Article

Attending psychiatrists who work night shift in a psychiatric emergency department (ED) or medical ED require a different set of skills than when working daytime or evening shifts, especially when working full-time or solo. While all patients should be treated carefully and meticulously regardless of the shift, this article offers tips for efficiency for solo attending psychiatrists who work night shift in an ED.

Check orders. Typically, multiple psychiatric clinicians are available on other shifts, but only 1 at night. This can lead to significant variability and potential errors in patients’ orders. Such errors filter down to night shift and often must be addressed by the solo clinician, who can’t say “that person is not my patient” because there are no other clinicians available to help. Carefully check orders (ideally, on all patients every shift) to ensure there are no errors or omissions.

Use note templates. While it is important to avoid using mere checklists, with electronic medical record systems, create templates for typical notes. This will save time when the pace of patients increases.

Be brief in your documentation. Brevity is key when documenting at night. Focus on what is necessary and sufficient.

Conduct thorough but efficient interviews. Be aware of how much time you spend on patient interviews. While still thorough, interviews must often be shorter due to a higher staff-to-patient ratio at night.

Be aware of potential medical issues. Many psychiatric EDs are not attached to a hospital. With other medical consultants not readily available in the middle of the night, be particularly alert for any acute medical issues that may arise, and act accordingly.

Focus on the order of tasks. Be aware of which tasks you complete and in what order. For example, at night you may need to medicate sooner for agitation because other patients are sleeping, instead of letting one patient’s agitation disrupt the entire night milieu.

Continue to: Don't let tasks pile up

Don’t let tasks pile up. Time management and multitasking are key skills at night. Take care of clinical issues as they arise. Finish documentation as you go along. Don’t let things pile up throughout your shift and then spend significant time after your shift to catch up.

Know your staff. The staff around you are your eyes and ears. Get to know your clinical and nonclinical staff’s tendencies. This can be immensely helpful in picking up any different patterns when interviewing and observing patients.

Know your limits. You may not be able to solve everything or obtain the ideal collateral at night. Don’t get caught up in definitively trying to resolve things and end up wasting precious time at night. Let it go. Don’t overthink. If all else fails, hold the patient overnight.

Prioritize self-care. Night shift work has been shown to negatively impact one’s health.^1-3 If you choose this type of work, either part-time or full-time, maintain your own health by exercising regularly, eating a healthy diet, obtaining adequate rest between shifts, and seeing your health care team often.

Attending psychiatrists who work night shift in a psychiatric emergency department (ED) or medical ED require a different set of skills than when working daytime or evening shifts, especially when working full-time or solo. While all patients should be treated carefully and meticulously regardless of the shift, this article offers tips for efficiency for solo attending psychiatrists who work night shift in an ED.

Check orders. Typically, multiple psychiatric clinicians are available on other shifts, but only 1 at night. This can lead to significant variability and potential errors in patients’ orders. Such errors filter down to night shift and often must be addressed by the solo clinician, who can’t say “that person is not my patient” because there are no other clinicians available to help. Carefully check orders (ideally, on all patients every shift) to ensure there are no errors or omissions.

Use note templates. While it is important to avoid using mere checklists, with electronic medical record systems, create templates for typical notes. This will save time when the pace of patients increases.

Be brief in your documentation. Brevity is key when documenting at night. Focus on what is necessary and sufficient.

Conduct thorough but efficient interviews. Be aware of how much time you spend on patient interviews. While still thorough, interviews must often be shorter due to a higher staff-to-patient ratio at night.

Be aware of potential medical issues. Many psychiatric EDs are not attached to a hospital. With other medical consultants not readily available in the middle of the night, be particularly alert for any acute medical issues that may arise, and act accordingly.

Focus on the order of tasks. Be aware of which tasks you complete and in what order. For example, at night you may need to medicate sooner for agitation because other patients are sleeping, instead of letting one patient’s agitation disrupt the entire night milieu.

Continue to: Don't let tasks pile up

Don’t let tasks pile up. Time management and multitasking are key skills at night. Take care of clinical issues as they arise. Finish documentation as you go along. Don’t let things pile up throughout your shift and then spend significant time after your shift to catch up.

Know your staff. The staff around you are your eyes and ears. Get to know your clinical and nonclinical staff’s tendencies. This can be immensely helpful in picking up any different patterns when interviewing and observing patients.

Know your limits. You may not be able to solve everything or obtain the ideal collateral at night. Don’t get caught up in definitively trying to resolve things and end up wasting precious time at night. Let it go. Don’t overthink. If all else fails, hold the patient overnight.

Prioritize self-care. Night shift work has been shown to negatively impact one’s health.^1-3 If you choose this type of work, either part-time or full-time, maintain your own health by exercising regularly, eating a healthy diet, obtaining adequate rest between shifts, and seeing your health care team often.

Attending psychiatrists who work night shift in a psychiatric emergency department (ED) or medical ED require a different set of skills than when working daytime or evening shifts, especially when working full-time or solo. While all patients should be treated carefully and meticulously regardless of the shift, this article offers tips for efficiency for solo attending psychiatrists who work night shift in an ED.

Check orders. Typically, multiple psychiatric clinicians are available on other shifts, but only 1 at night. This can lead to significant variability and potential errors in patients’ orders. Such errors filter down to night shift and often must be addressed by the solo clinician, who can’t say “that person is not my patient” because there are no other clinicians available to help. Carefully check orders (ideally, on all patients every shift) to ensure there are no errors or omissions.

Use note templates. While it is important to avoid using mere checklists, with electronic medical record systems, create templates for typical notes. This will save time when the pace of patients increases.

Be brief in your documentation. Brevity is key when documenting at night. Focus on what is necessary and sufficient.

Conduct thorough but efficient interviews. Be aware of how much time you spend on patient interviews. While still thorough, interviews must often be shorter due to a higher staff-to-patient ratio at night.

Be aware of potential medical issues. Many psychiatric EDs are not attached to a hospital. With other medical consultants not readily available in the middle of the night, be particularly alert for any acute medical issues that may arise, and act accordingly.

Focus on the order of tasks. Be aware of which tasks you complete and in what order. For example, at night you may need to medicate sooner for agitation because other patients are sleeping, instead of letting one patient’s agitation disrupt the entire night milieu.

Continue to: Don't let tasks pile up

Don’t let tasks pile up. Time management and multitasking are key skills at night. Take care of clinical issues as they arise. Finish documentation as you go along. Don’t let things pile up throughout your shift and then spend significant time after your shift to catch up.

Know your staff. The staff around you are your eyes and ears. Get to know your clinical and nonclinical staff’s tendencies. This can be immensely helpful in picking up any different patterns when interviewing and observing patients.

Know your limits. You may not be able to solve everything or obtain the ideal collateral at night. Don’t get caught up in definitively trying to resolve things and end up wasting precious time at night. Let it go. Don’t overthink. If all else fails, hold the patient overnight.

Prioritize self-care. Night shift work has been shown to negatively impact one’s health.^1-3 If you choose this type of work, either part-time or full-time, maintain your own health by exercising regularly, eating a healthy diet, obtaining adequate rest between shifts, and seeing your health care team often.

Sound moral principles are essential in the development of all physicians. Given how heavily each clinical encounter is laden with ethical implications, this is taught early in medical school. The medical student and resident physician must be able to make ethical and moral decisions on a consistent basis.

Speaking as a psychiatrist in training, there is an intimate relationship between psychiatry and moral questions.¹ Issues such as determining an individual’s ability to make decisions about their medical care, hospitalizing patients against their will, and involuntarily administering medication are an almost-daily occurrence.² Physicians, especially those who practice psychiatric medicine, must be ethically grounded to properly make these difficult but common decisions. It is also imperative that residents are given proper guidance in ethical practice in structured didactics and hands-on training.

However, many residents may be unfamiliar with ethics in research, more specifically ethical authorship. While some trainees might have participated in scholarly activities before residency, residency is the time to discover one’s interests, and residents are encouraged to engage in research. Unfortunately, many of the considerations surrounding ethical authorship are not emphasized, and questionable practices are common.³ In this article, I summarize the different faces of unethical authorship, and call for a greater emphasis on ethical authorship in medical residency training programs.

What drives unethical authorship practices

One of the main drivers for the increase in unethical practices is the need to publish to advance one’s academic career. The academic principle of “publish or perish” pressures many faculty researchers.³ The impact of this expectation plays a significant role in potentially unethical authorship practices, and also has increased the number of publications of mediocre quality or fraudulent data.⁴ This mindset has also seeped into the clinical world because promotions and financial bonuses are incentives for attending physicians to perform scholarly work. Due to these incentives and pressures, a senior academician might compel a junior researcher to include them as a coauthor on the junior researcher’s paper, even when the senior’s contributions to the paper might be limited.⁵

Most journals have specific criteria for authorship. The International Committee of Medical Journal Editors (ICMJE) has 4 core criteria for authorship: 1) substantial contributions to the conception or design of the work, or the acquisition, analysis, or interpretation of data for the work; 2) drafting the work or revising it critically for important intellectual content; 3) providing final approval of the version to be published, and 4) agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.^5,6 One survey found that in certain journals, approximately 15% of authors met full ICMJE authorship criteria, while one-half claimed there were substantial contributions but did not state anything more specific.⁷

There are several types of authorship abuse.⁵ Gift authorship is when authorship is awarded to a friend either out of respect or in hopes that friend will return the favor (quid pro quo). Ghost authorship occurs when a third party commissions an author to write or help write a paper (eg, when a pharmaceutical company hires writers to produce a paper about a medication they manufacture) or when legitimate authors are denied recognition on a paper. Honorary authorship occurs when authorship is granted with the hope that the reputation of the honorary author will increase the chances of the paper getting published and possibly boost citations.

While these forms of authorship abuse occur with unsettling frequency, they might not be common among physician trainees who do not engage in full-time research.⁵ Resident authors might be more likely to experience coercive authorship.

Continue to: Coercive authorship is when...

Coercive authorship is when an individual in a superior position (such as an attending physician) forces their name onto a paper of a junior individual (such as a resident). Kwok⁸ called this “The White Bull effect,” based on Greek mythology in which Zeus transformed himself into a white bull to seduce Europa. The White Bull represents the predatory nature of the senior individual who exploits ambiguous institutional research regulations to their benefit.⁸ They stretch out the ICMJE criteria, only superficially satisfying them to justify authorship. In this scenario, the attending physician with promotional incentives notices the work of a resident and demands authorship, given their role as the “supervising” physician (akin to general supervision of a research group). This is not justification for authorship per the ICMJE or any major medical journal criteria. However, a resident with limited research experience may agree to include the attending as a coauthor for a variety of reasons, including fear of a poor performance evaluation or professionalism complaints, or just to maintain a positive working relationship.

Serious implications

While there are countless reasons to be concerned about this behavior, the central issue is the attending physician’s role to train and/or mentor the resident. As previously stated, a physician—especially one practicing psychiatric medicine—must be of morally sound mind. A resident being taught unethical behaviors by their attending physician has dangerous implications. Academic dishonesty does not occur in vacuum. It is likely that dishonest and unethical behavior in research matters can cross over into the clinical arena. One study found that individuals who exhibit dishonest academic behavior are more likely to violate workplace policies.⁹ Also, these behaviors lead to increased moral disengagement in all areas.^10,11 Imagining a morally disengaged attending psychiatrist practicing medicine and training the next generation of psychiatrists is unsettling.

My hope is that residency programs discourage this detrimental conduct in their departments and support those trying to uphold integrity.

Sound moral principles are essential in the development of all physicians. Given how heavily each clinical encounter is laden with ethical implications, this is taught early in medical school. The medical student and resident physician must be able to make ethical and moral decisions on a consistent basis.

Speaking as a psychiatrist in training, there is an intimate relationship between psychiatry and moral questions.¹ Issues such as determining an individual’s ability to make decisions about their medical care, hospitalizing patients against their will, and involuntarily administering medication are an almost-daily occurrence.² Physicians, especially those who practice psychiatric medicine, must be ethically grounded to properly make these difficult but common decisions. It is also imperative that residents are given proper guidance in ethical practice in structured didactics and hands-on training.

However, many residents may be unfamiliar with ethics in research, more specifically ethical authorship. While some trainees might have participated in scholarly activities before residency, residency is the time to discover one’s interests, and residents are encouraged to engage in research. Unfortunately, many of the considerations surrounding ethical authorship are not emphasized, and questionable practices are common.³ In this article, I summarize the different faces of unethical authorship, and call for a greater emphasis on ethical authorship in medical residency training programs.

What drives unethical authorship practices

One of the main drivers for the increase in unethical practices is the need to publish to advance one’s academic career. The academic principle of “publish or perish” pressures many faculty researchers.³ The impact of this expectation plays a significant role in potentially unethical authorship practices, and also has increased the number of publications of mediocre quality or fraudulent data.⁴ This mindset has also seeped into the clinical world because promotions and financial bonuses are incentives for attending physicians to perform scholarly work. Due to these incentives and pressures, a senior academician might compel a junior researcher to include them as a coauthor on the junior researcher’s paper, even when the senior’s contributions to the paper might be limited.⁵

Most journals have specific criteria for authorship. The International Committee of Medical Journal Editors (ICMJE) has 4 core criteria for authorship: 1) substantial contributions to the conception or design of the work, or the acquisition, analysis, or interpretation of data for the work; 2) drafting the work or revising it critically for important intellectual content; 3) providing final approval of the version to be published, and 4) agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.^5,6 One survey found that in certain journals, approximately 15% of authors met full ICMJE authorship criteria, while one-half claimed there were substantial contributions but did not state anything more specific.⁷

There are several types of authorship abuse.⁵ Gift authorship is when authorship is awarded to a friend either out of respect or in hopes that friend will return the favor (quid pro quo). Ghost authorship occurs when a third party commissions an author to write or help write a paper (eg, when a pharmaceutical company hires writers to produce a paper about a medication they manufacture) or when legitimate authors are denied recognition on a paper. Honorary authorship occurs when authorship is granted with the hope that the reputation of the honorary author will increase the chances of the paper getting published and possibly boost citations.

While these forms of authorship abuse occur with unsettling frequency, they might not be common among physician trainees who do not engage in full-time research.⁵ Resident authors might be more likely to experience coercive authorship.

Continue to: Coercive authorship is when...

Coercive authorship is when an individual in a superior position (such as an attending physician) forces their name onto a paper of a junior individual (such as a resident). Kwok⁸ called this “The White Bull effect,” based on Greek mythology in which Zeus transformed himself into a white bull to seduce Europa. The White Bull represents the predatory nature of the senior individual who exploits ambiguous institutional research regulations to their benefit.⁸ They stretch out the ICMJE criteria, only superficially satisfying them to justify authorship. In this scenario, the attending physician with promotional incentives notices the work of a resident and demands authorship, given their role as the “supervising” physician (akin to general supervision of a research group). This is not justification for authorship per the ICMJE or any major medical journal criteria. However, a resident with limited research experience may agree to include the attending as a coauthor for a variety of reasons, including fear of a poor performance evaluation or professionalism complaints, or just to maintain a positive working relationship.

Serious implications

While there are countless reasons to be concerned about this behavior, the central issue is the attending physician’s role to train and/or mentor the resident. As previously stated, a physician—especially one practicing psychiatric medicine—must be of morally sound mind. A resident being taught unethical behaviors by their attending physician has dangerous implications. Academic dishonesty does not occur in vacuum. It is likely that dishonest and unethical behavior in research matters can cross over into the clinical arena. One study found that individuals who exhibit dishonest academic behavior are more likely to violate workplace policies.⁹ Also, these behaviors lead to increased moral disengagement in all areas.^10,11 Imagining a morally disengaged attending psychiatrist practicing medicine and training the next generation of psychiatrists is unsettling.

My hope is that residency programs discourage this detrimental conduct in their departments and support those trying to uphold integrity.

Sound moral principles are essential in the development of all physicians. Given how heavily each clinical encounter is laden with ethical implications, this is taught early in medical school. The medical student and resident physician must be able to make ethical and moral decisions on a consistent basis.

Speaking as a psychiatrist in training, there is an intimate relationship between psychiatry and moral questions.¹ Issues such as determining an individual’s ability to make decisions about their medical care, hospitalizing patients against their will, and involuntarily administering medication are an almost-daily occurrence.² Physicians, especially those who practice psychiatric medicine, must be ethically grounded to properly make these difficult but common decisions. It is also imperative that residents are given proper guidance in ethical practice in structured didactics and hands-on training.

However, many residents may be unfamiliar with ethics in research, more specifically ethical authorship. While some trainees might have participated in scholarly activities before residency, residency is the time to discover one’s interests, and residents are encouraged to engage in research. Unfortunately, many of the considerations surrounding ethical authorship are not emphasized, and questionable practices are common.³ In this article, I summarize the different faces of unethical authorship, and call for a greater emphasis on ethical authorship in medical residency training programs.

What drives unethical authorship practices

One of the main drivers for the increase in unethical practices is the need to publish to advance one’s academic career. The academic principle of “publish or perish” pressures many faculty researchers.³ The impact of this expectation plays a significant role in potentially unethical authorship practices, and also has increased the number of publications of mediocre quality or fraudulent data.⁴ This mindset has also seeped into the clinical world because promotions and financial bonuses are incentives for attending physicians to perform scholarly work. Due to these incentives and pressures, a senior academician might compel a junior researcher to include them as a coauthor on the junior researcher’s paper, even when the senior’s contributions to the paper might be limited.⁵

Most journals have specific criteria for authorship. The International Committee of Medical Journal Editors (ICMJE) has 4 core criteria for authorship: 1) substantial contributions to the conception or design of the work, or the acquisition, analysis, or interpretation of data for the work; 2) drafting the work or revising it critically for important intellectual content; 3) providing final approval of the version to be published, and 4) agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.^5,6 One survey found that in certain journals, approximately 15% of authors met full ICMJE authorship criteria, while one-half claimed there were substantial contributions but did not state anything more specific.⁷

There are several types of authorship abuse.⁵ Gift authorship is when authorship is awarded to a friend either out of respect or in hopes that friend will return the favor (quid pro quo). Ghost authorship occurs when a third party commissions an author to write or help write a paper (eg, when a pharmaceutical company hires writers to produce a paper about a medication they manufacture) or when legitimate authors are denied recognition on a paper. Honorary authorship occurs when authorship is granted with the hope that the reputation of the honorary author will increase the chances of the paper getting published and possibly boost citations.

