that mines medical records for suspected cases of osteoporosis be so successful that it becomes a potential liability? Yes, according to Christopher White, PhD, executive director of Maridulu Budyari Gumal, the Sydney Partnership for Health, Education, Research, and Enterprise, a research translation center in Liverpool, Australia.

In a thought-provoking presentation at the Endocrine Society’s AI in Healthcare Virtual Summit, White described the results after his fracture liaison team at Prince of Wales Hospital in Randwick, Australia, tried to plug the “osteoporosis treatment gap” by mining medical records to identify patients with the disorder.

 

‘Be Careful What You Wish For’

White and colleagues developed a robust standalone database over 20 years that informed fracture risk among patients with osteoporosis in Sydney. The database included all relevant clinical information, as well as bone density measurements, on about 30,000 patients and could be interrogated for randomized controlled trial recruitment.

However, a “crisis” occurred around 2011, when the team received a recruitment request for the first head-to-head comparison of alendronate with romosozumab. “We had numerous postmenopausal women in the age range with the required bone density, but we hadn’t captured the severity of their vertebral fracture or how many they actually had,” White told the this news organization. For recruitment into the study, participants must have had at least two moderate or severe vertebral fractures or a proximal vertebral fracture that was sustained between 3 and 24 months before recruitment.

White turned to his hospital’s mainframe, which had coding data and time intervals for patients who were admitted with vertebral or hip fractures. He calculated how many patients who met the study criteria had been discharged and how many of those he thought he’d be able to capture through the mainframe. He was confident he would have enough, but he was wrong. He underrecruited and could not participate in the trial.

Determined not to wind up in a similar situation in the future, he investigated and found that other centers were struggling with similar problems. This led to a collaboration with four investigators who were using AI and Advanced Encryption Standard (AES) coding to identify patients at risk for osteoporotic fractures. White, meanwhile, had developed a natural language processing tool called XRAIT that also identified patients at fracture risk. A study comparing the two electronic search programs, which screen medical records for fractures, found that both reliably identified patients who had had a fracture. White and his colleagues concluded that hybrid tools combining XRAIT and AES would likely improve the identification of patients with osteoporosis who would require follow-up or might participate in future trials.

Those patients were not being identified sooner for multiple reasons, White explained. Sometimes, the radiologist would report osteoporosis, but it wouldn’t get coded. Or, in the emergency department, a patient with a fracture would be treated and then sent home, and the possibility of osteoporosis wasn’t reported.

“As we went deeper and deeper with our tools into the medical record, we found more and more patients who hadn’t been coded or reported but who actually had osteoporosis,” White said. “It was incredibly prevalent.”

But the number of patients identified was more than the hospital could comfortably handle.

Ironically, he added, “To my relief and probably not to the benefit of the patients, there was a system upgrade of the radiology reporting system, which was incompatible with the natural language processing technology that I had installed. The AI was turned off at that point, but I had a look over the edge and into the mine pit.”

“The lesson learned,” White told this news organization, is “If you mine the medical record for unidentified patients before you know what to do with the output, you create a medico-legal minefield. You need to be careful what you wish for with technology, because it may actually come true.”

 

Grappling With the Treatment Gap

An (over)abundance of patients is likely contributing to the “osteoporosis treatment gap” that Australia’s fracture liaison services, which handle many of these patients, are grappling with. One recent meta-analysis showed that not all eligible patients are treated and that not all patients who are treated actually start treatment. Another study showed that only a minority of patients — anywhere between 20% and 40% — who start are still persisting at about 3 years, White said.

Various types of fracture liaison services exist, he noted. The model that has been shown to best promote adherence is the one requiring clinicians to “identify, educate [usually, the primary care physician], evaluate, start treatment, continue treatment, and follow-up at 12 months for to confirm that there is adherence.”

What’s happening now, he said, is that the technology is identifying a high number of vertebral crush fractures, and there’s no education or evaluation. “The radiologist just refers the patient to a primary care physician and hopes for the best. AI isn’t contributing to solving the treatment gap problem; it’s amplifying it. It’s ahead of the ability of organizations to accommodate the findings.”

Solutions, he said, would require support at the top of health systems and organizations, and funding to proceed; data surveys concentrating on vertical integration of the medical record to follow patients wherever they are — eg, hospital, primary care — in their health journeys; a workflow with synchronous diagnosis and treatment planning, delivery, monitoring, and payment; and clinical and community champions advocating and “leading the charge in health tech.”

Furthermore, he advised, organizations need to be “very, very careful with safety and security — that is, managing the digital risks.”

“Oscar Wilde said there are two tragedies in life: One is not getting what one wants, and the other is getting it,” White concluded. “In my career, we’ve moved on from not knowing how to treat osteoporosis to knowing how to treat it. And that is both an asset and a liability.”

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

Gestational hypertension, preeclampsia, or eclampsia is associated with a significantly higher risk for neurologic disorders such as migraine or epilepsy in the years following a first pregnancy, new research suggests.

The risk was highest in those with gestational eclampsia, who had a 70% increased chance of developing a neurologic disorder, including a fivefold increased risk for epilepsy, investigators found.

“When consulting women with new-onset neurological disorders, it’s important to inquire about their pregnancy history, as pregnancy complications such as gestational hypertension, preeclampsia, and eclampsia have been associated with an increased risk of neurological disorders later in life.” Therese Friis, MD, PhD student, Department of Women’s and Children’s Health, Uppsala University in Sweden, said in an interview.

The findings were published online in JAMA Neurology.

Most studies of maternal outcomes after gestational hypertension, preeclampsia, or eclampsia have focused on long-term risks for cardiovascular disease or neurologic complications such as stroke, dementia, and cognitive impairment. And many of these studies were relatively small and based on interviews or questionnaires.

“We wanted to investigate whether women with a hypertensive disorder of pregnancy also had a risk of other neurological complications, closer in time to the pregnancy,” said Friis.

The new study included 648,385 women (mean age, 28.5 years) whose first pregnancy occurred between 2005 and 2018. Of these, 94% had a normotensive pregnancy, 2% had gestational hypertension, 4% had preeclampsia without eclampsia, and 0.1% had eclampsia.

Gestational hypertension was defined as new-onset systolic blood pressure of ≥ 140 mm Hg and/or diastolic blood pressure ≥ 90 mm Hg; preeclampsia was defined as gestational hypertension accompanied by proteinuria; and eclampsia was defined as tonic-clonic seizures without other etiology accompanied by preeclampsia.

Researchers used linked Swedish national registries that collect data on pregnancies, births, and infant and maternal characteristics. Among other things, they controlled for maternal age, early pregnancy body mass index, education level, and pregestational and gestational diabetes.

The primary outcome was a composite of five new-onset neurologic diagnoses: Migraine, headache, epilepsy, sleep disorder, and mental fatigue (neurasthenia), although one diagnosis was sufficient, from 42 days to 15 years after childbirth. Mean follow-up was 7.7 years.

 

Fivefold Epilepsy Risk

Compared with normotensive pregnancies, the risk for the primary outcome was 70% greater in those with eclampsia (adjusted hazard ratio [aHR], 1.70; 95% CI, 1.16-2.50), 27% higher for gestational hypertension (aHR, 1.27; 95% CI, 1.12-1.45), and 32% for preeclampsia (aHR, 1.32; 95% CI, 1.22-1.42).

Researchers also looked at the risk for individual neurologic disorders. There were too few neurasthenia events to generate meaningful results, so this diagnosis was omitted from the analysis.

Here, the study found women with eclampsia had five times the risk for epilepsy (aHR, 5.31; 95% CI, 2.85-9.89) compared with women with normotensive pregnancies.

The underlying mechanism for this association is unclear. However, said Friis, eclampsia and epilepsy share common pathways, such as neuroinflammation, and women with epilepsy before pregnancy run an increased risk for eclampsia.

“So common underlying pathways might increase the risk both for eclampsia in cases of a seizure disorder and a future seizure disorder after eclampsia,” she said.

In addition, preeclampsia and, in particular, eclampsia can cause irreversible subclinical cerebral infarcts found in areas of cerebral edema, she added. “These infarcts or scarring of brain tissue could potentially serve as foci for later epileptic activity.”

Researchers separated women with preeclampsia (with or without eclampsia) into those with preterm (less than 37 weeks; 21%) and term (79%) deliveries. As Friis explained, women with preterm preeclampsia have a higher risk for acute complications and long-term cardiovascular outcomes than those with term preeclampsia.

Compared with those with normotensive pregnancies, investigators found an increased risk for the composite neurologic outcome among women with preterm preeclampsia (aHR, 1.54; 95% CI, 1.34-1.79), but also for those with term preeclampsia (aHR, 1.27; 95% CI, 1.17-1.38).

 

Common Vascular Component

The study also showed gestational hypertension and preeclampsia were associated with a later diagnosis of migraine, suggesting a possible common underlying vascular component.

“The increased risk of migraine following preeclampsia could be linked to endothelial damage at the blood-brain barrier level and alterations in cerebral blood flow and arterial vasospasm found in eclampsia, but this is only speculation,” said Friis.

The analysis also found an association between preeclampsia and a later diagnosis of headache. But this result likely encompasses several headache diagnoses, including migraine, so “it’s challenging to draw conclusions about the underlying mechanisms,” Friis added.

The study didn’t consider diagnoses from primary healthcare, which resulted in relatively few outcomes. The authors explained they could only identify the most severe cases; for example, women referred to specialized care.

Another potential study limitation is that Swedish registers don’t include information on race or ethnicity. Evidence shows there are racial differences in the risk for cardiovascular outcomes after preeclampsia.

This area of research is important as most women will experience at least one pregnancy in their lifetime, and preeclampsia affects 3%-5% of pregnancies. Further research is needed to understand the underlying pathophysiological mechanisms and the long-term consequences of this disorder, said Friis.

She added she hopes more therapeutic options will be available in the future for neuroprotective treatment for women with gestational hypertensive disorders.

Asked to comment, Thomas Vidic, MD, clinical professor of neurology, Indiana University School of Medicine, South Bend, said in an interview that this is an important study that includes robust data.

In his opinion, the most significant study finding is the marked increase in epilepsy risk after gestational eclampsia.

“In women who have new-onset epilepsy of unknown cause, asking about having eclampsia or preeclampsia during pregnancy is definitely a worthwhile question,” he said.

Confirming an etiology paints “a better picture” for patients wondering why they’re experiencing seizures, he added.

As with any registry-based study, this one had some acknowledged limitations, “but at the same time, the authors were able to have such a large database that I think this study is very worthwhile,” said Vidic.

The study received support from the Swedish Research Council. Neither Friis nor Vidic had relevant conflicts of interest.

A version of this article appeared on Medscape.com.

Gestational hypertension, preeclampsia, or eclampsia is associated with a significantly higher risk for neurologic disorders such as migraine or epilepsy in the years following a first pregnancy, new research suggests.

The risk was highest in those with gestational eclampsia, who had a 70% increased chance of developing a neurologic disorder, including a fivefold increased risk for epilepsy, investigators found.

“When consulting women with new-onset neurological disorders, it’s important to inquire about their pregnancy history, as pregnancy complications such as gestational hypertension, preeclampsia, and eclampsia have been associated with an increased risk of neurological disorders later in life.” Therese Friis, MD, PhD student, Department of Women’s and Children’s Health, Uppsala University in Sweden, said in an interview.

The findings were published online in JAMA Neurology.

Most studies of maternal outcomes after gestational hypertension, preeclampsia, or eclampsia have focused on long-term risks for cardiovascular disease or neurologic complications such as stroke, dementia, and cognitive impairment. And many of these studies were relatively small and based on interviews or questionnaires.

“We wanted to investigate whether women with a hypertensive disorder of pregnancy also had a risk of other neurological complications, closer in time to the pregnancy,” said Friis.

The new study included 648,385 women (mean age, 28.5 years) whose first pregnancy occurred between 2005 and 2018. Of these, 94% had a normotensive pregnancy, 2% had gestational hypertension, 4% had preeclampsia without eclampsia, and 0.1% had eclampsia.

Gestational hypertension was defined as new-onset systolic blood pressure of ≥ 140 mm Hg and/or diastolic blood pressure ≥ 90 mm Hg; preeclampsia was defined as gestational hypertension accompanied by proteinuria; and eclampsia was defined as tonic-clonic seizures without other etiology accompanied by preeclampsia.

Researchers used linked Swedish national registries that collect data on pregnancies, births, and infant and maternal characteristics. Among other things, they controlled for maternal age, early pregnancy body mass index, education level, and pregestational and gestational diabetes.

The primary outcome was a composite of five new-onset neurologic diagnoses: Migraine, headache, epilepsy, sleep disorder, and mental fatigue (neurasthenia), although one diagnosis was sufficient, from 42 days to 15 years after childbirth. Mean follow-up was 7.7 years.

