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The moving target of gestational diabetes care
With the rise of obesity and diabetes, especially type 2 diabetes, in the general population, the likelihood of encountering a patient with diabetes in pregnancy also continues to increase. Women with diabetes who are pregnant require specialized medical guidance, additional monitoring, and a health care team well versed in the possible complications that can arise during pregnancy, delivery, and after birth.
Even with strict glycemic control, women with diabetes in pregnancy are much more likely to experience complications, such as preeclampsia, babies with major congenital defects, large-for-gestational-age fetuses, and children with a higher propensity for chronic diseases later in life, compared with women without diabetes.
Therefore, it has been an incredible honor for me to have taken part in the work of the Diabetes in Pregnancy Study Group of North America (DPSG-NA) for the last 20 years. The DPSG-NA meetings have served as a forum for the dissemination of data, gathered through collaboration between researchers and clinical care teams in the United States and abroad. This year, the DPSG-NA will meet in Washington, D.C., Oct. 26-28, to discuss a range of topics under the theme of managing and preventing diabetes and obesity in pregnancy.
I am delighted that one of the speakers at the DPSG-NA meeting is this month’s Master Class guest author, Lynn Yee, MD, assistant professor of obstetrics and gynecology at Northwestern University Feinberg School of Medicine, Chicago. Dr. Yee will address the need to reduce disparities in the quality and availability of care for patients with diabetes in pregnancy, an extension of the June Master Class column that discussed the critical role that ob.gyns. can play in improving health equity for all patients.
Dr. Reece, who specializes in maternal-fetal medicine, is vice president for medical affairs at the University of Maryland, Baltimore, as well as the John Z. and Akiko K. Bowers Distinguished Professor and dean of the school of medicine. Dr. Reece said he had no relevant financial disclosures. He is the medical editor of this column. Contact him at obnews@frontlinemedcom.com.
With the rise of obesity and diabetes, especially type 2 diabetes, in the general population, the likelihood of encountering a patient with diabetes in pregnancy also continues to increase. Women with diabetes who are pregnant require specialized medical guidance, additional monitoring, and a health care team well versed in the possible complications that can arise during pregnancy, delivery, and after birth.
Even with strict glycemic control, women with diabetes in pregnancy are much more likely to experience complications, such as preeclampsia, babies with major congenital defects, large-for-gestational-age fetuses, and children with a higher propensity for chronic diseases later in life, compared with women without diabetes.
Therefore, it has been an incredible honor for me to have taken part in the work of the Diabetes in Pregnancy Study Group of North America (DPSG-NA) for the last 20 years. The DPSG-NA meetings have served as a forum for the dissemination of data, gathered through collaboration between researchers and clinical care teams in the United States and abroad. This year, the DPSG-NA will meet in Washington, D.C., Oct. 26-28, to discuss a range of topics under the theme of managing and preventing diabetes and obesity in pregnancy.
I am delighted that one of the speakers at the DPSG-NA meeting is this month’s Master Class guest author, Lynn Yee, MD, assistant professor of obstetrics and gynecology at Northwestern University Feinberg School of Medicine, Chicago. Dr. Yee will address the need to reduce disparities in the quality and availability of care for patients with diabetes in pregnancy, an extension of the June Master Class column that discussed the critical role that ob.gyns. can play in improving health equity for all patients.
Dr. Reece, who specializes in maternal-fetal medicine, is vice president for medical affairs at the University of Maryland, Baltimore, as well as the John Z. and Akiko K. Bowers Distinguished Professor and dean of the school of medicine. Dr. Reece said he had no relevant financial disclosures. He is the medical editor of this column. Contact him at obnews@frontlinemedcom.com.
With the rise of obesity and diabetes, especially type 2 diabetes, in the general population, the likelihood of encountering a patient with diabetes in pregnancy also continues to increase. Women with diabetes who are pregnant require specialized medical guidance, additional monitoring, and a health care team well versed in the possible complications that can arise during pregnancy, delivery, and after birth.
Even with strict glycemic control, women with diabetes in pregnancy are much more likely to experience complications, such as preeclampsia, babies with major congenital defects, large-for-gestational-age fetuses, and children with a higher propensity for chronic diseases later in life, compared with women without diabetes.
Therefore, it has been an incredible honor for me to have taken part in the work of the Diabetes in Pregnancy Study Group of North America (DPSG-NA) for the last 20 years. The DPSG-NA meetings have served as a forum for the dissemination of data, gathered through collaboration between researchers and clinical care teams in the United States and abroad. This year, the DPSG-NA will meet in Washington, D.C., Oct. 26-28, to discuss a range of topics under the theme of managing and preventing diabetes and obesity in pregnancy.
I am delighted that one of the speakers at the DPSG-NA meeting is this month’s Master Class guest author, Lynn Yee, MD, assistant professor of obstetrics and gynecology at Northwestern University Feinberg School of Medicine, Chicago. Dr. Yee will address the need to reduce disparities in the quality and availability of care for patients with diabetes in pregnancy, an extension of the June Master Class column that discussed the critical role that ob.gyns. can play in improving health equity for all patients.
Dr. Reece, who specializes in maternal-fetal medicine, is vice president for medical affairs at the University of Maryland, Baltimore, as well as the John Z. and Akiko K. Bowers Distinguished Professor and dean of the school of medicine. Dr. Reece said he had no relevant financial disclosures. He is the medical editor of this column. Contact him at obnews@frontlinemedcom.com.
Safety of oral antidiabetic agents in pregnancy
The three most potent human teratogens, with the possible inclusion of some of the first antineoplastics, are isotretinoin, alcohol, and hyperglycemia.
As with all teratogens, the toxicity is dose related. For example, the risk of embryo-fetal harm from hyperglycemia increases markedly when the HbA1c is greater than 8%. Moreover, diabetes accounts for more than 90% of the harm caused by chronic diseases. Consequently, control of glucose levels in pregnancy is critical.
If these agents are used near term, there is a risk that they will cause hypoglycemia in the newborn. Changing from oral therapy to insulin is the safest course.
There are seven pharmacologic subclasses of oral antidiabetic agents: alpha-glucosidase inhibitors, biguanides, dipeptidyl peptidase-4 inhibitors, meglitinides, sulfonylureas, sodium-glucose cotransporter-2 inhibitors, and thiazolidinediones. Many of these drugs are available in combination with metformin. All of these agents are indicated as adjunct to diet and exercise for type 2 diabetes, but they also can be used for gestational diabetes. Although the human pregnancy data are very limited or nonexistent for most of these agents, none are known to cause structural defects in humans. Additional details of the exposures are available in the 11th edition of “Drugs in Pregnancy and Lactation” (2017: Wolters Kluwer).
Alpha-glucosidase inhibitors
The two agents is this subclass are acarbose (Precose) and miglitol (Glyset). The human pregnancy data with acarbose are limited, and no human pregnancy data have been found for miglitol. The animal data for both drugs suggest low risk.
Biguanides
There are substantial human pregnancy data for metformin in both type 2 and gestational diabetes. When combined with insulin, it is effective in significantly lowering the amount of insulin required to control hyperglycemia. It also may be effective when used alone. The risk of embryo-fetal harm with this drug appears to be very low or nonexistent. The animal data suggest low risk.
Dipeptidyl peptidase-4 inhibitors
There are four drugs in this subclass: alogliptin (Nesina), linagliptin (Tradjenta), saxagliptin (Onglyza), and sitagliptin (Januvia). No reports of the use of the first three drugs in human pregnancy have been found. However, the Merck Pregnancy Registries (2006-2009) described the outcomes of eight women who were exposed to sitagliptin or sitagliptin/metformin in the first trimester. The outcomes of these pregnancies were five healthy newborns, two spontaneous abortions, and one fetal death at 34 weeks’ gestation. In that case, the mother took sitagliptin and metformin separately during the first 5 weeks of gestation. The animal data for all four drugs suggest low risk.
Meglitinides
Nateglinide (Starlix) and repaglinide (Prandin) are the agents in this subclass. There is no human pregnancy data for nateglinide, but there is limited data (eight pregnancies) for repaglinide. No birth defects or other toxicity was noted in these cases. The animal data suggest low risk.
Sulfonylureas
Six drugs are included in this subclass: chlorpropamide, glimepiride (Amaryl), glipizide (Glucotrol), glyburide, tolazamide (Tolinase), and tolbutamide. These agents were among the first oral antidiabetic agents. As a result, they have the most human pregnancy data. Although birth defects were observed in newborns of mothers who had used one of these drugs, the defects were thought to be the result of uncontrolled diabetes. The animal data suggest low risk.
SGLT2 inhibitors
There are three drugs in this sodium-glucose cotransporter-2 inhibitor subclass: canagliflozin (Invokana), dapagliflozin (Farxiga), and empagliflozin (Jardiance). No reports describing the use of these drugs in human pregnancy have been located. The animal data suggest low risk.
Thiazolidinediones
Pioglitazone (Actos) and rosiglitazone (Avandia) form this subclass. There are limited human pregnancy data for both drugs. The animal data suggest moderate risk for embryo-fetal toxicity but not for structural defects.
Lactation
All of the above drugs will probably be excreted into breast milk, but the amounts are typically unknown. When they have been measured, the amounts were usually low. However, there is still a risk for hypoglycemia in a nursing infant. Combination products containing two antidiabetic agents are best avoided. The safest course is to use insulin, but, if this is not an option, then the lowest effective dose should be used. In addition, the infant’s blood glucose levels should be routinely monitored.
Mr. Briggs is a clinical professor of pharmacy at the University of California, San Francisco, and an adjunct professor of pharmacy at the University of Southern California, Los Angeles, as well as at Washington State University, Spokane. He coauthored “Drugs in Pregnancy and Lactation” and coedited “Diseases, Complications, and Drug Therapy in Obstetrics.” He reported having no relevant financial disclosures.
The three most potent human teratogens, with the possible inclusion of some of the first antineoplastics, are isotretinoin, alcohol, and hyperglycemia.
As with all teratogens, the toxicity is dose related. For example, the risk of embryo-fetal harm from hyperglycemia increases markedly when the HbA1c is greater than 8%. Moreover, diabetes accounts for more than 90% of the harm caused by chronic diseases. Consequently, control of glucose levels in pregnancy is critical.
If these agents are used near term, there is a risk that they will cause hypoglycemia in the newborn. Changing from oral therapy to insulin is the safest course.
There are seven pharmacologic subclasses of oral antidiabetic agents: alpha-glucosidase inhibitors, biguanides, dipeptidyl peptidase-4 inhibitors, meglitinides, sulfonylureas, sodium-glucose cotransporter-2 inhibitors, and thiazolidinediones. Many of these drugs are available in combination with metformin. All of these agents are indicated as adjunct to diet and exercise for type 2 diabetes, but they also can be used for gestational diabetes. Although the human pregnancy data are very limited or nonexistent for most of these agents, none are known to cause structural defects in humans. Additional details of the exposures are available in the 11th edition of “Drugs in Pregnancy and Lactation” (2017: Wolters Kluwer).
Alpha-glucosidase inhibitors
The two agents is this subclass are acarbose (Precose) and miglitol (Glyset). The human pregnancy data with acarbose are limited, and no human pregnancy data have been found for miglitol. The animal data for both drugs suggest low risk.
Biguanides
There are substantial human pregnancy data for metformin in both type 2 and gestational diabetes. When combined with insulin, it is effective in significantly lowering the amount of insulin required to control hyperglycemia. It also may be effective when used alone. The risk of embryo-fetal harm with this drug appears to be very low or nonexistent. The animal data suggest low risk.
Dipeptidyl peptidase-4 inhibitors
There are four drugs in this subclass: alogliptin (Nesina), linagliptin (Tradjenta), saxagliptin (Onglyza), and sitagliptin (Januvia). No reports of the use of the first three drugs in human pregnancy have been found. However, the Merck Pregnancy Registries (2006-2009) described the outcomes of eight women who were exposed to sitagliptin or sitagliptin/metformin in the first trimester. The outcomes of these pregnancies were five healthy newborns, two spontaneous abortions, and one fetal death at 34 weeks’ gestation. In that case, the mother took sitagliptin and metformin separately during the first 5 weeks of gestation. The animal data for all four drugs suggest low risk.