While these forms of authorship abuse occur with unsettling frequency, they might not be common among physician trainees who do not engage in full-time research.⁵ Resident authors might be more likely to experience coercive authorship.

Continue to: Coercive authorship is when...

Coercive authorship is when an individual in a superior position (such as an attending physician) forces their name onto a paper of a junior individual (such as a resident). Kwok⁸ called this “The White Bull effect,” based on Greek mythology in which Zeus transformed himself into a white bull to seduce Europa. The White Bull represents the predatory nature of the senior individual who exploits ambiguous institutional research regulations to their benefit.⁸ They stretch out the ICMJE criteria, only superficially satisfying them to justify authorship. In this scenario, the attending physician with promotional incentives notices the work of a resident and demands authorship, given their role as the “supervising” physician (akin to general supervision of a research group). This is not justification for authorship per the ICMJE or any major medical journal criteria. However, a resident with limited research experience may agree to include the attending as a coauthor for a variety of reasons, including fear of a poor performance evaluation or professionalism complaints, or just to maintain a positive working relationship.

Serious implications

While there are countless reasons to be concerned about this behavior, the central issue is the attending physician’s role to train and/or mentor the resident. As previously stated, a physician—especially one practicing psychiatric medicine—must be of morally sound mind. A resident being taught unethical behaviors by their attending physician has dangerous implications. Academic dishonesty does not occur in vacuum. It is likely that dishonest and unethical behavior in research matters can cross over into the clinical arena. One study found that individuals who exhibit dishonest academic behavior are more likely to violate workplace policies.⁹ Also, these behaviors lead to increased moral disengagement in all areas.^10,11 Imagining a morally disengaged attending psychiatrist practicing medicine and training the next generation of psychiatrists is unsettling.

My hope is that residency programs discourage this detrimental conduct in their departments and support those trying to uphold integrity.

MASTER CLASS

Prepare for endometriosis excision surgery with a multidisciplinary approach

Iris Kerin Orbuch, MD

Director, Advanced Gynecologic Laparoscopy Center, Los Angeles and New York City.

Series introduction

Charles Miller, MD

Professor, Obstetrics and Gynecology, Department of Clinical Sciences, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois.
 

As I gained more interest and expertise in the treatment of endometriosis, I became aware of several articles concluding that if a woman sought treatment for chronic pelvic pain with an internist, the diagnosis would be irritable bowel syndrome (IBS); with a urologist, it would be interstitial cystitis; and with a gynecologist, endometriosis. Moreover, there is an increased propensity for IBS and IC in patients with endometriosis. There also is an increased risk of small intestine bacterial overgrowth (SIBO), as noted by our guest author for this latest installment of the Master Class in Gynecologic Surgery, Iris Orbuch, MD.

Like our guest author, I have also noted increased risk of pelvic floor myalgia. Dr. Orbuch clearly outlines why this occurs. In fact, we can now understand why many patients have multiple pelvic pain–inducing issues compounding their pain secondary to endometriosis and leading to remodeling of the central nervous system. Therefore, it certainly makes sense to follow Dr. Orbuch’s recommendation for a multidisciplinary pre- and postsurgical approach “to downregulate the pain generators.”

Dr. Orbuch is a minimally invasive gynecologic surgeon in Los Angeles who specializes in the treatment of patients diagnosed with endometriosis. Dr. Orbuch serves on the Board of Directors of the Foundation of the American Association of Gynecologic Laparoscopists and has served as the chair of the AAGL’s Special Interest Group on Endometriosis and Reproductive Surgery. She is the coauthor of the book “Beating Endo —How to Reclaim Your Life From Endometriosis” (New York: HarperCollins; 2019). The book is written for patients but addresses many issues discussed in this installment of the Master Class in Gynecologic Surgery.

https://www.mdedge.com/obgyn/master-class
 

GYNECOLOGIC ONCOLOGY CONSULT

The perils of CA-125 as a diagnostic tool in patients with adnexal masses

Katherine Tucker, MD

Assistant Professor of Gynecologic Oncology at the University of North Carolina at Chapel Hill.
 

CA-125, or cancer antigen 125, is an epitope (antigen) on the transmembrane glycoprotein MUC16, or mucin 16. This protein is expressed on the surface of tissue derived from embryonic coelomic and Müllerian epithelium including the reproductive tract. CA-125 is also expressed in other tissue such as the pleura, lungs, pericardium, intestines, and kidneys. MUC16 plays an important role in tumor proliferation, invasiveness, and cell motility.1 In patients with epithelial ovarian cancer (EOC), CA-125 may be found on the surface of ovarian cancer cells. It is shed in the bloodstream and can be quantified using a serum test.

There are a number of CA-125 assays in commercial use, and although none have been deemed to be clinically superior, there can be some differences between assays. It is important, if possible, to use the same assay when following serial CA-125 values. Most frequently, this will mean getting the test through the same laboratory.

https://www.mdedge.com/obgyn/gynecologic-oncology-consult

LATEST NEWS

Few women identify breast density as a breast cancer risk

Walter Alexander
 

A qualitative study of breast cancer screening–age women finds that few women identified breast density as a risk factor for breast cancer.

Most women did not feel confident they knew what actions could mitigate breast cancer risk, leading researchers to the conclusion that comprehensive education about breast cancer risks and prevention strategies is needed.

CDC recommends universal hepatitis B screening of adults

Lucy Hicks
 

Adults should be tested for hepatitis B virus (HBV) at least once in their lifetime, according to updated guidelines from the Centers for Disease Control and Prevention.

This is the first update to HBV screening guidelines since 2008, the agency said.

“Risk-based testing alone has not identified most persons living with chronic HBV infection and is considered inefficient for providers to implement,” the authors write in the new guidance, published in the CDC’s Morbidity and Mortality Weekly Report. “Universal screening of adults for HBV infection is cost-effective, compared with risk-based screening and averts liver disease and death. Although a curative treatment is not yet available, early diagnosis and treatment of chronic HBV infections reduces the risk for cirrhosis, liver cancer, nd death.”

An estimated 580,000 to 2.4 million individuals are living with HBV infection in the United States, and two-thirds may be unaware they are infected, the agency said.

The virus spreads through contact with blood, semen, and other body fluids of an infected person.

The guidance now recommends using the triple panel (HBsAg, anti-HBs, total anti-HBc) for initial screening.

“It can help identify persons who have an active HBV infection and could be linked to care; have [a] resolved infection and might be susceptible to reactivation (for example, immunosuppressed persons); are susceptible and need vaccination; or are vaccinated,” the authors write.
 

Ectopic pregnancy risk and levonorgestrel-releasing IUD

Diana Swift
 

Researchers report that use of any levonorgestrel-releasing intrauterine system was associated with a significantly increased risk of ectopic pregnancy, compared with other hormonal contraceptives, in a study published in JAMA.

A national health database analysis headed by Amani Meaidi, MD, PhD, of the Danish Cancer Society Research Center, Cancer Surveillance and Pharmacoepidemiology, in Copenhagen, compared the 13.5-mg with the 19.5-mg and 52-mg dosages of levonorgestrel-releasing intrauterine systems (IUSs).

The hormone content in levonorgestrel-releasing IUSs must be high enough to maintain optimal contraceptive effect but sufficiently low to minimize progestin-related adverse events, Dr. Meaidi and colleagues noted; they advised using the middle dosage of 19.5 mg. All dosages are recommended for contraception, with the highest dosage also recommended for heavy menstrual bleeding.

“If 10,000 women using the hormonal IUD for 1 year were given the 19.5-mg hormonal IUD instead of the 13.5-mg hormonal IUD, around nine ectopic pregnancies would be avoided,” Dr. Meaidi said in an interview.
 

EPA seeks to limit ‘forever’ chemicals in U.S. drinking water

Lisa Nainggolan
 

The Environmental Protection Agency is proposing a new rule that would greatly limit the concentration of endocrine-disrupting “forever” chemicals in drinking water.

The EPA on Tuesday announced the proposed National Primary Drinking Water Regulation (NPDWR) for six polyfluoroalkyl substances, more commonly known as PFAS, which are human-made chemicals used as oil and water repellents and coatings for common products including cookware, carpets, and textiles. Such substances are also widely used in cosmetics and food packaging.

The Endocrine Society, which represents more than 18,000 doctors who treat hormone disorders, says it fully supports the new EPA proposal. It explains that these substances, also known as endocrine-disrupting chemicals, “do not break down when they are released into the environment, and they continue to accumulate over time. They pose health dangers at incredibly low levels and have been linked to endocrine disorders such as cancer, thyroid disruption, and reproductive difficulties.”

https://www.mdedge.com /obgyn/latest-news

MASTER CLASS

Prepare for endometriosis excision surgery with a multidisciplinary approach

Iris Kerin Orbuch, MD

Director, Advanced Gynecologic Laparoscopy Center, Los Angeles and New York City.

Series introduction

Charles Miller, MD

Professor, Obstetrics and Gynecology, Department of Clinical Sciences, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois.
 

As I gained more interest and expertise in the treatment of endometriosis, I became aware of several articles concluding that if a woman sought treatment for chronic pelvic pain with an internist, the diagnosis would be irritable bowel syndrome (IBS); with a urologist, it would be interstitial cystitis; and with a gynecologist, endometriosis. Moreover, there is an increased propensity for IBS and IC in patients with endometriosis. There also is an increased risk of small intestine bacterial overgrowth (SIBO), as noted by our guest author for this latest installment of the Master Class in Gynecologic Surgery, Iris Orbuch, MD.

Like our guest author, I have also noted increased risk of pelvic floor myalgia. Dr. Orbuch clearly outlines why this occurs. In fact, we can now understand why many patients have multiple pelvic pain–inducing issues compounding their pain secondary to endometriosis and leading to remodeling of the central nervous system. Therefore, it certainly makes sense to follow Dr. Orbuch’s recommendation for a multidisciplinary pre- and postsurgical approach “to downregulate the pain generators.”

Dr. Orbuch is a minimally invasive gynecologic surgeon in Los Angeles who specializes in the treatment of patients diagnosed with endometriosis. Dr. Orbuch serves on the Board of Directors of the Foundation of the American Association of Gynecologic Laparoscopists and has served as the chair of the AAGL’s Special Interest Group on Endometriosis and Reproductive Surgery. She is the coauthor of the book “Beating Endo —How to Reclaim Your Life From Endometriosis” (New York: HarperCollins; 2019). The book is written for patients but addresses many issues discussed in this installment of the Master Class in Gynecologic Surgery.

https://www.mdedge.com/obgyn/master-class
 

GYNECOLOGIC ONCOLOGY CONSULT

The perils of CA-125 as a diagnostic tool in patients with adnexal masses

Katherine Tucker, MD

Assistant Professor of Gynecologic Oncology at the University of North Carolina at Chapel Hill.
 

CA-125, or cancer antigen 125, is an epitope (antigen) on the transmembrane glycoprotein MUC16, or mucin 16. This protein is expressed on the surface of tissue derived from embryonic coelomic and Müllerian epithelium including the reproductive tract. CA-125 is also expressed in other tissue such as the pleura, lungs, pericardium, intestines, and kidneys. MUC16 plays an important role in tumor proliferation, invasiveness, and cell motility.1 In patients with epithelial ovarian cancer (EOC), CA-125 may be found on the surface of ovarian cancer cells. It is shed in the bloodstream and can be quantified using a serum test.

There are a number of CA-125 assays in commercial use, and although none have been deemed to be clinically superior, there can be some differences between assays. It is important, if possible, to use the same assay when following serial CA-125 values. Most frequently, this will mean getting the test through the same laboratory.

https://www.mdedge.com/obgyn/gynecologic-oncology-consult

LATEST NEWS

Few women identify breast density as a breast cancer risk

Walter Alexander
 

A qualitative study of breast cancer screening–age women finds that few women identified breast density as a risk factor for breast cancer.

Most women did not feel confident they knew what actions could mitigate breast cancer risk, leading researchers to the conclusion that comprehensive education about breast cancer risks and prevention strategies is needed.

CDC recommends universal hepatitis B screening of adults

Lucy Hicks
 

Adults should be tested for hepatitis B virus (HBV) at least once in their lifetime, according to updated guidelines from the Centers for Disease Control and Prevention.

This is the first update to HBV screening guidelines since 2008, the agency said.

“Risk-based testing alone has not identified most persons living with chronic HBV infection and is considered inefficient for providers to implement,” the authors write in the new guidance, published in the CDC’s Morbidity and Mortality Weekly Report. “Universal screening of adults for HBV infection is cost-effective, compared with risk-based screening and averts liver disease and death. Although a curative treatment is not yet available, early diagnosis and treatment of chronic HBV infections reduces the risk for cirrhosis, liver cancer, nd death.”

An estimated 580,000 to 2.4 million individuals are living with HBV infection in the United States, and two-thirds may be unaware they are infected, the agency said.

The virus spreads through contact with blood, semen, and other body fluids of an infected person.

The guidance now recommends using the triple panel (HBsAg, anti-HBs, total anti-HBc) for initial screening.

“It can help identify persons who have an active HBV infection and could be linked to care; have [a] resolved infection and might be susceptible to reactivation (for example, immunosuppressed persons); are susceptible and need vaccination; or are vaccinated,” the authors write.
 

Ectopic pregnancy risk and levonorgestrel-releasing IUD

Diana Swift
 

Researchers report that use of any levonorgestrel-releasing intrauterine system was associated with a significantly increased risk of ectopic pregnancy, compared with other hormonal contraceptives, in a study published in JAMA.

A national health database analysis headed by Amani Meaidi, MD, PhD, of the Danish Cancer Society Research Center, Cancer Surveillance and Pharmacoepidemiology, in Copenhagen, compared the 13.5-mg with the 19.5-mg and 52-mg dosages of levonorgestrel-releasing intrauterine systems (IUSs).

The hormone content in levonorgestrel-releasing IUSs must be high enough to maintain optimal contraceptive effect but sufficiently low to minimize progestin-related adverse events, Dr. Meaidi and colleagues noted; they advised using the middle dosage of 19.5 mg. All dosages are recommended for contraception, with the highest dosage also recommended for heavy menstrual bleeding.

“If 10,000 women using the hormonal IUD for 1 year were given the 19.5-mg hormonal IUD instead of the 13.5-mg hormonal IUD, around nine ectopic pregnancies would be avoided,” Dr. Meaidi said in an interview.
 

EPA seeks to limit ‘forever’ chemicals in U.S. drinking water

Lisa Nainggolan
 

The Environmental Protection Agency is proposing a new rule that would greatly limit the concentration of endocrine-disrupting “forever” chemicals in drinking water.

The EPA on Tuesday announced the proposed National Primary Drinking Water Regulation (NPDWR) for six polyfluoroalkyl substances, more commonly known as PFAS, which are human-made chemicals used as oil and water repellents and coatings for common products including cookware, carpets, and textiles. Such substances are also widely used in cosmetics and food packaging.

The Endocrine Society, which represents more than 18,000 doctors who treat hormone disorders, says it fully supports the new EPA proposal. It explains that these substances, also known as endocrine-disrupting chemicals, “do not break down when they are released into the environment, and they continue to accumulate over time. They pose health dangers at incredibly low levels and have been linked to endocrine disorders such as cancer, thyroid disruption, and reproductive difficulties.”

https://www.mdedge.com /obgyn/latest-news

MASTER CLASS

Prepare for endometriosis excision surgery with a multidisciplinary approach

Iris Kerin Orbuch, MD

Director, Advanced Gynecologic Laparoscopy Center, Los Angeles and New York City.

Series introduction

Charles Miller, MD

Professor, Obstetrics and Gynecology, Department of Clinical Sciences, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois.
 

As I gained more interest and expertise in the treatment of endometriosis, I became aware of several articles concluding that if a woman sought treatment for chronic pelvic pain with an internist, the diagnosis would be irritable bowel syndrome (IBS); with a urologist, it would be interstitial cystitis; and with a gynecologist, endometriosis. Moreover, there is an increased propensity for IBS and IC in patients with endometriosis. There also is an increased risk of small intestine bacterial overgrowth (SIBO), as noted by our guest author for this latest installment of the Master Class in Gynecologic Surgery, Iris Orbuch, MD.

Like our guest author, I have also noted increased risk of pelvic floor myalgia. Dr. Orbuch clearly outlines why this occurs. In fact, we can now understand why many patients have multiple pelvic pain–inducing issues compounding their pain secondary to endometriosis and leading to remodeling of the central nervous system. Therefore, it certainly makes sense to follow Dr. Orbuch’s recommendation for a multidisciplinary pre- and postsurgical approach “to downregulate the pain generators.”