 

Fivefold Epilepsy Risk

Compared with normotensive pregnancies, the risk for the primary outcome was 70% greater in those with eclampsia (adjusted hazard ratio [aHR], 1.70; 95% CI, 1.16-2.50), 27% higher for gestational hypertension (aHR, 1.27; 95% CI, 1.12-1.45), and 32% for preeclampsia (aHR, 1.32; 95% CI, 1.22-1.42).

Researchers also looked at the risk for individual neurologic disorders. There were too few neurasthenia events to generate meaningful results, so this diagnosis was omitted from the analysis.

Here, the study found women with eclampsia had five times the risk for epilepsy (aHR, 5.31; 95% CI, 2.85-9.89) compared with women with normotensive pregnancies.

The underlying mechanism for this association is unclear. However, said Friis, eclampsia and epilepsy share common pathways, such as neuroinflammation, and women with epilepsy before pregnancy run an increased risk for eclampsia.

“So common underlying pathways might increase the risk both for eclampsia in cases of a seizure disorder and a future seizure disorder after eclampsia,” she said.

In addition, preeclampsia and, in particular, eclampsia can cause irreversible subclinical cerebral infarcts found in areas of cerebral edema, she added. “These infarcts or scarring of brain tissue could potentially serve as foci for later epileptic activity.”

Researchers separated women with preeclampsia (with or without eclampsia) into those with preterm (less than 37 weeks; 21%) and term (79%) deliveries. As Friis explained, women with preterm preeclampsia have a higher risk for acute complications and long-term cardiovascular outcomes than those with term preeclampsia.

Compared with those with normotensive pregnancies, investigators found an increased risk for the composite neurologic outcome among women with preterm preeclampsia (aHR, 1.54; 95% CI, 1.34-1.79), but also for those with term preeclampsia (aHR, 1.27; 95% CI, 1.17-1.38).

 

Common Vascular Component

The study also showed gestational hypertension and preeclampsia were associated with a later diagnosis of migraine, suggesting a possible common underlying vascular component.

“The increased risk of migraine following preeclampsia could be linked to endothelial damage at the blood-brain barrier level and alterations in cerebral blood flow and arterial vasospasm found in eclampsia, but this is only speculation,” said Friis.

The analysis also found an association between preeclampsia and a later diagnosis of headache. But this result likely encompasses several headache diagnoses, including migraine, so “it’s challenging to draw conclusions about the underlying mechanisms,” Friis added.

The study didn’t consider diagnoses from primary healthcare, which resulted in relatively few outcomes. The authors explained they could only identify the most severe cases; for example, women referred to specialized care.

Another potential study limitation is that Swedish registers don’t include information on race or ethnicity. Evidence shows there are racial differences in the risk for cardiovascular outcomes after preeclampsia.

This area of research is important as most women will experience at least one pregnancy in their lifetime, and preeclampsia affects 3%-5% of pregnancies. Further research is needed to understand the underlying pathophysiological mechanisms and the long-term consequences of this disorder, said Friis.

She added she hopes more therapeutic options will be available in the future for neuroprotective treatment for women with gestational hypertensive disorders.

Asked to comment, Thomas Vidic, MD, clinical professor of neurology, Indiana University School of Medicine, South Bend, said in an interview that this is an important study that includes robust data.

In his opinion, the most significant study finding is the marked increase in epilepsy risk after gestational eclampsia.

“In women who have new-onset epilepsy of unknown cause, asking about having eclampsia or preeclampsia during pregnancy is definitely a worthwhile question,” he said.

Confirming an etiology paints “a better picture” for patients wondering why they’re experiencing seizures, he added.

As with any registry-based study, this one had some acknowledged limitations, “but at the same time, the authors were able to have such a large database that I think this study is very worthwhile,” said Vidic.

The study received support from the Swedish Research Council. Neither Friis nor Vidic had relevant conflicts of interest.

A version of this article appeared on Medscape.com.

Gestational hypertension, preeclampsia, or eclampsia is associated with a significantly higher risk for neurologic disorders such as migraine or epilepsy in the years following a first pregnancy, new research suggests.

The risk was highest in those with gestational eclampsia, who had a 70% increased chance of developing a neurologic disorder, including a fivefold increased risk for epilepsy, investigators found.

“When consulting women with new-onset neurological disorders, it’s important to inquire about their pregnancy history, as pregnancy complications such as gestational hypertension, preeclampsia, and eclampsia have been associated with an increased risk of neurological disorders later in life.” Therese Friis, MD, PhD student, Department of Women’s and Children’s Health, Uppsala University in Sweden, said in an interview.

The findings were published online in JAMA Neurology.

Most studies of maternal outcomes after gestational hypertension, preeclampsia, or eclampsia have focused on long-term risks for cardiovascular disease or neurologic complications such as stroke, dementia, and cognitive impairment. And many of these studies were relatively small and based on interviews or questionnaires.

“We wanted to investigate whether women with a hypertensive disorder of pregnancy also had a risk of other neurological complications, closer in time to the pregnancy,” said Friis.

The new study included 648,385 women (mean age, 28.5 years) whose first pregnancy occurred between 2005 and 2018. Of these, 94% had a normotensive pregnancy, 2% had gestational hypertension, 4% had preeclampsia without eclampsia, and 0.1% had eclampsia.

Gestational hypertension was defined as new-onset systolic blood pressure of ≥ 140 mm Hg and/or diastolic blood pressure ≥ 90 mm Hg; preeclampsia was defined as gestational hypertension accompanied by proteinuria; and eclampsia was defined as tonic-clonic seizures without other etiology accompanied by preeclampsia.

Researchers used linked Swedish national registries that collect data on pregnancies, births, and infant and maternal characteristics. Among other things, they controlled for maternal age, early pregnancy body mass index, education level, and pregestational and gestational diabetes.

The primary outcome was a composite of five new-onset neurologic diagnoses: Migraine, headache, epilepsy, sleep disorder, and mental fatigue (neurasthenia), although one diagnosis was sufficient, from 42 days to 15 years after childbirth. Mean follow-up was 7.7 years.

 

Fivefold Epilepsy Risk

Compared with normotensive pregnancies, the risk for the primary outcome was 70% greater in those with eclampsia (adjusted hazard ratio [aHR], 1.70; 95% CI, 1.16-2.50), 27% higher for gestational hypertension (aHR, 1.27; 95% CI, 1.12-1.45), and 32% for preeclampsia (aHR, 1.32; 95% CI, 1.22-1.42).

Researchers also looked at the risk for individual neurologic disorders. There were too few neurasthenia events to generate meaningful results, so this diagnosis was omitted from the analysis.

Here, the study found women with eclampsia had five times the risk for epilepsy (aHR, 5.31; 95% CI, 2.85-9.89) compared with women with normotensive pregnancies.

The underlying mechanism for this association is unclear. However, said Friis, eclampsia and epilepsy share common pathways, such as neuroinflammation, and women with epilepsy before pregnancy run an increased risk for eclampsia.

“So common underlying pathways might increase the risk both for eclampsia in cases of a seizure disorder and a future seizure disorder after eclampsia,” she said.

In addition, preeclampsia and, in particular, eclampsia can cause irreversible subclinical cerebral infarcts found in areas of cerebral edema, she added. “These infarcts or scarring of brain tissue could potentially serve as foci for later epileptic activity.”

Researchers separated women with preeclampsia (with or without eclampsia) into those with preterm (less than 37 weeks; 21%) and term (79%) deliveries. As Friis explained, women with preterm preeclampsia have a higher risk for acute complications and long-term cardiovascular outcomes than those with term preeclampsia.

Compared with those with normotensive pregnancies, investigators found an increased risk for the composite neurologic outcome among women with preterm preeclampsia (aHR, 1.54; 95% CI, 1.34-1.79), but also for those with term preeclampsia (aHR, 1.27; 95% CI, 1.17-1.38).

 

Common Vascular Component

The study also showed gestational hypertension and preeclampsia were associated with a later diagnosis of migraine, suggesting a possible common underlying vascular component.

“The increased risk of migraine following preeclampsia could be linked to endothelial damage at the blood-brain barrier level and alterations in cerebral blood flow and arterial vasospasm found in eclampsia, but this is only speculation,” said Friis.

The analysis also found an association between preeclampsia and a later diagnosis of headache. But this result likely encompasses several headache diagnoses, including migraine, so “it’s challenging to draw conclusions about the underlying mechanisms,” Friis added.

The study didn’t consider diagnoses from primary healthcare, which resulted in relatively few outcomes. The authors explained they could only identify the most severe cases; for example, women referred to specialized care.

Another potential study limitation is that Swedish registers don’t include information on race or ethnicity. Evidence shows there are racial differences in the risk for cardiovascular outcomes after preeclampsia.

This area of research is important as most women will experience at least one pregnancy in their lifetime, and preeclampsia affects 3%-5% of pregnancies. Further research is needed to understand the underlying pathophysiological mechanisms and the long-term consequences of this disorder, said Friis.

She added she hopes more therapeutic options will be available in the future for neuroprotective treatment for women with gestational hypertensive disorders.

Asked to comment, Thomas Vidic, MD, clinical professor of neurology, Indiana University School of Medicine, South Bend, said in an interview that this is an important study that includes robust data.

In his opinion, the most significant study finding is the marked increase in epilepsy risk after gestational eclampsia.

“In women who have new-onset epilepsy of unknown cause, asking about having eclampsia or preeclampsia during pregnancy is definitely a worthwhile question,” he said.

Confirming an etiology paints “a better picture” for patients wondering why they’re experiencing seizures, he added.

As with any registry-based study, this one had some acknowledged limitations, “but at the same time, the authors were able to have such a large database that I think this study is very worthwhile,” said Vidic.

The study received support from the Swedish Research Council. Neither Friis nor Vidic had relevant conflicts of interest.

A version of this article appeared on Medscape.com.

TOPLINE:

Healthcare utilization after immediate and delayed intrauterine device (IUD) placement postpartum was comparable, with the immediate placement group making slightly fewer visits to obstetricians or gynecologists (ob/gyns). While immediate placement was associated with increased rates of imaging, it showed lower rates of laparoscopic surgery for IUD-related complications.

METHODOLOGY:

• Researchers conducted a retrospective cohort study using data from Kaiser Permanente Northern California electronic health records to compare healthcare utilization after immediate (within 24 hours of placental delivery) and delayed (after 24 hours up to 6 weeks later) IUD placement.
• They included 11,875 patients who delivered a live neonate and had an IUD placed between 0 and 63 days postpartum from 2016 to 2020, of whom 1543 received immediate IUD placement.
• The primary outcome measures focused on the number of outpatient visits to ob/gyns for any indication within 1 year after delivery.
• The secondary outcomes included pelvic or abdominal ultrasonograms performed in radiology departments, surgical interventions, hospitalizations related to IUD placement, and rates of pregnancy within 1 year.

TAKEAWAY:

• Immediate placement of an IUD was associated with a modest decrease in the number of overall visits to ob/gyns compared with delayed placement (mean visits, 2.30 vs 2.47; adjusted risk ratio [aRR], 0.91; 95% CI, 0.87-0.94; P < .001).
• Immediate placement of an IUD was associated with more imaging studies not within an ob/gyn visit (aRR, 2.26; P < .001); however, the rates of laparoscopic surgeries for complications related to IUD were lower in the immediate than in the delayed group (0.0% vs 0.4%; P = .005).
• Hospitalizations related to IUD insertion were rare and increased in the immediate group (0.4% immediate; 0.02% delayed; P < .001).
• No significant differences in repeat pregnancies were observed between the groups at 1 year (P = .342), and immediate placement of an IUD was not associated with an increased risk for ectopic pregnancies.

IN PRACTICE:

“Because one of the main goals of immediate IUD is preventing short-interval unintended pregnancies, it is of critical importance to highlight that there was no difference in the pregnancy rate between groups in the study,” the authors wrote. “This study can guide patient counseling and consent for immediate IUD,” they further added.

SOURCE:

This study was led by Talis M. Swisher, MD, of the Department of Obstetrics and Gynecology at the San Leandro Medical Center of Kaiser Permanente in San Leandro, California. It was published online on December 12, 2024, in Obstetrics & Gynecology.

LIMITATIONS:

Data on patient satisfaction were not included in this study. No analysis of cost-benefit was carried out due to challenges in comparing differences in insurance plans and regional disparities in costs across the United States. The study setting was unique to Kaiser Permanente Northern California, in which all patients in the hospital had access to IUDs and multiple settings of ultrasonography were readily available. Visits carried out virtually were not included in the analysis.

DISCLOSURES:

This study was supported by the Kaiser Permanente Northern California Graduate Medical Education Program, Kaiser Foundation Hospitals. The authors reported no potential conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

TOPLINE:

Healthcare utilization after immediate and delayed intrauterine device (IUD) placement postpartum was comparable, with the immediate placement group making slightly fewer visits to obstetricians or gynecologists (ob/gyns). While immediate placement was associated with increased rates of imaging, it showed lower rates of laparoscopic surgery for IUD-related complications.