Meglitinides
Nateglinide (Starlix) and repaglinide (Prandin) are the agents in this subclass. There is no human pregnancy data for nateglinide, but there is limited data (eight pregnancies) for repaglinide. No birth defects or other toxicity was noted in these cases. The animal data suggest low risk.
Sulfonylureas
Six drugs are included in this subclass: chlorpropamide, glimepiride (Amaryl), glipizide (Glucotrol), glyburide, tolazamide (Tolinase), and tolbutamide. These agents were among the first oral antidiabetic agents. As a result, they have the most human pregnancy data. Although birth defects were observed in newborns of mothers who had used one of these drugs, the defects were thought to be the result of uncontrolled diabetes. The animal data suggest low risk.
SGLT2 inhibitors
There are three drugs in this sodium-glucose cotransporter-2 inhibitor subclass: canagliflozin (Invokana), dapagliflozin (Farxiga), and empagliflozin (Jardiance). No reports describing the use of these drugs in human pregnancy have been located. The animal data suggest low risk.
Thiazolidinediones
Pioglitazone (Actos) and rosiglitazone (Avandia) form this subclass. There are limited human pregnancy data for both drugs. The animal data suggest moderate risk for embryo-fetal toxicity but not for structural defects.
Lactation
All of the above drugs will probably be excreted into breast milk, but the amounts are typically unknown. When they have been measured, the amounts were usually low. However, there is still a risk for hypoglycemia in a nursing infant. Combination products containing two antidiabetic agents are best avoided. The safest course is to use insulin, but, if this is not an option, then the lowest effective dose should be used. In addition, the infant’s blood glucose levels should be routinely monitored.
Mr. Briggs is a clinical professor of pharmacy at the University of California, San Francisco, and an adjunct professor of pharmacy at the University of Southern California, Los Angeles, as well as at Washington State University, Spokane. He coauthored “Drugs in Pregnancy and Lactation” and coedited “Diseases, Complications, and Drug Therapy in Obstetrics.” He reported having no relevant financial disclosures.
The three most potent human teratogens, with the possible inclusion of some of the first antineoplastics, are isotretinoin, alcohol, and hyperglycemia.
As with all teratogens, the toxicity is dose related. For example, the risk of embryo-fetal harm from hyperglycemia increases markedly when the HbA1c is greater than 8%. Moreover, diabetes accounts for more than 90% of the harm caused by chronic diseases. Consequently, control of glucose levels in pregnancy is critical.
If these agents are used near term, there is a risk that they will cause hypoglycemia in the newborn. Changing from oral therapy to insulin is the safest course.
There are seven pharmacologic subclasses of oral antidiabetic agents: alpha-glucosidase inhibitors, biguanides, dipeptidyl peptidase-4 inhibitors, meglitinides, sulfonylureas, sodium-glucose cotransporter-2 inhibitors, and thiazolidinediones. Many of these drugs are available in combination with metformin. All of these agents are indicated as adjunct to diet and exercise for type 2 diabetes, but they also can be used for gestational diabetes. Although the human pregnancy data are very limited or nonexistent for most of these agents, none are known to cause structural defects in humans. Additional details of the exposures are available in the 11th edition of “Drugs in Pregnancy and Lactation” (2017: Wolters Kluwer).
Alpha-glucosidase inhibitors
The two agents is this subclass are acarbose (Precose) and miglitol (Glyset). The human pregnancy data with acarbose are limited, and no human pregnancy data have been found for miglitol. The animal data for both drugs suggest low risk.
Biguanides
There are substantial human pregnancy data for metformin in both type 2 and gestational diabetes. When combined with insulin, it is effective in significantly lowering the amount of insulin required to control hyperglycemia. It also may be effective when used alone. The risk of embryo-fetal harm with this drug appears to be very low or nonexistent. The animal data suggest low risk.
Dipeptidyl peptidase-4 inhibitors
There are four drugs in this subclass: alogliptin (Nesina), linagliptin (Tradjenta), saxagliptin (Onglyza), and sitagliptin (Januvia). No reports of the use of the first three drugs in human pregnancy have been found. However, the Merck Pregnancy Registries (2006-2009) described the outcomes of eight women who were exposed to sitagliptin or sitagliptin/metformin in the first trimester. The outcomes of these pregnancies were five healthy newborns, two spontaneous abortions, and one fetal death at 34 weeks’ gestation. In that case, the mother took sitagliptin and metformin separately during the first 5 weeks of gestation. The animal data for all four drugs suggest low risk.
Meglitinides
Nateglinide (Starlix) and repaglinide (Prandin) are the agents in this subclass. There is no human pregnancy data for nateglinide, but there is limited data (eight pregnancies) for repaglinide. No birth defects or other toxicity was noted in these cases. The animal data suggest low risk.
Sulfonylureas
Six drugs are included in this subclass: chlorpropamide, glimepiride (Amaryl), glipizide (Glucotrol), glyburide, tolazamide (Tolinase), and tolbutamide. These agents were among the first oral antidiabetic agents. As a result, they have the most human pregnancy data. Although birth defects were observed in newborns of mothers who had used one of these drugs, the defects were thought to be the result of uncontrolled diabetes. The animal data suggest low risk.
SGLT2 inhibitors
There are three drugs in this sodium-glucose cotransporter-2 inhibitor subclass: canagliflozin (Invokana), dapagliflozin (Farxiga), and empagliflozin (Jardiance). No reports describing the use of these drugs in human pregnancy have been located. The animal data suggest low risk.
Thiazolidinediones
Pioglitazone (Actos) and rosiglitazone (Avandia) form this subclass. There are limited human pregnancy data for both drugs. The animal data suggest moderate risk for embryo-fetal toxicity but not for structural defects.
Lactation
All of the above drugs will probably be excreted into breast milk, but the amounts are typically unknown. When they have been measured, the amounts were usually low. However, there is still a risk for hypoglycemia in a nursing infant. Combination products containing two antidiabetic agents are best avoided. The safest course is to use insulin, but, if this is not an option, then the lowest effective dose should be used. In addition, the infant’s blood glucose levels should be routinely monitored.
Mr. Briggs is a clinical professor of pharmacy at the University of California, San Francisco, and an adjunct professor of pharmacy at the University of Southern California, Los Angeles, as well as at Washington State University, Spokane. He coauthored “Drugs in Pregnancy and Lactation” and coedited “Diseases, Complications, and Drug Therapy in Obstetrics.” He reported having no relevant financial disclosures.
Optimizing HPV vaccination
Human papillomavirus (HPV) is the most common sexually transmitted infection. Exposure is widespread and most individuals clear the infection without symptoms or development of disease. However, a subset of individuals experience persistent infection, a state which can lead to carcinogenesis of lower genital tract malignancies, particularly cervical cancer.1
Vaccine coverage
Persistent infection with high-risk (oncogenic) HPV is well known to be the cause of cervical cancer. There are two HPV vaccines manufactured for the purposes of cervical cancer, anal cancer, and genital wart prevention (Cervarix and Gardasil). The Cervarix vaccine covers high-risk HPV subtypes 16 and 18 and the Gardasil vaccine prevents both low-risk HPV subtypes 6 and 11, which can cause genital warts, and high-risk HPV subtypes 16, 18, 31, 33, 45, 52 and 58, which cause cervical dysplasia and cancer.
High-risk HPV is also associated with head and neck, vulvar, vaginal, and penile cancers, though the vaccines are not approved by the Food and Drug Administration for prevention of these diseases.2
Vaccination indications
Since vaccination prevents multiple subtypes of HPV, an individual who has already been exposed will still benefit from protection from other subtypes of HPV through vaccination. HPV vaccination is not approved during pregnancy but can be initiated in the postpartum period when women are engaged in their health care and receiving other vaccinations, such as varicella or the MMR vaccine.
Recommended schedule
Until October 2016, the vaccination schedule was based on a three-dose series (0, 2, and 6 months). Currently, the CDC recommends that children aged under 15 years at the time of first dose may opt for a two-dose series (0 and 6-12 months). For those aged 15-26 years, the three-dose schedule remains the recommended course.
The benefits of two-dose schedule are convenience, cost, and increased likelihood of completion. Data presented at the 2017 Society of Gynecologic Oncology Annual Meeting on Women’s Cancer showed that rates of cervical dysplasia were equivalent for women who completed a two-dose schedule versus a three-dose schedule.4
Efficacy
A recent meta-analysis of clinical trials of the HPV vaccines describe efficacy of 95%-97% in prevention of CIN 1-3.5 While its greatest efficacy is in its ability to prevent primary HPV infection, there still is some benefit for individuals who already were exposed to HPV prior to vaccination. As stated previously, women with a history of prior HPV vaccination have lower rates of recurrence of cervical dysplasia after treatment. Additionally, recent research has shown that women who received HPV vaccinations after a LEEP procedure for CIN 2 or 3 experience significantly lower recurrence rates, compared with women who did not receive vaccinations after LEEP (2.5% vs. 8.5%).6 This raises the possibility of a therapeutic role for HPV vaccination in women infected with HPV. Prospective studies are currently evaluating this question.
Myths
The most common side effects of the HPV vaccine are pain, redness, or swelling at the injection site. Other known side effects include fever, headache or malaise, nausea, syncope, or muscle/joint pain – similar to other vaccinations. Anaphylaxis is a rare complication.
Some parents and pediatricians report concerns that vaccination could lead to earlier sexual activity. Multiple studies have shown that girls who receive HPV vaccination are no more likely to become pregnant or get a sexually transmitted infection (proxies for intercourse) than are girls who were not vaccinated.7,8
Maximizing vaccination rates
HPV vaccination rates in the United States lag significantly behind rates in countries with national vaccine programs, such as Australia and Denmark.9 Early data from Australia already have shown a decrease in genital warts and CIN 2+ incidence within the 10 years of starting its school-based vaccine program, with approximately 73% of 12- to 15-year-olds having completed the vaccine series.2 In contrast, just 40% and 22% of 13- to 17-year-old girls and boys in the United States, respectively, had completed the vaccine series in 2014, according to the CDC.10
Vaccination gaps between girls and boys are narrowing, and more teens will be able to complete the series with the new two-dose recommendation for those younger than 15 years. However, our current rates of vaccination are significantly lower for HPV than for other routinely recommended adolescent vaccines (such as Tdap and meningococcal) and more must be done to encourage vaccination.
Studies have shown that parents are more likely to vaccinate their children if providers recommend the vaccine.11 As women’s health care providers, we do not always see children during the time period that is ideal for vaccination. However, we take care of many women who are presenting for routine gynecologic care, pregnancy, or with abnormal Pap smear screenings. These are ideal opportunities to educate and offer HPV vaccination to women in the approved age groups, as well as to encourage parents to vaccinate their children.
As with other vaccines, the recommendation should be clear and focused on the cancer prevention benefit. Using methods in which the recommendation is “announced” in a brief statement assuming parents/patients are ready to vaccinate versus open-ended conversations, has been studied as a potentially successful method to increase uptake of HPV vaccination.12 Additionally, documentation of HPV vaccination status should be built into electronic medical record templates to prompt clinicians to ask and offer HPV vaccination at visits, including postpartum visits.
Dr. Rahangdale is an associate professor of ob.gyn. at the University of North Carolina, Chapel Hill, and is director of the North Carolina Women’s Hospital Cervical Dysplasia Clinic. Dr. Rossi is an assistant professor in the division of gynecologic oncology at UNC-Chapel Hill. They reported having no relevant financial disclosures.
References
1. Am J Epidemiol. 2008 Jul 15;168(2):123-37.
2. Int J Cancer. 2012 Nov 1;131(9):1969-82.
3. BMJ. 2012 Mar 27;344:e1401. doi: 10.1136/bmj.e1401.
4. Gynecol Oncol. 2017 Jun. doi. org/10.1016/j.ygyno.2017.03.031.
5. Int J Prev Med. 2017 Jun 1;8:44. doi: 10.4103/ijpvm.IJPVM_413_16.
6. Gynecol Oncol. 2013 Aug;130(2):264-8.
7. Pediatrics. 2012 Nov;130(5):798-805.
8. JAMA Intern Med. 2015 Apr;175(4):617-23.
9. Clin Pediatr (Phila). 2016 Sep;55(10):904-14.
10. MMWR Morb Mortal Wkly Rep. 2015 Jul 31;64(29):784-92.
11. Vaccine. 2016 Feb 24;34(9):1187-92.
12. Pediatrics. 2017 Jan;139(1). pii:e20161764. doi: 10.1542/peds.2016-1764.
Human papillomavirus (HPV) is the most common sexually transmitted infection. Exposure is widespread and most individuals clear the infection without symptoms or development of disease. However, a subset of individuals experience persistent infection, a state which can lead to carcinogenesis of lower genital tract malignancies, particularly cervical cancer.1
Vaccine coverage
Persistent infection with high-risk (oncogenic) HPV is well known to be the cause of cervical cancer. There are two HPV vaccines manufactured for the purposes of cervical cancer, anal cancer, and genital wart prevention (Cervarix and Gardasil). The Cervarix vaccine covers high-risk HPV subtypes 16 and 18 and the Gardasil vaccine prevents both low-risk HPV subtypes 6 and 11, which can cause genital warts, and high-risk HPV subtypes 16, 18, 31, 33, 45, 52 and 58, which cause cervical dysplasia and cancer.