Dr. Orbuch is a minimally invasive gynecologic surgeon in Los Angeles who specializes in the treatment of patients diagnosed with endometriosis. Dr. Orbuch serves on the Board of Directors of the Foundation of the American Association of Gynecologic Laparoscopists and has served as the chair of the AAGL’s Special Interest Group on Endometriosis and Reproductive Surgery. She is the coauthor of the book “Beating Endo —How to Reclaim Your Life From Endometriosis” (New York: HarperCollins; 2019). The book is written for patients but addresses many issues discussed in this installment of the Master Class in Gynecologic Surgery.

https://www.mdedge.com/obgyn/master-class
 

GYNECOLOGIC ONCOLOGY CONSULT

The perils of CA-125 as a diagnostic tool in patients with adnexal masses

Katherine Tucker, MD

Assistant Professor of Gynecologic Oncology at the University of North Carolina at Chapel Hill.
 

CA-125, or cancer antigen 125, is an epitope (antigen) on the transmembrane glycoprotein MUC16, or mucin 16. This protein is expressed on the surface of tissue derived from embryonic coelomic and Müllerian epithelium including the reproductive tract. CA-125 is also expressed in other tissue such as the pleura, lungs, pericardium, intestines, and kidneys. MUC16 plays an important role in tumor proliferation, invasiveness, and cell motility.1 In patients with epithelial ovarian cancer (EOC), CA-125 may be found on the surface of ovarian cancer cells. It is shed in the bloodstream and can be quantified using a serum test.

There are a number of CA-125 assays in commercial use, and although none have been deemed to be clinically superior, there can be some differences between assays. It is important, if possible, to use the same assay when following serial CA-125 values. Most frequently, this will mean getting the test through the same laboratory.

https://www.mdedge.com/obgyn/gynecologic-oncology-consult

LATEST NEWS

Few women identify breast density as a breast cancer risk

Walter Alexander
 

A qualitative study of breast cancer screening–age women finds that few women identified breast density as a risk factor for breast cancer.

Most women did not feel confident they knew what actions could mitigate breast cancer risk, leading researchers to the conclusion that comprehensive education about breast cancer risks and prevention strategies is needed.

CDC recommends universal hepatitis B screening of adults

Lucy Hicks
 

Adults should be tested for hepatitis B virus (HBV) at least once in their lifetime, according to updated guidelines from the Centers for Disease Control and Prevention.

This is the first update to HBV screening guidelines since 2008, the agency said.

“Risk-based testing alone has not identified most persons living with chronic HBV infection and is considered inefficient for providers to implement,” the authors write in the new guidance, published in the CDC’s Morbidity and Mortality Weekly Report. “Universal screening of adults for HBV infection is cost-effective, compared with risk-based screening and averts liver disease and death. Although a curative treatment is not yet available, early diagnosis and treatment of chronic HBV infections reduces the risk for cirrhosis, liver cancer, nd death.”

An estimated 580,000 to 2.4 million individuals are living with HBV infection in the United States, and two-thirds may be unaware they are infected, the agency said.

The virus spreads through contact with blood, semen, and other body fluids of an infected person.

The guidance now recommends using the triple panel (HBsAg, anti-HBs, total anti-HBc) for initial screening.

“It can help identify persons who have an active HBV infection and could be linked to care; have [a] resolved infection and might be susceptible to reactivation (for example, immunosuppressed persons); are susceptible and need vaccination; or are vaccinated,” the authors write.
 

Ectopic pregnancy risk and levonorgestrel-releasing IUD

Diana Swift
 

Researchers report that use of any levonorgestrel-releasing intrauterine system was associated with a significantly increased risk of ectopic pregnancy, compared with other hormonal contraceptives, in a study published in JAMA.

A national health database analysis headed by Amani Meaidi, MD, PhD, of the Danish Cancer Society Research Center, Cancer Surveillance and Pharmacoepidemiology, in Copenhagen, compared the 13.5-mg with the 19.5-mg and 52-mg dosages of levonorgestrel-releasing intrauterine systems (IUSs).

The hormone content in levonorgestrel-releasing IUSs must be high enough to maintain optimal contraceptive effect but sufficiently low to minimize progestin-related adverse events, Dr. Meaidi and colleagues noted; they advised using the middle dosage of 19.5 mg. All dosages are recommended for contraception, with the highest dosage also recommended for heavy menstrual bleeding.

“If 10,000 women using the hormonal IUD for 1 year were given the 19.5-mg hormonal IUD instead of the 13.5-mg hormonal IUD, around nine ectopic pregnancies would be avoided,” Dr. Meaidi said in an interview.
 

EPA seeks to limit ‘forever’ chemicals in U.S. drinking water

Lisa Nainggolan
 

The Environmental Protection Agency is proposing a new rule that would greatly limit the concentration of endocrine-disrupting “forever” chemicals in drinking water.

The EPA on Tuesday announced the proposed National Primary Drinking Water Regulation (NPDWR) for six polyfluoroalkyl substances, more commonly known as PFAS, which are human-made chemicals used as oil and water repellents and coatings for common products including cookware, carpets, and textiles. Such substances are also widely used in cosmetics and food packaging.

The Endocrine Society, which represents more than 18,000 doctors who treat hormone disorders, says it fully supports the new EPA proposal. It explains that these substances, also known as endocrine-disrupting chemicals, “do not break down when they are released into the environment, and they continue to accumulate over time. They pose health dangers at incredibly low levels and have been linked to endocrine disorders such as cancer, thyroid disruption, and reproductive difficulties.”

https://www.mdedge.com /obgyn/latest-news

Have you ever looked at the operating room (OR) trash bin at the end of a case and wondered if all that waste is necessary? Since I started my residency, not a day goes by that I have not asked myself this question.

In the mid-1990s, John Elkington introduced the concept of the triple bottom line—that is, people, planet, and profit—for implementation and measurement of sustainability in businesses.¹ The health care sector is no exception when it comes to the bottom line! However, “people” remain the priority. What is our role, as ObGyns, in protecting the “planet” while keeping the “people” safe?

According to the World Health Organization (WHO), climate change remains the single biggest health threat to humanity.² The health care system is both the victim and the culprit. Studies suggest that the health care system, second to the food industry, is the biggest contributor to waste production in the United States. This sector generates more than 6,000 metric tons of waste each day and nearly 4 million tons (3.6 million metric tons) of solid waste each year.³ The health care system is responsible for an estimated 8% to 10% of total greenhouse gas emissions in the United States; the US health care system alone contributes to more than one-fourth of the global health care carbon footprint. If it were a country, the US health care system would rank 13th among all countries in emissions.⁴In turn, pollution produced by the health sector negatively impacts population health, further burdening the health care system. According to 2013 study data, the annual health damage caused by health care pollution was comparable to that of the deaths caused by preventable medical error.⁴

Aside from the environmental aspects, hospital waste disposal is expensive; reducing this cost is a potential area of interest for institutions.

As ObGyns, what is our role in reducing our waste generation and carbon footprint while keeping patients safe?

Defining health care waste, and disposal considerations

The WHO defines health care waste as including “the waste generated by health-care establishments, research facilities, and laboratories” as well as waste from scattered sources such as home dialysis and insulin injections.⁵ Despite representing a relatively small physical area of hospitals, labor and delivery units combined with ORs account for approximately 70% of all hospital waste.³ Operating room waste consists of disposable surgical supplies, personal protective equipment, drapes, plastic wrappers, sterile blue wraps, glass, cardboard, packaging material, medications, fluids, and other materials (FIGURE 1).

Photo: Courtesy of Golnaz Namazi, MD

The WHO also notes that of all the waste generated by health care activities, about 85% is general, nonhazardous waste that is comparable to domestic waste.⁶ Hazardous waste is any material that poses a health risk, including potentially infectious materials, such as blood-soaked gauze, sharps, pharmaceuticals, or radioactive materials.⁶

Disposal of hazardous waste is expensiveand energy consuming as it is typically incinerated rather than disposed of in a landfill. This process produces substantial greenhouse gases, about 3 kg of carbon dioxide for every 1 kg of hazardous waste.⁷

Red bags are used for hazardous waste disposal, while clear bags are used for general waste. Operating rooms produce about two-thirds of the hospital red-bag waste.⁸ Waste segregation unfortunately is not accurate, and as much as 90% of OR general waste is improperly designated as hazardous waste.³ Drapes and uncontaminated, needleless syringes, for example, should be disposed of in clear bags, but often they are instead directed to the red-bag and sharps container (FIGURE 2).

Photo: Courtesy of Golnaz Namazi, MD

Recycling in the OR

Recycling has become an established practice in many health care facilities and ORs. Studies suggest that introducing recycling programs in ORs not only reduces carbon footprints but also reduces costs.³ One study reported that US academic medical centers consume 2 million lb ($15 million) each year of recoverable medical supplies.⁹

Single-stream recycling, a system in which all recyclable material—including plastics, paper, metal, and glass—are placed in a single bin without segregation at the collection site, has gained in popularity. Recycling can be implemented both in ORs and in other perioperative areas where regular trash bins are located.

In a study done at Oxford University Hospitals in the United Kingdom, introducing recycling bins in every OR, as well as in recovery and staff rest areas, helped improve waste segregation such that approximately 22% of OR waste was recycled.¹⁰ Studies show that recycling programs not only decrease the health care carbon footprint but also have a considerable financial impact. Albert and colleagues demonstrated that introducing a single-stream recycling program to a 9-OR day (or ambulatory) surgery center could redirect more than 4 tons of waste each month and saved thousands of dollars.¹¹

Despite continued improvement in recycling programs, the segregation process is still far from optimal. In a survey done at the Mayo Clinic by Azouz and colleagues, more than half of the staff reported being unclear about which OR items are recyclable and nearly half reported that lack of knowledge was the barrier to proper recycling.¹² That study also showed that after implementation of a recycling education program, costs decreased 10% relative to the same time period in prior years.¹²

Blue wraps. One example of recycling optimization is blue wraps, the polypropylene (No. 5 plastic) material used for wrapping surgical instruments. Blue wraps account for approximately 19% of OR waste and 5% of all hospital waste.¹¹ Blue wraps are not biodegradable and also are not widely recycled. In recent years, a resale market has emerged for blue wraps, as they can be used for production of other No. 5 plastic items.⁹ By reselling blue wraps, revenue can be generated by recycling a necessary packing material that would otherwise require payment for disposal.

Sterility considerations. While recycling in ORs may raise concern due to the absolute sterility required in procedural settings, technologic developments have been promising in advancing safe recycling to reduce carbon footprints and health care costs without compromising patients’ safety. Segregation of waste from recyclable packaging material prior to the case, as well as directing trash to the correct bin (regular vs red bin), is one example. Moreover, because about 80% of all OR waste is generated during the set up before the patient arrives in the OR, it is not contaminated and can be safely recycled.¹³

Continue to: Packaging material...

 

 

Packaging material

A substantial part of OR waste consists of packaging material; of all OR waste, 26% consists of plastics and 7%, paper and cartons.¹⁴ Increasing use of disposable or “single use” medical products in ORs, along with the intention to safeguard sterility, contributes significantly to the generation of medical waste in operating units. Containers, wraps and overwraps, cardboard, and plastic packaging are all composed of materials that when clean, can be recycled; however, these items often end up in the landfill (FIGURE 3).

Photo: Courtesy of Golnaz Namazi, MD

Although the segregation of packaging material to recycling versus regular trash versus red bin is of paramount importance, packaging design plays a significant role as well. In 2018, Boston Scientific introduced a new packaging design for ureteral stents that reduced plastic use in packaging by 120,000 lb each year.¹⁵ Despite the advances in the medical packaging industry to increase sustainability while safeguarding sterility for medical devices, there is still room for innovation in this area.

Reducing overage by judicious selection of surgical devices, instruments, and supplies

Overage is the term used to describe surgical inventory that is opened and prepared for surgery but ultimately not used and therefore discarded. Design of surgical carts and instrument and supply selection requires direct input from ObGyns. Opening only the needed instruments while ensuring ready availability of potentially needed supplies can significantly reduce OR waste generation as well as decrease chemical pollution generated by instrument sterilization. Decreasing OR overage reduces overall costs as well (FIGURE 4).

Photo: Courtesy of Golnaz Namazi, MD

In a pilot study at the University of Massachusetts, Albert and colleagues examined the sets of disposable items and instruments designated for common plastic and hand surgery procedures.¹¹ They identified the supplies and instruments that are routinely opened and wasted, based on surgeons’ interview responses, and redesigned the sets. Fifteen items were removed from disposable plastic surgery packs and 7 items from hand surgery packs. The authors reported saving thousands of dollars per year with these changes alone, as well as reducing waste.¹¹ This same concept easily could be implemented in obstetrics and gynecology. We must ask ourselves: Do we always need, for example, a complete dilation and curettage kit to place the uterine manipulator prior to a minimally invasive hysterectomy?

In another pilot study, Greenberg and colleagues investigated whether cesarean deliveries consistently could be performed in a safe manner with only 20 instruments in the surgical kit.¹⁶ Obstetricians rated the 20-instrument kit an 8.7 out of 10 for performing cesarean deliveries safely.¹⁶

In addition to instrument selection, surgeons have a role in other supply use and waste generation: for instance, opening multiple pairs of surgical gloves and surgical gowns in advance when most of them will not be used during the case. Furthermore, many ObGyn surgeons routinely change gloves or even gowns during gynecologic procedures when they go back and forth between the vaginal and abdominal fields. Is the perineum “dirty” after application of a surgical prep solution?

In an observational study, Shockley and colleagues investigated the type and quantity of bacteria found intraoperatively on the abdomen, vagina, surgical gloves, instrument tips, and uterus at distinct time points during total laparoscopic hysterectomy.¹⁷ They showed that in 98.9% of cultures, the overall bacterial concentrations did not exceed the threshold for infection. There was no bacterial growth from vaginal cultures, and the only samples with some bacterial growth belonged to the surgeon’s gloves after specimen extraction; about one-third of samples showed growth after specimen extraction, but only 1 sample had a bacterial load above the infectious threshold of 5,000 colony-forming units per mL. The authors therefore suggested that if a surgeon changes gloves, doing so after specimen extraction and before turning attention back to the abdomen for vaginal cuff closure may be most effective in reducing bacterial load.¹⁷

Surgical site infection contributes to medical cost and likely medical waste as well. For example, surgical site infection may require prolonged treatments, tests, and medical instruments. In severe cases with abscesses, treatment entails hospitalization with prolonged antibiotic therapy with or without procedures to drain the collections. Further research therefore is warranted to investigate safe and environmentally friendly practices.

Myriad products are introduced to the medical system each day, some of which replace conventional tools. For instance, low-density polyethylene, or LDPE, transfer sheet is advertised for lateral patient transfer from the OR table to the bed or stretcher. This No. 4–coded plastic, while recyclable, is routinely discarded as trash in ORs. One ergonomic study found that reusable slide boards are as effective for reducing friction and staff muscle activities and are noninferior to the plastic sheets.¹⁸

Steps to making an impact

Operating rooms and labor and delivery units are responsible for a large proportion of hospital waste, and therefore they are of paramount importance in reducing waste and carbon footprint at the individual and institutional level. Reduction of OR waste not only is environmentally conscious but also decreases cost. Steps as small as individual practices to as big as changing infrastructures can make an impact. For instance:

• redesigning surgical carts
• reformulating surgeon-specific supply lists
• raising awareness about surgical overage
• encouraging recycling through education and audit
• optimizing surgical waste segregation through educational posters.

These are all simple steps that could significantly reduce waste and carbon footprint.

Bottom line

Although waste reduction is the responsibility of all health care providers, as leaders in their workplace physicians can serve as role models by implementing “green” practices in procedural units. Raising awareness and using a team approach is critical to succeed in our endeavors to move toward an environmentally friendly future. ●

Have you ever looked at the operating room (OR) trash bin at the end of a case and wondered if all that waste is necessary? Since I started my residency, not a day goes by that I have not asked myself this question.

In the mid-1990s, John Elkington introduced the concept of the triple bottom line—that is, people, planet, and profit—for implementation and measurement of sustainability in businesses.¹ The health care sector is no exception when it comes to the bottom line! However, “people” remain the priority. What is our role, as ObGyns, in protecting the “planet” while keeping the “people” safe?

According to the World Health Organization (WHO), climate change remains the single biggest health threat to humanity.² The health care system is both the victim and the culprit. Studies suggest that the health care system, second to the food industry, is the biggest contributor to waste production in the United States. This sector generates more than 6,000 metric tons of waste each day and nearly 4 million tons (3.6 million metric tons) of solid waste each year.³ The health care system is responsible for an estimated 8% to 10% of total greenhouse gas emissions in the United States; the US health care system alone contributes to more than one-fourth of the global health care carbon footprint. If it were a country, the US health care system would rank 13th among all countries in emissions.⁴In turn, pollution produced by the health sector negatively impacts population health, further burdening the health care system. According to 2013 study data, the annual health damage caused by health care pollution was comparable to that of the deaths caused by preventable medical error.⁴

Aside from the environmental aspects, hospital waste disposal is expensive; reducing this cost is a potential area of interest for institutions.

As ObGyns, what is our role in reducing our waste generation and carbon footprint while keeping patients safe?

Defining health care waste, and disposal considerations

The WHO defines health care waste as including “the waste generated by health-care establishments, research facilities, and laboratories” as well as waste from scattered sources such as home dialysis and insulin injections.⁵ Despite representing a relatively small physical area of hospitals, labor and delivery units combined with ORs account for approximately 70% of all hospital waste.³ Operating room waste consists of disposable surgical supplies, personal protective equipment, drapes, plastic wrappers, sterile blue wraps, glass, cardboard, packaging material, medications, fluids, and other materials (FIGURE 1).