METHODOLOGY:

• Researchers conducted a retrospective cohort study using data from Kaiser Permanente Northern California electronic health records to compare healthcare utilization after immediate (within 24 hours of placental delivery) and delayed (after 24 hours up to 6 weeks later) IUD placement.
• They included 11,875 patients who delivered a live neonate and had an IUD placed between 0 and 63 days postpartum from 2016 to 2020, of whom 1543 received immediate IUD placement.
• The primary outcome measures focused on the number of outpatient visits to ob/gyns for any indication within 1 year after delivery.
• The secondary outcomes included pelvic or abdominal ultrasonograms performed in radiology departments, surgical interventions, hospitalizations related to IUD placement, and rates of pregnancy within 1 year.

TAKEAWAY:

• Immediate placement of an IUD was associated with a modest decrease in the number of overall visits to ob/gyns compared with delayed placement (mean visits, 2.30 vs 2.47; adjusted risk ratio [aRR], 0.91; 95% CI, 0.87-0.94; P < .001).
• Immediate placement of an IUD was associated with more imaging studies not within an ob/gyn visit (aRR, 2.26; P < .001); however, the rates of laparoscopic surgeries for complications related to IUD were lower in the immediate than in the delayed group (0.0% vs 0.4%; P = .005).
• Hospitalizations related to IUD insertion were rare and increased in the immediate group (0.4% immediate; 0.02% delayed; P < .001).
• No significant differences in repeat pregnancies were observed between the groups at 1 year (P = .342), and immediate placement of an IUD was not associated with an increased risk for ectopic pregnancies.

IN PRACTICE:

“Because one of the main goals of immediate IUD is preventing short-interval unintended pregnancies, it is of critical importance to highlight that there was no difference in the pregnancy rate between groups in the study,” the authors wrote. “This study can guide patient counseling and consent for immediate IUD,” they further added.

SOURCE:

This study was led by Talis M. Swisher, MD, of the Department of Obstetrics and Gynecology at the San Leandro Medical Center of Kaiser Permanente in San Leandro, California. It was published online on December 12, 2024, in Obstetrics & Gynecology.

LIMITATIONS:

Data on patient satisfaction were not included in this study. No analysis of cost-benefit was carried out due to challenges in comparing differences in insurance plans and regional disparities in costs across the United States. The study setting was unique to Kaiser Permanente Northern California, in which all patients in the hospital had access to IUDs and multiple settings of ultrasonography were readily available. Visits carried out virtually were not included in the analysis.

DISCLOSURES:

This study was supported by the Kaiser Permanente Northern California Graduate Medical Education Program, Kaiser Foundation Hospitals. The authors reported no potential conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

TOPLINE:

Healthcare utilization after immediate and delayed intrauterine device (IUD) placement postpartum was comparable, with the immediate placement group making slightly fewer visits to obstetricians or gynecologists (ob/gyns). While immediate placement was associated with increased rates of imaging, it showed lower rates of laparoscopic surgery for IUD-related complications.

METHODOLOGY:

• Researchers conducted a retrospective cohort study using data from Kaiser Permanente Northern California electronic health records to compare healthcare utilization after immediate (within 24 hours of placental delivery) and delayed (after 24 hours up to 6 weeks later) IUD placement.
• They included 11,875 patients who delivered a live neonate and had an IUD placed between 0 and 63 days postpartum from 2016 to 2020, of whom 1543 received immediate IUD placement.
• The primary outcome measures focused on the number of outpatient visits to ob/gyns for any indication within 1 year after delivery.
• The secondary outcomes included pelvic or abdominal ultrasonograms performed in radiology departments, surgical interventions, hospitalizations related to IUD placement, and rates of pregnancy within 1 year.

TAKEAWAY:

• Immediate placement of an IUD was associated with a modest decrease in the number of overall visits to ob/gyns compared with delayed placement (mean visits, 2.30 vs 2.47; adjusted risk ratio [aRR], 0.91; 95% CI, 0.87-0.94; P < .001).
• Immediate placement of an IUD was associated with more imaging studies not within an ob/gyn visit (aRR, 2.26; P < .001); however, the rates of laparoscopic surgeries for complications related to IUD were lower in the immediate than in the delayed group (0.0% vs 0.4%; P = .005).
• Hospitalizations related to IUD insertion were rare and increased in the immediate group (0.4% immediate; 0.02% delayed; P < .001).
• No significant differences in repeat pregnancies were observed between the groups at 1 year (P = .342), and immediate placement of an IUD was not associated with an increased risk for ectopic pregnancies.

IN PRACTICE:

“Because one of the main goals of immediate IUD is preventing short-interval unintended pregnancies, it is of critical importance to highlight that there was no difference in the pregnancy rate between groups in the study,” the authors wrote. “This study can guide patient counseling and consent for immediate IUD,” they further added.

SOURCE:

This study was led by Talis M. Swisher, MD, of the Department of Obstetrics and Gynecology at the San Leandro Medical Center of Kaiser Permanente in San Leandro, California. It was published online on December 12, 2024, in Obstetrics & Gynecology.

LIMITATIONS:

Data on patient satisfaction were not included in this study. No analysis of cost-benefit was carried out due to challenges in comparing differences in insurance plans and regional disparities in costs across the United States. The study setting was unique to Kaiser Permanente Northern California, in which all patients in the hospital had access to IUDs and multiple settings of ultrasonography were readily available. Visits carried out virtually were not included in the analysis.

DISCLOSURES:

This study was supported by the Kaiser Permanente Northern California Graduate Medical Education Program, Kaiser Foundation Hospitals. The authors reported no potential conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

TOPLINE:

Coffee consumption is associated with the abundance of the gut bacterium Lawsonibacter asaccharolyticus, suggesting that specific foods can affect the intestinal microbiome.

METHODOLOGY:

• The researchers selected coffee as a model to investigate the interplay between specific foods and the intestinal microbial community.
• They conducted a multicohort, multiomic analysis of US and UK populations with detailed dietary information from 22,867 participants, which they then integrated with public data from 211 cohorts comprising 54,198 participants.
• They conducted various in vitro experiments to expand and validate their findings, including adding coffee to media containing the L asaccharolyticus species that had been isolated from human feces.

TAKEAWAY:

• L asaccharolyticus is highly prevalent, with about fourfold higher average abundance in coffee drinkers, and its growth is stimulated in vitro by coffee supplementation.
• The link between coffee consumption and the microbiome was highly reproducible across different populations (area under the curve, 0.89), driven largely by the presence and abundance of L asaccharolyticus.
• Similar associations were found in analyses of data from 25 countries. The prevalence of the bacterium was high in European countries with high per capita coffee consumption, such as Luxembourg, Denmark, and Sweden, and very low in countries with low per capita coffee consumption, such as China, Argentina, and India.
• Plasma metabolomics on 438 samples identified several metabolites enriched among coffee drinkers, with quinic acid and its potential derivatives associated with both coffee and L asaccharolyticus.

IN PRACTICE:

“Our study provides insights into how the gut microbiome potentially mediates the chemistry — and thus health benefits — of coffee,” the study authors wrote. “The microbial mechanisms underlying the metabolism of coffee are a step towards mapping the role of specific foods on the gut microbiome, and similar patterns of microorganism–food interactions for other dietary elements should be sought with systematic epidemiologic and metagenomic investigations.”

SOURCE:

Paolo Manghi, PhD, University of Trento, Italy, led the study, which was published online in Nature Microbiology.

LIMITATIONS:

The authors relied on food questionnaires to assess coffee intake. The study is observational, and the clinical implications are unknown.

DISCLOSURES:

This work was supported by ZOE, a biotech company, and TwinsUK, an adult twin registry funded by the Wellcome Trust, Medical Research Council, Versus Arthritis, European Union Horizon 2020, Chronic Disease Research Foundation, the National Institute for Health and Care Research — Clinical Research Network and Biomedical Research Centre based at Guy’s and St. Thomas’ NHS Foundation Trust in partnership with King’s College London. Manghi had no competing interests. Several other coauthors reported financial relationships with ZOE, and three are cofounders of the company.

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

TOPLINE:

Coffee consumption is associated with the abundance of the gut bacterium Lawsonibacter asaccharolyticus, suggesting that specific foods can affect the intestinal microbiome.

METHODOLOGY:

• The researchers selected coffee as a model to investigate the interplay between specific foods and the intestinal microbial community.
• They conducted a multicohort, multiomic analysis of US and UK populations with detailed dietary information from 22,867 participants, which they then integrated with public data from 211 cohorts comprising 54,198 participants.
• They conducted various in vitro experiments to expand and validate their findings, including adding coffee to media containing the L asaccharolyticus species that had been isolated from human feces.

TAKEAWAY:

• L asaccharolyticus is highly prevalent, with about fourfold higher average abundance in coffee drinkers, and its growth is stimulated in vitro by coffee supplementation.
• The link between coffee consumption and the microbiome was highly reproducible across different populations (area under the curve, 0.89), driven largely by the presence and abundance of L asaccharolyticus.
• Similar associations were found in analyses of data from 25 countries. The prevalence of the bacterium was high in European countries with high per capita coffee consumption, such as Luxembourg, Denmark, and Sweden, and very low in countries with low per capita coffee consumption, such as China, Argentina, and India.
• Plasma metabolomics on 438 samples identified several metabolites enriched among coffee drinkers, with quinic acid and its potential derivatives associated with both coffee and L asaccharolyticus.

IN PRACTICE:

“Our study provides insights into how the gut microbiome potentially mediates the chemistry — and thus health benefits — of coffee,” the study authors wrote. “The microbial mechanisms underlying the metabolism of coffee are a step towards mapping the role of specific foods on the gut microbiome, and similar patterns of microorganism–food interactions for other dietary elements should be sought with systematic epidemiologic and metagenomic investigations.”

SOURCE:

Paolo Manghi, PhD, University of Trento, Italy, led the study, which was published online in Nature Microbiology.

LIMITATIONS:

The authors relied on food questionnaires to assess coffee intake. The study is observational, and the clinical implications are unknown.

DISCLOSURES:

This work was supported by ZOE, a biotech company, and TwinsUK, an adult twin registry funded by the Wellcome Trust, Medical Research Council, Versus Arthritis, European Union Horizon 2020, Chronic Disease Research Foundation, the National Institute for Health and Care Research — Clinical Research Network and Biomedical Research Centre based at Guy’s and St. Thomas’ NHS Foundation Trust in partnership with King’s College London. Manghi had no competing interests. Several other coauthors reported financial relationships with ZOE, and three are cofounders of the company.

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

TOPLINE:

Coffee consumption is associated with the abundance of the gut bacterium Lawsonibacter asaccharolyticus, suggesting that specific foods can affect the intestinal microbiome.

METHODOLOGY:

• The researchers selected coffee as a model to investigate the interplay between specific foods and the intestinal microbial community.
• They conducted a multicohort, multiomic analysis of US and UK populations with detailed dietary information from 22,867 participants, which they then integrated with public data from 211 cohorts comprising 54,198 participants.
• They conducted various in vitro experiments to expand and validate their findings, including adding coffee to media containing the L asaccharolyticus species that had been isolated from human feces.

TAKEAWAY:

• L asaccharolyticus is highly prevalent, with about fourfold higher average abundance in coffee drinkers, and its growth is stimulated in vitro by coffee supplementation.
• The link between coffee consumption and the microbiome was highly reproducible across different populations (area under the curve, 0.89), driven largely by the presence and abundance of L asaccharolyticus.
• Similar associations were found in analyses of data from 25 countries. The prevalence of the bacterium was high in European countries with high per capita coffee consumption, such as Luxembourg, Denmark, and Sweden, and very low in countries with low per capita coffee consumption, such as China, Argentina, and India.
• Plasma metabolomics on 438 samples identified several metabolites enriched among coffee drinkers, with quinic acid and its potential derivatives associated with both coffee and L asaccharolyticus.

IN PRACTICE:

“Our study provides insights into how the gut microbiome potentially mediates the chemistry — and thus health benefits — of coffee,” the study authors wrote. “The microbial mechanisms underlying the metabolism of coffee are a step towards mapping the role of specific foods on the gut microbiome, and similar patterns of microorganism–food interactions for other dietary elements should be sought with systematic epidemiologic and metagenomic investigations.”

SOURCE:

Paolo Manghi, PhD, University of Trento, Italy, led the study, which was published online in Nature Microbiology.

LIMITATIONS:

The authors relied on food questionnaires to assess coffee intake. The study is observational, and the clinical implications are unknown.