High-risk HPV is also associated with head and neck, vulvar, vaginal, and penile cancers, though the vaccines are not approved by the Food and Drug Administration for prevention of these diseases.2
Vaccination indications
Since vaccination prevents multiple subtypes of HPV, an individual who has already been exposed will still benefit from protection from other subtypes of HPV through vaccination. HPV vaccination is not approved during pregnancy but can be initiated in the postpartum period when women are engaged in their health care and receiving other vaccinations, such as varicella or the MMR vaccine.
Recommended schedule
Until October 2016, the vaccination schedule was based on a three-dose series (0, 2, and 6 months). Currently, the CDC recommends that children aged under 15 years at the time of first dose may opt for a two-dose series (0 and 6-12 months). For those aged 15-26 years, the three-dose schedule remains the recommended course.
The benefits of two-dose schedule are convenience, cost, and increased likelihood of completion. Data presented at the 2017 Society of Gynecologic Oncology Annual Meeting on Women’s Cancer showed that rates of cervical dysplasia were equivalent for women who completed a two-dose schedule versus a three-dose schedule.4
Efficacy
A recent meta-analysis of clinical trials of the HPV vaccines describe efficacy of 95%-97% in prevention of CIN 1-3.5 While its greatest efficacy is in its ability to prevent primary HPV infection, there still is some benefit for individuals who already were exposed to HPV prior to vaccination. As stated previously, women with a history of prior HPV vaccination have lower rates of recurrence of cervical dysplasia after treatment. Additionally, recent research has shown that women who received HPV vaccinations after a LEEP procedure for CIN 2 or 3 experience significantly lower recurrence rates, compared with women who did not receive vaccinations after LEEP (2.5% vs. 8.5%).6 This raises the possibility of a therapeutic role for HPV vaccination in women infected with HPV. Prospective studies are currently evaluating this question.
Myths
The most common side effects of the HPV vaccine are pain, redness, or swelling at the injection site. Other known side effects include fever, headache or malaise, nausea, syncope, or muscle/joint pain – similar to other vaccinations. Anaphylaxis is a rare complication.
Some parents and pediatricians report concerns that vaccination could lead to earlier sexual activity. Multiple studies have shown that girls who receive HPV vaccination are no more likely to become pregnant or get a sexually transmitted infection (proxies for intercourse) than are girls who were not vaccinated.7,8
Maximizing vaccination rates
HPV vaccination rates in the United States lag significantly behind rates in countries with national vaccine programs, such as Australia and Denmark.9 Early data from Australia already have shown a decrease in genital warts and CIN 2+ incidence within the 10 years of starting its school-based vaccine program, with approximately 73% of 12- to 15-year-olds having completed the vaccine series.2 In contrast, just 40% and 22% of 13- to 17-year-old girls and boys in the United States, respectively, had completed the vaccine series in 2014, according to the CDC.10
Vaccination gaps between girls and boys are narrowing, and more teens will be able to complete the series with the new two-dose recommendation for those younger than 15 years. However, our current rates of vaccination are significantly lower for HPV than for other routinely recommended adolescent vaccines (such as Tdap and meningococcal) and more must be done to encourage vaccination.
Studies have shown that parents are more likely to vaccinate their children if providers recommend the vaccine.11 As women’s health care providers, we do not always see children during the time period that is ideal for vaccination. However, we take care of many women who are presenting for routine gynecologic care, pregnancy, or with abnormal Pap smear screenings. These are ideal opportunities to educate and offer HPV vaccination to women in the approved age groups, as well as to encourage parents to vaccinate their children.
As with other vaccines, the recommendation should be clear and focused on the cancer prevention benefit. Using methods in which the recommendation is “announced” in a brief statement assuming parents/patients are ready to vaccinate versus open-ended conversations, has been studied as a potentially successful method to increase uptake of HPV vaccination.12 Additionally, documentation of HPV vaccination status should be built into electronic medical record templates to prompt clinicians to ask and offer HPV vaccination at visits, including postpartum visits.
Dr. Rahangdale is an associate professor of ob.gyn. at the University of North Carolina, Chapel Hill, and is director of the North Carolina Women’s Hospital Cervical Dysplasia Clinic. Dr. Rossi is an assistant professor in the division of gynecologic oncology at UNC-Chapel Hill. They reported having no relevant financial disclosures.
References
1. Am J Epidemiol. 2008 Jul 15;168(2):123-37.
2. Int J Cancer. 2012 Nov 1;131(9):1969-82.
3. BMJ. 2012 Mar 27;344:e1401. doi: 10.1136/bmj.e1401.
4. Gynecol Oncol. 2017 Jun. doi. org/10.1016/j.ygyno.2017.03.031.
5. Int J Prev Med. 2017 Jun 1;8:44. doi: 10.4103/ijpvm.IJPVM_413_16.
6. Gynecol Oncol. 2013 Aug;130(2):264-8.
7. Pediatrics. 2012 Nov;130(5):798-805.
8. JAMA Intern Med. 2015 Apr;175(4):617-23.
9. Clin Pediatr (Phila). 2016 Sep;55(10):904-14.
10. MMWR Morb Mortal Wkly Rep. 2015 Jul 31;64(29):784-92.
11. Vaccine. 2016 Feb 24;34(9):1187-92.
12. Pediatrics. 2017 Jan;139(1). pii:e20161764. doi: 10.1542/peds.2016-1764.
Human papillomavirus (HPV) is the most common sexually transmitted infection. Exposure is widespread and most individuals clear the infection without symptoms or development of disease. However, a subset of individuals experience persistent infection, a state which can lead to carcinogenesis of lower genital tract malignancies, particularly cervical cancer.1
Vaccine coverage
Persistent infection with high-risk (oncogenic) HPV is well known to be the cause of cervical cancer. There are two HPV vaccines manufactured for the purposes of cervical cancer, anal cancer, and genital wart prevention (Cervarix and Gardasil). The Cervarix vaccine covers high-risk HPV subtypes 16 and 18 and the Gardasil vaccine prevents both low-risk HPV subtypes 6 and 11, which can cause genital warts, and high-risk HPV subtypes 16, 18, 31, 33, 45, 52 and 58, which cause cervical dysplasia and cancer.
High-risk HPV is also associated with head and neck, vulvar, vaginal, and penile cancers, though the vaccines are not approved by the Food and Drug Administration for prevention of these diseases.2
Vaccination indications
Since vaccination prevents multiple subtypes of HPV, an individual who has already been exposed will still benefit from protection from other subtypes of HPV through vaccination. HPV vaccination is not approved during pregnancy but can be initiated in the postpartum period when women are engaged in their health care and receiving other vaccinations, such as varicella or the MMR vaccine.
Recommended schedule
Until October 2016, the vaccination schedule was based on a three-dose series (0, 2, and 6 months). Currently, the CDC recommends that children aged under 15 years at the time of first dose may opt for a two-dose series (0 and 6-12 months). For those aged 15-26 years, the three-dose schedule remains the recommended course.
The benefits of two-dose schedule are convenience, cost, and increased likelihood of completion. Data presented at the 2017 Society of Gynecologic Oncology Annual Meeting on Women’s Cancer showed that rates of cervical dysplasia were equivalent for women who completed a two-dose schedule versus a three-dose schedule.4
Efficacy
A recent meta-analysis of clinical trials of the HPV vaccines describe efficacy of 95%-97% in prevention of CIN 1-3.5 While its greatest efficacy is in its ability to prevent primary HPV infection, there still is some benefit for individuals who already were exposed to HPV prior to vaccination. As stated previously, women with a history of prior HPV vaccination have lower rates of recurrence of cervical dysplasia after treatment. Additionally, recent research has shown that women who received HPV vaccinations after a LEEP procedure for CIN 2 or 3 experience significantly lower recurrence rates, compared with women who did not receive vaccinations after LEEP (2.5% vs. 8.5%).6 This raises the possibility of a therapeutic role for HPV vaccination in women infected with HPV. Prospective studies are currently evaluating this question.
Myths
The most common side effects of the HPV vaccine are pain, redness, or swelling at the injection site. Other known side effects include fever, headache or malaise, nausea, syncope, or muscle/joint pain – similar to other vaccinations. Anaphylaxis is a rare complication.
Some parents and pediatricians report concerns that vaccination could lead to earlier sexual activity. Multiple studies have shown that girls who receive HPV vaccination are no more likely to become pregnant or get a sexually transmitted infection (proxies for intercourse) than are girls who were not vaccinated.7,8
Maximizing vaccination rates
HPV vaccination rates in the United States lag significantly behind rates in countries with national vaccine programs, such as Australia and Denmark.9 Early data from Australia already have shown a decrease in genital warts and CIN 2+ incidence within the 10 years of starting its school-based vaccine program, with approximately 73% of 12- to 15-year-olds having completed the vaccine series.2 In contrast, just 40% and 22% of 13- to 17-year-old girls and boys in the United States, respectively, had completed the vaccine series in 2014, according to the CDC.10
Vaccination gaps between girls and boys are narrowing, and more teens will be able to complete the series with the new two-dose recommendation for those younger than 15 years. However, our current rates of vaccination are significantly lower for HPV than for other routinely recommended adolescent vaccines (such as Tdap and meningococcal) and more must be done to encourage vaccination.
Studies have shown that parents are more likely to vaccinate their children if providers recommend the vaccine.11 As women’s health care providers, we do not always see children during the time period that is ideal for vaccination. However, we take care of many women who are presenting for routine gynecologic care, pregnancy, or with abnormal Pap smear screenings. These are ideal opportunities to educate and offer HPV vaccination to women in the approved age groups, as well as to encourage parents to vaccinate their children.
As with other vaccines, the recommendation should be clear and focused on the cancer prevention benefit. Using methods in which the recommendation is “announced” in a brief statement assuming parents/patients are ready to vaccinate versus open-ended conversations, has been studied as a potentially successful method to increase uptake of HPV vaccination.12 Additionally, documentation of HPV vaccination status should be built into electronic medical record templates to prompt clinicians to ask and offer HPV vaccination at visits, including postpartum visits.
Dr. Rahangdale is an associate professor of ob.gyn. at the University of North Carolina, Chapel Hill, and is director of the North Carolina Women’s Hospital Cervical Dysplasia Clinic. Dr. Rossi is an assistant professor in the division of gynecologic oncology at UNC-Chapel Hill. They reported having no relevant financial disclosures.
References
1. Am J Epidemiol. 2008 Jul 15;168(2):123-37.
2. Int J Cancer. 2012 Nov 1;131(9):1969-82.
3. BMJ. 2012 Mar 27;344:e1401. doi: 10.1136/bmj.e1401.
4. Gynecol Oncol. 2017 Jun. doi. org/10.1016/j.ygyno.2017.03.031.
5. Int J Prev Med. 2017 Jun 1;8:44. doi: 10.4103/ijpvm.IJPVM_413_16.
6. Gynecol Oncol. 2013 Aug;130(2):264-8.
7. Pediatrics. 2012 Nov;130(5):798-805.
8. JAMA Intern Med. 2015 Apr;175(4):617-23.
9. Clin Pediatr (Phila). 2016 Sep;55(10):904-14.
10. MMWR Morb Mortal Wkly Rep. 2015 Jul 31;64(29):784-92.
11. Vaccine. 2016 Feb 24;34(9):1187-92.
12. Pediatrics. 2017 Jan;139(1). pii:e20161764. doi: 10.1542/peds.2016-1764.
Skin care Q and A for your staff
in helping us be more efficient with our time. I asked my staff to put together a list of the most common patient skin care questions. This column can be used as a guide for your staff when answering questions about skin care.