Photo: Courtesy of Golnaz Namazi, MD

The WHO also notes that of all the waste generated by health care activities, about 85% is general, nonhazardous waste that is comparable to domestic waste.⁶ Hazardous waste is any material that poses a health risk, including potentially infectious materials, such as blood-soaked gauze, sharps, pharmaceuticals, or radioactive materials.⁶

Disposal of hazardous waste is expensiveand energy consuming as it is typically incinerated rather than disposed of in a landfill. This process produces substantial greenhouse gases, about 3 kg of carbon dioxide for every 1 kg of hazardous waste.⁷

Red bags are used for hazardous waste disposal, while clear bags are used for general waste. Operating rooms produce about two-thirds of the hospital red-bag waste.⁸ Waste segregation unfortunately is not accurate, and as much as 90% of OR general waste is improperly designated as hazardous waste.³ Drapes and uncontaminated, needleless syringes, for example, should be disposed of in clear bags, but often they are instead directed to the red-bag and sharps container (FIGURE 2).

Photo: Courtesy of Golnaz Namazi, MD

Recycling in the OR

Recycling has become an established practice in many health care facilities and ORs. Studies suggest that introducing recycling programs in ORs not only reduces carbon footprints but also reduces costs.³ One study reported that US academic medical centers consume 2 million lb ($15 million) each year of recoverable medical supplies.⁹

Single-stream recycling, a system in which all recyclable material—including plastics, paper, metal, and glass—are placed in a single bin without segregation at the collection site, has gained in popularity. Recycling can be implemented both in ORs and in other perioperative areas where regular trash bins are located.

In a study done at Oxford University Hospitals in the United Kingdom, introducing recycling bins in every OR, as well as in recovery and staff rest areas, helped improve waste segregation such that approximately 22% of OR waste was recycled.¹⁰ Studies show that recycling programs not only decrease the health care carbon footprint but also have a considerable financial impact. Albert and colleagues demonstrated that introducing a single-stream recycling program to a 9-OR day (or ambulatory) surgery center could redirect more than 4 tons of waste each month and saved thousands of dollars.¹¹

Despite continued improvement in recycling programs, the segregation process is still far from optimal. In a survey done at the Mayo Clinic by Azouz and colleagues, more than half of the staff reported being unclear about which OR items are recyclable and nearly half reported that lack of knowledge was the barrier to proper recycling.¹² That study also showed that after implementation of a recycling education program, costs decreased 10% relative to the same time period in prior years.¹²

Blue wraps. One example of recycling optimization is blue wraps, the polypropylene (No. 5 plastic) material used for wrapping surgical instruments. Blue wraps account for approximately 19% of OR waste and 5% of all hospital waste.¹¹ Blue wraps are not biodegradable and also are not widely recycled. In recent years, a resale market has emerged for blue wraps, as they can be used for production of other No. 5 plastic items.⁹ By reselling blue wraps, revenue can be generated by recycling a necessary packing material that would otherwise require payment for disposal.

Sterility considerations. While recycling in ORs may raise concern due to the absolute sterility required in procedural settings, technologic developments have been promising in advancing safe recycling to reduce carbon footprints and health care costs without compromising patients’ safety. Segregation of waste from recyclable packaging material prior to the case, as well as directing trash to the correct bin (regular vs red bin), is one example. Moreover, because about 80% of all OR waste is generated during the set up before the patient arrives in the OR, it is not contaminated and can be safely recycled.¹³

Continue to: Packaging material...

 

 

Packaging material

A substantial part of OR waste consists of packaging material; of all OR waste, 26% consists of plastics and 7%, paper and cartons.¹⁴ Increasing use of disposable or “single use” medical products in ORs, along with the intention to safeguard sterility, contributes significantly to the generation of medical waste in operating units. Containers, wraps and overwraps, cardboard, and plastic packaging are all composed of materials that when clean, can be recycled; however, these items often end up in the landfill (FIGURE 3).

Photo: Courtesy of Golnaz Namazi, MD

Although the segregation of packaging material to recycling versus regular trash versus red bin is of paramount importance, packaging design plays a significant role as well. In 2018, Boston Scientific introduced a new packaging design for ureteral stents that reduced plastic use in packaging by 120,000 lb each year.¹⁵ Despite the advances in the medical packaging industry to increase sustainability while safeguarding sterility for medical devices, there is still room for innovation in this area.

Reducing overage by judicious selection of surgical devices, instruments, and supplies

Overage is the term used to describe surgical inventory that is opened and prepared for surgery but ultimately not used and therefore discarded. Design of surgical carts and instrument and supply selection requires direct input from ObGyns. Opening only the needed instruments while ensuring ready availability of potentially needed supplies can significantly reduce OR waste generation as well as decrease chemical pollution generated by instrument sterilization. Decreasing OR overage reduces overall costs as well (FIGURE 4).

Photo: Courtesy of Golnaz Namazi, MD

In a pilot study at the University of Massachusetts, Albert and colleagues examined the sets of disposable items and instruments designated for common plastic and hand surgery procedures.¹¹ They identified the supplies and instruments that are routinely opened and wasted, based on surgeons’ interview responses, and redesigned the sets. Fifteen items were removed from disposable plastic surgery packs and 7 items from hand surgery packs. The authors reported saving thousands of dollars per year with these changes alone, as well as reducing waste.¹¹ This same concept easily could be implemented in obstetrics and gynecology. We must ask ourselves: Do we always need, for example, a complete dilation and curettage kit to place the uterine manipulator prior to a minimally invasive hysterectomy?

In another pilot study, Greenberg and colleagues investigated whether cesarean deliveries consistently could be performed in a safe manner with only 20 instruments in the surgical kit.¹⁶ Obstetricians rated the 20-instrument kit an 8.7 out of 10 for performing cesarean deliveries safely.¹⁶

In addition to instrument selection, surgeons have a role in other supply use and waste generation: for instance, opening multiple pairs of surgical gloves and surgical gowns in advance when most of them will not be used during the case. Furthermore, many ObGyn surgeons routinely change gloves or even gowns during gynecologic procedures when they go back and forth between the vaginal and abdominal fields. Is the perineum “dirty” after application of a surgical prep solution?

In an observational study, Shockley and colleagues investigated the type and quantity of bacteria found intraoperatively on the abdomen, vagina, surgical gloves, instrument tips, and uterus at distinct time points during total laparoscopic hysterectomy.¹⁷ They showed that in 98.9% of cultures, the overall bacterial concentrations did not exceed the threshold for infection. There was no bacterial growth from vaginal cultures, and the only samples with some bacterial growth belonged to the surgeon’s gloves after specimen extraction; about one-third of samples showed growth after specimen extraction, but only 1 sample had a bacterial load above the infectious threshold of 5,000 colony-forming units per mL. The authors therefore suggested that if a surgeon changes gloves, doing so after specimen extraction and before turning attention back to the abdomen for vaginal cuff closure may be most effective in reducing bacterial load.¹⁷

Surgical site infection contributes to medical cost and likely medical waste as well. For example, surgical site infection may require prolonged treatments, tests, and medical instruments. In severe cases with abscesses, treatment entails hospitalization with prolonged antibiotic therapy with or without procedures to drain the collections. Further research therefore is warranted to investigate safe and environmentally friendly practices.

Myriad products are introduced to the medical system each day, some of which replace conventional tools. For instance, low-density polyethylene, or LDPE, transfer sheet is advertised for lateral patient transfer from the OR table to the bed or stretcher. This No. 4–coded plastic, while recyclable, is routinely discarded as trash in ORs. One ergonomic study found that reusable slide boards are as effective for reducing friction and staff muscle activities and are noninferior to the plastic sheets.¹⁸

Steps to making an impact

Operating rooms and labor and delivery units are responsible for a large proportion of hospital waste, and therefore they are of paramount importance in reducing waste and carbon footprint at the individual and institutional level. Reduction of OR waste not only is environmentally conscious but also decreases cost. Steps as small as individual practices to as big as changing infrastructures can make an impact. For instance:

• redesigning surgical carts
• reformulating surgeon-specific supply lists
• raising awareness about surgical overage
• encouraging recycling through education and audit
• optimizing surgical waste segregation through educational posters.

These are all simple steps that could significantly reduce waste and carbon footprint.

Bottom line

Although waste reduction is the responsibility of all health care providers, as leaders in their workplace physicians can serve as role models by implementing “green” practices in procedural units. Raising awareness and using a team approach is critical to succeed in our endeavors to move toward an environmentally friendly future. ●

Have you ever looked at the operating room (OR) trash bin at the end of a case and wondered if all that waste is necessary? Since I started my residency, not a day goes by that I have not asked myself this question.

In the mid-1990s, John Elkington introduced the concept of the triple bottom line—that is, people, planet, and profit—for implementation and measurement of sustainability in businesses.¹ The health care sector is no exception when it comes to the bottom line! However, “people” remain the priority. What is our role, as ObGyns, in protecting the “planet” while keeping the “people” safe?

According to the World Health Organization (WHO), climate change remains the single biggest health threat to humanity.² The health care system is both the victim and the culprit. Studies suggest that the health care system, second to the food industry, is the biggest contributor to waste production in the United States. This sector generates more than 6,000 metric tons of waste each day and nearly 4 million tons (3.6 million metric tons) of solid waste each year.³ The health care system is responsible for an estimated 8% to 10% of total greenhouse gas emissions in the United States; the US health care system alone contributes to more than one-fourth of the global health care carbon footprint. If it were a country, the US health care system would rank 13th among all countries in emissions.⁴In turn, pollution produced by the health sector negatively impacts population health, further burdening the health care system. According to 2013 study data, the annual health damage caused by health care pollution was comparable to that of the deaths caused by preventable medical error.⁴

Aside from the environmental aspects, hospital waste disposal is expensive; reducing this cost is a potential area of interest for institutions.

As ObGyns, what is our role in reducing our waste generation and carbon footprint while keeping patients safe?

Defining health care waste, and disposal considerations

The WHO defines health care waste as including “the waste generated by health-care establishments, research facilities, and laboratories” as well as waste from scattered sources such as home dialysis and insulin injections.⁵ Despite representing a relatively small physical area of hospitals, labor and delivery units combined with ORs account for approximately 70% of all hospital waste.³ Operating room waste consists of disposable surgical supplies, personal protective equipment, drapes, plastic wrappers, sterile blue wraps, glass, cardboard, packaging material, medications, fluids, and other materials (FIGURE 1).

Photo: Courtesy of Golnaz Namazi, MD

The WHO also notes that of all the waste generated by health care activities, about 85% is general, nonhazardous waste that is comparable to domestic waste.⁶ Hazardous waste is any material that poses a health risk, including potentially infectious materials, such as blood-soaked gauze, sharps, pharmaceuticals, or radioactive materials.⁶

Disposal of hazardous waste is expensiveand energy consuming as it is typically incinerated rather than disposed of in a landfill. This process produces substantial greenhouse gases, about 3 kg of carbon dioxide for every 1 kg of hazardous waste.⁷

Red bags are used for hazardous waste disposal, while clear bags are used for general waste. Operating rooms produce about two-thirds of the hospital red-bag waste.⁸ Waste segregation unfortunately is not accurate, and as much as 90% of OR general waste is improperly designated as hazardous waste.³ Drapes and uncontaminated, needleless syringes, for example, should be disposed of in clear bags, but often they are instead directed to the red-bag and sharps container (FIGURE 2).

Photo: Courtesy of Golnaz Namazi, MD

Recycling in the OR

Recycling has become an established practice in many health care facilities and ORs. Studies suggest that introducing recycling programs in ORs not only reduces carbon footprints but also reduces costs.³ One study reported that US academic medical centers consume 2 million lb ($15 million) each year of recoverable medical supplies.⁹

Single-stream recycling, a system in which all recyclable material—including plastics, paper, metal, and glass—are placed in a single bin without segregation at the collection site, has gained in popularity. Recycling can be implemented both in ORs and in other perioperative areas where regular trash bins are located.

In a study done at Oxford University Hospitals in the United Kingdom, introducing recycling bins in every OR, as well as in recovery and staff rest areas, helped improve waste segregation such that approximately 22% of OR waste was recycled.¹⁰ Studies show that recycling programs not only decrease the health care carbon footprint but also have a considerable financial impact. Albert and colleagues demonstrated that introducing a single-stream recycling program to a 9-OR day (or ambulatory) surgery center could redirect more than 4 tons of waste each month and saved thousands of dollars.¹¹

Despite continued improvement in recycling programs, the segregation process is still far from optimal. In a survey done at the Mayo Clinic by Azouz and colleagues, more than half of the staff reported being unclear about which OR items are recyclable and nearly half reported that lack of knowledge was the barrier to proper recycling.¹² That study also showed that after implementation of a recycling education program, costs decreased 10% relative to the same time period in prior years.¹²

Blue wraps. One example of recycling optimization is blue wraps, the polypropylene (No. 5 plastic) material used for wrapping surgical instruments. Blue wraps account for approximately 19% of OR waste and 5% of all hospital waste.¹¹ Blue wraps are not biodegradable and also are not widely recycled. In recent years, a resale market has emerged for blue wraps, as they can be used for production of other No. 5 plastic items.⁹ By reselling blue wraps, revenue can be generated by recycling a necessary packing material that would otherwise require payment for disposal.

Sterility considerations. While recycling in ORs may raise concern due to the absolute sterility required in procedural settings, technologic developments have been promising in advancing safe recycling to reduce carbon footprints and health care costs without compromising patients’ safety. Segregation of waste from recyclable packaging material prior to the case, as well as directing trash to the correct bin (regular vs red bin), is one example. Moreover, because about 80% of all OR waste is generated during the set up before the patient arrives in the OR, it is not contaminated and can be safely recycled.¹³

Continue to: Packaging material...

 

 

Packaging material

A substantial part of OR waste consists of packaging material; of all OR waste, 26% consists of plastics and 7%, paper and cartons.¹⁴ Increasing use of disposable or “single use” medical products in ORs, along with the intention to safeguard sterility, contributes significantly to the generation of medical waste in operating units. Containers, wraps and overwraps, cardboard, and plastic packaging are all composed of materials that when clean, can be recycled; however, these items often end up in the landfill (FIGURE 3).

Photo: Courtesy of Golnaz Namazi, MD

Although the segregation of packaging material to recycling versus regular trash versus red bin is of paramount importance, packaging design plays a significant role as well. In 2018, Boston Scientific introduced a new packaging design for ureteral stents that reduced plastic use in packaging by 120,000 lb each year.¹⁵ Despite the advances in the medical packaging industry to increase sustainability while safeguarding sterility for medical devices, there is still room for innovation in this area.

Reducing overage by judicious selection of surgical devices, instruments, and supplies

Overage is the term used to describe surgical inventory that is opened and prepared for surgery but ultimately not used and therefore discarded. Design of surgical carts and instrument and supply selection requires direct input from ObGyns. Opening only the needed instruments while ensuring ready availability of potentially needed supplies can significantly reduce OR waste generation as well as decrease chemical pollution generated by instrument sterilization. Decreasing OR overage reduces overall costs as well (FIGURE 4).

Photo: Courtesy of Golnaz Namazi, MD

In a pilot study at the University of Massachusetts, Albert and colleagues examined the sets of disposable items and instruments designated for common plastic and hand surgery procedures.¹¹ They identified the supplies and instruments that are routinely opened and wasted, based on surgeons’ interview responses, and redesigned the sets. Fifteen items were removed from disposable plastic surgery packs and 7 items from hand surgery packs. The authors reported saving thousands of dollars per year with these changes alone, as well as reducing waste.¹¹ This same concept easily could be implemented in obstetrics and gynecology. We must ask ourselves: Do we always need, for example, a complete dilation and curettage kit to place the uterine manipulator prior to a minimally invasive hysterectomy?

In another pilot study, Greenberg and colleagues investigated whether cesarean deliveries consistently could be performed in a safe manner with only 20 instruments in the surgical kit.¹⁶ Obstetricians rated the 20-instrument kit an 8.7 out of 10 for performing cesarean deliveries safely.¹⁶

In addition to instrument selection, surgeons have a role in other supply use and waste generation: for instance, opening multiple pairs of surgical gloves and surgical gowns in advance when most of them will not be used during the case. Furthermore, many ObGyn surgeons routinely change gloves or even gowns during gynecologic procedures when they go back and forth between the vaginal and abdominal fields. Is the perineum “dirty” after application of a surgical prep solution?

In an observational study, Shockley and colleagues investigated the type and quantity of bacteria found intraoperatively on the abdomen, vagina, surgical gloves, instrument tips, and uterus at distinct time points during total laparoscopic hysterectomy.¹⁷ They showed that in 98.9% of cultures, the overall bacterial concentrations did not exceed the threshold for infection. There was no bacterial growth from vaginal cultures, and the only samples with some bacterial growth belonged to the surgeon’s gloves after specimen extraction; about one-third of samples showed growth after specimen extraction, but only 1 sample had a bacterial load above the infectious threshold of 5,000 colony-forming units per mL. The authors therefore suggested that if a surgeon changes gloves, doing so after specimen extraction and before turning attention back to the abdomen for vaginal cuff closure may be most effective in reducing bacterial load.¹⁷

Surgical site infection contributes to medical cost and likely medical waste as well. For example, surgical site infection may require prolonged treatments, tests, and medical instruments. In severe cases with abscesses, treatment entails hospitalization with prolonged antibiotic therapy with or without procedures to drain the collections. Further research therefore is warranted to investigate safe and environmentally friendly practices.

Myriad products are introduced to the medical system each day, some of which replace conventional tools. For instance, low-density polyethylene, or LDPE, transfer sheet is advertised for lateral patient transfer from the OR table to the bed or stretcher. This No. 4–coded plastic, while recyclable, is routinely discarded as trash in ORs. One ergonomic study found that reusable slide boards are as effective for reducing friction and staff muscle activities and are noninferior to the plastic sheets.¹⁸

Steps to making an impact

Operating rooms and labor and delivery units are responsible for a large proportion of hospital waste, and therefore they are of paramount importance in reducing waste and carbon footprint at the individual and institutional level. Reduction of OR waste not only is environmentally conscious but also decreases cost. Steps as small as individual practices to as big as changing infrastructures can make an impact. For instance:

• redesigning surgical carts
• reformulating surgeon-specific supply lists
• raising awareness about surgical overage
• encouraging recycling through education and audit
• optimizing surgical waste segregation through educational posters.