DISCLOSURES:

This work was supported by ZOE, a biotech company, and TwinsUK, an adult twin registry funded by the Wellcome Trust, Medical Research Council, Versus Arthritis, European Union Horizon 2020, Chronic Disease Research Foundation, the National Institute for Health and Care Research — Clinical Research Network and Biomedical Research Centre based at Guy’s and St. Thomas’ NHS Foundation Trust in partnership with King’s College London. Manghi had no competing interests. Several other coauthors reported financial relationships with ZOE, and three are cofounders of the company.

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

The Food and Drug Administration (FDA) has added a boxed warning about liver injury to fezolinetant (Veozah), a drug often prescribed for hot flashes in menopausal women, according to an FDA statement.

The warning is based on data from a postmarketing report of an individual who experienced elevated liver blood test values as well as symptoms of liver injury after approximately 40 days of taking fezolinetant, according to the statement.

The boxed warning is in addition to the existing warning about elevated liver blood test values and requirements for liver blood testing in the prescribing information.

The updated information also includes recommendations to increase the frequency of liver blood testing to monthly testing for 2 months after starting fezolinetant, then following the previous recommendations for testing at 3, 6, and 9 months.

In addition, the new information advises patients to discontinue the drug immediately and contact their prescribing healthcare professional if signs of liver injury occur, according to the statement. These signs may include nausea, vomiting, unusual itching, light-colored stool, jaundice, dark urine, abdominal swelling, or pain in the right upper abdomen.

The risk for liver injury is real, but rare, said Kathryn Marko, MD, assistant professor of obstetrics and gynecology at George Washington University, Washington, DC, in an interview.

Clinicians should advise patients that their liver function will be monitored closely if they take fezolinetant, Marko said. If elevations in liver function tests occur, they often return to normal after stopping the drug.

 

Clinical Implications and Research Gaps

The boxed warning may affect prescribing patterns in that patients or clinicians may fear the risk for liver injury, Marko said. “In addition, patients may be hesitant to start a medication that requires frequent blood test monitoring.” However, many alternative treatments are available for vasomotor symptoms of menopause, including hormonal and nonhormonal therapies, and patients and physicians should work together to come up with the best option for each individual.

“More research is needed to discover new therapies for menopause,” said Marko. “Veozah is unique in its mechanism of action, and it would be wonderful to see more new medications coming down the pipeline.”

Marko had no financial conflicts to disclose.

A version of this article appeared on Medscape.com.

The Food and Drug Administration (FDA) has added a boxed warning about liver injury to fezolinetant (Veozah), a drug often prescribed for hot flashes in menopausal women, according to an FDA statement.

The warning is based on data from a postmarketing report of an individual who experienced elevated liver blood test values as well as symptoms of liver injury after approximately 40 days of taking fezolinetant, according to the statement.

The boxed warning is in addition to the existing warning about elevated liver blood test values and requirements for liver blood testing in the prescribing information.

The updated information also includes recommendations to increase the frequency of liver blood testing to monthly testing for 2 months after starting fezolinetant, then following the previous recommendations for testing at 3, 6, and 9 months.

In addition, the new information advises patients to discontinue the drug immediately and contact their prescribing healthcare professional if signs of liver injury occur, according to the statement. These signs may include nausea, vomiting, unusual itching, light-colored stool, jaundice, dark urine, abdominal swelling, or pain in the right upper abdomen.

The risk for liver injury is real, but rare, said Kathryn Marko, MD, assistant professor of obstetrics and gynecology at George Washington University, Washington, DC, in an interview.

Clinicians should advise patients that their liver function will be monitored closely if they take fezolinetant, Marko said. If elevations in liver function tests occur, they often return to normal after stopping the drug.

 

Clinical Implications and Research Gaps

The boxed warning may affect prescribing patterns in that patients or clinicians may fear the risk for liver injury, Marko said. “In addition, patients may be hesitant to start a medication that requires frequent blood test monitoring.” However, many alternative treatments are available for vasomotor symptoms of menopause, including hormonal and nonhormonal therapies, and patients and physicians should work together to come up with the best option for each individual.

“More research is needed to discover new therapies for menopause,” said Marko. “Veozah is unique in its mechanism of action, and it would be wonderful to see more new medications coming down the pipeline.”

Marko had no financial conflicts to disclose.

A version of this article appeared on Medscape.com.

The Food and Drug Administration (FDA) has added a boxed warning about liver injury to fezolinetant (Veozah), a drug often prescribed for hot flashes in menopausal women, according to an FDA statement.

The warning is based on data from a postmarketing report of an individual who experienced elevated liver blood test values as well as symptoms of liver injury after approximately 40 days of taking fezolinetant, according to the statement.

The boxed warning is in addition to the existing warning about elevated liver blood test values and requirements for liver blood testing in the prescribing information.

The updated information also includes recommendations to increase the frequency of liver blood testing to monthly testing for 2 months after starting fezolinetant, then following the previous recommendations for testing at 3, 6, and 9 months.

In addition, the new information advises patients to discontinue the drug immediately and contact their prescribing healthcare professional if signs of liver injury occur, according to the statement. These signs may include nausea, vomiting, unusual itching, light-colored stool, jaundice, dark urine, abdominal swelling, or pain in the right upper abdomen.

The risk for liver injury is real, but rare, said Kathryn Marko, MD, assistant professor of obstetrics and gynecology at George Washington University, Washington, DC, in an interview.

Clinicians should advise patients that their liver function will be monitored closely if they take fezolinetant, Marko said. If elevations in liver function tests occur, they often return to normal after stopping the drug.

 

Clinical Implications and Research Gaps

The boxed warning may affect prescribing patterns in that patients or clinicians may fear the risk for liver injury, Marko said. “In addition, patients may be hesitant to start a medication that requires frequent blood test monitoring.” However, many alternative treatments are available for vasomotor symptoms of menopause, including hormonal and nonhormonal therapies, and patients and physicians should work together to come up with the best option for each individual.

“More research is needed to discover new therapies for menopause,” said Marko. “Veozah is unique in its mechanism of action, and it would be wonderful to see more new medications coming down the pipeline.”

Marko had no financial conflicts to disclose.

A version of this article appeared on Medscape.com.

Cutaneous melanoma is a type of skin cancer typically associated with significant ultraviolet radiation exposure. Melanoma arises from melanocytes, cells found within the lower portion of the epidermis that make the pigment melanin.

While much less common than squamous cell carcinoma or basal cell carcinoma, melanoma is responsible for most deaths from skin cancer. In 2024, there will be more than 100,000 new cases of melanoma and over 8,000 melanoma-related deaths.¹ If localized at the time of diagnosis, survival rates are excellent. Cutaneous melanomas are more common in those with fair complexions or who have had long periods of exposure to natural or artificial sunlight.

Melanoma can also occur in mucous membranes. Mucosal melanoma is much less common than cutaneous melanoma and accounts for only a very small percentage of all new melanoma diagnoses. Unlike their cutaneous counterparts, risk factors for mucosal melanomas have yet to be identified. Although there is some disagreement on whether vulvar melanomas represent cutaneous or mucous melanomas, vulvovaginal melanomas have historically been considered to be mucosal melanomas.

Vulvovaginal melanomas are characterized by a high mortality rate, diagnostic challenges, and lack of awareness, making early detection and intervention crucial to improving patient outcomes. The 5-year overall survival rate for vulvar melanoma is 36% and for vaginal melanoma ranges between 5% and 25%.² Survival rates for vulvovaginal melanomas are lower than for other types of vulvar cancers (72%) or for cutaneous melanomas (72%-81%).²

Racial disparities in survival rates for mucosal and cutaneous melanomas were highlighted in a retrospective study using the Surveillance Epidemiology and End Results (SEER) database. Although the number of Black patients included was small, the median overall survival in that population was less than that in non-Black patients with vulvovaginal melanoma (16 vs. 39 months). Similar findings were noted in Black patients with cutaneous melanoma, compared with non-Black patients (median overall survival, 124 vs 319 months).³

One of the most significant obstacles in the diagnosis of vulvar and vaginal melanoma is its rarity. Both patients and clinicians alike may fail to recognize early warning signs. In a world where skin cancer is heavily publicized, melanoma in the genital area is not as frequently discussed or understood. Postmenopausal patients may have less regular gynecologic care, and unless they present with specific symptoms prompting an exam, melanomas can grow undetected, progressing to more advanced stages before they are discovered.

The median age of patients diagnosed with vulvar and vaginal melanomas is 67-68.^4,5 Symptoms can be subtle and nonspecific. Women with vulvar melanoma may experience symptoms that are similar to other vulvar cancers including pruritus, irritation, pain, bleeding, or a new or growing mass. While vaginal melanoma can be asymptomatic, patients frequently present with vaginal bleeding, discharge, and/or pain (including dyspareunia).

Vulvovaginal melanomas may present differently than cutaneous melanomas. Vulvar melanomas are often pigmented and frequently present as ulcerated lesions. In some cases, though, they appear amelanotic (lacking pigment), making them even harder to identify. The ABCDEs of skin cancer (asymmetry, border, color, diameter, evolving) should be applied to these lesions. Change in the size, shape, or pigment of preexisting melanosis (areas of hyperpigmentation caused by increased melanin), should raise concern for possible malignant transformation. 

Most vaginal melanomas occur within the distal third of the vagina, frequently along the anterior vaginal wall.⁶ They can be polypoid or nodular in appearance and may be ulcerated. While biopsy of any suspicious, enlarging/changing, or symptomatic lesion should be performed, it may be prudent to pause prior to biopsy of a vaginal lesion depending on its appearance. Although rare, gestational trophoblastic neoplasia (GTN) can present with vaginal metastases, and these lesions are frequently very vascular and pose a high bleeding risk if biopsied. They may look dark blue or black. If there is any concern for metastatic GTN on vaginal exam, a beta-hCG level should be obtained prior to biopsy.

Treatment of vulvovaginal melanoma may include surgical excision, systemic therapy, radiation therapy, or a combination of treatments. There is growing use of immunotherapy that mirrors cutaneous melanoma therapy.

Vulvar and vaginal melanoma represent a rare yet serious health issue for women and their impact on public health should not be underestimated. Vulvovaginal melanoma often goes unrecognized until it has reached an advanced stage. Increased awareness about these rare forms of melanoma among both patients and healthcare professionals is vital to improve early detection and treatment outcomes. With greater attention to this disease, we can strive for better diagnostic methods, more effective treatments, and ultimately, a reduction in mortality rates associated with vulvar and vaginal melanoma.

Dr. Tucker is assistant professor of gynecologic oncology at the University of North Carolina at Chapel Hill. She has no conflicts of interest.

References

1. National Cancer Institute. Cancer Stat Facts: Melanoma of the skin. 2024 Dec 2. Available from: https://seer.cancer.gov/statfacts/html/melan.html.

2. Piura B. Lancet Oncol. 2008 Oct;9(10):973-81. .

3. Mert I et al. Int J Gynecol Cancer. 2013;23(6):1118-25.

4. Wang D et al. Am J Cancer Res. 2020 Dec 1;10(12):4017-37.

5. Albert A et al. J Gynecol Oncol. 2020 Sep;31(5):e66.

Cutaneous melanoma is a type of skin cancer typically associated with significant ultraviolet radiation exposure. Melanoma arises from melanocytes, cells found within the lower portion of the epidermis that make the pigment melanin.

While much less common than squamous cell carcinoma or basal cell carcinoma, melanoma is responsible for most deaths from skin cancer. In 2024, there will be more than 100,000 new cases of melanoma and over 8,000 melanoma-related deaths.¹ If localized at the time of diagnosis, survival rates are excellent. Cutaneous melanomas are more common in those with fair complexions or who have had long periods of exposure to natural or artificial sunlight.

Melanoma can also occur in mucous membranes. Mucosal melanoma is much less common than cutaneous melanoma and accounts for only a very small percentage of all new melanoma diagnoses. Unlike their cutaneous counterparts, risk factors for mucosal melanomas have yet to be identified. Although there is some disagreement on whether vulvar melanomas represent cutaneous or mucous melanomas, vulvovaginal melanomas have historically been considered to be mucosal melanomas.

Vulvovaginal melanomas are characterized by a high mortality rate, diagnostic challenges, and lack of awareness, making early detection and intervention crucial to improving patient outcomes. The 5-year overall survival rate for vulvar melanoma is 36% and for vaginal melanoma ranges between 5% and 25%.² Survival rates for vulvovaginal melanomas are lower than for other types of vulvar cancers (72%) or for cutaneous melanomas (72%-81%).²

Racial disparities in survival rates for mucosal and cutaneous melanomas were highlighted in a retrospective study using the Surveillance Epidemiology and End Results (SEER) database. Although the number of Black patients included was small, the median overall survival in that population was less than that in non-Black patients with vulvovaginal melanoma (16 vs. 39 months). Similar findings were noted in Black patients with cutaneous melanoma, compared with non-Black patients (median overall survival, 124 vs 319 months).³

One of the most significant obstacles in the diagnosis of vulvar and vaginal melanoma is its rarity. Both patients and clinicians alike may fail to recognize early warning signs. In a world where skin cancer is heavily publicized, melanoma in the genital area is not as frequently discussed or understood. Postmenopausal patients may have less regular gynecologic care, and unless they present with specific symptoms prompting an exam, melanomas can grow undetected, progressing to more advanced stages before they are discovered.