Q: Should my sunscreen be applied first or last?
A: The best way to remember is that medications should be applied closest to the skin and sunscreen should be applied closest to the sun. I recommend that morning skin care be applied in the following order:
Step 1. Facial cleanser
Step 2. Eye products (protect the delicate eye area from the medication)
Step 3. Treatment product (medications, or the most important active ingredients)
Step 4. Moisturizer (if needed)
Step 5. Sunscreen
Q: When can I restart my normal skin care regimen after receiving dermal fillers?
A: The morning after receiving dermal fillers, you can resume your normal facial skin care regimen.
Q: How do I treat my skin after receiving cosmetic injections such as Botox?
A: After you are injected with dermal fillers, keep the Arnica gel, Arnica pads, or post procedure product on your face until bedtime. Prior to bed, wash your face with a gentle cleanser and lukewarm water. Do not use any scrubs, facial brushes, or hydroxy acids. Apply a soothing gel or soothing moisturizer. Do not use hot water on the face for 48 hours. Avoid hot showers, saunas, facial steaming, facial massage, and exercise for 48 hours. If you must exercise, try to keep the face cool with an ice filled bottle of water. Heat makes you more likely to bruise.
Q: Will retinol make my skin sun sensitive?
A: Retinol breaks down upon sun exposure so it should only be used at night. It is a myth that retinol makes your skin sun sensitive. Retinol is a form of vitamin A that helps protect your skin from sun damage by reducing levels of an enzyme called collagenase that is produced after sun exposure. For this and other reasons, retinol can help protect your skin from sun damage. However, if your skin gets irritated from the retinol and you go into the sun, you can develop postinflammatory hyperpigmentation – or dark patches on the skin. It is a good idea to always wear sunscreen in the morning every day whether you are using retinol or not.
Q: What do I do to treat the dark circles under my eyes?
A: Dark circles can be caused by sluggish blood flow around the eyes leading to deposition of a pigment found in blood called hemosiderin. Dark circles around the eyes also can be caused by an increased amount of the pigment melanin that occurs from sun exposure, heat, estrogen, and stress. Treatments include lifestyle habits that increase blood circulation, such as smoking cessation and exercise. Supplements such as horse chestnut may help improve circulation. Ingredients such as the tyrosinase inhibitors ascorbic acid, kojic acid, arbutin, and hydroquinone will help decrease melanin production, and may improve dark circles caused by increased melanin. Wearing a daily sunscreen around the eyes is a very important part of improving the appearance of dark circles under the eyes.
Q: Do I need an eye cream?
A: Most people need an eye product whether it is a serum, gel, or cream. Eye treatment products are usually one of the first skin care products that male patients purchase. The most common indications for eye treatment products are dark circles under the eyes, puffy eyes, dryness, fine lines, or redness. Each one of these indications requires very different ingredients; therefore, most people need more than one eye product depending on what eye issues they are experiencing. Eye treatment products can protect the delicate eye area from medications such as tretinoin that gets on the pillowcase and is transferred to the eye area at night. Eye products that have humectants, such as heparan sulfate or hyaluronic acid, should be used to treat fines lines and dryness, but these may make eyes puffy. For those with dry and puffy eyes, a second eye product with vasoconstrictive ingredients should be used in the daytime while the hydrating one is used at night. Antiaging eye products with retinol and hydroxy acids may irritate sensitive skin types so they can be paired with a soothing eye product. Consider using different eye products for the morning and evening depending on what eye issues need to be treated.
Q: Will moisturizer make my acne worse?
A: Noncomedogenic moisturizers can help improve acne and speed recovery. Using the proper cleanser and moisturizer will make acne medications more tolerable. Many patients cannot tolerate their acne medications every day. The bacteria that cause acne reproduce every 12 hours. For this reason, acne medications must be used consistently twice a day. Using the proper cleanser and moisturizer makes this possible in most patients. Avoid moisturizers with coconut oil, isopropyl myristate, and other ingredients known to cause acne.
Q: Why does my face get so red after washing it?
A: Rosacea-prone skin types get red from the friction of washing the face – even if just using water. If this occurs, use skin care products with anti-inflammatory ingredients such as argan oil, green tea, fever few, chamomile, caffeine, resveratrol, and niacinamide to sooth the skin. These can be paired with prescription rosacea medications such as Rhofade (oxymetazoline hydrochloride) to reduce facial redness. People with rosacea-prone skin types should avoid facial brushes, scrubs, and vigorous exfoliation.
Q: Why is my melasma not getting better on skin lighteners?
Educating our staff on the basics of skin care can make our office much more efficient. If you liked the format of this column or have questions that you hear often from patients, please email me at DrB@derm.net.
Dr. Baumann is a private practice dermatologist, researcher, author and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and “Cosmeceuticals and Cosmetic Ingredients,” (New York: McGraw-Hill, 2014), and a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, Aclaris, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC.
in helping us be more efficient with our time. I asked my staff to put together a list of the most common patient skin care questions. This column can be used as a guide for your staff when answering questions about skin care.
Q: Should my sunscreen be applied first or last?
A: The best way to remember is that medications should be applied closest to the skin and sunscreen should be applied closest to the sun. I recommend that morning skin care be applied in the following order:
Step 1. Facial cleanser
Step 2. Eye products (protect the delicate eye area from the medication)
Step 3. Treatment product (medications, or the most important active ingredients)
Step 4. Moisturizer (if needed)
Step 5. Sunscreen
Q: When can I restart my normal skin care regimen after receiving dermal fillers?
A: The morning after receiving dermal fillers, you can resume your normal facial skin care regimen.
Q: How do I treat my skin after receiving cosmetic injections such as Botox?
A: After you are injected with dermal fillers, keep the Arnica gel, Arnica pads, or post procedure product on your face until bedtime. Prior to bed, wash your face with a gentle cleanser and lukewarm water. Do not use any scrubs, facial brushes, or hydroxy acids. Apply a soothing gel or soothing moisturizer. Do not use hot water on the face for 48 hours. Avoid hot showers, saunas, facial steaming, facial massage, and exercise for 48 hours. If you must exercise, try to keep the face cool with an ice filled bottle of water. Heat makes you more likely to bruise.
Q: Will retinol make my skin sun sensitive?
A: Retinol breaks down upon sun exposure so it should only be used at night. It is a myth that retinol makes your skin sun sensitive. Retinol is a form of vitamin A that helps protect your skin from sun damage by reducing levels of an enzyme called collagenase that is produced after sun exposure. For this and other reasons, retinol can help protect your skin from sun damage. However, if your skin gets irritated from the retinol and you go into the sun, you can develop postinflammatory hyperpigmentation – or dark patches on the skin. It is a good idea to always wear sunscreen in the morning every day whether you are using retinol or not.
Q: What do I do to treat the dark circles under my eyes?
A: Dark circles can be caused by sluggish blood flow around the eyes leading to deposition of a pigment found in blood called hemosiderin. Dark circles around the eyes also can be caused by an increased amount of the pigment melanin that occurs from sun exposure, heat, estrogen, and stress. Treatments include lifestyle habits that increase blood circulation, such as smoking cessation and exercise. Supplements such as horse chestnut may help improve circulation. Ingredients such as the tyrosinase inhibitors ascorbic acid, kojic acid, arbutin, and hydroquinone will help decrease melanin production, and may improve dark circles caused by increased melanin. Wearing a daily sunscreen around the eyes is a very important part of improving the appearance of dark circles under the eyes.
Q: Do I need an eye cream?
A: Most people need an eye product whether it is a serum, gel, or cream. Eye treatment products are usually one of the first skin care products that male patients purchase. The most common indications for eye treatment products are dark circles under the eyes, puffy eyes, dryness, fine lines, or redness. Each one of these indications requires very different ingredients; therefore, most people need more than one eye product depending on what eye issues they are experiencing. Eye treatment products can protect the delicate eye area from medications such as tretinoin that gets on the pillowcase and is transferred to the eye area at night. Eye products that have humectants, such as heparan sulfate or hyaluronic acid, should be used to treat fines lines and dryness, but these may make eyes puffy. For those with dry and puffy eyes, a second eye product with vasoconstrictive ingredients should be used in the daytime while the hydrating one is used at night. Antiaging eye products with retinol and hydroxy acids may irritate sensitive skin types so they can be paired with a soothing eye product. Consider using different eye products for the morning and evening depending on what eye issues need to be treated.
Q: Will moisturizer make my acne worse?
A: Noncomedogenic moisturizers can help improve acne and speed recovery. Using the proper cleanser and moisturizer will make acne medications more tolerable. Many patients cannot tolerate their acne medications every day. The bacteria that cause acne reproduce every 12 hours. For this reason, acne medications must be used consistently twice a day. Using the proper cleanser and moisturizer makes this possible in most patients. Avoid moisturizers with coconut oil, isopropyl myristate, and other ingredients known to cause acne.
Q: Why does my face get so red after washing it?
A: Rosacea-prone skin types get red from the friction of washing the face – even if just using water. If this occurs, use skin care products with anti-inflammatory ingredients such as argan oil, green tea, fever few, chamomile, caffeine, resveratrol, and niacinamide to sooth the skin. These can be paired with prescription rosacea medications such as Rhofade (oxymetazoline hydrochloride) to reduce facial redness. People with rosacea-prone skin types should avoid facial brushes, scrubs, and vigorous exfoliation.
Q: Why is my melasma not getting better on skin lighteners?
Educating our staff on the basics of skin care can make our office much more efficient. If you liked the format of this column or have questions that you hear often from patients, please email me at DrB@derm.net.
Dr. Baumann is a private practice dermatologist, researcher, author and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and “Cosmeceuticals and Cosmetic Ingredients,” (New York: McGraw-Hill, 2014), and a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, Aclaris, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC.
in helping us be more efficient with our time. I asked my staff to put together a list of the most common patient skin care questions. This column can be used as a guide for your staff when answering questions about skin care.
Q: Should my sunscreen be applied first or last?
A: The best way to remember is that medications should be applied closest to the skin and sunscreen should be applied closest to the sun. I recommend that morning skin care be applied in the following order:
Step 1. Facial cleanser
Step 2. Eye products (protect the delicate eye area from the medication)
Step 3. Treatment product (medications, or the most important active ingredients)
Step 4. Moisturizer (if needed)
Step 5. Sunscreen
Q: When can I restart my normal skin care regimen after receiving dermal fillers?
A: The morning after receiving dermal fillers, you can resume your normal facial skin care regimen.
Q: How do I treat my skin after receiving cosmetic injections such as Botox?
A: After you are injected with dermal fillers, keep the Arnica gel, Arnica pads, or post procedure product on your face until bedtime. Prior to bed, wash your face with a gentle cleanser and lukewarm water. Do not use any scrubs, facial brushes, or hydroxy acids. Apply a soothing gel or soothing moisturizer. Do not use hot water on the face for 48 hours. Avoid hot showers, saunas, facial steaming, facial massage, and exercise for 48 hours. If you must exercise, try to keep the face cool with an ice filled bottle of water. Heat makes you more likely to bruise.
Q: Will retinol make my skin sun sensitive?
A: Retinol breaks down upon sun exposure so it should only be used at night. It is a myth that retinol makes your skin sun sensitive. Retinol is a form of vitamin A that helps protect your skin from sun damage by reducing levels of an enzyme called collagenase that is produced after sun exposure. For this and other reasons, retinol can help protect your skin from sun damage. However, if your skin gets irritated from the retinol and you go into the sun, you can develop postinflammatory hyperpigmentation – or dark patches on the skin. It is a good idea to always wear sunscreen in the morning every day whether you are using retinol or not.
Q: What do I do to treat the dark circles under my eyes?
A: Dark circles can be caused by sluggish blood flow around the eyes leading to deposition of a pigment found in blood called hemosiderin. Dark circles around the eyes also can be caused by an increased amount of the pigment melanin that occurs from sun exposure, heat, estrogen, and stress. Treatments include lifestyle habits that increase blood circulation, such as smoking cessation and exercise. Supplements such as horse chestnut may help improve circulation. Ingredients such as the tyrosinase inhibitors ascorbic acid, kojic acid, arbutin, and hydroquinone will help decrease melanin production, and may improve dark circles caused by increased melanin. Wearing a daily sunscreen around the eyes is a very important part of improving the appearance of dark circles under the eyes.