These are all simple steps that could significantly reduce waste and carbon footprint.

Bottom line

Although waste reduction is the responsibility of all health care providers, as leaders in their workplace physicians can serve as role models by implementing “green” practices in procedural units. Raising awareness and using a team approach is critical to succeed in our endeavors to move toward an environmentally friendly future. ●

Although rheumatoid arthritis (RA) is well understood to be associated with cigarette smoking as well as with a risk for interstitial lung disease (ILD), its association with airway diseases such as asthma and chronic obstructive pulmonary disease (COPD), and with allergic disorders such as atopic dermatitis and allergic rhinitis, is unknown. Kim and colleagues performed a cross-sectional study using information from the Korean National Health and Nutrition Examination Survey by 334 respondents with RA and over 13,000 respondents without RA and analyzed the association of RA with asthma and asthma-related comorbidities. The prevalence of asthma was higher in respondents with RA (7.5% vs 2.8%; P < .001), but the prevalence of other allergic disorders and COPD wassimilar between groups. This finding in a small group of respondents is not striking and its importance is unclear compared with other nonallergic pulmonary disorders. Inferring a mechanistic connection to T-helper (Th) 1- vs Th2 immunity would thus be premature.

Baker and colleagues examined the risk for RA-associated ILD in patients taking different therapies for RA, a topic of great interest due to the frequency of this complication as well as uncertainty regarding its association with medications, including anti-tumor necrosis factor (TNF) agents and methotrexate. Using a claims database, they performed a retrospective study of patients with RA without existing ILD who were treated with a biologic (b) or targeted synthetic disease-modifying antirheumatic drugs (DMARD; abatacept, adalimumab, rituximab, tocilizumab, and tofacitinib). In over 28,000 patients with RA, incidence ratios for ILD were > 1 for all bDMARD, while the incidence ratio for ILD with tofacitinib was 1.47. As the group of patients treated with tofacitinib was the smallest, the reliability of this result is uncertain and thus not strong enough to suggest a protective effect or preference for this medication in patients with known ILD. However, prospective studies looking at ILD in RA patients taking tofacitinib would be of interest.

Kristensen and colleagues also looked at risks associated with tofacitinib and anti-TNF agents, in particular cardiovascular disease, malignancy, and venous thromboembolism, using data from the open-label randomized ORAL Surveillance study, which looked at patients taking 5 mg or 10 mg tofacitinib twice daily, adalimumab, or etanercept. The 10 mg dose was reduced to 5 mg twice daily after it was found that rates of pulmonary embolism were higher in the group taking the higher dose. Age and smoking are also known to be risk factors for malignancy and cardiovascular disease in patients with RA, and these findings carried through in this analysis as well. Within the study, patients taking tofacitinib over age 65 who had ever smoked had a higher risk for cardiovascular events, myocardial infarction, malignancy, venous thromboembolism, and death compared with patients on anti-TNF therapy, while patients taking tofacitinib who were younger than 65 and had never smoked had a risk similar to those on anti-TNF therapy.The study confirms prior knowledge regarding the risks of tofacitinib in different patient populations, suggesting that caution should be used with this medication in older patients and those who smoke.

Although rheumatoid arthritis (RA) is well understood to be associated with cigarette smoking as well as with a risk for interstitial lung disease (ILD), its association with airway diseases such as asthma and chronic obstructive pulmonary disease (COPD), and with allergic disorders such as atopic dermatitis and allergic rhinitis, is unknown. Kim and colleagues performed a cross-sectional study using information from the Korean National Health and Nutrition Examination Survey by 334 respondents with RA and over 13,000 respondents without RA and analyzed the association of RA with asthma and asthma-related comorbidities. The prevalence of asthma was higher in respondents with RA (7.5% vs 2.8%; P < .001), but the prevalence of other allergic disorders and COPD wassimilar between groups. This finding in a small group of respondents is not striking and its importance is unclear compared with other nonallergic pulmonary disorders. Inferring a mechanistic connection to T-helper (Th) 1- vs Th2 immunity would thus be premature.

Baker and colleagues examined the risk for RA-associated ILD in patients taking different therapies for RA, a topic of great interest due to the frequency of this complication as well as uncertainty regarding its association with medications, including anti-tumor necrosis factor (TNF) agents and methotrexate. Using a claims database, they performed a retrospective study of patients with RA without existing ILD who were treated with a biologic (b) or targeted synthetic disease-modifying antirheumatic drugs (DMARD; abatacept, adalimumab, rituximab, tocilizumab, and tofacitinib). In over 28,000 patients with RA, incidence ratios for ILD were > 1 for all bDMARD, while the incidence ratio for ILD with tofacitinib was 1.47. As the group of patients treated with tofacitinib was the smallest, the reliability of this result is uncertain and thus not strong enough to suggest a protective effect or preference for this medication in patients with known ILD. However, prospective studies looking at ILD in RA patients taking tofacitinib would be of interest.

Kristensen and colleagues also looked at risks associated with tofacitinib and anti-TNF agents, in particular cardiovascular disease, malignancy, and venous thromboembolism, using data from the open-label randomized ORAL Surveillance study, which looked at patients taking 5 mg or 10 mg tofacitinib twice daily, adalimumab, or etanercept. The 10 mg dose was reduced to 5 mg twice daily after it was found that rates of pulmonary embolism were higher in the group taking the higher dose. Age and smoking are also known to be risk factors for malignancy and cardiovascular disease in patients with RA, and these findings carried through in this analysis as well. Within the study, patients taking tofacitinib over age 65 who had ever smoked had a higher risk for cardiovascular events, myocardial infarction, malignancy, venous thromboembolism, and death compared with patients on anti-TNF therapy, while patients taking tofacitinib who were younger than 65 and had never smoked had a risk similar to those on anti-TNF therapy.The study confirms prior knowledge regarding the risks of tofacitinib in different patient populations, suggesting that caution should be used with this medication in older patients and those who smoke.

Although rheumatoid arthritis (RA) is well understood to be associated with cigarette smoking as well as with a risk for interstitial lung disease (ILD), its association with airway diseases such as asthma and chronic obstructive pulmonary disease (COPD), and with allergic disorders such as atopic dermatitis and allergic rhinitis, is unknown. Kim and colleagues performed a cross-sectional study using information from the Korean National Health and Nutrition Examination Survey by 334 respondents with RA and over 13,000 respondents without RA and analyzed the association of RA with asthma and asthma-related comorbidities. The prevalence of asthma was higher in respondents with RA (7.5% vs 2.8%; P < .001), but the prevalence of other allergic disorders and COPD wassimilar between groups. This finding in a small group of respondents is not striking and its importance is unclear compared with other nonallergic pulmonary disorders. Inferring a mechanistic connection to T-helper (Th) 1- vs Th2 immunity would thus be premature.

Baker and colleagues examined the risk for RA-associated ILD in patients taking different therapies for RA, a topic of great interest due to the frequency of this complication as well as uncertainty regarding its association with medications, including anti-tumor necrosis factor (TNF) agents and methotrexate. Using a claims database, they performed a retrospective study of patients with RA without existing ILD who were treated with a biologic (b) or targeted synthetic disease-modifying antirheumatic drugs (DMARD; abatacept, adalimumab, rituximab, tocilizumab, and tofacitinib). In over 28,000 patients with RA, incidence ratios for ILD were > 1 for all bDMARD, while the incidence ratio for ILD with tofacitinib was 1.47. As the group of patients treated with tofacitinib was the smallest, the reliability of this result is uncertain and thus not strong enough to suggest a protective effect or preference for this medication in patients with known ILD. However, prospective studies looking at ILD in RA patients taking tofacitinib would be of interest.

Kristensen and colleagues also looked at risks associated with tofacitinib and anti-TNF agents, in particular cardiovascular disease, malignancy, and venous thromboembolism, using data from the open-label randomized ORAL Surveillance study, which looked at patients taking 5 mg or 10 mg tofacitinib twice daily, adalimumab, or etanercept. The 10 mg dose was reduced to 5 mg twice daily after it was found that rates of pulmonary embolism were higher in the group taking the higher dose. Age and smoking are also known to be risk factors for malignancy and cardiovascular disease in patients with RA, and these findings carried through in this analysis as well. Within the study, patients taking tofacitinib over age 65 who had ever smoked had a higher risk for cardiovascular events, myocardial infarction, malignancy, venous thromboembolism, and death compared with patients on anti-TNF therapy, while patients taking tofacitinib who were younger than 65 and had never smoked had a risk similar to those on anti-TNF therapy.The study confirms prior knowledge regarding the risks of tofacitinib in different patient populations, suggesting that caution should be used with this medication in older patients and those who smoke.

In September 2021, a community in Virginia experienced an outbreak of hepatitis A virus (HAV) that was ultimately linked to an infected food handler.¹ A total of 149 cases were reported over the next 12 months; 51 were directly related to the food handler and the remainder were the result of sustained community transmission. Of the 51 people who were directly infected by the food handler, 31 were hospitalized and 3 died. This incident offers important reminders about public health surveillance and the role that family physicians can play.

Hepatitis A virus is transmitted through food and drinks that have been contaminated by small amounts of stool that contains the virus or through close contact (including sexual contact) with a person who is infected. The incubation period can range from 15 to 59 days.

HAV generally resolves in a few days to weeks, with no long-term effects. However, recent outbreaks have been associated with high hospitalization and mortality rates because of the underlying comorbidities of those infected.

An increase in incidence. The national rate of HAV infection reached a low of less than 1/100,000 in 2015 but has since increased to almost 6/100,000 in 2019. This increase is mostly due to outbreaks linked to spread among people without a fixed residence, those who use illicit drugs, and men who have sex with men.²

In the Virginia outbreak, the food handler had a risk factor for HAV and was unvaccinated. He worked at 3 different locations of a restaurant chain for a total of 16 days while infectious, preparing ready-to-eat food without using gloves. Furthermore, he delayed seeking medical care for more than 2 weeks—at which time, the nature of his employment was not disclosed.

Prevention is straightforward. HAV infection can be prevented by administration of either HAV vaccine or immune globulin within 2 weeks of exposure.³ During an HAV outbreak, vaccination is recommended for people considered to be at risk, including those without a fixed residence, those who use illicit drugs, those who travel internationally, and men who have sex with men.³

There are 3 HAV vaccines available in the United States: 2 single-antigen vaccines, Havrix and Vaqta, both approved for children and adults, and a combination vaccine (containing both HAV and hepatitis B antigens), Twinrix, which is approved for those ages 18 years and older. All are inactivated vaccines.

What you can do. The Virginia outbreak illustrates the important role that family physicians can and do play in public health. We should:

• Encourage adults with risk factors for HAV to be vaccinated.
• Ask those with an HAV diagnosis about the people they may have exposed through personal contact or occupational exposure.
• Promptly report infectious diseases that are designated “reportable” to the public health department.
• Immediately report (by telephone) when HAV and other enteric infections involve a food handler.

In September 2021, a community in Virginia experienced an outbreak of hepatitis A virus (HAV) that was ultimately linked to an infected food handler.¹ A total of 149 cases were reported over the next 12 months; 51 were directly related to the food handler and the remainder were the result of sustained community transmission. Of the 51 people who were directly infected by the food handler, 31 were hospitalized and 3 died. This incident offers important reminders about public health surveillance and the role that family physicians can play.

Hepatitis A virus is transmitted through food and drinks that have been contaminated by small amounts of stool that contains the virus or through close contact (including sexual contact) with a person who is infected. The incubation period can range from 15 to 59 days.

HAV generally resolves in a few days to weeks, with no long-term effects. However, recent outbreaks have been associated with high hospitalization and mortality rates because of the underlying comorbidities of those infected.

An increase in incidence. The national rate of HAV infection reached a low of less than 1/100,000 in 2015 but has since increased to almost 6/100,000 in 2019. This increase is mostly due to outbreaks linked to spread among people without a fixed residence, those who use illicit drugs, and men who have sex with men.²

In the Virginia outbreak, the food handler had a risk factor for HAV and was unvaccinated. He worked at 3 different locations of a restaurant chain for a total of 16 days while infectious, preparing ready-to-eat food without using gloves. Furthermore, he delayed seeking medical care for more than 2 weeks—at which time, the nature of his employment was not disclosed.

Prevention is straightforward. HAV infection can be prevented by administration of either HAV vaccine or immune globulin within 2 weeks of exposure.³ During an HAV outbreak, vaccination is recommended for people considered to be at risk, including those without a fixed residence, those who use illicit drugs, those who travel internationally, and men who have sex with men.³

There are 3 HAV vaccines available in the United States: 2 single-antigen vaccines, Havrix and Vaqta, both approved for children and adults, and a combination vaccine (containing both HAV and hepatitis B antigens), Twinrix, which is approved for those ages 18 years and older. All are inactivated vaccines.

What you can do. The Virginia outbreak illustrates the important role that family physicians can and do play in public health. We should:

• Encourage adults with risk factors for HAV to be vaccinated.
• Ask those with an HAV diagnosis about the people they may have exposed through personal contact or occupational exposure.
• Promptly report infectious diseases that are designated “reportable” to the public health department.
• Immediately report (by telephone) when HAV and other enteric infections involve a food handler.

In September 2021, a community in Virginia experienced an outbreak of hepatitis A virus (HAV) that was ultimately linked to an infected food handler.¹ A total of 149 cases were reported over the next 12 months; 51 were directly related to the food handler and the remainder were the result of sustained community transmission. Of the 51 people who were directly infected by the food handler, 31 were hospitalized and 3 died. This incident offers important reminders about public health surveillance and the role that family physicians can play.

Hepatitis A virus is transmitted through food and drinks that have been contaminated by small amounts of stool that contains the virus or through close contact (including sexual contact) with a person who is infected. The incubation period can range from 15 to 59 days.

HAV generally resolves in a few days to weeks, with no long-term effects. However, recent outbreaks have been associated with high hospitalization and mortality rates because of the underlying comorbidities of those infected.

An increase in incidence. The national rate of HAV infection reached a low of less than 1/100,000 in 2015 but has since increased to almost 6/100,000 in 2019. This increase is mostly due to outbreaks linked to spread among people without a fixed residence, those who use illicit drugs, and men who have sex with men.²

In the Virginia outbreak, the food handler had a risk factor for HAV and was unvaccinated. He worked at 3 different locations of a restaurant chain for a total of 16 days while infectious, preparing ready-to-eat food without using gloves. Furthermore, he delayed seeking medical care for more than 2 weeks—at which time, the nature of his employment was not disclosed.

Prevention is straightforward. HAV infection can be prevented by administration of either HAV vaccine or immune globulin within 2 weeks of exposure.³ During an HAV outbreak, vaccination is recommended for people considered to be at risk, including those without a fixed residence, those who use illicit drugs, those who travel internationally, and men who have sex with men.³

There are 3 HAV vaccines available in the United States: 2 single-antigen vaccines, Havrix and Vaqta, both approved for children and adults, and a combination vaccine (containing both HAV and hepatitis B antigens), Twinrix, which is approved for those ages 18 years and older. All are inactivated vaccines.

What you can do. The Virginia outbreak illustrates the important role that family physicians can and do play in public health. We should:

• Encourage adults with risk factors for HAV to be vaccinated.
• Ask those with an HAV diagnosis about the people they may have exposed through personal contact or occupational exposure.
• Promptly report infectious diseases that are designated “reportable” to the public health department.
• Immediately report (by telephone) when HAV and other enteric infections involve a food handler.

Erythema ab igne (EAI)(also known as toasted skin syndrome) was first described in the British Journal of Dermatology in the 20th century, ¹ though it was known by physicians long before. Reticular netlike skin changes were seen in association with patients who spent extended time directly next to a heat source. This association led to the name of this condition, which literally means “redness by fire.” Indeed, EAI induced by chronic heat exposure has been described across the world for centuries. For example, in the cold regions of northern China, people used to sleep on beds of hot bricks called kang to stay warm at night. The people of India’s Kashmir district carried pots of hot coals called kangri next to the skin under large woven shawls to stay warm. In the past, Irish women often spent much time by a turf- or peat-burning fire. Chronic heat exposure in these cases can lead not only to EAI but also to aggressive types of cancer, often with a latency of 30 years or more. ²

More recently, the invention of home central heating led to a stark decrease in the number of cases associated with combustion-based heat, with a transition to etiologies such as use of hot water bottles, electric blankets, and electric space heaters. Over time, technological advances led to ever-increasing potential causes for EAI, such as laptops or cell phones, car heaters and heated seats, heated blankets,^3,4 infrared lamps for food, and even medical devices such as ultrasound-based heating products and convective temperature management systems for hospitalized patients. As technology evolves, so do the potential causes of EAI, requiring clinicians to diagnose and deduce the cause through a thorough social and medical history as well as a workup on the present illness with considerations for the anatomical location.^5-7 Herein, we describe the etiology of EAI, diagnosis, and treatment options.