The median age of patients diagnosed with vulvar and vaginal melanomas is 67-68.^4,5 Symptoms can be subtle and nonspecific. Women with vulvar melanoma may experience symptoms that are similar to other vulvar cancers including pruritus, irritation, pain, bleeding, or a new or growing mass. While vaginal melanoma can be asymptomatic, patients frequently present with vaginal bleeding, discharge, and/or pain (including dyspareunia).

Vulvovaginal melanomas may present differently than cutaneous melanomas. Vulvar melanomas are often pigmented and frequently present as ulcerated lesions. In some cases, though, they appear amelanotic (lacking pigment), making them even harder to identify. The ABCDEs of skin cancer (asymmetry, border, color, diameter, evolving) should be applied to these lesions. Change in the size, shape, or pigment of preexisting melanosis (areas of hyperpigmentation caused by increased melanin), should raise concern for possible malignant transformation. 

Most vaginal melanomas occur within the distal third of the vagina, frequently along the anterior vaginal wall.⁶ They can be polypoid or nodular in appearance and may be ulcerated. While biopsy of any suspicious, enlarging/changing, or symptomatic lesion should be performed, it may be prudent to pause prior to biopsy of a vaginal lesion depending on its appearance. Although rare, gestational trophoblastic neoplasia (GTN) can present with vaginal metastases, and these lesions are frequently very vascular and pose a high bleeding risk if biopsied. They may look dark blue or black. If there is any concern for metastatic GTN on vaginal exam, a beta-hCG level should be obtained prior to biopsy.

Treatment of vulvovaginal melanoma may include surgical excision, systemic therapy, radiation therapy, or a combination of treatments. There is growing use of immunotherapy that mirrors cutaneous melanoma therapy.

Vulvar and vaginal melanoma represent a rare yet serious health issue for women and their impact on public health should not be underestimated. Vulvovaginal melanoma often goes unrecognized until it has reached an advanced stage. Increased awareness about these rare forms of melanoma among both patients and healthcare professionals is vital to improve early detection and treatment outcomes. With greater attention to this disease, we can strive for better diagnostic methods, more effective treatments, and ultimately, a reduction in mortality rates associated with vulvar and vaginal melanoma.

Dr. Tucker is assistant professor of gynecologic oncology at the University of North Carolina at Chapel Hill. She has no conflicts of interest.

References

1. National Cancer Institute. Cancer Stat Facts: Melanoma of the skin. 2024 Dec 2. Available from: https://seer.cancer.gov/statfacts/html/melan.html.

2. Piura B. Lancet Oncol. 2008 Oct;9(10):973-81. .

3. Mert I et al. Int J Gynecol Cancer. 2013;23(6):1118-25.

4. Wang D et al. Am J Cancer Res. 2020 Dec 1;10(12):4017-37.

5. Albert A et al. J Gynecol Oncol. 2020 Sep;31(5):e66.

Cutaneous melanoma is a type of skin cancer typically associated with significant ultraviolet radiation exposure. Melanoma arises from melanocytes, cells found within the lower portion of the epidermis that make the pigment melanin.

While much less common than squamous cell carcinoma or basal cell carcinoma, melanoma is responsible for most deaths from skin cancer. In 2024, there will be more than 100,000 new cases of melanoma and over 8,000 melanoma-related deaths.¹ If localized at the time of diagnosis, survival rates are excellent. Cutaneous melanomas are more common in those with fair complexions or who have had long periods of exposure to natural or artificial sunlight.

Melanoma can also occur in mucous membranes. Mucosal melanoma is much less common than cutaneous melanoma and accounts for only a very small percentage of all new melanoma diagnoses. Unlike their cutaneous counterparts, risk factors for mucosal melanomas have yet to be identified. Although there is some disagreement on whether vulvar melanomas represent cutaneous or mucous melanomas, vulvovaginal melanomas have historically been considered to be mucosal melanomas.

Vulvovaginal melanomas are characterized by a high mortality rate, diagnostic challenges, and lack of awareness, making early detection and intervention crucial to improving patient outcomes. The 5-year overall survival rate for vulvar melanoma is 36% and for vaginal melanoma ranges between 5% and 25%.² Survival rates for vulvovaginal melanomas are lower than for other types of vulvar cancers (72%) or for cutaneous melanomas (72%-81%).²

Racial disparities in survival rates for mucosal and cutaneous melanomas were highlighted in a retrospective study using the Surveillance Epidemiology and End Results (SEER) database. Although the number of Black patients included was small, the median overall survival in that population was less than that in non-Black patients with vulvovaginal melanoma (16 vs. 39 months). Similar findings were noted in Black patients with cutaneous melanoma, compared with non-Black patients (median overall survival, 124 vs 319 months).³

One of the most significant obstacles in the diagnosis of vulvar and vaginal melanoma is its rarity. Both patients and clinicians alike may fail to recognize early warning signs. In a world where skin cancer is heavily publicized, melanoma in the genital area is not as frequently discussed or understood. Postmenopausal patients may have less regular gynecologic care, and unless they present with specific symptoms prompting an exam, melanomas can grow undetected, progressing to more advanced stages before they are discovered.

The median age of patients diagnosed with vulvar and vaginal melanomas is 67-68.^4,5 Symptoms can be subtle and nonspecific. Women with vulvar melanoma may experience symptoms that are similar to other vulvar cancers including pruritus, irritation, pain, bleeding, or a new or growing mass. While vaginal melanoma can be asymptomatic, patients frequently present with vaginal bleeding, discharge, and/or pain (including dyspareunia).

Vulvovaginal melanomas may present differently than cutaneous melanomas. Vulvar melanomas are often pigmented and frequently present as ulcerated lesions. In some cases, though, they appear amelanotic (lacking pigment), making them even harder to identify. The ABCDEs of skin cancer (asymmetry, border, color, diameter, evolving) should be applied to these lesions. Change in the size, shape, or pigment of preexisting melanosis (areas of hyperpigmentation caused by increased melanin), should raise concern for possible malignant transformation. 

Most vaginal melanomas occur within the distal third of the vagina, frequently along the anterior vaginal wall.⁶ They can be polypoid or nodular in appearance and may be ulcerated. While biopsy of any suspicious, enlarging/changing, or symptomatic lesion should be performed, it may be prudent to pause prior to biopsy of a vaginal lesion depending on its appearance. Although rare, gestational trophoblastic neoplasia (GTN) can present with vaginal metastases, and these lesions are frequently very vascular and pose a high bleeding risk if biopsied. They may look dark blue or black. If there is any concern for metastatic GTN on vaginal exam, a beta-hCG level should be obtained prior to biopsy.

Treatment of vulvovaginal melanoma may include surgical excision, systemic therapy, radiation therapy, or a combination of treatments. There is growing use of immunotherapy that mirrors cutaneous melanoma therapy.

Vulvar and vaginal melanoma represent a rare yet serious health issue for women and their impact on public health should not be underestimated. Vulvovaginal melanoma often goes unrecognized until it has reached an advanced stage. Increased awareness about these rare forms of melanoma among both patients and healthcare professionals is vital to improve early detection and treatment outcomes. With greater attention to this disease, we can strive for better diagnostic methods, more effective treatments, and ultimately, a reduction in mortality rates associated with vulvar and vaginal melanoma.

Dr. Tucker is assistant professor of gynecologic oncology at the University of North Carolina at Chapel Hill. She has no conflicts of interest.

References

1. National Cancer Institute. Cancer Stat Facts: Melanoma of the skin. 2024 Dec 2. Available from: https://seer.cancer.gov/statfacts/html/melan.html.

2. Piura B. Lancet Oncol. 2008 Oct;9(10):973-81. .

3. Mert I et al. Int J Gynecol Cancer. 2013;23(6):1118-25.

4. Wang D et al. Am J Cancer Res. 2020 Dec 1;10(12):4017-37.

5. Albert A et al. J Gynecol Oncol. 2020 Sep;31(5):e66.

In preparation for a future international treaty aimed at reducing plastic pollution, the French Parliamentary Office for the Evaluation of Scientific and Technological Choices presented the conclusions of a public hearing on the impact of plastics on various aspects of human health.

Increased Global Plastic Production

Philippe Bolo, a member of the French Democratic Party and the rapporteur for the public mission on the health impacts of plastics, spoke about the latest round of treaty negotiations, held from November 25 to December 1 in South Korea, attended by leading French and global experts about the impact of plastics on human health.

The hearing highlighted a sharp increase in plastic production. “It has doubled in the last 20 years and is expected to exceed 500 million tons in 2024,” Bolo said. This is about 60 kg per person. According to projections from the Organization for Economic Co-operation and Development, on its current trajectory, plastic production will reach 750 million tons by 2040 and surpass 1 billion tons before 2050, he said.

 

Minimal Plastic Waste Recycling

Around one third (32%) of plastics are used for packaging. “Therefore, most plastic production is still intended for single-use purposes,” he said. Plastic waste follows a similar growth trajectory, with volumes expected to rise from 360 million tons in 2020 to 617 million tons by 2040 unless action is taken. Very little of this waste is recycled, even in the most countries that are most advanced in terms of collection, sorting, and processing.

In France, for example, in 2018, only 0.6 million tons of the 3.6 million tons of plastic waste produced was truly recycled. This is less than one fifth (17%). Globally, less than 10% of plastic waste is recycled. In 2020, plastic waste that ended up in the environment represented 81 million tons, or 22% of the total. “Beyond waste, this leads to pollution by microplastics and nanoplastics, resulting from their fragmentation. All environments are affected: Seas, rivers, soils, air, and even living organisms,” Bolo said.

 

Methodological Challenges

However, measuring the impact of plastics on health faces methodological difficulties due to the wide variety of composition, size, and shape of plastics. Nevertheless, the French Standardization Association (Association Française de Normalisation) has conducted work to establish a characterization standard for microplastics in water, which serves as an international reference.

“It is also very difficult to know what we are ingesting,” Bolo said. “A study conducted in 2019 estimated that the average human absorbs 5 grams of plastics per week, the equivalent of a credit card.» Since then, other studies have revised this estimate downward, but no consensus has been reached.

A recent study across 109 countries, both industrialized and developing, found significant exposure, estimated at 500 mg/d, particularly in Southeast Asian countries, where it was due mainly to seafood consumption.

A study concluded that plastic water bottles contain 240,000 particles per liter, 90% of which are nanoplastics. These nanoparticles can pass through the intestinal barrier to enter the bloodstream and reach several organs including the heart, brain, and placenta, as well as the fetus.

 

Changes to the Microbiome

Microplastics also accumulate in organs. Thus, the amount of plastic in the lungs increases with age, suggesting that particles may persist in the body without being eliminated. The health consequences of this are still poorly understood, but exposure to plastics appears to cause changes in the composition of the intestinal microbiota. Pathobionts (commensal bacteria with harmful potential) have been found in both adults and children, which could contribute to dysbiosis of the gut microbiome. Furthermore, a decrease in butyrate, a short-chain fatty acid beneficial to health, has been observed in children’s intestines.

Inhaled nanoplastics may disrupt the mucociliary clearance mechanisms of the respiratory system. The toxicity of inhaled plastic particles was demonstrated as early as the 1970s among workers in the flocking industry. Some developed lung function impairments, shortness of breath, inflammation, fibrosis, and even lung cancer. Similar symptoms have been observed in workers in the textile and polyvinyl chloride industries.

A study published recently in The New England Journal of Medicine measured the amount of microplastics collected from carotid plaque of more than 300 patients who had undergone carotid endarterectomy for asymptomatic carotid artery disease. It found a 4.53 times higher risk for the primary endpoint, a composite of myocardial infarction, stroke, and all-cause mortality, among individuals with microplastics and nanoplastics in plaque compared with those without.

 

Health Affects High

The danger of plastics is also directly linked to the chemical substances they contain. A general scientific review looked at the health impacts of three chemicals used almost exclusively in plastics: Polybromodiphenyl ethers (PBDEs), used as flame retardants in textiles or electronics; bisphenol A (BPA), used in the lining of cans and bottles; and phthalates, particularly diethylhexyl phthalate (DEHP), used to make plastics more flexible.

The review highlighted strong epidemiological evidence linking fetal exposure to PBDEs during pregnancy to low birth weight and later exposure to delayed or impaired cognitive development in children and even a loss of IQ. Statistically significant evidence of disruption of thyroid function in adults was also found.