Q: Do I need an eye cream?
A: Most people need an eye product whether it is a serum, gel, or cream. Eye treatment products are usually one of the first skin care products that male patients purchase. The most common indications for eye treatment products are dark circles under the eyes, puffy eyes, dryness, fine lines, or redness. Each one of these indications requires very different ingredients; therefore, most people need more than one eye product depending on what eye issues they are experiencing. Eye treatment products can protect the delicate eye area from medications such as tretinoin that gets on the pillowcase and is transferred to the eye area at night. Eye products that have humectants, such as heparan sulfate or hyaluronic acid, should be used to treat fines lines and dryness, but these may make eyes puffy. For those with dry and puffy eyes, a second eye product with vasoconstrictive ingredients should be used in the daytime while the hydrating one is used at night. Antiaging eye products with retinol and hydroxy acids may irritate sensitive skin types so they can be paired with a soothing eye product. Consider using different eye products for the morning and evening depending on what eye issues need to be treated.
Q: Will moisturizer make my acne worse?
A: Noncomedogenic moisturizers can help improve acne and speed recovery. Using the proper cleanser and moisturizer will make acne medications more tolerable. Many patients cannot tolerate their acne medications every day. The bacteria that cause acne reproduce every 12 hours. For this reason, acne medications must be used consistently twice a day. Using the proper cleanser and moisturizer makes this possible in most patients. Avoid moisturizers with coconut oil, isopropyl myristate, and other ingredients known to cause acne.
Q: Why does my face get so red after washing it?
A: Rosacea-prone skin types get red from the friction of washing the face – even if just using water. If this occurs, use skin care products with anti-inflammatory ingredients such as argan oil, green tea, fever few, chamomile, caffeine, resveratrol, and niacinamide to sooth the skin. These can be paired with prescription rosacea medications such as Rhofade (oxymetazoline hydrochloride) to reduce facial redness. People with rosacea-prone skin types should avoid facial brushes, scrubs, and vigorous exfoliation.
Q: Why is my melasma not getting better on skin lighteners?
Educating our staff on the basics of skin care can make our office much more efficient. If you liked the format of this column or have questions that you hear often from patients, please email me at DrB@derm.net.
Dr. Baumann is a private practice dermatologist, researcher, author and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and “Cosmeceuticals and Cosmetic Ingredients,” (New York: McGraw-Hill, 2014), and a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, Aclaris, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC.
The team and I
As a physician or a patient, you probably have noticed that the quality of health care is better when there is a continuous relationship between the physician and the patient. Discontinuity can make doctor-patient communication less fluid, but familiarity can breed comfort and confidence. Patients often complain when they see a different physician at every visit. And physicians know they are less efficient when they are seeing a patient they have never seen before.
They discovered that less continuity was associated with more ambulatory sick visits and more ambulatory sensitive hospitalizations, particularly for children with chronic conditions. Interestingly, they could find no association between continuity measured at well visits and patients’ health outcomes.
With only a gut level and personal relationship with the subject, I wondered how the researchers measured something as nebulous as continuity. It turns out there are several ways to measure continuity, of which the investigators focused on two. The Usual Provider of Care is calculated by dividing the number of visits with the most common provider by the total number of primary care visits. The Bice and Boxerman Continuity of Care Index is more difficult to calculate because, rather than using a single provider, it lumps a small core of providers together (such as a team) as the most the common provider.
As a curmudgeonly, old school, egotistical kind of guy, I was surprised and disappointed to learn from this paper’s references of another study that found, in at least one scenario, the individual-based (Usual Provider of Care) and team-based (Bice and Boxerman Continuity of Care Index) methods of defining continuity yielded comparable results (Med Care. 2016 May;54[5]:e30-4). I always have assumed that, regardless of how well it had been crafted, that I could provide better continuity than a team of providers.
I know what you are thinking: This guy hasn’t bought into the maxim that “There is no I in team.” No, no, I do believe in it, but in the context of continuity of care, it seemed to me that sometimes the more links there are in the chain, the more chances there are for miscommunication. And we all know that primary care is 90% communication.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@frontlinemedcom.com.
As a physician or a patient, you probably have noticed that the quality of health care is better when there is a continuous relationship between the physician and the patient. Discontinuity can make doctor-patient communication less fluid, but familiarity can breed comfort and confidence. Patients often complain when they see a different physician at every visit. And physicians know they are less efficient when they are seeing a patient they have never seen before.
They discovered that less continuity was associated with more ambulatory sick visits and more ambulatory sensitive hospitalizations, particularly for children with chronic conditions. Interestingly, they could find no association between continuity measured at well visits and patients’ health outcomes.
With only a gut level and personal relationship with the subject, I wondered how the researchers measured something as nebulous as continuity. It turns out there are several ways to measure continuity, of which the investigators focused on two. The Usual Provider of Care is calculated by dividing the number of visits with the most common provider by the total number of primary care visits. The Bice and Boxerman Continuity of Care Index is more difficult to calculate because, rather than using a single provider, it lumps a small core of providers together (such as a team) as the most the common provider.
As a curmudgeonly, old school, egotistical kind of guy, I was surprised and disappointed to learn from this paper’s references of another study that found, in at least one scenario, the individual-based (Usual Provider of Care) and team-based (Bice and Boxerman Continuity of Care Index) methods of defining continuity yielded comparable results (Med Care. 2016 May;54[5]:e30-4). I always have assumed that, regardless of how well it had been crafted, that I could provide better continuity than a team of providers.
I know what you are thinking: This guy hasn’t bought into the maxim that “There is no I in team.” No, no, I do believe in it, but in the context of continuity of care, it seemed to me that sometimes the more links there are in the chain, the more chances there are for miscommunication. And we all know that primary care is 90% communication.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@frontlinemedcom.com.
As a physician or a patient, you probably have noticed that the quality of health care is better when there is a continuous relationship between the physician and the patient. Discontinuity can make doctor-patient communication less fluid, but familiarity can breed comfort and confidence. Patients often complain when they see a different physician at every visit. And physicians know they are less efficient when they are seeing a patient they have never seen before.
They discovered that less continuity was associated with more ambulatory sick visits and more ambulatory sensitive hospitalizations, particularly for children with chronic conditions. Interestingly, they could find no association between continuity measured at well visits and patients’ health outcomes.
With only a gut level and personal relationship with the subject, I wondered how the researchers measured something as nebulous as continuity. It turns out there are several ways to measure continuity, of which the investigators focused on two. The Usual Provider of Care is calculated by dividing the number of visits with the most common provider by the total number of primary care visits. The Bice and Boxerman Continuity of Care Index is more difficult to calculate because, rather than using a single provider, it lumps a small core of providers together (such as a team) as the most the common provider.
As a curmudgeonly, old school, egotistical kind of guy, I was surprised and disappointed to learn from this paper’s references of another study that found, in at least one scenario, the individual-based (Usual Provider of Care) and team-based (Bice and Boxerman Continuity of Care Index) methods of defining continuity yielded comparable results (Med Care. 2016 May;54[5]:e30-4). I always have assumed that, regardless of how well it had been crafted, that I could provide better continuity than a team of providers.
I know what you are thinking: This guy hasn’t bought into the maxim that “There is no I in team.” No, no, I do believe in it, but in the context of continuity of care, it seemed to me that sometimes the more links there are in the chain, the more chances there are for miscommunication. And we all know that primary care is 90% communication.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@frontlinemedcom.com.
Successful teams
As physicians, we know, and have been taught, that success comes from being smart and answering questions correctly. By doing so, we excelled in school, scored high on standardized tests, and confidently raised our hands in class. As a result, we were chosen for plum assignments like class officer, yearbook editor, and team captain. Success bred success and we were initiated into honor societies, accepted into prestigious internships, and allowed to work on important research projects.
These achievements guaranteed further success in medical school where the tradition of competition continued as we positioned for the attention of those who would someday write our letters of recommendation. This model of individual success served us very well until we joined a hematology group to begin our practice.
When we join a group of physicians, we join a team. The team might organize around diagnoses, laboratories, or geographic location, but it is a team nonetheless. The team, of course, includes more than just physicians. As a team member, we are expected to fulfill a role that advances the mission of the team and the larger organization. That mission may include some combination of academic, educational, and clinical productivity.
As physicians trained to compete with other individuals, teamwork does not come naturally. We might think that so long as the team consists of more and mor
As Margaret Heffernan brilliantly points out in “Margaret Heffernan: Why it’s time to forget the pecking order at work,” a TED talk video posted on YouTube, teams consisting of those skilled in interpersonal relationships are much more effective, efficient, and productive than are teams consisting of those skilled in problem-solving with superior IQs. The teams that function most successfully are those that create a culture of trust and helpfulness no matter the individual talents of those on the team.
As a department chair, I try to see past the thickness of the CV to ensure that I see into the person’s ability to relate with other people. If the CV is thick and the emotional intelligence high, then that is the person I want on my team, but I would rather have the latter than the former, and so would teammates and patients.
Research has shown repeatedly that no individuals can hope to achieve on their own what a good, functional team can achieve as a group. Yet, the academic hierarchy rewards individuals, not teams. Hopefully, the rewarded individual will recognize the support and effort of the team, but that is not always the case and not always done adequately.
How can academic departments develop social capital in their teams and reward them, in addition to individuals, for their successes? Social capital grows when the relationships between people become stronger. Those bonds develop though informal interaction outside the work environment. The more the team knows each other, the more they trust each other, the more they are willing to help each other, and the more they are likely to be civil to one another. Teams of friends are much more likely to solve problems quickly for less cost than teams of strangers.
Reward and recognition for a team is not as easy as it sounds. Everyone wants individual recognition for their work, not just as an integral member of a team. The world loves All-Stars and MVPs as much as they love their teams. We do not need to change the way we reward individuals, but we do need to also include teams for reward and recognition. How can a leader determine which teams are most deserving of the highest reward? Many institutions measure employee engagement through surveys. High-functioning teams are likely to be highly engaged and high scores on surveys should be recognized and rewarded. Teams with low employee turnover help reduce training costs and should be appreciated.
Successful implementation of continuous improvement projects are an often overlooked opportunity for an expression of gratitude. I am sure there are other ways to acknowledge a team’s efforts and I hope readers will write to us with their ideas for all to share. Perhaps by doing so, we can accelerate the cultural transformation of academic medicine from one of personal achievement to one of team success.
Dr. Kalaycio is editor in chief of Hematology News. He chairs the department of hematologic oncology and blood disorders at Cleveland Clinic Taussig Cancer Institute. Contact him at kalaycm@ccf.org.
As physicians, we know, and have been taught, that success comes from being smart and answering questions correctly. By doing so, we excelled in school, scored high on standardized tests, and confidently raised our hands in class. As a result, we were chosen for plum assignments like class officer, yearbook editor, and team captain. Success bred success and we were initiated into honor societies, accepted into prestigious internships, and allowed to work on important research projects.
These achievements guaranteed further success in medical school where the tradition of competition continued as we positioned for the attention of those who would someday write our letters of recommendation. This model of individual success served us very well until we joined a hematology group to begin our practice.
When we join a group of physicians, we join a team. The team might organize around diagnoses, laboratories, or geographic location, but it is a team nonetheless. The team, of course, includes more than just physicians. As a team member, we are expected to fulfill a role that advances the mission of the team and the larger organization. That mission may include some combination of academic, educational, and clinical productivity.
As physicians trained to compete with other individuals, teamwork does not come naturally. We might think that so long as the team consists of more and mor
As Margaret Heffernan brilliantly points out in “Margaret Heffernan: Why it’s time to forget the pecking order at work,” a TED talk video posted on YouTube, teams consisting of those skilled in interpersonal relationships are much more effective, efficient, and productive than are teams consisting of those skilled in problem-solving with superior IQs. The teams that function most successfully are those that create a culture of trust and helpfulness no matter the individual talents of those on the team.
As a department chair, I try to see past the thickness of the CV to ensure that I see into the person’s ability to relate with other people. If the CV is thick and the emotional intelligence high, then that is the person I want on my team, but I would rather have the latter than the former, and so would teammates and patients.