Clinical Characteristics

Erythema ab igne begins as mild, transient, and erythematous macules and patches in a reticular pattern that resolve minutes to hours after removal of the heat source. With weeks to months of continued or repeated application of the heat source, the affected area eventually becomes hyperpigmented where there once was erythema (Figures 1 and 2). Sometimes papules, bullae, telangiectasia, and hyperkeratosis also form. The rash usually is asymptomatic, though pain, pruritus, and dysesthesia have been reported.⁷ Dermoscopy of EAI in the hyperpigmented stage can reveal diffuse superficial dark pigmentation, telangiectasia, and mild whitish scaling.⁸ Although the pathogenesis has remained elusive over the years, lesions do seem to be mostly associated with cumulative exposure to heat rather than length of exposure.⁷

Etiology of EAI

Anatomic Location—The affected site depends on the source of heat (Table). Classic examples of this condition include a patient with EAI presenting on the anterior thighs after working in front of a hot oven or a patient with chronic back pain presenting with lower-back EAI secondary to frequent use of a hot water bottle or heating pad.⁷ With evolving technology over the last few decades, new etiologies have become more common—teenagers are presenting with anterior thigh EAI secondary to frequent laptop use^2-29; patients are holding warm cell phones in their pant pockets, leading to unilateral geometric EAI on the anterior thigh (front pocket) or buttock (back pocket)³⁰; plug-in radiators under computer desks are causing EAI on the lower legs^31-34; and automobile seat heaters have been shown to cause EAI on the posterior legs.^5,35-37 Clinicians should consider anatomic location a critical clue for etiology.

Social History—There are rarer and more highly specific causes of EAI than simple heat exposure that can be parsed from a patient’s social history. Occupational exposure has been documented, such as bakers with exposure to ovens, foundry workers with exposure to heated metals, or fast-food workers with chronic exposure to infrared food lamps.^6,7 There also are cultural practices that can cause EAI. For example, the practice of cupping with moxibustion was shown to create a specific pattern in the shape of the cultural tool used.³⁸ When footbaths with Chinese herbal remedies are performed frequently with high heat, they can lead to EAI on the feet with a linear border at the ankles. There also have been reports of kotatsu (heated tables in Japan) leading to lower-body EAI.^39,40 These cultural practices also are more common in patients with darker skin types, which can lead to hyperpigmentation that is difficult to treat, making early diagnosis important.⁷

Medical History—Case reports have shown EAI caused by patients attempting to use heat-based methods for pain relief of an underlying serious disease such as cancer, bowel pathology (abdominal EAI), spinal disc prolapse (midline back EAI),⁴¹ sickle cell anemia, and renal pathology (posterior upper flank EAI).^6,7,40-49 Patients with hypothyroidism or anorexia have been noted to have generalized EAI sparing the face secondary to repeated and extended hot baths or showers.^50-53 One patient with schizophrenia was shown to have associated thermophilia due to a delusion that led the patient to soak in hot baths for long periods of time, leading to EAI.⁵⁴ Finally, all physicians should be aware of iatrogenic causes of EAI, such as use of warming devices, ultrasound-based warming techniques, and laser therapy for lipolysis. Inquire about the patient’s surgical history or intensive care unit stays as well as alternative medicine or chiropractic visits. Obtaining a history of medical procedures can be enlightening when an etiology is not immediately clear.^7,55,56

Diagnosis

Erythema ab igne is a clinical diagnosis based on recognizable cutaneous findings and a clear history of moderate heat exposure. However, when a clinical diagnosis of EAI is not certain (eg, when unable to obtain a clear history from the patient) or when malignant transformation is suspected, a biopsy can be performed. Pathologically, hematoxylin and eosin staining of EAI classically reveals dilated small vascular channels in the superficial dermis, hence a clinically reticular rash; interface dermatitis clinically manifesting as erythema; and pigment incontinence with melanin-laden macrophages consistent with clinical hyperpigmentation. Finally, for unclear reasons, increased numbers of elastic fibers classically are seen in biopsies of EAI.⁷

 

 

Differential Diagnosis

The differential diagnosis for a reticular patch includes livedo reticularis (Figure 3), which usually manifests as a more generalized rash in patients with chronic disease or coagulopathy such as systemic lupus erythematosus, cryoglobulinemia, or Raynaud phenomenon. When differentiating EAI from livedo reticularis or cutis marmorata, consider that both alternative diagnoses are more vascular appearing and are associated with cold exposure rather than heat exposure. In cases that are less reticular, livedo racemosa can be considered in the differential diagnosis. Finally, poikiloderma of Civatte can be reticular, particularly on dermoscopy, but the distribution on the neck with submental sparing should help to distinguish it from EAI unless a heat source around the neck is identified while taking the patient’s history.⁷

In babies, a reticular generalized rash is most likely to be cutis marmorata (Figure 4), which is a physiologic response to cold exposure that resolves with rewarming of the skin. A more serious condition—cutis marmorata telangiectatica congenita (Figure 5)—usually is present at birth, most frequently involves a single extremity, and notably does not resolve with rewarming. This is an important differential for EAI in children because it can be associated with vascular and neurologic anomalies as well as limb asymmetry. Finally, port-wine stains can sometimes be reticular in appearance and can mimic the early erythematous stages of EAI. However, unlike the erythematous stage of EAI, the port-wine stains will be present at birth.⁷

Emerging in 2020, an important differential diagnosis to consider is a cutaneous manifestation of COVID-19 infection. An erythematous, reticular, chilblainlike or transient livedo reticularis–like rash has been described as a cutaneous manifestation of COVID-19. Although the pathophysiology is still being elucidated, it is suspected that this is caused by a major vaso-occlusive crisis secondary to COVID-19–induced thrombotic vasculopathy. Interestingly, the majority of patients with this COVID-related exanthem also displayed symptoms of COVID-19 (eg, fever, cough) at the time of presentation,^57-60 but there also have been cases in patients who were asymptomatic or mildly symptomatic.⁶⁰

In some cases, EAI is an indication to screen for an underlying disease. For example, uncontrolled pain is an opportunity to improve interventions such as modifying the patient’s pain-control regimen, placing a palliative care pain consultation, or checking if the patient has had age-appropriate screenings for malignancy. New focal pain in a patient with a prior diagnosis of cancer may be a sign of a new metastasis. A thermophilic patient leaves opportunity to assess for underlying medical causes such as thyroid abnormalities or social/psychological issues. Geriatric patients who are diagnosed with EAI may need to be assessed for dementia or home safety issues. Patients with a history of diabetes mellitus can unknowingly develop EAI on the lower extremities, which may signal a need to assess the patient for peripheral neuropathy. Patients with gastroparesis secondary to diabetes also may develop EAI on the abdomen secondary to heating pad use for discomfort. These examples are a reminder to consider possible secondary comorbidities in all diagnoses of EAI.⁷ 

Prognosis

Although the prognosis of EAI is excellent if caught early, failure to diagnose this condition can lead to permanent discoloration of the skin and even malignancy.⁶ A rare sequela includes squamous cell carcinoma, most commonly seen in chronic cases of the lower leg, which is likely related to chronic inflammation of the skin.^61-65 Rare cases of poorly differentiated carcinoma,⁶⁶ cutaneous marginal zone lymphoma,⁶⁷ and Merkel cell carcinoma⁶⁸ have been reported. Patients diagnosed with EAI should receive normal periodic surveillance of the skin based on their medical history, though the physician should have an increased suspicion and plan for biopsy of any nodules or ulcerations found on the skin of the affected area.⁷

Treatments

Once the diagnosis of EAI is made, treatment starts with removal of the heat source causing the rash. Because the rash usually is asymptomatic, further treatment typically is not required. The discoloration can resolve over months or years, but permanent hyperpigmentation is not uncommon. If hyperpigmentation persists despite removal of the heat source and the patient desires further treatment for discoloration, there are few treatment options, none of which are approved by the US Food and Drug Administration for this condition.⁷ There is some evidence for the use of Nd:YAG lasers to reduce hyperpigmentation in EAI.⁶⁹ There have been some reports of treatment using topical hydroquinone and topical tretinoin in an attempt to lighten the skin. If associated hyperkeratosis or other epithelial atypia is present, the use of 5-fluorouracil may show some improvement.⁷⁰ One case report has been published of successful treatment with systemic mesoglycan and topical bioflavonoids.⁷¹ It also is conceivable that medications used to treat postinflammatory hyperpigmentation may be helpful in this condition (eg, kojic acid, arbutin, mild topical steroids, azelaic acid). Patients with darker skin may experience permanent discoloration and may not be good candidates for alternative treatments such as laser therapy due to the risk for inducible hyperpigmentation.⁷

Conclusion

No matter the etiology, EAI usually is a benign skin condition that is treated by removal of the causative heat source. Once a diagnosis is made, the clinician must work with the patient to determine the etiology. Care must be taken to ensure that there are no underlying signs, such as chronic pain or psychiatric illness, that could point to associated conditions. Rarely, sequalae such as cancers have been documented in areas of chronic EAI. Once the heat source is identified and removed, any remaining hyperpigmentation usually will self-resolve over months to years, though this may take longer in patients with darker skin types. If more aggressive treatment is preferred by the patient, laser therapy, topical medications, and oral over-the-counter vitamins have been tried with minimal responses. 

Erythema ab igne (EAI)(also known as toasted skin syndrome) was first described in the British Journal of Dermatology in the 20th century, ¹ though it was known by physicians long before. Reticular netlike skin changes were seen in association with patients who spent extended time directly next to a heat source. This association led to the name of this condition, which literally means “redness by fire.” Indeed, EAI induced by chronic heat exposure has been described across the world for centuries. For example, in the cold regions of northern China, people used to sleep on beds of hot bricks called kang to stay warm at night. The people of India’s Kashmir district carried pots of hot coals called kangri next to the skin under large woven shawls to stay warm. In the past, Irish women often spent much time by a turf- or peat-burning fire. Chronic heat exposure in these cases can lead not only to EAI but also to aggressive types of cancer, often with a latency of 30 years or more. ²

More recently, the invention of home central heating led to a stark decrease in the number of cases associated with combustion-based heat, with a transition to etiologies such as use of hot water bottles, electric blankets, and electric space heaters. Over time, technological advances led to ever-increasing potential causes for EAI, such as laptops or cell phones, car heaters and heated seats, heated blankets,^3,4 infrared lamps for food, and even medical devices such as ultrasound-based heating products and convective temperature management systems for hospitalized patients. As technology evolves, so do the potential causes of EAI, requiring clinicians to diagnose and deduce the cause through a thorough social and medical history as well as a workup on the present illness with considerations for the anatomical location.^5-7 Herein, we describe the etiology of EAI, diagnosis, and treatment options.

Clinical Characteristics

Erythema ab igne begins as mild, transient, and erythematous macules and patches in a reticular pattern that resolve minutes to hours after removal of the heat source. With weeks to months of continued or repeated application of the heat source, the affected area eventually becomes hyperpigmented where there once was erythema (Figures 1 and 2). Sometimes papules, bullae, telangiectasia, and hyperkeratosis also form. The rash usually is asymptomatic, though pain, pruritus, and dysesthesia have been reported.⁷ Dermoscopy of EAI in the hyperpigmented stage can reveal diffuse superficial dark pigmentation, telangiectasia, and mild whitish scaling.⁸ Although the pathogenesis has remained elusive over the years, lesions do seem to be mostly associated with cumulative exposure to heat rather than length of exposure.⁷

Etiology of EAI

Anatomic Location—The affected site depends on the source of heat (Table). Classic examples of this condition include a patient with EAI presenting on the anterior thighs after working in front of a hot oven or a patient with chronic back pain presenting with lower-back EAI secondary to frequent use of a hot water bottle or heating pad.⁷ With evolving technology over the last few decades, new etiologies have become more common—teenagers are presenting with anterior thigh EAI secondary to frequent laptop use^2-29; patients are holding warm cell phones in their pant pockets, leading to unilateral geometric EAI on the anterior thigh (front pocket) or buttock (back pocket)³⁰; plug-in radiators under computer desks are causing EAI on the lower legs^31-34; and automobile seat heaters have been shown to cause EAI on the posterior legs.^5,35-37 Clinicians should consider anatomic location a critical clue for etiology.

Social History—There are rarer and more highly specific causes of EAI than simple heat exposure that can be parsed from a patient’s social history. Occupational exposure has been documented, such as bakers with exposure to ovens, foundry workers with exposure to heated metals, or fast-food workers with chronic exposure to infrared food lamps.^6,7 There also are cultural practices that can cause EAI. For example, the practice of cupping with moxibustion was shown to create a specific pattern in the shape of the cultural tool used.³⁸ When footbaths with Chinese herbal remedies are performed frequently with high heat, they can lead to EAI on the feet with a linear border at the ankles. There also have been reports of kotatsu (heated tables in Japan) leading to lower-body EAI.^39,40 These cultural practices also are more common in patients with darker skin types, which can lead to hyperpigmentation that is difficult to treat, making early diagnosis important.⁷

Medical History—Case reports have shown EAI caused by patients attempting to use heat-based methods for pain relief of an underlying serious disease such as cancer, bowel pathology (abdominal EAI), spinal disc prolapse (midline back EAI),⁴¹ sickle cell anemia, and renal pathology (posterior upper flank EAI).^6,7,40-49 Patients with hypothyroidism or anorexia have been noted to have generalized EAI sparing the face secondary to repeated and extended hot baths or showers.^50-53 One patient with schizophrenia was shown to have associated thermophilia due to a delusion that led the patient to soak in hot baths for long periods of time, leading to EAI.⁵⁴ Finally, all physicians should be aware of iatrogenic causes of EAI, such as use of warming devices, ultrasound-based warming techniques, and laser therapy for lipolysis. Inquire about the patient’s surgical history or intensive care unit stays as well as alternative medicine or chiropractic visits. Obtaining a history of medical procedures can be enlightening when an etiology is not immediately clear.^7,55,56

Diagnosis

Erythema ab igne is a clinical diagnosis based on recognizable cutaneous findings and a clear history of moderate heat exposure. However, when a clinical diagnosis of EAI is not certain (eg, when unable to obtain a clear history from the patient) or when malignant transformation is suspected, a biopsy can be performed. Pathologically, hematoxylin and eosin staining of EAI classically reveals dilated small vascular channels in the superficial dermis, hence a clinically reticular rash; interface dermatitis clinically manifesting as erythema; and pigment incontinence with melanin-laden macrophages consistent with clinical hyperpigmentation. Finally, for unclear reasons, increased numbers of elastic fibers classically are seen in biopsies of EAI.⁷

 

 

Differential Diagnosis

The differential diagnosis for a reticular patch includes livedo reticularis (Figure 3), which usually manifests as a more generalized rash in patients with chronic disease or coagulopathy such as systemic lupus erythematosus, cryoglobulinemia, or Raynaud phenomenon. When differentiating EAI from livedo reticularis or cutis marmorata, consider that both alternative diagnoses are more vascular appearing and are associated with cold exposure rather than heat exposure. In cases that are less reticular, livedo racemosa can be considered in the differential diagnosis. Finally, poikiloderma of Civatte can be reticular, particularly on dermoscopy, but the distribution on the neck with submental sparing should help to distinguish it from EAI unless a heat source around the neck is identified while taking the patient’s history.⁷

In babies, a reticular generalized rash is most likely to be cutis marmorata (Figure 4), which is a physiologic response to cold exposure that resolves with rewarming of the skin. A more serious condition—cutis marmorata telangiectatica congenita (Figure 5)—usually is present at birth, most frequently involves a single extremity, and notably does not resolve with rewarming. This is an important differential for EAI in children because it can be associated with vascular and neurologic anomalies as well as limb asymmetry. Finally, port-wine stains can sometimes be reticular in appearance and can mimic the early erythematous stages of EAI. However, unlike the erythematous stage of EAI, the port-wine stains will be present at birth.⁷

Emerging in 2020, an important differential diagnosis to consider is a cutaneous manifestation of COVID-19 infection. An erythematous, reticular, chilblainlike or transient livedo reticularis–like rash has been described as a cutaneous manifestation of COVID-19. Although the pathophysiology is still being elucidated, it is suspected that this is caused by a major vaso-occlusive crisis secondary to COVID-19–induced thrombotic vasculopathy. Interestingly, the majority of patients with this COVID-related exanthem also displayed symptoms of COVID-19 (eg, fever, cough) at the time of presentation,^57-60 but there also have been cases in patients who were asymptomatic or mildly symptomatic.⁶⁰

In some cases, EAI is an indication to screen for an underlying disease. For example, uncontrolled pain is an opportunity to improve interventions such as modifying the patient’s pain-control regimen, placing a palliative care pain consultation, or checking if the patient has had age-appropriate screenings for malignancy. New focal pain in a patient with a prior diagnosis of cancer may be a sign of a new metastasis. A thermophilic patient leaves opportunity to assess for underlying medical causes such as thyroid abnormalities or social/psychological issues. Geriatric patients who are diagnosed with EAI may need to be assessed for dementia or home safety issues. Patients with a history of diabetes mellitus can unknowingly develop EAI on the lower extremities, which may signal a need to assess the patient for peripheral neuropathy. Patients with gastroparesis secondary to diabetes also may develop EAI on the abdomen secondary to heating pad use for discomfort. These examples are a reminder to consider possible secondary comorbidities in all diagnoses of EAI.⁷ 

Prognosis

Although the prognosis of EAI is excellent if caught early, failure to diagnose this condition can lead to permanent discoloration of the skin and even malignancy.⁶ A rare sequela includes squamous cell carcinoma, most commonly seen in chronic cases of the lower leg, which is likely related to chronic inflammation of the skin.^61-65 Rare cases of poorly differentiated carcinoma,⁶⁶ cutaneous marginal zone lymphoma,⁶⁷ and Merkel cell carcinoma⁶⁸ have been reported. Patients diagnosed with EAI should receive normal periodic surveillance of the skin based on their medical history, though the physician should have an increased suspicion and plan for biopsy of any nodules or ulcerations found on the skin of the affected area.⁷

Treatments

Once the diagnosis of EAI is made, treatment starts with removal of the heat source causing the rash. Because the rash usually is asymptomatic, further treatment typically is not required. The discoloration can resolve over months or years, but permanent hyperpigmentation is not uncommon. If hyperpigmentation persists despite removal of the heat source and the patient desires further treatment for discoloration, there are few treatment options, none of which are approved by the US Food and Drug Administration for this condition.⁷ There is some evidence for the use of Nd:YAG lasers to reduce hyperpigmentation in EAI.⁶⁹ There have been some reports of treatment using topical hydroquinone and topical tretinoin in an attempt to lighten the skin. If associated hyperkeratosis or other epithelial atypia is present, the use of 5-fluorouracil may show some improvement.⁷⁰ One case report has been published of successful treatment with systemic mesoglycan and topical bioflavonoids.⁷¹ It also is conceivable that medications used to treat postinflammatory hyperpigmentation may be helpful in this condition (eg, kojic acid, arbutin, mild topical steroids, azelaic acid). Patients with darker skin may experience permanent discoloration and may not be good candidates for alternative treatments such as laser therapy due to the risk for inducible hyperpigmentation.⁷

Conclusion

No matter the etiology, EAI usually is a benign skin condition that is treated by removal of the causative heat source. Once a diagnosis is made, the clinician must work with the patient to determine the etiology. Care must be taken to ensure that there are no underlying signs, such as chronic pain or psychiatric illness, that could point to associated conditions. Rarely, sequalae such as cancers have been documented in areas of chronic EAI. Once the heat source is identified and removed, any remaining hyperpigmentation usually will self-resolve over months to years, though this may take longer in patients with darker skin types. If more aggressive treatment is preferred by the patient, laser therapy, topical medications, and oral over-the-counter vitamins have been tried with minimal responses. 