BPA is linked to genital malformations in female newborns exposed to BPA in utero, type 2 diabetes in adults, insulin resistance, and polycystic ovary syndrome in women. BPA exposure also increases the risk for obesity and hypertension in both children and adults, as well as the risk for cardiovascular disease in adults.

Finally, the review established links between exposure to DEHP and miscarriages, genital malformations in male newborns, delayed or impaired cognitive development in children, loss of IQ, delayed psychomotor development, early puberty in young girls, and endometriosis in young women. DEHP exposure also has multiple effects on cardiometabolic health, including insulin resistance, obesity, and elevated blood pressure.

The economic costs associated with the health impacts of these three substances have been estimated at $675 billion in the United States.

Bolo said that the solution to this plastic pollution is necessarily international. “We need an ambitious and legally binding treaty to reduce plastic production,” he said. “The damage is already done; we need to act to protect human health,” he concluded. The parliamentary office has made nine recommendations to the treaty negotiators.

This story was translated from Medscape’s French edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

In preparation for a future international treaty aimed at reducing plastic pollution, the French Parliamentary Office for the Evaluation of Scientific and Technological Choices presented the conclusions of a public hearing on the impact of plastics on various aspects of human health.

Increased Global Plastic Production

Philippe Bolo, a member of the French Democratic Party and the rapporteur for the public mission on the health impacts of plastics, spoke about the latest round of treaty negotiations, held from November 25 to December 1 in South Korea, attended by leading French and global experts about the impact of plastics on human health.

The hearing highlighted a sharp increase in plastic production. “It has doubled in the last 20 years and is expected to exceed 500 million tons in 2024,” Bolo said. This is about 60 kg per person. According to projections from the Organization for Economic Co-operation and Development, on its current trajectory, plastic production will reach 750 million tons by 2040 and surpass 1 billion tons before 2050, he said.

 

Minimal Plastic Waste Recycling

Around one third (32%) of plastics are used for packaging. “Therefore, most plastic production is still intended for single-use purposes,” he said. Plastic waste follows a similar growth trajectory, with volumes expected to rise from 360 million tons in 2020 to 617 million tons by 2040 unless action is taken. Very little of this waste is recycled, even in the most countries that are most advanced in terms of collection, sorting, and processing.

In France, for example, in 2018, only 0.6 million tons of the 3.6 million tons of plastic waste produced was truly recycled. This is less than one fifth (17%). Globally, less than 10% of plastic waste is recycled. In 2020, plastic waste that ended up in the environment represented 81 million tons, or 22% of the total. “Beyond waste, this leads to pollution by microplastics and nanoplastics, resulting from their fragmentation. All environments are affected: Seas, rivers, soils, air, and even living organisms,” Bolo said.

 

Methodological Challenges

However, measuring the impact of plastics on health faces methodological difficulties due to the wide variety of composition, size, and shape of plastics. Nevertheless, the French Standardization Association (Association Française de Normalisation) has conducted work to establish a characterization standard for microplastics in water, which serves as an international reference.

“It is also very difficult to know what we are ingesting,” Bolo said. “A study conducted in 2019 estimated that the average human absorbs 5 grams of plastics per week, the equivalent of a credit card.» Since then, other studies have revised this estimate downward, but no consensus has been reached.

A recent study across 109 countries, both industrialized and developing, found significant exposure, estimated at 500 mg/d, particularly in Southeast Asian countries, where it was due mainly to seafood consumption.

A study concluded that plastic water bottles contain 240,000 particles per liter, 90% of which are nanoplastics. These nanoparticles can pass through the intestinal barrier to enter the bloodstream and reach several organs including the heart, brain, and placenta, as well as the fetus.

 

Changes to the Microbiome

Microplastics also accumulate in organs. Thus, the amount of plastic in the lungs increases with age, suggesting that particles may persist in the body without being eliminated. The health consequences of this are still poorly understood, but exposure to plastics appears to cause changes in the composition of the intestinal microbiota. Pathobionts (commensal bacteria with harmful potential) have been found in both adults and children, which could contribute to dysbiosis of the gut microbiome. Furthermore, a decrease in butyrate, a short-chain fatty acid beneficial to health, has been observed in children’s intestines.

Inhaled nanoplastics may disrupt the mucociliary clearance mechanisms of the respiratory system. The toxicity of inhaled plastic particles was demonstrated as early as the 1970s among workers in the flocking industry. Some developed lung function impairments, shortness of breath, inflammation, fibrosis, and even lung cancer. Similar symptoms have been observed in workers in the textile and polyvinyl chloride industries.

A study published recently in The New England Journal of Medicine measured the amount of microplastics collected from carotid plaque of more than 300 patients who had undergone carotid endarterectomy for asymptomatic carotid artery disease. It found a 4.53 times higher risk for the primary endpoint, a composite of myocardial infarction, stroke, and all-cause mortality, among individuals with microplastics and nanoplastics in plaque compared with those without.

 

Health Affects High

The danger of plastics is also directly linked to the chemical substances they contain. A general scientific review looked at the health impacts of three chemicals used almost exclusively in plastics: Polybromodiphenyl ethers (PBDEs), used as flame retardants in textiles or electronics; bisphenol A (BPA), used in the lining of cans and bottles; and phthalates, particularly diethylhexyl phthalate (DEHP), used to make plastics more flexible.

The review highlighted strong epidemiological evidence linking fetal exposure to PBDEs during pregnancy to low birth weight and later exposure to delayed or impaired cognitive development in children and even a loss of IQ. Statistically significant evidence of disruption of thyroid function in adults was also found.

BPA is linked to genital malformations in female newborns exposed to BPA in utero, type 2 diabetes in adults, insulin resistance, and polycystic ovary syndrome in women. BPA exposure also increases the risk for obesity and hypertension in both children and adults, as well as the risk for cardiovascular disease in adults.

Finally, the review established links between exposure to DEHP and miscarriages, genital malformations in male newborns, delayed or impaired cognitive development in children, loss of IQ, delayed psychomotor development, early puberty in young girls, and endometriosis in young women. DEHP exposure also has multiple effects on cardiometabolic health, including insulin resistance, obesity, and elevated blood pressure.

The economic costs associated with the health impacts of these three substances have been estimated at $675 billion in the United States.

Bolo said that the solution to this plastic pollution is necessarily international. “We need an ambitious and legally binding treaty to reduce plastic production,” he said. “The damage is already done; we need to act to protect human health,” he concluded. The parliamentary office has made nine recommendations to the treaty negotiators.

This story was translated from Medscape’s French edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

In preparation for a future international treaty aimed at reducing plastic pollution, the French Parliamentary Office for the Evaluation of Scientific and Technological Choices presented the conclusions of a public hearing on the impact of plastics on various aspects of human health.

Increased Global Plastic Production

Philippe Bolo, a member of the French Democratic Party and the rapporteur for the public mission on the health impacts of plastics, spoke about the latest round of treaty negotiations, held from November 25 to December 1 in South Korea, attended by leading French and global experts about the impact of plastics on human health.

The hearing highlighted a sharp increase in plastic production. “It has doubled in the last 20 years and is expected to exceed 500 million tons in 2024,” Bolo said. This is about 60 kg per person. According to projections from the Organization for Economic Co-operation and Development, on its current trajectory, plastic production will reach 750 million tons by 2040 and surpass 1 billion tons before 2050, he said.

 

Minimal Plastic Waste Recycling

Around one third (32%) of plastics are used for packaging. “Therefore, most plastic production is still intended for single-use purposes,” he said. Plastic waste follows a similar growth trajectory, with volumes expected to rise from 360 million tons in 2020 to 617 million tons by 2040 unless action is taken. Very little of this waste is recycled, even in the most countries that are most advanced in terms of collection, sorting, and processing.

In France, for example, in 2018, only 0.6 million tons of the 3.6 million tons of plastic waste produced was truly recycled. This is less than one fifth (17%). Globally, less than 10% of plastic waste is recycled. In 2020, plastic waste that ended up in the environment represented 81 million tons, or 22% of the total. “Beyond waste, this leads to pollution by microplastics and nanoplastics, resulting from their fragmentation. All environments are affected: Seas, rivers, soils, air, and even living organisms,” Bolo said.

 

Methodological Challenges

However, measuring the impact of plastics on health faces methodological difficulties due to the wide variety of composition, size, and shape of plastics. Nevertheless, the French Standardization Association (Association Française de Normalisation) has conducted work to establish a characterization standard for microplastics in water, which serves as an international reference.

“It is also very difficult to know what we are ingesting,” Bolo said. “A study conducted in 2019 estimated that the average human absorbs 5 grams of plastics per week, the equivalent of a credit card.» Since then, other studies have revised this estimate downward, but no consensus has been reached.

A recent study across 109 countries, both industrialized and developing, found significant exposure, estimated at 500 mg/d, particularly in Southeast Asian countries, where it was due mainly to seafood consumption.

A study concluded that plastic water bottles contain 240,000 particles per liter, 90% of which are nanoplastics. These nanoparticles can pass through the intestinal barrier to enter the bloodstream and reach several organs including the heart, brain, and placenta, as well as the fetus.

 

Changes to the Microbiome

Microplastics also accumulate in organs. Thus, the amount of plastic in the lungs increases with age, suggesting that particles may persist in the body without being eliminated. The health consequences of this are still poorly understood, but exposure to plastics appears to cause changes in the composition of the intestinal microbiota. Pathobionts (commensal bacteria with harmful potential) have been found in both adults and children, which could contribute to dysbiosis of the gut microbiome. Furthermore, a decrease in butyrate, a short-chain fatty acid beneficial to health, has been observed in children’s intestines.

Inhaled nanoplastics may disrupt the mucociliary clearance mechanisms of the respiratory system. The toxicity of inhaled plastic particles was demonstrated as early as the 1970s among workers in the flocking industry. Some developed lung function impairments, shortness of breath, inflammation, fibrosis, and even lung cancer. Similar symptoms have been observed in workers in the textile and polyvinyl chloride industries.

A study published recently in The New England Journal of Medicine measured the amount of microplastics collected from carotid plaque of more than 300 patients who had undergone carotid endarterectomy for asymptomatic carotid artery disease. It found a 4.53 times higher risk for the primary endpoint, a composite of myocardial infarction, stroke, and all-cause mortality, among individuals with microplastics and nanoplastics in plaque compared with those without.

 

Health Affects High

The danger of plastics is also directly linked to the chemical substances they contain. A general scientific review looked at the health impacts of three chemicals used almost exclusively in plastics: Polybromodiphenyl ethers (PBDEs), used as flame retardants in textiles or electronics; bisphenol A (BPA), used in the lining of cans and bottles; and phthalates, particularly diethylhexyl phthalate (DEHP), used to make plastics more flexible.

The review highlighted strong epidemiological evidence linking fetal exposure to PBDEs during pregnancy to low birth weight and later exposure to delayed or impaired cognitive development in children and even a loss of IQ. Statistically significant evidence of disruption of thyroid function in adults was also found.

BPA is linked to genital malformations in female newborns exposed to BPA in utero, type 2 diabetes in adults, insulin resistance, and polycystic ovary syndrome in women. BPA exposure also increases the risk for obesity and hypertension in both children and adults, as well as the risk for cardiovascular disease in adults.

Finally, the review established links between exposure to DEHP and miscarriages, genital malformations in male newborns, delayed or impaired cognitive development in children, loss of IQ, delayed psychomotor development, early puberty in young girls, and endometriosis in young women. DEHP exposure also has multiple effects on cardiometabolic health, including insulin resistance, obesity, and elevated blood pressure.

The economic costs associated with the health impacts of these three substances have been estimated at $675 billion in the United States.

Bolo said that the solution to this plastic pollution is necessarily international. “We need an ambitious and legally binding treaty to reduce plastic production,” he said. “The damage is already done; we need to act to protect human health,” he concluded. The parliamentary office has made nine recommendations to the treaty negotiators.

This story was translated from Medscape’s French edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

TOPLINE:

Virtual visits for urinary tract infections (UTIs) increased by more than 600% from 2015 to 2022, with overall UTI encounters growing by 325.9%. The rate of antibiotic dispensation climbed by 227.3% per 1000 patients, outpacing the 159.8% increase in positive urine cultures.

METHODOLOGY:

• Researchers conducted a retrospective cohort study analyzing 1,220,698 UTI encounters among 428,855 nonpregnant women aged ≥ 18 years at Kaiser Permanente Southern California from 2015 to 2022.
• Analysis included outpatient UTI encounters in ambulatory and urgent care settings, excluding emergency and inpatient visits.
• Data collection encompassed demographic information, urine tests, antibiotic dispensation, and UTI diagnoses using International Classification of Diseases, 9th and 10th Revision codes.
• Encounters conducted by physicians, physician assistants, nurse practitioners, and registered nurses through in-person, phone, video, and health portal platforms were evaluated.