Research has shown repeatedly that no individuals can hope to achieve on their own what a good, functional team can achieve as a group. Yet, the academic hierarchy rewards individuals, not teams. Hopefully, the rewarded individual will recognize the support and effort of the team, but that is not always the case and not always done adequately.
How can academic departments develop social capital in their teams and reward them, in addition to individuals, for their successes? Social capital grows when the relationships between people become stronger. Those bonds develop though informal interaction outside the work environment. The more the team knows each other, the more they trust each other, the more they are willing to help each other, and the more they are likely to be civil to one another. Teams of friends are much more likely to solve problems quickly for less cost than teams of strangers.
Reward and recognition for a team is not as easy as it sounds. Everyone wants individual recognition for their work, not just as an integral member of a team. The world loves All-Stars and MVPs as much as they love their teams. We do not need to change the way we reward individuals, but we do need to also include teams for reward and recognition. How can a leader determine which teams are most deserving of the highest reward? Many institutions measure employee engagement through surveys. High-functioning teams are likely to be highly engaged and high scores on surveys should be recognized and rewarded. Teams with low employee turnover help reduce training costs and should be appreciated.
Successful implementation of continuous improvement projects are an often overlooked opportunity for an expression of gratitude. I am sure there are other ways to acknowledge a team’s efforts and I hope readers will write to us with their ideas for all to share. Perhaps by doing so, we can accelerate the cultural transformation of academic medicine from one of personal achievement to one of team success.
Dr. Kalaycio is editor in chief of Hematology News. He chairs the department of hematologic oncology and blood disorders at Cleveland Clinic Taussig Cancer Institute. Contact him at kalaycm@ccf.org.
As physicians, we know, and have been taught, that success comes from being smart and answering questions correctly. By doing so, we excelled in school, scored high on standardized tests, and confidently raised our hands in class. As a result, we were chosen for plum assignments like class officer, yearbook editor, and team captain. Success bred success and we were initiated into honor societies, accepted into prestigious internships, and allowed to work on important research projects.
These achievements guaranteed further success in medical school where the tradition of competition continued as we positioned for the attention of those who would someday write our letters of recommendation. This model of individual success served us very well until we joined a hematology group to begin our practice.
When we join a group of physicians, we join a team. The team might organize around diagnoses, laboratories, or geographic location, but it is a team nonetheless. The team, of course, includes more than just physicians. As a team member, we are expected to fulfill a role that advances the mission of the team and the larger organization. That mission may include some combination of academic, educational, and clinical productivity.
As physicians trained to compete with other individuals, teamwork does not come naturally. We might think that so long as the team consists of more and mor
As Margaret Heffernan brilliantly points out in “Margaret Heffernan: Why it’s time to forget the pecking order at work,” a TED talk video posted on YouTube, teams consisting of those skilled in interpersonal relationships are much more effective, efficient, and productive than are teams consisting of those skilled in problem-solving with superior IQs. The teams that function most successfully are those that create a culture of trust and helpfulness no matter the individual talents of those on the team.
As a department chair, I try to see past the thickness of the CV to ensure that I see into the person’s ability to relate with other people. If the CV is thick and the emotional intelligence high, then that is the person I want on my team, but I would rather have the latter than the former, and so would teammates and patients.
Research has shown repeatedly that no individuals can hope to achieve on their own what a good, functional team can achieve as a group. Yet, the academic hierarchy rewards individuals, not teams. Hopefully, the rewarded individual will recognize the support and effort of the team, but that is not always the case and not always done adequately.
How can academic departments develop social capital in their teams and reward them, in addition to individuals, for their successes? Social capital grows when the relationships between people become stronger. Those bonds develop though informal interaction outside the work environment. The more the team knows each other, the more they trust each other, the more they are willing to help each other, and the more they are likely to be civil to one another. Teams of friends are much more likely to solve problems quickly for less cost than teams of strangers.
Reward and recognition for a team is not as easy as it sounds. Everyone wants individual recognition for their work, not just as an integral member of a team. The world loves All-Stars and MVPs as much as they love their teams. We do not need to change the way we reward individuals, but we do need to also include teams for reward and recognition. How can a leader determine which teams are most deserving of the highest reward? Many institutions measure employee engagement through surveys. High-functioning teams are likely to be highly engaged and high scores on surveys should be recognized and rewarded. Teams with low employee turnover help reduce training costs and should be appreciated.
Successful implementation of continuous improvement projects are an often overlooked opportunity for an expression of gratitude. I am sure there are other ways to acknowledge a team’s efforts and I hope readers will write to us with their ideas for all to share. Perhaps by doing so, we can accelerate the cultural transformation of academic medicine from one of personal achievement to one of team success.
Dr. Kalaycio is editor in chief of Hematology News. He chairs the department of hematologic oncology and blood disorders at Cleveland Clinic Taussig Cancer Institute. Contact him at kalaycm@ccf.org.
The impact of Election 2016
Because of the health care policy work I have done over the years, I often get asked about what to expect from Capitol Hill and from federal policy makers in D.C. Since the surprise election results in November, the most common questions revolve around what impact the Trump administration is likely to have on the delivery system reform work done since the passage of the Affordable Care Act (ACA).
While much uncertainty remains, events since the election have given us some clues to answer these and other questions.
Let’s address the ACA. It’s important to recognize that the ACA cannot be repealed completely for at least two reasons. First, it does not even exist as it was passed, having undergone several changes, including adjustments and exemptions. Second, parts of the bill would require 60 votes in the Senate to repeal, and those votes are not available to the party seeking repeal.
Yes, parts of the bill could be changed significantly with only Republican votes. However, the reality is that many changes would have occurred even if Hillary Clinton had won the election; there are elements of the current law that are not working and that both sides acknowledge need to be fixed, such as state individual insurance exchanges.
There also are parts of the ACA that neither party would like to see rescinded, which are unlikely to be removed in a new law – for example, losing insurance for preexisting conditions.
From the standpoint of providers, the most notable aspect of the current discussion is that proposed changes have largely been limited to addressing areas of insurance reform. This has potential impact on who is covered under a revised plan. In the meantime, the important work of delivery system reform – the elements of the ACA that providers care the most about (and that will have the most impact on their careers) – have been left untouched. There are strong signs that this will remain the case and that this important work will continue.
What are those signs? First of all, neither the “repeal” bill passed by the House nor any of the bills considered by the Senate made any mention of interrupting any of the important work being done by the Center for Medicare & Medicaid Innovation (CMMI), the part of the Centers for Medicare & Medicaid Services created by the ACA to develop and test alternative payment models (APMs), like accountable care organizations, bundled payments, etc. If successful, this work will improve quality while lowering the growth of health care costs and may save a health care system that, if unchecked, will create a crushing financial burden that threatens the Medicare Trust Fund. It also is a strong and clear sign that the CMMI continues its work today under the same effective leadership that first created excitement about its potential to improve the delivery system.
But probably the clearest sign that delivery system reform will continue was the strong bipartisan support shown in the passage of the Medicare Access and CHIP Reauthorization Act (MACRA) in April of 2015. This landmark piece of legislation creates a pathway that moves the entire health care system away from fee for service and toward payment models that will reward providers for innovations that will lower the cost of care, eliminate waste, improve safety, and achieve better outcomes. It puts in place a plan that will use APMs to offer providers the incentives to create care models that may be the salvation of our health care system. In the long run, isn’t this what matters the most?
Politicians in Washington can’t save our system. They can create or remove entitlements or support one segment of the population at the expense of another. But, in the end, they are only moving dollars around from one pocket to another, rearranging deck chairs on the Titanic of the American health care system.
The reality is that the only thing that can save our health care system is to lower the cost of care. And we all know that, as providers, only we can do that. SHM will be helping its members lead the way, providing educational content, training, advocacy, and policy leadership.
It will be up to the nation’s caregivers to reform the delivery system in a way that is sustainable for our generation and generations to come. We continue that work today, and I see no evidence that anyone on Capitol Hill wants us to stop.
Dr. Greeno is president of the Society of Hospital Medicine and senior adviser for medical affairs at TeamHealth.
Because of the health care policy work I have done over the years, I often get asked about what to expect from Capitol Hill and from federal policy makers in D.C. Since the surprise election results in November, the most common questions revolve around what impact the Trump administration is likely to have on the delivery system reform work done since the passage of the Affordable Care Act (ACA).
While much uncertainty remains, events since the election have given us some clues to answer these and other questions.
Let’s address the ACA. It’s important to recognize that the ACA cannot be repealed completely for at least two reasons. First, it does not even exist as it was passed, having undergone several changes, including adjustments and exemptions. Second, parts of the bill would require 60 votes in the Senate to repeal, and those votes are not available to the party seeking repeal.
Yes, parts of the bill could be changed significantly with only Republican votes. However, the reality is that many changes would have occurred even if Hillary Clinton had won the election; there are elements of the current law that are not working and that both sides acknowledge need to be fixed, such as state individual insurance exchanges.
There also are parts of the ACA that neither party would like to see rescinded, which are unlikely to be removed in a new law – for example, losing insurance for preexisting conditions.
From the standpoint of providers, the most notable aspect of the current discussion is that proposed changes have largely been limited to addressing areas of insurance reform. This has potential impact on who is covered under a revised plan. In the meantime, the important work of delivery system reform – the elements of the ACA that providers care the most about (and that will have the most impact on their careers) – have been left untouched. There are strong signs that this will remain the case and that this important work will continue.
What are those signs? First of all, neither the “repeal” bill passed by the House nor any of the bills considered by the Senate made any mention of interrupting any of the important work being done by the Center for Medicare & Medicaid Innovation (CMMI), the part of the Centers for Medicare & Medicaid Services created by the ACA to develop and test alternative payment models (APMs), like accountable care organizations, bundled payments, etc. If successful, this work will improve quality while lowering the growth of health care costs and may save a health care system that, if unchecked, will create a crushing financial burden that threatens the Medicare Trust Fund. It also is a strong and clear sign that the CMMI continues its work today under the same effective leadership that first created excitement about its potential to improve the delivery system.
But probably the clearest sign that delivery system reform will continue was the strong bipartisan support shown in the passage of the Medicare Access and CHIP Reauthorization Act (MACRA) in April of 2015. This landmark piece of legislation creates a pathway that moves the entire health care system away from fee for service and toward payment models that will reward providers for innovations that will lower the cost of care, eliminate waste, improve safety, and achieve better outcomes. It puts in place a plan that will use APMs to offer providers the incentives to create care models that may be the salvation of our health care system. In the long run, isn’t this what matters the most?
Politicians in Washington can’t save our system. They can create or remove entitlements or support one segment of the population at the expense of another. But, in the end, they are only moving dollars around from one pocket to another, rearranging deck chairs on the Titanic of the American health care system.
The reality is that the only thing that can save our health care system is to lower the cost of care. And we all know that, as providers, only we can do that. SHM will be helping its members lead the way, providing educational content, training, advocacy, and policy leadership.
It will be up to the nation’s caregivers to reform the delivery system in a way that is sustainable for our generation and generations to come. We continue that work today, and I see no evidence that anyone on Capitol Hill wants us to stop.
Dr. Greeno is president of the Society of Hospital Medicine and senior adviser for medical affairs at TeamHealth.
Because of the health care policy work I have done over the years, I often get asked about what to expect from Capitol Hill and from federal policy makers in D.C. Since the surprise election results in November, the most common questions revolve around what impact the Trump administration is likely to have on the delivery system reform work done since the passage of the Affordable Care Act (ACA).
While much uncertainty remains, events since the election have given us some clues to answer these and other questions.
Let’s address the ACA. It’s important to recognize that the ACA cannot be repealed completely for at least two reasons. First, it does not even exist as it was passed, having undergone several changes, including adjustments and exemptions. Second, parts of the bill would require 60 votes in the Senate to repeal, and those votes are not available to the party seeking repeal.
Yes, parts of the bill could be changed significantly with only Republican votes. However, the reality is that many changes would have occurred even if Hillary Clinton had won the election; there are elements of the current law that are not working and that both sides acknowledge need to be fixed, such as state individual insurance exchanges.
There also are parts of the ACA that neither party would like to see rescinded, which are unlikely to be removed in a new law – for example, losing insurance for preexisting conditions.
From the standpoint of providers, the most notable aspect of the current discussion is that proposed changes have largely been limited to addressing areas of insurance reform. This has potential impact on who is covered under a revised plan. In the meantime, the important work of delivery system reform – the elements of the ACA that providers care the most about (and that will have the most impact on their careers) – have been left untouched. There are strong signs that this will remain the case and that this important work will continue.