Erythema ab igne (EAI)(also known as toasted skin syndrome) was first described in the British Journal of Dermatology in the 20th century, ¹ though it was known by physicians long before. Reticular netlike skin changes were seen in association with patients who spent extended time directly next to a heat source. This association led to the name of this condition, which literally means “redness by fire.” Indeed, EAI induced by chronic heat exposure has been described across the world for centuries. For example, in the cold regions of northern China, people used to sleep on beds of hot bricks called kang to stay warm at night. The people of India’s Kashmir district carried pots of hot coals called kangri next to the skin under large woven shawls to stay warm. In the past, Irish women often spent much time by a turf- or peat-burning fire. Chronic heat exposure in these cases can lead not only to EAI but also to aggressive types of cancer, often with a latency of 30 years or more. ²

More recently, the invention of home central heating led to a stark decrease in the number of cases associated with combustion-based heat, with a transition to etiologies such as use of hot water bottles, electric blankets, and electric space heaters. Over time, technological advances led to ever-increasing potential causes for EAI, such as laptops or cell phones, car heaters and heated seats, heated blankets,^3,4 infrared lamps for food, and even medical devices such as ultrasound-based heating products and convective temperature management systems for hospitalized patients. As technology evolves, so do the potential causes of EAI, requiring clinicians to diagnose and deduce the cause through a thorough social and medical history as well as a workup on the present illness with considerations for the anatomical location.^5-7 Herein, we describe the etiology of EAI, diagnosis, and treatment options.

Clinical Characteristics

Erythema ab igne begins as mild, transient, and erythematous macules and patches in a reticular pattern that resolve minutes to hours after removal of the heat source. With weeks to months of continued or repeated application of the heat source, the affected area eventually becomes hyperpigmented where there once was erythema (Figures 1 and 2). Sometimes papules, bullae, telangiectasia, and hyperkeratosis also form. The rash usually is asymptomatic, though pain, pruritus, and dysesthesia have been reported.⁷ Dermoscopy of EAI in the hyperpigmented stage can reveal diffuse superficial dark pigmentation, telangiectasia, and mild whitish scaling.⁸ Although the pathogenesis has remained elusive over the years, lesions do seem to be mostly associated with cumulative exposure to heat rather than length of exposure.⁷

Etiology of EAI

Anatomic Location—The affected site depends on the source of heat (Table). Classic examples of this condition include a patient with EAI presenting on the anterior thighs after working in front of a hot oven or a patient with chronic back pain presenting with lower-back EAI secondary to frequent use of a hot water bottle or heating pad.⁷ With evolving technology over the last few decades, new etiologies have become more common—teenagers are presenting with anterior thigh EAI secondary to frequent laptop use^2-29; patients are holding warm cell phones in their pant pockets, leading to unilateral geometric EAI on the anterior thigh (front pocket) or buttock (back pocket)³⁰; plug-in radiators under computer desks are causing EAI on the lower legs^31-34; and automobile seat heaters have been shown to cause EAI on the posterior legs.^5,35-37 Clinicians should consider anatomic location a critical clue for etiology.

Social History—There are rarer and more highly specific causes of EAI than simple heat exposure that can be parsed from a patient’s social history. Occupational exposure has been documented, such as bakers with exposure to ovens, foundry workers with exposure to heated metals, or fast-food workers with chronic exposure to infrared food lamps.^6,7 There also are cultural practices that can cause EAI. For example, the practice of cupping with moxibustion was shown to create a specific pattern in the shape of the cultural tool used.³⁸ When footbaths with Chinese herbal remedies are performed frequently with high heat, they can lead to EAI on the feet with a linear border at the ankles. There also have been reports of kotatsu (heated tables in Japan) leading to lower-body EAI.^39,40 These cultural practices also are more common in patients with darker skin types, which can lead to hyperpigmentation that is difficult to treat, making early diagnosis important.⁷

Medical History—Case reports have shown EAI caused by patients attempting to use heat-based methods for pain relief of an underlying serious disease such as cancer, bowel pathology (abdominal EAI), spinal disc prolapse (midline back EAI),⁴¹ sickle cell anemia, and renal pathology (posterior upper flank EAI).^6,7,40-49 Patients with hypothyroidism or anorexia have been noted to have generalized EAI sparing the face secondary to repeated and extended hot baths or showers.^50-53 One patient with schizophrenia was shown to have associated thermophilia due to a delusion that led the patient to soak in hot baths for long periods of time, leading to EAI.⁵⁴ Finally, all physicians should be aware of iatrogenic causes of EAI, such as use of warming devices, ultrasound-based warming techniques, and laser therapy for lipolysis. Inquire about the patient’s surgical history or intensive care unit stays as well as alternative medicine or chiropractic visits. Obtaining a history of medical procedures can be enlightening when an etiology is not immediately clear.^7,55,56

Diagnosis

Erythema ab igne is a clinical diagnosis based on recognizable cutaneous findings and a clear history of moderate heat exposure. However, when a clinical diagnosis of EAI is not certain (eg, when unable to obtain a clear history from the patient) or when malignant transformation is suspected, a biopsy can be performed. Pathologically, hematoxylin and eosin staining of EAI classically reveals dilated small vascular channels in the superficial dermis, hence a clinically reticular rash; interface dermatitis clinically manifesting as erythema; and pigment incontinence with melanin-laden macrophages consistent with clinical hyperpigmentation. Finally, for unclear reasons, increased numbers of elastic fibers classically are seen in biopsies of EAI.⁷

 

 

Differential Diagnosis

The differential diagnosis for a reticular patch includes livedo reticularis (Figure 3), which usually manifests as a more generalized rash in patients with chronic disease or coagulopathy such as systemic lupus erythematosus, cryoglobulinemia, or Raynaud phenomenon. When differentiating EAI from livedo reticularis or cutis marmorata, consider that both alternative diagnoses are more vascular appearing and are associated with cold exposure rather than heat exposure. In cases that are less reticular, livedo racemosa can be considered in the differential diagnosis. Finally, poikiloderma of Civatte can be reticular, particularly on dermoscopy, but the distribution on the neck with submental sparing should help to distinguish it from EAI unless a heat source around the neck is identified while taking the patient’s history.⁷

In babies, a reticular generalized rash is most likely to be cutis marmorata (Figure 4), which is a physiologic response to cold exposure that resolves with rewarming of the skin. A more serious condition—cutis marmorata telangiectatica congenita (Figure 5)—usually is present at birth, most frequently involves a single extremity, and notably does not resolve with rewarming. This is an important differential for EAI in children because it can be associated with vascular and neurologic anomalies as well as limb asymmetry. Finally, port-wine stains can sometimes be reticular in appearance and can mimic the early erythematous stages of EAI. However, unlike the erythematous stage of EAI, the port-wine stains will be present at birth.⁷

Emerging in 2020, an important differential diagnosis to consider is a cutaneous manifestation of COVID-19 infection. An erythematous, reticular, chilblainlike or transient livedo reticularis–like rash has been described as a cutaneous manifestation of COVID-19. Although the pathophysiology is still being elucidated, it is suspected that this is caused by a major vaso-occlusive crisis secondary to COVID-19–induced thrombotic vasculopathy. Interestingly, the majority of patients with this COVID-related exanthem also displayed symptoms of COVID-19 (eg, fever, cough) at the time of presentation,^57-60 but there also have been cases in patients who were asymptomatic or mildly symptomatic.⁶⁰

In some cases, EAI is an indication to screen for an underlying disease. For example, uncontrolled pain is an opportunity to improve interventions such as modifying the patient’s pain-control regimen, placing a palliative care pain consultation, or checking if the patient has had age-appropriate screenings for malignancy. New focal pain in a patient with a prior diagnosis of cancer may be a sign of a new metastasis. A thermophilic patient leaves opportunity to assess for underlying medical causes such as thyroid abnormalities or social/psychological issues. Geriatric patients who are diagnosed with EAI may need to be assessed for dementia or home safety issues. Patients with a history of diabetes mellitus can unknowingly develop EAI on the lower extremities, which may signal a need to assess the patient for peripheral neuropathy. Patients with gastroparesis secondary to diabetes also may develop EAI on the abdomen secondary to heating pad use for discomfort. These examples are a reminder to consider possible secondary comorbidities in all diagnoses of EAI.⁷ 

Prognosis

Although the prognosis of EAI is excellent if caught early, failure to diagnose this condition can lead to permanent discoloration of the skin and even malignancy.⁶ A rare sequela includes squamous cell carcinoma, most commonly seen in chronic cases of the lower leg, which is likely related to chronic inflammation of the skin.^61-65 Rare cases of poorly differentiated carcinoma,⁶⁶ cutaneous marginal zone lymphoma,⁶⁷ and Merkel cell carcinoma⁶⁸ have been reported. Patients diagnosed with EAI should receive normal periodic surveillance of the skin based on their medical history, though the physician should have an increased suspicion and plan for biopsy of any nodules or ulcerations found on the skin of the affected area.⁷

Treatments

Once the diagnosis of EAI is made, treatment starts with removal of the heat source causing the rash. Because the rash usually is asymptomatic, further treatment typically is not required. The discoloration can resolve over months or years, but permanent hyperpigmentation is not uncommon. If hyperpigmentation persists despite removal of the heat source and the patient desires further treatment for discoloration, there are few treatment options, none of which are approved by the US Food and Drug Administration for this condition.⁷ There is some evidence for the use of Nd:YAG lasers to reduce hyperpigmentation in EAI.⁶⁹ There have been some reports of treatment using topical hydroquinone and topical tretinoin in an attempt to lighten the skin. If associated hyperkeratosis or other epithelial atypia is present, the use of 5-fluorouracil may show some improvement.⁷⁰ One case report has been published of successful treatment with systemic mesoglycan and topical bioflavonoids.⁷¹ It also is conceivable that medications used to treat postinflammatory hyperpigmentation may be helpful in this condition (eg, kojic acid, arbutin, mild topical steroids, azelaic acid). Patients with darker skin may experience permanent discoloration and may not be good candidates for alternative treatments such as laser therapy due to the risk for inducible hyperpigmentation.⁷

Conclusion

No matter the etiology, EAI usually is a benign skin condition that is treated by removal of the causative heat source. Once a diagnosis is made, the clinician must work with the patient to determine the etiology. Care must be taken to ensure that there are no underlying signs, such as chronic pain or psychiatric illness, that could point to associated conditions. Rarely, sequalae such as cancers have been documented in areas of chronic EAI. Once the heat source is identified and removed, any remaining hyperpigmentation usually will self-resolve over months to years, though this may take longer in patients with darker skin types. If more aggressive treatment is preferred by the patient, laser therapy, topical medications, and oral over-the-counter vitamins have been tried with minimal responses. 

PHOENIX – Combining a serum containing silymarin with nonablative laser therapy could serve as a promising solution for decreasing inflammation, postinflammatory erythema (PIE), and postinflammatory hyperpigmentation (PIH) associated with acne lesions, results from a prospective, single-center study showed.

“Acne vulgaris is the most common inflammatory dermatosis worldwide, often resulting in sequelae such as scarring, PIE, and PIH,” presenting author Jamie Hu, MD, said at the annual conference of the American Society for Laser Medicine and Surgery, where the study results were presented during an abstract session. “This dyschromia can cause greater psychological distress than the original acne lesions, and disproportionately affects skin of color patients.”

Blemish-prone skin is known to have higher levels of sebum and lower levels of antioxidants, leading to lipid peroxidation and oxidative stress, resulting in proliferation of Cutibacterium acnes and an inflammatory cascade that has recently been implicated in postinflammatory dyschromia and the development of PIE and PIH, noted Dr. Hu, a dermatology resident at the University of Miami. “Therefore, the use of antioxidants presents an opportunity to disrupt blemish and dyschromia,” she said.

One such antioxidant is silymarin, which is derived from the milk thistle plant. Recent studies have demonstrated that silymarin reduces proinflammatory mediators, prevents lipid peroxidation, and presents a new way to target the treatment of both acne and postinflammatory dyschromia.

Dr. Hu’s mentor, Jill S. Waibel, MD, owner and medical director of the Miami Dermatology and Laser Institute, hypothesized that nonablative laser therapy followed by topical application of silymarin would improve acne-associated postinflammatory dyschromia. To test her hunch, she conducted a 12-week, prospective trial in which 24 patients with PIE and/or PIH were randomized to one of two treatment arms: laser treatment with topical antioxidants or laser treatment with vehicle control. Patients received three laser treatments, each 1 month apart. The topical antioxidant used was Silymarin CF, a serum that contains 0.5% silymarin, 0.5% salicylic acid, 15% L-ascorbic acid, and 0.5% ferulic acid. (The study was sponsored by SkinCeuticals, the manufacturer of the serum.)

Laser selection was made primarily on the type of dyschromia, with PIE patients receiving treatment with the pulsed dye laser and PIH patients receiving treatment with the 1,927-nm thulium laser. Patients were treated on days 0, 28, and 56 of the 12-week study, followed by immediate application of topical antioxidants or vehicle control. They were also instructed to apply the assigned topical twice daily for the duration of the study. Patients ranged in age from 21 to 61 years, and 20 had skin types III-IV.

To evaluate efficacy, the researchers conducted blinded clinical assessments with the postacne hyperpigmentation index (PAHPI) and the Global Aesthetic Improvement Scale (GAIS), instrumentation with the Mexameter, a device that captures erythema and melanin index values, and visual diagnostics with optical coherence tomography (OCT).

Dr. Hu reported that at week 12, the PAHPI in the silymarin-plus-laser treatment group fell from an average of 3.18 to 1.74 (a decrease of 1.44), which suggested an improvement trend, compared with the laser treatment–only group, whose PAHPI fell from an average of 3.25 to 1.97 (a decrease of 1.28).

As for the GAIS, a one-time score assessed at the end of the trial, the average score for all patients was 3.24, which translated to “much improved/very much improved.” Patients in the silymarin-plus-laser treatment group had higher average scores compared with patients in the laser treatment–only group (3.35 vs. 3.10, respectively), but the differences did not reach statistical significance.

According to results of the Mexameter assessment, paired t-tests showed that the levels of intralesional melanin decreased significantly for patients in the silymarin-plus-laser treatment group, compared with the laser treatment–only group (P < .05). OCT assessments demonstrated an increase in dermal brightness in both groups, corresponding to an increase in dermal collagen, as well as an increase in blood vessel density.

In an interview at the meeting, Dr. Waibel, subsection chief of dermatology at Baptist Hospital of Miami, said that future studies will focus on long-term follow-up to determine if acne scars can be prevented by combining silymarin with lasers to prevent PIH and PIE. “That would be priceless,” she said. “I believe that the PIH is what causes damage to the collagen, and that damage to the collagen is what causes the scarring. So, if we can prevent or treat PIH, we may be able to prevent scarring.”

This approach, she added, “would decrease the pharmaceutical cost because I think there are many dermatologists who are treating PEI and PIH as active acne. You really have to have a keen eye for understanding the differences and you really have to be looking, because PIE and PIH are flat, whereas active acne consists of either comedones or nodules.”

She noted that in skin of color patients, she has seen PIH persist for 9 or 10 months after treatment with isotretinoin. “It’s not the isotretinoin causing the scars, or even the acne, it’s the prolonged inflammation,” she said.

Catherine M. DiGiorgio, MD, a Boston-based laser and cosmetic dermatologist who was asked to comment on the study, said that patients and dermatologists frequently seek alternatives to hydroquinone for unwanted hyperpigmentation.

Dr. DiGiorgio

Dr. Jalian

“While the study failed to show statistically significant improvement in postinflammatory erythema with concomitant laser and topical therapy versus laser alone, the promising data supporting concurrent use of topicals and fractional lasers for treatment of PIH, particularly in dark skin phototypes, is a clinically impactful contribution to our daily practice,” he said.

Dr. Waibel disclosed that she has conducted clinical trials for many device and pharmaceutical companies including SkinCeuticals. Dr. Hu, Dr. DiGiorgio, and Dr. Jalian were not involved with the study and reported having no relevant disclosures.