TAKEAWAY:

• Virtual encounters grew by 603.2% compared with a 122.8% increase for in-person visits, with virtual visits accounting for 60% (733,263) of all UTI encounters.
• The rate of UTI encounters per 1000 adult female patients increased by 241.6%, while membership in the health system grew by only 24.4%.
• Antibiotics were prescribed without urine testing in 42.5% (519,135) of encounters, and among encounters with both antibiotic dispensation and urine testing, 57.1% (278,903) had a positive culture.
• According to the authors, the increasing rate of antibiotic dispensation surpassed the growth in positive urine culture rates, suggesting increased use of empiric antibiotics.

IN PRACTICE:

“Our findings underscore the importance of balancing telemedicine’s accessibility with maintaining antibiotic stewardship and highlight the need for updated guidelines,” wrote the authors of the study. An accompanying editorial said, “Unfortunately, our misguided conceptual model has led to several decades of UTI research focusing on bad bugs rather than investigating the natural host defenses, how we might boost these, what perturbs the ecosystem, and how microbial defense occurs within the bladder.”

SOURCE:

The study was led by Ghanshyam Yadav, MD, Kaiser Permanente Southern California in San Diego. It was published online in Obstetrics & Gynecology. The editorial, written by Nazema Y. Siddiqui, MD, MHSc, from the Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina, was also published in Obstetrics & Gynecology.

LIMITATIONS:

The retrospective design and analysis at the encounter level did not allow for control of patient and clinician clustering. The study was limited to a single health maintenance organization, which may affect the generalizability of the findings.

DISCLOSURES:

This research received support through a grant from the Regional Research Committee of Kaiser Permanente Southern California (RRC grant number: KP-RRC-20221002). Heidi Brown and Jasmine Tan-Kim disclosed receiving royalties from UpToDate. Additional disclosures are noted in the original article.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

TOPLINE:

Virtual visits for urinary tract infections (UTIs) increased by more than 600% from 2015 to 2022, with overall UTI encounters growing by 325.9%. The rate of antibiotic dispensation climbed by 227.3% per 1000 patients, outpacing the 159.8% increase in positive urine cultures.

METHODOLOGY:

• Researchers conducted a retrospective cohort study analyzing 1,220,698 UTI encounters among 428,855 nonpregnant women aged ≥ 18 years at Kaiser Permanente Southern California from 2015 to 2022.
• Analysis included outpatient UTI encounters in ambulatory and urgent care settings, excluding emergency and inpatient visits.
• Data collection encompassed demographic information, urine tests, antibiotic dispensation, and UTI diagnoses using International Classification of Diseases, 9th and 10th Revision codes.
• Encounters conducted by physicians, physician assistants, nurse practitioners, and registered nurses through in-person, phone, video, and health portal platforms were evaluated.

TAKEAWAY:

• Virtual encounters grew by 603.2% compared with a 122.8% increase for in-person visits, with virtual visits accounting for 60% (733,263) of all UTI encounters.
• The rate of UTI encounters per 1000 adult female patients increased by 241.6%, while membership in the health system grew by only 24.4%.
• Antibiotics were prescribed without urine testing in 42.5% (519,135) of encounters, and among encounters with both antibiotic dispensation and urine testing, 57.1% (278,903) had a positive culture.
• According to the authors, the increasing rate of antibiotic dispensation surpassed the growth in positive urine culture rates, suggesting increased use of empiric antibiotics.

IN PRACTICE:

“Our findings underscore the importance of balancing telemedicine’s accessibility with maintaining antibiotic stewardship and highlight the need for updated guidelines,” wrote the authors of the study. An accompanying editorial said, “Unfortunately, our misguided conceptual model has led to several decades of UTI research focusing on bad bugs rather than investigating the natural host defenses, how we might boost these, what perturbs the ecosystem, and how microbial defense occurs within the bladder.”

SOURCE:

The study was led by Ghanshyam Yadav, MD, Kaiser Permanente Southern California in San Diego. It was published online in Obstetrics & Gynecology. The editorial, written by Nazema Y. Siddiqui, MD, MHSc, from the Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina, was also published in Obstetrics & Gynecology.

LIMITATIONS:

The retrospective design and analysis at the encounter level did not allow for control of patient and clinician clustering. The study was limited to a single health maintenance organization, which may affect the generalizability of the findings.

DISCLOSURES:

This research received support through a grant from the Regional Research Committee of Kaiser Permanente Southern California (RRC grant number: KP-RRC-20221002). Heidi Brown and Jasmine Tan-Kim disclosed receiving royalties from UpToDate. Additional disclosures are noted in the original article.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

TOPLINE:

Virtual visits for urinary tract infections (UTIs) increased by more than 600% from 2015 to 2022, with overall UTI encounters growing by 325.9%. The rate of antibiotic dispensation climbed by 227.3% per 1000 patients, outpacing the 159.8% increase in positive urine cultures.

METHODOLOGY:

• Researchers conducted a retrospective cohort study analyzing 1,220,698 UTI encounters among 428,855 nonpregnant women aged ≥ 18 years at Kaiser Permanente Southern California from 2015 to 2022.
• Analysis included outpatient UTI encounters in ambulatory and urgent care settings, excluding emergency and inpatient visits.
• Data collection encompassed demographic information, urine tests, antibiotic dispensation, and UTI diagnoses using International Classification of Diseases, 9th and 10th Revision codes.
• Encounters conducted by physicians, physician assistants, nurse practitioners, and registered nurses through in-person, phone, video, and health portal platforms were evaluated.

TAKEAWAY:

• Virtual encounters grew by 603.2% compared with a 122.8% increase for in-person visits, with virtual visits accounting for 60% (733,263) of all UTI encounters.
• The rate of UTI encounters per 1000 adult female patients increased by 241.6%, while membership in the health system grew by only 24.4%.
• Antibiotics were prescribed without urine testing in 42.5% (519,135) of encounters, and among encounters with both antibiotic dispensation and urine testing, 57.1% (278,903) had a positive culture.
• According to the authors, the increasing rate of antibiotic dispensation surpassed the growth in positive urine culture rates, suggesting increased use of empiric antibiotics.

IN PRACTICE:

“Our findings underscore the importance of balancing telemedicine’s accessibility with maintaining antibiotic stewardship and highlight the need for updated guidelines,” wrote the authors of the study. An accompanying editorial said, “Unfortunately, our misguided conceptual model has led to several decades of UTI research focusing on bad bugs rather than investigating the natural host defenses, how we might boost these, what perturbs the ecosystem, and how microbial defense occurs within the bladder.”

SOURCE:

The study was led by Ghanshyam Yadav, MD, Kaiser Permanente Southern California in San Diego. It was published online in Obstetrics & Gynecology. The editorial, written by Nazema Y. Siddiqui, MD, MHSc, from the Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina, was also published in Obstetrics & Gynecology.

LIMITATIONS:

The retrospective design and analysis at the encounter level did not allow for control of patient and clinician clustering. The study was limited to a single health maintenance organization, which may affect the generalizability of the findings.

DISCLOSURES:

This research received support through a grant from the Regional Research Committee of Kaiser Permanente Southern California (RRC grant number: KP-RRC-20221002). Heidi Brown and Jasmine Tan-Kim disclosed receiving royalties from UpToDate. Additional disclosures are noted in the original article.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

This transcript has been edited for clarity. 

We often see urinary tract infections in primary care, so these guidelines for the prevention, diagnosis and management of urinary tract infection (UTI) are very helpful to reaffirm our knowledge in the areas where know what we’re doing and update our knowledge in areas of uncertainty. These guidelines are from a new group called the WikiGuidelines group. Ordinarily, I wouldn’t have considered reviewing one of these guidelines, but this one was published in JAMA Network Open. It is evidence based and covers the topic really well. 

Diagnosis. Order a urinalysis or a urine culture only if the patient is having symptoms of a UTI. This may seem obvious, but particularly among older individuals, in whom asymptomatic bacteriuria is very common and should not be treated, nonspecific symptoms such as just not feeling well for a day do not warrant obtaining a urinalysis and culture. With no clear way to distinguish between asymptomatic bacteriuria and a true UTI, the first step in making the diagnosis of a UTI accurately is ordering urine studies only in people who have a reasonable chance of having an infection.

The guideline suggests that the diagnosis of UTI should be primarily based on clinical symptoms. A urinalysis can provide further information, but the authors caution us against relying solely on the urinalysis. This is an incredibly important evidence-based recommendation. If you think about it, this supports the common practice of treating UTIs over the phone without having to see the patient or check a urinalysis. 

The rationale for this recommendation is that urinalysis is neither a sensitive nor specific test for UTI. The sensitivity of leukocyte esterase is only about 80%, and the specificity is even lower. For positive nitrite on urinalysis, the sensitivity is below 50%, meaning the test would be negative more than half the time when someone actually has a UTI. The specificity of urine nitrate is very high (more than 90%), so if the patient is nitrite positive, they clearly have a UTI. This means that a patient’s report of classic UTI symptoms — urinary burning, frequency, and urgency — is about as good if not a better indicator of a UTI than a urinalysis. 

The guidelines also say that in simple uncomplicated cystitis in healthy nonpregnant patients, routine urine cultures are not necessary. A fascinating meta-analysis in JAMA showed that, for women presenting to outpatient clinics with at least two symptoms of UTI and absence of vaginal discharge, there was a greater than 90% likelihood of having acute cystitis. A reminder here, however: If a woman is sexually active and at risk for sexually transmitted infections, then consider testing for STIs as well, because the symptoms of an STI can mimic those of a UTI.

Treatment. Treatment for UTI is usually empiric, with treatment initiated before the culture results are known and with cultures being done only for people with complicated infections, such as pyelonephritis, or with recurrent infections. Decisions about what to use for treatment can be influenced by local patterns of resistance and an individual’s risk factors for antimicrobial resistance. As a general rule, for uncomplicated cystitis, nitrofurantoin for 5 days is a reasonable first-line agent. Evidence of efficacy is good, and the risk for antimicrobial resistance is lower vs using antibiotics for other systemic infections. 

Other reasonable first-line agents for uncomplicated cystitis include trimethoprim-sulfamethoxazole (TMP-SMX) for 3 days; fosfomycin (oral) single dose; or a beta-lactam (most commonly a first generation cephalosporin), although evidence for duration is unclear. Also mentioned are two unfamiliar antibiotics: pivmecillinam (a beta-lactam agent recently approved by the Food and Drug Administration [FDA], given for 3 days) and gepotidacin (from a new class of antibiotic that is currently under FDA review). Fluoroquinolones should not usually be first-line agents unless other treatment options are not appropriate. 

It’s important to distinguish between uncomplicated cystitis and pyelonephritis. For pyelonephritis (infection of the upper urinary tract), the first decision has to do with setting for care, depending on how sick someone is, and the likelihood of gram-negative bacteremia — all of which help whether the patient needs to be hospitalized for intravenous antibiotics, or can be treated as an outpatient. Determine if they need to be admitted for intravenous antibiotics or whether they can be treated as an outpatient. For outpatient treatment of pyelonephritis, the guideline suggests that TMP-SMX or a first-generation cephalosporin are both reasonable first-line agents, with fluoroquinolones being a reasonable choice as well. Ceftriaxone is recommended for first-line therapy for patients who require intravenous treatment. 

People often forget that we can do a lot to prevent UTIs, particularly among women with recurrent UTIs. The prevention of UTIs has both nonpharmacologic and pharmacologic approaches.

Nonpharmacologic prevention. One nonpharmacologic strategy is increasing water intake. A randomized controlled trial in women with recurrent cystitis who drank less than 1.5 L of fluid a day showed that the women randomized to consume an additional 1.5 L of water daily had significantly reduced cystitis frequency — approximately 50%. Because this was the only randomized trial to show this effect, this is not a strong recommendation, but there is very little downside in healthy women, so increasing water intake is a reasonable recommendation.

Another commonly discussed intervention is the use of cranberry products. As it turns out, most prospective studies have shown that cranberry products can reduce the risk for symptomatic UTIs in women with recurrent UTI. 

Pharmacologic prevention. For postmenopausal women with recurrent UTI, topical vaginal estrogen has a strong base of evidence — more than 30 randomized trials — supporting its effectiveness in UTI: a 50%-90% reduction in the incidence of recurrent UTIs. Topical estrogen has minimal systemic absorption, and there are no concerning safety signals with respect to either thromboembolic disease or cancer (endometrial or breast). 

Methenamine hippurate is also recommended and is FDA-approved for prevention of UTIs. It works by releasing formaldehyde in the urine, leading to bacteriostasis, which is how it leads to a decrease in UTIs. Finally, postcoital or daily administration of TMP-SMX, nitrofurantoin, norfloxacin, and ciprofloxacin all have comparable efficacy for prophylaxis, with a meta-analysis showing a decrease in recurrence rate of approximately 85%. The guideline states that there is insufficient evidence to support the use of either probiotics or D-mannose to prevent UTIs. 