What are those signs? First of all, neither the “repeal” bill passed by the House nor any of the bills considered by the Senate made any mention of interrupting any of the important work being done by the Center for Medicare & Medicaid Innovation (CMMI), the part of the Centers for Medicare & Medicaid Services created by the ACA to develop and test alternative payment models (APMs), like accountable care organizations, bundled payments, etc. If successful, this work will improve quality while lowering the growth of health care costs and may save a health care system that, if unchecked, will create a crushing financial burden that threatens the Medicare Trust Fund. It also is a strong and clear sign that the CMMI continues its work today under the same effective leadership that first created excitement about its potential to improve the delivery system.
But probably the clearest sign that delivery system reform will continue was the strong bipartisan support shown in the passage of the Medicare Access and CHIP Reauthorization Act (MACRA) in April of 2015. This landmark piece of legislation creates a pathway that moves the entire health care system away from fee for service and toward payment models that will reward providers for innovations that will lower the cost of care, eliminate waste, improve safety, and achieve better outcomes. It puts in place a plan that will use APMs to offer providers the incentives to create care models that may be the salvation of our health care system. In the long run, isn’t this what matters the most?
Politicians in Washington can’t save our system. They can create or remove entitlements or support one segment of the population at the expense of another. But, in the end, they are only moving dollars around from one pocket to another, rearranging deck chairs on the Titanic of the American health care system.
The reality is that the only thing that can save our health care system is to lower the cost of care. And we all know that, as providers, only we can do that. SHM will be helping its members lead the way, providing educational content, training, advocacy, and policy leadership.
It will be up to the nation’s caregivers to reform the delivery system in a way that is sustainable for our generation and generations to come. We continue that work today, and I see no evidence that anyone on Capitol Hill wants us to stop.
Dr. Greeno is president of the Society of Hospital Medicine and senior adviser for medical affairs at TeamHealth.
PANS and PANDAS – A step forward?
In the Journal of Child and Adolescent Psychopharmacology’s July 2017 issue, a group of respected individuals representing diverse expertise published “guidelines” to support clinical management of pediatric acute-onset neuropsychiatric syndrome (PANS) and its subclass PANDAS (those associated with streptococcal infection). PANS represents an enigmatic clinical syndrome that includes abrupt onset of obsessive-compulsive disorder (OCD) or eating restriction in combination with anxiety, attention deficit, hyperkinesia, emotional lability, irritability, aggressive or oppositional behavior, or academic decline. Neurologic findings also may be present; these are most often motor or vocal tics, but choreiform movements of the finger (repetitive motions that are rapid, jerky, and involuntary), deteriorating penmanship, sleep disruptions, or urinary frequency also may be present. The clinical course most often is relapsing and remitting with overall improvement over months or years.
(J Child Adolesc Psychopharmacol. 2017 Apr 7. doi: 10.1089/cap.2016.0151).
Specific recommendations include:
1. Searching for a coexisting infectious etiology with history, exam, and appropriate laboratory testing (including ASO and ADB antibodies), and, when present, treating accordingly. Even in the absence of definitive evidence of GAS infection, they recommend an initial course of antimicrobial therapy such as that given to patients with rheumatic fever.
2. For children with PANDAS (PANS with either culture or serologic evidence of GAS), consider instituting long-term streptococcal prophylaxis. The data on its value is mixed; however, most studies find more than 40% (and as many as 75%) of exacerbations are associated with GAS, and at least one study reports a reduction in neuropsychiatric exacerbations in children on penicillin or azithromycin prophylaxis for a 1-year period. Such decisions should be individualized: In children with strong evidence of exacerbations linked to GAS, there was thought to be greater likelihood of benefit, while, in those with no evidence for prior GAS infection, the potential for benefit was thought to be insufficient to justify prophylaxis. Furthermore, the optimal duration of prophylaxis is unknown. The guidelines recommend up to 2 years, but individualization is appropriate since severe cases may warrant prolonged prophylaxis.
3. In children who present with PANDAS and a positive throat culture for GAS, follow-up should be the same as that given for rheumatic fever, with reculture at 2-7 days and retreatment if there is persistence of GAS.
4. Vigilance for GAS infection in family members is appropriate, including obtaining throat cultures from persons with pharyngitis and treating them promptly when results are positive.
5. When GAS infection is not identified, the clinician should search for alternative infectious agents, such as Mycoplasma pneumoniae (using polymerase chain reaction on throat or nasopharyngeal swab), influenza virus, or alternative infections such as sinusitis, and treat accordingly.
6. Children with PANS and PANDAS should be immunized according to Advisory Committee of Immunization Practices recommendations, which includes annual influenza immunization. The committee reported that symptom flares after immunization were uncommon, brief, and manageable with NSAIDs.
7. The committee suggested that optimization of serum vitamin D levels among children with PANS and PANDAS could be of benefit, despite limited evidence. The committee members recommended treating children with PANS/PANDAS with vitamin D3 as needed to maintain serum 25-hydroxy vitamin D levels above 30 ng/mL. No benefit for adenotonsillectomy was identified. The committee recommended that tonsillectomy and/or adenoidectomy should limited to those with traditional indications (sleep apnea, failure to thrive, and abnormally large tonsils, etc.). The committee also found no evidence to suggest that probiotics modulate this condition.
These guidelines come with an important caveat. They represent a practical clinical approach for the management of infection in the context of PANS or PANDAS and rely heavily on the clinical experience of the members of the PANS/PANDAS Consortium. They provide criteria for the retrospective diagnosis of GAS infection and recommend treatment of GAS in all patients with newly diagnosed PANS. The suggested guidelines are supported by limited data and recognize that further prospective study of the mechanistic link between infection and PANS, clarification of the risk factors for development of PANS, and definitive study of the risks and benefits of antimicrobial prophylaxis are needed.
The consortium also has published two accompanying guidelines that address psychiatric (J Child Adolesc Psychopharmacol. 2017. doi: 10.1089/cap.2016.0145) and immunomodulatory management (J Child Adolesc Psychopharmacol. 2017. doi: 10.1089/cap.2016.0148) in the same issue of the Journal of Child and Adolescent Psychopharmacology.
Proposed criteria for documenting GAS infection in PANS pediatric patients
- A rise in serial antibody level, regardless of rapid test or culture result. This definition does not require clinical pharyngitis.
- Acute pharyngitis with a positive GAS throat culture, with or without a rising antibody level.
- Pharyngitis with characteristic palatal petechiae.
- Pharyngitis with a characteristic scarlatiniform rash.
- Pharyngitis without a throat swab or serology, but intimate (usually household) exposure to a proven GAS case.
- Asymptomatic pharyngeal colonization documented after an intimate exposure.
- Asymptomatic pharyngeal colonization after a negative throat swab documented within the prior 3-4 months.
- Single ASO or ADB antibody level within 6 months after the initial onset of neuropsychiatric symptoms may be accepted as positive if it is more than 95th percentile, using the laboratory’s normal standard for children of comparable age, or provisionally ASO greater than or equal to 1:480 or ADB greater than or equal to 1:1280.
- Both ASO and ADB are elevated at more than 80% percentile for age in the same serum sample within 6 months after the initial onset of neuropsychiatric symptoms.
- Culture-documented streptococcal dermatitis.
Source: J Child Adolesc Psychopharmacol. 2017. doi: 10.1089/cap.2016.0151.
Dr. Pelton is chief of pediatric infectious disease and coordinator of the maternal-child HIV program at Boston Medical Center. Dr. Pelton said he had no relevant financial disclosures. Email him at pdnews@frontlinemedcom.com.
In the Journal of Child and Adolescent Psychopharmacology’s July 2017 issue, a group of respected individuals representing diverse expertise published “guidelines” to support clinical management of pediatric acute-onset neuropsychiatric syndrome (PANS) and its subclass PANDAS (those associated with streptococcal infection). PANS represents an enigmatic clinical syndrome that includes abrupt onset of obsessive-compulsive disorder (OCD) or eating restriction in combination with anxiety, attention deficit, hyperkinesia, emotional lability, irritability, aggressive or oppositional behavior, or academic decline. Neurologic findings also may be present; these are most often motor or vocal tics, but choreiform movements of the finger (repetitive motions that are rapid, jerky, and involuntary), deteriorating penmanship, sleep disruptions, or urinary frequency also may be present. The clinical course most often is relapsing and remitting with overall improvement over months or years.
(J Child Adolesc Psychopharmacol. 2017 Apr 7. doi: 10.1089/cap.2016.0151).
Specific recommendations include:
1. Searching for a coexisting infectious etiology with history, exam, and appropriate laboratory testing (including ASO and ADB antibodies), and, when present, treating accordingly. Even in the absence of definitive evidence of GAS infection, they recommend an initial course of antimicrobial therapy such as that given to patients with rheumatic fever.
2. For children with PANDAS (PANS with either culture or serologic evidence of GAS), consider instituting long-term streptococcal prophylaxis. The data on its value is mixed; however, most studies find more than 40% (and as many as 75%) of exacerbations are associated with GAS, and at least one study reports a reduction in neuropsychiatric exacerbations in children on penicillin or azithromycin prophylaxis for a 1-year period. Such decisions should be individualized: In children with strong evidence of exacerbations linked to GAS, there was thought to be greater likelihood of benefit, while, in those with no evidence for prior GAS infection, the potential for benefit was thought to be insufficient to justify prophylaxis. Furthermore, the optimal duration of prophylaxis is unknown. The guidelines recommend up to 2 years, but individualization is appropriate since severe cases may warrant prolonged prophylaxis.
3. In children who present with PANDAS and a positive throat culture for GAS, follow-up should be the same as that given for rheumatic fever, with reculture at 2-7 days and retreatment if there is persistence of GAS.
4. Vigilance for GAS infection in family members is appropriate, including obtaining throat cultures from persons with pharyngitis and treating them promptly when results are positive.
5. When GAS infection is not identified, the clinician should search for alternative infectious agents, such as Mycoplasma pneumoniae (using polymerase chain reaction on throat or nasopharyngeal swab), influenza virus, or alternative infections such as sinusitis, and treat accordingly.
6. Children with PANS and PANDAS should be immunized according to Advisory Committee of Immunization Practices recommendations, which includes annual influenza immunization. The committee reported that symptom flares after immunization were uncommon, brief, and manageable with NSAIDs.
7. The committee suggested that optimization of serum vitamin D levels among children with PANS and PANDAS could be of benefit, despite limited evidence. The committee members recommended treating children with PANS/PANDAS with vitamin D3 as needed to maintain serum 25-hydroxy vitamin D levels above 30 ng/mL. No benefit for adenotonsillectomy was identified. The committee recommended that tonsillectomy and/or adenoidectomy should limited to those with traditional indications (sleep apnea, failure to thrive, and abnormally large tonsils, etc.). The committee also found no evidence to suggest that probiotics modulate this condition.
These guidelines come with an important caveat. They represent a practical clinical approach for the management of infection in the context of PANS or PANDAS and rely heavily on the clinical experience of the members of the PANS/PANDAS Consortium. They provide criteria for the retrospective diagnosis of GAS infection and recommend treatment of GAS in all patients with newly diagnosed PANS. The suggested guidelines are supported by limited data and recognize that further prospective study of the mechanistic link between infection and PANS, clarification of the risk factors for development of PANS, and definitive study of the risks and benefits of antimicrobial prophylaxis are needed.
The consortium also has published two accompanying guidelines that address psychiatric (J Child Adolesc Psychopharmacol. 2017. doi: 10.1089/cap.2016.0145) and immunomodulatory management (J Child Adolesc Psychopharmacol. 2017. doi: 10.1089/cap.2016.0148) in the same issue of the Journal of Child and Adolescent Psychopharmacology.
Proposed criteria for documenting GAS infection in PANS pediatric patients
- A rise in serial antibody level, regardless of rapid test or culture result. This definition does not require clinical pharyngitis.
- Acute pharyngitis with a positive GAS throat culture, with or without a rising antibody level.
- Pharyngitis with characteristic palatal petechiae.
- Pharyngitis with a characteristic scarlatiniform rash.
- Pharyngitis without a throat swab or serology, but intimate (usually household) exposure to a proven GAS case.