PHOENIX – Combining a serum containing silymarin with nonablative laser therapy could serve as a promising solution for decreasing inflammation, postinflammatory erythema (PIE), and postinflammatory hyperpigmentation (PIH) associated with acne lesions, results from a prospective, single-center study showed.

“Acne vulgaris is the most common inflammatory dermatosis worldwide, often resulting in sequelae such as scarring, PIE, and PIH,” presenting author Jamie Hu, MD, said at the annual conference of the American Society for Laser Medicine and Surgery, where the study results were presented during an abstract session. “This dyschromia can cause greater psychological distress than the original acne lesions, and disproportionately affects skin of color patients.”

Blemish-prone skin is known to have higher levels of sebum and lower levels of antioxidants, leading to lipid peroxidation and oxidative stress, resulting in proliferation of Cutibacterium acnes and an inflammatory cascade that has recently been implicated in postinflammatory dyschromia and the development of PIE and PIH, noted Dr. Hu, a dermatology resident at the University of Miami. “Therefore, the use of antioxidants presents an opportunity to disrupt blemish and dyschromia,” she said.

One such antioxidant is silymarin, which is derived from the milk thistle plant. Recent studies have demonstrated that silymarin reduces proinflammatory mediators, prevents lipid peroxidation, and presents a new way to target the treatment of both acne and postinflammatory dyschromia.

Dr. Hu’s mentor, Jill S. Waibel, MD, owner and medical director of the Miami Dermatology and Laser Institute, hypothesized that nonablative laser therapy followed by topical application of silymarin would improve acne-associated postinflammatory dyschromia. To test her hunch, she conducted a 12-week, prospective trial in which 24 patients with PIE and/or PIH were randomized to one of two treatment arms: laser treatment with topical antioxidants or laser treatment with vehicle control. Patients received three laser treatments, each 1 month apart. The topical antioxidant used was Silymarin CF, a serum that contains 0.5% silymarin, 0.5% salicylic acid, 15% L-ascorbic acid, and 0.5% ferulic acid. (The study was sponsored by SkinCeuticals, the manufacturer of the serum.)

Laser selection was made primarily on the type of dyschromia, with PIE patients receiving treatment with the pulsed dye laser and PIH patients receiving treatment with the 1,927-nm thulium laser. Patients were treated on days 0, 28, and 56 of the 12-week study, followed by immediate application of topical antioxidants or vehicle control. They were also instructed to apply the assigned topical twice daily for the duration of the study. Patients ranged in age from 21 to 61 years, and 20 had skin types III-IV.

To evaluate efficacy, the researchers conducted blinded clinical assessments with the postacne hyperpigmentation index (PAHPI) and the Global Aesthetic Improvement Scale (GAIS), instrumentation with the Mexameter, a device that captures erythema and melanin index values, and visual diagnostics with optical coherence tomography (OCT).

Dr. Hu reported that at week 12, the PAHPI in the silymarin-plus-laser treatment group fell from an average of 3.18 to 1.74 (a decrease of 1.44), which suggested an improvement trend, compared with the laser treatment–only group, whose PAHPI fell from an average of 3.25 to 1.97 (a decrease of 1.28).

As for the GAIS, a one-time score assessed at the end of the trial, the average score for all patients was 3.24, which translated to “much improved/very much improved.” Patients in the silymarin-plus-laser treatment group had higher average scores compared with patients in the laser treatment–only group (3.35 vs. 3.10, respectively), but the differences did not reach statistical significance.

According to results of the Mexameter assessment, paired t-tests showed that the levels of intralesional melanin decreased significantly for patients in the silymarin-plus-laser treatment group, compared with the laser treatment–only group (P < .05). OCT assessments demonstrated an increase in dermal brightness in both groups, corresponding to an increase in dermal collagen, as well as an increase in blood vessel density.

In an interview at the meeting, Dr. Waibel, subsection chief of dermatology at Baptist Hospital of Miami, said that future studies will focus on long-term follow-up to determine if acne scars can be prevented by combining silymarin with lasers to prevent PIH and PIE. “That would be priceless,” she said. “I believe that the PIH is what causes damage to the collagen, and that damage to the collagen is what causes the scarring. So, if we can prevent or treat PIH, we may be able to prevent scarring.”

This approach, she added, “would decrease the pharmaceutical cost because I think there are many dermatologists who are treating PEI and PIH as active acne. You really have to have a keen eye for understanding the differences and you really have to be looking, because PIE and PIH are flat, whereas active acne consists of either comedones or nodules.”

She noted that in skin of color patients, she has seen PIH persist for 9 or 10 months after treatment with isotretinoin. “It’s not the isotretinoin causing the scars, or even the acne, it’s the prolonged inflammation,” she said.

Catherine M. DiGiorgio, MD, a Boston-based laser and cosmetic dermatologist who was asked to comment on the study, said that patients and dermatologists frequently seek alternatives to hydroquinone for unwanted hyperpigmentation.

Dr. DiGiorgio

Dr. Jalian

“While the study failed to show statistically significant improvement in postinflammatory erythema with concomitant laser and topical therapy versus laser alone, the promising data supporting concurrent use of topicals and fractional lasers for treatment of PIH, particularly in dark skin phototypes, is a clinically impactful contribution to our daily practice,” he said.

Dr. Waibel disclosed that she has conducted clinical trials for many device and pharmaceutical companies including SkinCeuticals. Dr. Hu, Dr. DiGiorgio, and Dr. Jalian were not involved with the study and reported having no relevant disclosures.

PHOENIX – Combining a serum containing silymarin with nonablative laser therapy could serve as a promising solution for decreasing inflammation, postinflammatory erythema (PIE), and postinflammatory hyperpigmentation (PIH) associated with acne lesions, results from a prospective, single-center study showed.

“Acne vulgaris is the most common inflammatory dermatosis worldwide, often resulting in sequelae such as scarring, PIE, and PIH,” presenting author Jamie Hu, MD, said at the annual conference of the American Society for Laser Medicine and Surgery, where the study results were presented during an abstract session. “This dyschromia can cause greater psychological distress than the original acne lesions, and disproportionately affects skin of color patients.”

Blemish-prone skin is known to have higher levels of sebum and lower levels of antioxidants, leading to lipid peroxidation and oxidative stress, resulting in proliferation of Cutibacterium acnes and an inflammatory cascade that has recently been implicated in postinflammatory dyschromia and the development of PIE and PIH, noted Dr. Hu, a dermatology resident at the University of Miami. “Therefore, the use of antioxidants presents an opportunity to disrupt blemish and dyschromia,” she said.

One such antioxidant is silymarin, which is derived from the milk thistle plant. Recent studies have demonstrated that silymarin reduces proinflammatory mediators, prevents lipid peroxidation, and presents a new way to target the treatment of both acne and postinflammatory dyschromia.

Dr. Hu’s mentor, Jill S. Waibel, MD, owner and medical director of the Miami Dermatology and Laser Institute, hypothesized that nonablative laser therapy followed by topical application of silymarin would improve acne-associated postinflammatory dyschromia. To test her hunch, she conducted a 12-week, prospective trial in which 24 patients with PIE and/or PIH were randomized to one of two treatment arms: laser treatment with topical antioxidants or laser treatment with vehicle control. Patients received three laser treatments, each 1 month apart. The topical antioxidant used was Silymarin CF, a serum that contains 0.5% silymarin, 0.5% salicylic acid, 15% L-ascorbic acid, and 0.5% ferulic acid. (The study was sponsored by SkinCeuticals, the manufacturer of the serum.)

Laser selection was made primarily on the type of dyschromia, with PIE patients receiving treatment with the pulsed dye laser and PIH patients receiving treatment with the 1,927-nm thulium laser. Patients were treated on days 0, 28, and 56 of the 12-week study, followed by immediate application of topical antioxidants or vehicle control. They were also instructed to apply the assigned topical twice daily for the duration of the study. Patients ranged in age from 21 to 61 years, and 20 had skin types III-IV.

To evaluate efficacy, the researchers conducted blinded clinical assessments with the postacne hyperpigmentation index (PAHPI) and the Global Aesthetic Improvement Scale (GAIS), instrumentation with the Mexameter, a device that captures erythema and melanin index values, and visual diagnostics with optical coherence tomography (OCT).

Dr. Hu reported that at week 12, the PAHPI in the silymarin-plus-laser treatment group fell from an average of 3.18 to 1.74 (a decrease of 1.44), which suggested an improvement trend, compared with the laser treatment–only group, whose PAHPI fell from an average of 3.25 to 1.97 (a decrease of 1.28).

As for the GAIS, a one-time score assessed at the end of the trial, the average score for all patients was 3.24, which translated to “much improved/very much improved.” Patients in the silymarin-plus-laser treatment group had higher average scores compared with patients in the laser treatment–only group (3.35 vs. 3.10, respectively), but the differences did not reach statistical significance.

According to results of the Mexameter assessment, paired t-tests showed that the levels of intralesional melanin decreased significantly for patients in the silymarin-plus-laser treatment group, compared with the laser treatment–only group (P < .05). OCT assessments demonstrated an increase in dermal brightness in both groups, corresponding to an increase in dermal collagen, as well as an increase in blood vessel density.

In an interview at the meeting, Dr. Waibel, subsection chief of dermatology at Baptist Hospital of Miami, said that future studies will focus on long-term follow-up to determine if acne scars can be prevented by combining silymarin with lasers to prevent PIH and PIE. “That would be priceless,” she said. “I believe that the PIH is what causes damage to the collagen, and that damage to the collagen is what causes the scarring. So, if we can prevent or treat PIH, we may be able to prevent scarring.”

This approach, she added, “would decrease the pharmaceutical cost because I think there are many dermatologists who are treating PEI and PIH as active acne. You really have to have a keen eye for understanding the differences and you really have to be looking, because PIE and PIH are flat, whereas active acne consists of either comedones or nodules.”

She noted that in skin of color patients, she has seen PIH persist for 9 or 10 months after treatment with isotretinoin. “It’s not the isotretinoin causing the scars, or even the acne, it’s the prolonged inflammation,” she said.

Catherine M. DiGiorgio, MD, a Boston-based laser and cosmetic dermatologist who was asked to comment on the study, said that patients and dermatologists frequently seek alternatives to hydroquinone for unwanted hyperpigmentation.

Dr. DiGiorgio

Dr. Jalian

“While the study failed to show statistically significant improvement in postinflammatory erythema with concomitant laser and topical therapy versus laser alone, the promising data supporting concurrent use of topicals and fractional lasers for treatment of PIH, particularly in dark skin phototypes, is a clinically impactful contribution to our daily practice,” he said.

Dr. Waibel disclosed that she has conducted clinical trials for many device and pharmaceutical companies including SkinCeuticals. Dr. Hu, Dr. DiGiorgio, and Dr. Jalian were not involved with the study and reported having no relevant disclosures.

Key clinical point: Rheumatoid arthritis (RA) is associated with a significant increase in the risk for ischemic heart disease (IHD) and myocardial infarction (MI), and managing RA activity may reduce the risk for cardiovascular diseases.

Major finding: RA is significantly associated with an increased risk for IHD (odds ratio [OR] 1.0006; P  =  .001551915) and MI (OR 1.0458; P  =  .001636), but not arrhythmia and atrial fibrillation.

Study details: Findings are from a two-sample Mendelian randomization study including patients and matched control individuals for RA (n = 14,361 and n = 43,923, respectively), MI (n = 12,801 and n = 187,840, respectively), IHD (n = 5861 and n = 457,149, respectively), atrial fibrillation (n = 60,620 and n = 970,216, respectively), and arrhythmia (n = 2545 and n = 460,388, respectively).

Disclosures: This study was supported by the Young Talent Development Plan of Changzhou Health Commission, China, and other sources. The authors declared no conflicts of interest.

Source: Wang M et al. Relationship between rheumatoid arthritis and cardiovascular comorbidity, causation or co-occurrence: A Mendelian randomization study. Front Cardiovasc Med. 2023;10:1099861 (Mar 17). Doi: 10.3389/fcvm.2023.1099861

Key clinical point: Rheumatoid arthritis (RA) is associated with a significant increase in the risk for ischemic heart disease (IHD) and myocardial infarction (MI), and managing RA activity may reduce the risk for cardiovascular diseases.

Major finding: RA is significantly associated with an increased risk for IHD (odds ratio [OR] 1.0006; P  =  .001551915) and MI (OR 1.0458; P  =  .001636), but not arrhythmia and atrial fibrillation.

Study details: Findings are from a two-sample Mendelian randomization study including patients and matched control individuals for RA (n = 14,361 and n = 43,923, respectively), MI (n = 12,801 and n = 187,840, respectively), IHD (n = 5861 and n = 457,149, respectively), atrial fibrillation (n = 60,620 and n = 970,216, respectively), and arrhythmia (n = 2545 and n = 460,388, respectively).

Disclosures: This study was supported by the Young Talent Development Plan of Changzhou Health Commission, China, and other sources. The authors declared no conflicts of interest.

Source: Wang M et al. Relationship between rheumatoid arthritis and cardiovascular comorbidity, causation or co-occurrence: A Mendelian randomization study. Front Cardiovasc Med. 2023;10:1099861 (Mar 17). Doi: 10.3389/fcvm.2023.1099861

Key clinical point: Rheumatoid arthritis (RA) is associated with a significant increase in the risk for ischemic heart disease (IHD) and myocardial infarction (MI), and managing RA activity may reduce the risk for cardiovascular diseases.

Major finding: RA is significantly associated with an increased risk for IHD (odds ratio [OR] 1.0006; P  =  .001551915) and MI (OR 1.0458; P  =  .001636), but not arrhythmia and atrial fibrillation.

Study details: Findings are from a two-sample Mendelian randomization study including patients and matched control individuals for RA (n = 14,361 and n = 43,923, respectively), MI (n = 12,801 and n = 187,840, respectively), IHD (n = 5861 and n = 457,149, respectively), atrial fibrillation (n = 60,620 and n = 970,216, respectively), and arrhythmia (n = 2545 and n = 460,388, respectively).

Disclosures: This study was supported by the Young Talent Development Plan of Changzhou Health Commission, China, and other sources. The authors declared no conflicts of interest.

Source: Wang M et al. Relationship between rheumatoid arthritis and cardiovascular comorbidity, causation or co-occurrence: A Mendelian randomization study. Front Cardiovasc Med. 2023;10:1099861 (Mar 17). Doi: 10.3389/fcvm.2023.1099861

Key clinical point: Mortality risk varied with time and increased only during the second not the first decade after the diagnosis of rheumatoid arthritis (RA), with respiratory diseases potentially surpassing cardiovascular diseases as major attributable factors.

Major finding: Increase in mortality was observed at 20 years (standardized mortality ratio [SMR] 1.49; P < .001) but not during the first 10 years (P  =  .44) after RA diagnosis, with pneumonia (cause-specific SMR 5.22; 95% CI 2.26-10.29) and interstitial lung disease (cause-specific SMR 7.64; 95% CI 2.98-14.69) being major contributors.

Study details: Findings are from an analysis of 1895 patients with RA from the Australian Rheumatology Association Database (ARAD) registry who received biologic, targeted synthetic, or conventional synthetic disease-modifying antirheumatic drugs.

Disclosures: ARAD received support through the Australian Rheumatology Association from various sources. Three authors declared receiving grants, funding, or honoraria from different sources unrelated to this study.

Source: Black RJ et al. Mortality estimates and excess mortality in rheumatoid arthritis. Rheumatology (Oxford). 2023 (Mar 15). Doi: 10.1093/rheumatology/kead106

Key clinical point: Mortality risk varied with time and increased only during the second not the first decade after the diagnosis of rheumatoid arthritis (RA), with respiratory diseases potentially surpassing cardiovascular diseases as major attributable factors.

Major finding: Increase in mortality was observed at 20 years (standardized mortality ratio [SMR] 1.49; P < .001) but not during the first 10 years (P  =  .44) after RA diagnosis, with pneumonia (cause-specific SMR 5.22; 95% CI 2.26-10.29) and interstitial lung disease (cause-specific SMR 7.64; 95% CI 2.98-14.69) being major contributors.

Study details: Findings are from an analysis of 1895 patients with RA from the Australian Rheumatology Association Database (ARAD) registry who received biologic, targeted synthetic, or conventional synthetic disease-modifying antirheumatic drugs.

Disclosures: ARAD received support through the Australian Rheumatology Association from various sources. Three authors declared receiving grants, funding, or honoraria from different sources unrelated to this study.

Source: Black RJ et al. Mortality estimates and excess mortality in rheumatoid arthritis. Rheumatology (Oxford). 2023 (Mar 15). Doi: 10.1093/rheumatology/kead106

Key clinical point: Mortality risk varied with time and increased only during the second not the first decade after the diagnosis of rheumatoid arthritis (RA), with respiratory diseases potentially surpassing cardiovascular diseases as major attributable factors.

Major finding: Increase in mortality was observed at 20 years (standardized mortality ratio [SMR] 1.49; P < .001) but not during the first 10 years (P  =  .44) after RA diagnosis, with pneumonia (cause-specific SMR 5.22; 95% CI 2.26-10.29) and interstitial lung disease (cause-specific SMR 7.64; 95% CI 2.98-14.69) being major contributors.

Study details: Findings are from an analysis of 1895 patients with RA from the Australian Rheumatology Association Database (ARAD) registry who received biologic, targeted synthetic, or conventional synthetic disease-modifying antirheumatic drugs.

Disclosures: ARAD received support through the Australian Rheumatology Association from various sources. Three authors declared receiving grants, funding, or honoraria from different sources unrelated to this study.

Source: Black RJ et al. Mortality estimates and excess mortality in rheumatoid arthritis. Rheumatology (Oxford). 2023 (Mar 15). Doi: 10.1093/rheumatology/kead106