This is a wonderful update on a common problem. We all have a lot of clinical experience here.

Dr Skolnik, Department of Family Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia; Associate Director, Department of Family Medicine, Abington Jefferson Health, Abington, Pennsylvania, disclosed ties with AstraZeneca, Teva, Eli Lilly, Boehringer Ingelheim, Sanofi, Sanofi Pasteur, GlaxoSmithKline, Merck, and Bayer. 

A version of this article appeared on Medscape.com.

This transcript has been edited for clarity. 

We often see urinary tract infections in primary care, so these guidelines for the prevention, diagnosis and management of urinary tract infection (UTI) are very helpful to reaffirm our knowledge in the areas where know what we’re doing and update our knowledge in areas of uncertainty. These guidelines are from a new group called the WikiGuidelines group. Ordinarily, I wouldn’t have considered reviewing one of these guidelines, but this one was published in JAMA Network Open. It is evidence based and covers the topic really well. 

Diagnosis. Order a urinalysis or a urine culture only if the patient is having symptoms of a UTI. This may seem obvious, but particularly among older individuals, in whom asymptomatic bacteriuria is very common and should not be treated, nonspecific symptoms such as just not feeling well for a day do not warrant obtaining a urinalysis and culture. With no clear way to distinguish between asymptomatic bacteriuria and a true UTI, the first step in making the diagnosis of a UTI accurately is ordering urine studies only in people who have a reasonable chance of having an infection.

The guideline suggests that the diagnosis of UTI should be primarily based on clinical symptoms. A urinalysis can provide further information, but the authors caution us against relying solely on the urinalysis. This is an incredibly important evidence-based recommendation. If you think about it, this supports the common practice of treating UTIs over the phone without having to see the patient or check a urinalysis. 

The rationale for this recommendation is that urinalysis is neither a sensitive nor specific test for UTI. The sensitivity of leukocyte esterase is only about 80%, and the specificity is even lower. For positive nitrite on urinalysis, the sensitivity is below 50%, meaning the test would be negative more than half the time when someone actually has a UTI. The specificity of urine nitrate is very high (more than 90%), so if the patient is nitrite positive, they clearly have a UTI. This means that a patient’s report of classic UTI symptoms — urinary burning, frequency, and urgency — is about as good if not a better indicator of a UTI than a urinalysis. 

The guidelines also say that in simple uncomplicated cystitis in healthy nonpregnant patients, routine urine cultures are not necessary. A fascinating meta-analysis in JAMA showed that, for women presenting to outpatient clinics with at least two symptoms of UTI and absence of vaginal discharge, there was a greater than 90% likelihood of having acute cystitis. A reminder here, however: If a woman is sexually active and at risk for sexually transmitted infections, then consider testing for STIs as well, because the symptoms of an STI can mimic those of a UTI.

Treatment. Treatment for UTI is usually empiric, with treatment initiated before the culture results are known and with cultures being done only for people with complicated infections, such as pyelonephritis, or with recurrent infections. Decisions about what to use for treatment can be influenced by local patterns of resistance and an individual’s risk factors for antimicrobial resistance. As a general rule, for uncomplicated cystitis, nitrofurantoin for 5 days is a reasonable first-line agent. Evidence of efficacy is good, and the risk for antimicrobial resistance is lower vs using antibiotics for other systemic infections. 

Other reasonable first-line agents for uncomplicated cystitis include trimethoprim-sulfamethoxazole (TMP-SMX) for 3 days; fosfomycin (oral) single dose; or a beta-lactam (most commonly a first generation cephalosporin), although evidence for duration is unclear. Also mentioned are two unfamiliar antibiotics: pivmecillinam (a beta-lactam agent recently approved by the Food and Drug Administration [FDA], given for 3 days) and gepotidacin (from a new class of antibiotic that is currently under FDA review). Fluoroquinolones should not usually be first-line agents unless other treatment options are not appropriate. 

It’s important to distinguish between uncomplicated cystitis and pyelonephritis. For pyelonephritis (infection of the upper urinary tract), the first decision has to do with setting for care, depending on how sick someone is, and the likelihood of gram-negative bacteremia — all of which help whether the patient needs to be hospitalized for intravenous antibiotics, or can be treated as an outpatient. Determine if they need to be admitted for intravenous antibiotics or whether they can be treated as an outpatient. For outpatient treatment of pyelonephritis, the guideline suggests that TMP-SMX or a first-generation cephalosporin are both reasonable first-line agents, with fluoroquinolones being a reasonable choice as well. Ceftriaxone is recommended for first-line therapy for patients who require intravenous treatment. 

People often forget that we can do a lot to prevent UTIs, particularly among women with recurrent UTIs. The prevention of UTIs has both nonpharmacologic and pharmacologic approaches.

Nonpharmacologic prevention. One nonpharmacologic strategy is increasing water intake. A randomized controlled trial in women with recurrent cystitis who drank less than 1.5 L of fluid a day showed that the women randomized to consume an additional 1.5 L of water daily had significantly reduced cystitis frequency — approximately 50%. Because this was the only randomized trial to show this effect, this is not a strong recommendation, but there is very little downside in healthy women, so increasing water intake is a reasonable recommendation.

Another commonly discussed intervention is the use of cranberry products. As it turns out, most prospective studies have shown that cranberry products can reduce the risk for symptomatic UTIs in women with recurrent UTI. 

Pharmacologic prevention. For postmenopausal women with recurrent UTI, topical vaginal estrogen has a strong base of evidence — more than 30 randomized trials — supporting its effectiveness in UTI: a 50%-90% reduction in the incidence of recurrent UTIs. Topical estrogen has minimal systemic absorption, and there are no concerning safety signals with respect to either thromboembolic disease or cancer (endometrial or breast). 

Methenamine hippurate is also recommended and is FDA-approved for prevention of UTIs. It works by releasing formaldehyde in the urine, leading to bacteriostasis, which is how it leads to a decrease in UTIs. Finally, postcoital or daily administration of TMP-SMX, nitrofurantoin, norfloxacin, and ciprofloxacin all have comparable efficacy for prophylaxis, with a meta-analysis showing a decrease in recurrence rate of approximately 85%. The guideline states that there is insufficient evidence to support the use of either probiotics or D-mannose to prevent UTIs. 

This is a wonderful update on a common problem. We all have a lot of clinical experience here.

Dr Skolnik, Department of Family Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia; Associate Director, Department of Family Medicine, Abington Jefferson Health, Abington, Pennsylvania, disclosed ties with AstraZeneca, Teva, Eli Lilly, Boehringer Ingelheim, Sanofi, Sanofi Pasteur, GlaxoSmithKline, Merck, and Bayer. 

A version of this article appeared on Medscape.com.

This transcript has been edited for clarity. 

We often see urinary tract infections in primary care, so these guidelines for the prevention, diagnosis and management of urinary tract infection (UTI) are very helpful to reaffirm our knowledge in the areas where know what we’re doing and update our knowledge in areas of uncertainty. These guidelines are from a new group called the WikiGuidelines group. Ordinarily, I wouldn’t have considered reviewing one of these guidelines, but this one was published in JAMA Network Open. It is evidence based and covers the topic really well. 

Diagnosis. Order a urinalysis or a urine culture only if the patient is having symptoms of a UTI. This may seem obvious, but particularly among older individuals, in whom asymptomatic bacteriuria is very common and should not be treated, nonspecific symptoms such as just not feeling well for a day do not warrant obtaining a urinalysis and culture. With no clear way to distinguish between asymptomatic bacteriuria and a true UTI, the first step in making the diagnosis of a UTI accurately is ordering urine studies only in people who have a reasonable chance of having an infection.

The guideline suggests that the diagnosis of UTI should be primarily based on clinical symptoms. A urinalysis can provide further information, but the authors caution us against relying solely on the urinalysis. This is an incredibly important evidence-based recommendation. If you think about it, this supports the common practice of treating UTIs over the phone without having to see the patient or check a urinalysis. 

The rationale for this recommendation is that urinalysis is neither a sensitive nor specific test for UTI. The sensitivity of leukocyte esterase is only about 80%, and the specificity is even lower. For positive nitrite on urinalysis, the sensitivity is below 50%, meaning the test would be negative more than half the time when someone actually has a UTI. The specificity of urine nitrate is very high (more than 90%), so if the patient is nitrite positive, they clearly have a UTI. This means that a patient’s report of classic UTI symptoms — urinary burning, frequency, and urgency — is about as good if not a better indicator of a UTI than a urinalysis. 

The guidelines also say that in simple uncomplicated cystitis in healthy nonpregnant patients, routine urine cultures are not necessary. A fascinating meta-analysis in JAMA showed that, for women presenting to outpatient clinics with at least two symptoms of UTI and absence of vaginal discharge, there was a greater than 90% likelihood of having acute cystitis. A reminder here, however: If a woman is sexually active and at risk for sexually transmitted infections, then consider testing for STIs as well, because the symptoms of an STI can mimic those of a UTI.

Treatment. Treatment for UTI is usually empiric, with treatment initiated before the culture results are known and with cultures being done only for people with complicated infections, such as pyelonephritis, or with recurrent infections. Decisions about what to use for treatment can be influenced by local patterns of resistance and an individual’s risk factors for antimicrobial resistance. As a general rule, for uncomplicated cystitis, nitrofurantoin for 5 days is a reasonable first-line agent. Evidence of efficacy is good, and the risk for antimicrobial resistance is lower vs using antibiotics for other systemic infections. 

Other reasonable first-line agents for uncomplicated cystitis include trimethoprim-sulfamethoxazole (TMP-SMX) for 3 days; fosfomycin (oral) single dose; or a beta-lactam (most commonly a first generation cephalosporin), although evidence for duration is unclear. Also mentioned are two unfamiliar antibiotics: pivmecillinam (a beta-lactam agent recently approved by the Food and Drug Administration [FDA], given for 3 days) and gepotidacin (from a new class of antibiotic that is currently under FDA review). Fluoroquinolones should not usually be first-line agents unless other treatment options are not appropriate. 

It’s important to distinguish between uncomplicated cystitis and pyelonephritis. For pyelonephritis (infection of the upper urinary tract), the first decision has to do with setting for care, depending on how sick someone is, and the likelihood of gram-negative bacteremia — all of which help whether the patient needs to be hospitalized for intravenous antibiotics, or can be treated as an outpatient. Determine if they need to be admitted for intravenous antibiotics or whether they can be treated as an outpatient. For outpatient treatment of pyelonephritis, the guideline suggests that TMP-SMX or a first-generation cephalosporin are both reasonable first-line agents, with fluoroquinolones being a reasonable choice as well. Ceftriaxone is recommended for first-line therapy for patients who require intravenous treatment. 

People often forget that we can do a lot to prevent UTIs, particularly among women with recurrent UTIs. The prevention of UTIs has both nonpharmacologic and pharmacologic approaches.

Nonpharmacologic prevention. One nonpharmacologic strategy is increasing water intake. A randomized controlled trial in women with recurrent cystitis who drank less than 1.5 L of fluid a day showed that the women randomized to consume an additional 1.5 L of water daily had significantly reduced cystitis frequency — approximately 50%. Because this was the only randomized trial to show this effect, this is not a strong recommendation, but there is very little downside in healthy women, so increasing water intake is a reasonable recommendation.

Another commonly discussed intervention is the use of cranberry products. As it turns out, most prospective studies have shown that cranberry products can reduce the risk for symptomatic UTIs in women with recurrent UTI. 

Pharmacologic prevention. For postmenopausal women with recurrent UTI, topical vaginal estrogen has a strong base of evidence — more than 30 randomized trials — supporting its effectiveness in UTI: a 50%-90% reduction in the incidence of recurrent UTIs. Topical estrogen has minimal systemic absorption, and there are no concerning safety signals with respect to either thromboembolic disease or cancer (endometrial or breast). 

Methenamine hippurate is also recommended and is FDA-approved for prevention of UTIs. It works by releasing formaldehyde in the urine, leading to bacteriostasis, which is how it leads to a decrease in UTIs. Finally, postcoital or daily administration of TMP-SMX, nitrofurantoin, norfloxacin, and ciprofloxacin all have comparable efficacy for prophylaxis, with a meta-analysis showing a decrease in recurrence rate of approximately 85%. The guideline states that there is insufficient evidence to support the use of either probiotics or D-mannose to prevent UTIs. 

This is a wonderful update on a common problem. We all have a lot of clinical experience here.

Dr Skolnik, Department of Family Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia; Associate Director, Department of Family Medicine, Abington Jefferson Health, Abington, Pennsylvania, disclosed ties with AstraZeneca, Teva, Eli Lilly, Boehringer Ingelheim, Sanofi, Sanofi Pasteur, GlaxoSmithKline, Merck, and Bayer. 

A version of this article appeared on Medscape.com.