- Asymptomatic pharyngeal colonization documented after an intimate exposure.
- Asymptomatic pharyngeal colonization after a negative throat swab documented within the prior 3-4 months.
- Single ASO or ADB antibody level within 6 months after the initial onset of neuropsychiatric symptoms may be accepted as positive if it is more than 95th percentile, using the laboratory’s normal standard for children of comparable age, or provisionally ASO greater than or equal to 1:480 or ADB greater than or equal to 1:1280.
- Both ASO and ADB are elevated at more than 80% percentile for age in the same serum sample within 6 months after the initial onset of neuropsychiatric symptoms.
- Culture-documented streptococcal dermatitis.
Source: J Child Adolesc Psychopharmacol. 2017. doi: 10.1089/cap.2016.0151.
Dr. Pelton is chief of pediatric infectious disease and coordinator of the maternal-child HIV program at Boston Medical Center. Dr. Pelton said he had no relevant financial disclosures. Email him at pdnews@frontlinemedcom.com.
In the Journal of Child and Adolescent Psychopharmacology’s July 2017 issue, a group of respected individuals representing diverse expertise published “guidelines” to support clinical management of pediatric acute-onset neuropsychiatric syndrome (PANS) and its subclass PANDAS (those associated with streptococcal infection). PANS represents an enigmatic clinical syndrome that includes abrupt onset of obsessive-compulsive disorder (OCD) or eating restriction in combination with anxiety, attention deficit, hyperkinesia, emotional lability, irritability, aggressive or oppositional behavior, or academic decline. Neurologic findings also may be present; these are most often motor or vocal tics, but choreiform movements of the finger (repetitive motions that are rapid, jerky, and involuntary), deteriorating penmanship, sleep disruptions, or urinary frequency also may be present. The clinical course most often is relapsing and remitting with overall improvement over months or years.
(J Child Adolesc Psychopharmacol. 2017 Apr 7. doi: 10.1089/cap.2016.0151).
Specific recommendations include:
1. Searching for a coexisting infectious etiology with history, exam, and appropriate laboratory testing (including ASO and ADB antibodies), and, when present, treating accordingly. Even in the absence of definitive evidence of GAS infection, they recommend an initial course of antimicrobial therapy such as that given to patients with rheumatic fever.
2. For children with PANDAS (PANS with either culture or serologic evidence of GAS), consider instituting long-term streptococcal prophylaxis. The data on its value is mixed; however, most studies find more than 40% (and as many as 75%) of exacerbations are associated with GAS, and at least one study reports a reduction in neuropsychiatric exacerbations in children on penicillin or azithromycin prophylaxis for a 1-year period. Such decisions should be individualized: In children with strong evidence of exacerbations linked to GAS, there was thought to be greater likelihood of benefit, while, in those with no evidence for prior GAS infection, the potential for benefit was thought to be insufficient to justify prophylaxis. Furthermore, the optimal duration of prophylaxis is unknown. The guidelines recommend up to 2 years, but individualization is appropriate since severe cases may warrant prolonged prophylaxis.
3. In children who present with PANDAS and a positive throat culture for GAS, follow-up should be the same as that given for rheumatic fever, with reculture at 2-7 days and retreatment if there is persistence of GAS.
4. Vigilance for GAS infection in family members is appropriate, including obtaining throat cultures from persons with pharyngitis and treating them promptly when results are positive.
5. When GAS infection is not identified, the clinician should search for alternative infectious agents, such as Mycoplasma pneumoniae (using polymerase chain reaction on throat or nasopharyngeal swab), influenza virus, or alternative infections such as sinusitis, and treat accordingly.
6. Children with PANS and PANDAS should be immunized according to Advisory Committee of Immunization Practices recommendations, which includes annual influenza immunization. The committee reported that symptom flares after immunization were uncommon, brief, and manageable with NSAIDs.
7. The committee suggested that optimization of serum vitamin D levels among children with PANS and PANDAS could be of benefit, despite limited evidence. The committee members recommended treating children with PANS/PANDAS with vitamin D3 as needed to maintain serum 25-hydroxy vitamin D levels above 30 ng/mL. No benefit for adenotonsillectomy was identified. The committee recommended that tonsillectomy and/or adenoidectomy should limited to those with traditional indications (sleep apnea, failure to thrive, and abnormally large tonsils, etc.). The committee also found no evidence to suggest that probiotics modulate this condition.
These guidelines come with an important caveat. They represent a practical clinical approach for the management of infection in the context of PANS or PANDAS and rely heavily on the clinical experience of the members of the PANS/PANDAS Consortium. They provide criteria for the retrospective diagnosis of GAS infection and recommend treatment of GAS in all patients with newly diagnosed PANS. The suggested guidelines are supported by limited data and recognize that further prospective study of the mechanistic link between infection and PANS, clarification of the risk factors for development of PANS, and definitive study of the risks and benefits of antimicrobial prophylaxis are needed.
The consortium also has published two accompanying guidelines that address psychiatric (J Child Adolesc Psychopharmacol. 2017. doi: 10.1089/cap.2016.0145) and immunomodulatory management (J Child Adolesc Psychopharmacol. 2017. doi: 10.1089/cap.2016.0148) in the same issue of the Journal of Child and Adolescent Psychopharmacology.
Proposed criteria for documenting GAS infection in PANS pediatric patients
- A rise in serial antibody level, regardless of rapid test or culture result. This definition does not require clinical pharyngitis.
- Acute pharyngitis with a positive GAS throat culture, with or without a rising antibody level.
- Pharyngitis with characteristic palatal petechiae.
- Pharyngitis with a characteristic scarlatiniform rash.
- Pharyngitis without a throat swab or serology, but intimate (usually household) exposure to a proven GAS case.
- Asymptomatic pharyngeal colonization documented after an intimate exposure.
- Asymptomatic pharyngeal colonization after a negative throat swab documented within the prior 3-4 months.
- Single ASO or ADB antibody level within 6 months after the initial onset of neuropsychiatric symptoms may be accepted as positive if it is more than 95th percentile, using the laboratory’s normal standard for children of comparable age, or provisionally ASO greater than or equal to 1:480 or ADB greater than or equal to 1:1280.
- Both ASO and ADB are elevated at more than 80% percentile for age in the same serum sample within 6 months after the initial onset of neuropsychiatric symptoms.
- Culture-documented streptococcal dermatitis.
Source: J Child Adolesc Psychopharmacol. 2017. doi: 10.1089/cap.2016.0151.
Dr. Pelton is chief of pediatric infectious disease and coordinator of the maternal-child HIV program at Boston Medical Center. Dr. Pelton said he had no relevant financial disclosures. Email him at pdnews@frontlinemedcom.com.
Religion and LGBTQ identities
JB is a 15-year-old female who presents to your office for a wellness check. Mom is concerned because she has seemed more depressed and withdrawn over the past few months. During the confidential portion of your visit, JB discloses that, while she has had boyfriends in the past, she is realizing that she is romantically and sexually attracted to females. Many members of her religious faith, which she is strongly connected to, believe that homosexuality is a sin. She has been secretly researching therapies to help her “not be gay” and asks you for advice.
Adolescence is a time of rapid growth and development. Two important developmental tasks of adolescence are to establish key aspects of identity and identify meaningful moral standards, values, and belief systems.1 For some LGBTQ adolescents, these tasks can become more complicated when the value system or religious faith in which they were raised views homosexuality or gender nonconformity as a sin.
- Identifying as lesbian, gay, bisexual, or transgender is normal, just different.
- LGBT people exist in almost every faith group across the country.
- Many religious groups have wrestled with homosexuality, gender identity, and religion and decided to be more welcoming to LGBT communities.
- Within most faiths, there are many interpretations of religious texts, such as the Bible and the Koran, on all issues, including homosexuality.
- While every religion has different teachings, almost all religions advocate love and compassion.
- Clergy and other faith leaders can be a source of support. However, every faith community is different and may not always be supportive. Safely investigate your individual community’s approach. You have the right to question and explore your faith, sexuality, and/or gender identity and reconcile these in a way that is true to you.
- Remember this is your journey. You get to decide the path and the pace.
- Recognize that this may involve working for change within your community or it may mean leaving it.
- Referral for “conversion” or “reparative therapy” is never indicated. Such therapy is not effective and may be harmful to LGBTQ individuals by increasing internalized stigma, distress, and depression.
Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus. She has no relevant financial disclosures. Email her at pdnews@frontlinemedcom.com.
Spirituality resources
- LGBTQ and Religion: Your Relationship with Religion is Completely Up to You, the FAQ Page by the Trevor Project, a national organization that provides crisis intervention and suicide prevention resources to LGBTQ young people ages 13-24 years. www.thetrevorproject.org/pages/lgbtq-and-religion
- Faith in Our Families: Parents, Families and Friends Talk About Religion and Homosexuality, a resource from PFLAG (Parents, Families, and Friends of Lesbians and Gays). www.pflag.org/sites/default/files/Faith%20In%20Our%20Families.pdf
- LGBT Center UNC Chapel Hill: Religion and Spirituality, a page with a link to nondenominational and denomination-specific resources with various religious and spiritual communities’ beliefs regarding faith and LGBTQIA+ (Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual). lgbtq.unc.edu/resources/exploring-identities/religion-and-spirituality
- HRC: Explore Religion and Faith, a Human Rights Campaign page containing links to resources on religion and faith. It also has links to the Coming Home Series, guides aimed at those who hope to lead their faith communities toward a more welcoming stance and those seeking a path back to beloved traditions. www.hrc.org/explore/topic/religion-faith
References
1. Raising teens: A synthesis or research and a foundation for action. (Boston: Center for Health Communication, Harvard School of Public Health, 2001).
2. Faith in Our Families: Parents, Families and Friends Talk About Religion and Homosexuality (Washington, D.C.: Parents, Families and Friends of Lesbians and Gays, 1997)
3. Pediatrics. 2013 Jul;132(1):198-203.
4. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. (Washington, D.C.: National Academies Press, 2011)
5. Coming Home: To Faith, to Spirit, to Self. Pamphlet by the Human Rights Campaign.
JB is a 15-year-old female who presents to your office for a wellness check. Mom is concerned because she has seemed more depressed and withdrawn over the past few months. During the confidential portion of your visit, JB discloses that, while she has had boyfriends in the past, she is realizing that she is romantically and sexually attracted to females. Many members of her religious faith, which she is strongly connected to, believe that homosexuality is a sin. She has been secretly researching therapies to help her “not be gay” and asks you for advice.
Adolescence is a time of rapid growth and development. Two important developmental tasks of adolescence are to establish key aspects of identity and identify meaningful moral standards, values, and belief systems.1 For some LGBTQ adolescents, these tasks can become more complicated when the value system or religious faith in which they were raised views homosexuality or gender nonconformity as a sin.
- Identifying as lesbian, gay, bisexual, or transgender is normal, just different.
- LGBT people exist in almost every faith group across the country.
- Many religious groups have wrestled with homosexuality, gender identity, and religion and decided to be more welcoming to LGBT communities.
- Within most faiths, there are many interpretations of religious texts, such as the Bible and the Koran, on all issues, including homosexuality.
- While every religion has different teachings, almost all religions advocate love and compassion.
- Clergy and other faith leaders can be a source of support. However, every faith community is different and may not always be supportive. Safely investigate your individual community’s approach. You have the right to question and explore your faith, sexuality, and/or gender identity and reconcile these in a way that is true to you.
- Remember this is your journey. You get to decide the path and the pace.
- Recognize that this may involve working for change within your community or it may mean leaving it.
- Referral for “conversion” or “reparative therapy” is never indicated. Such therapy is not effective and may be harmful to LGBTQ individuals by increasing internalized stigma, distress, and depression.
Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus. She has no relevant financial disclosures. Email her at pdnews@frontlinemedcom.com.
Spirituality resources
- LGBTQ and Religion: Your Relationship with Religion is Completely Up to You, the FAQ Page by the Trevor Project, a national organization that provides crisis intervention and suicide prevention resources to LGBTQ young people ages 13-24 years. www.thetrevorproject.org/pages/lgbtq-and-religion
- Faith in Our Families: Parents, Families and Friends Talk About Religion and Homosexuality, a resource from PFLAG (Parents, Families, and Friends of Lesbians and Gays). www.pflag.org/sites/default/files/Faith%20In%20Our%20Families.pdf
- LGBT Center UNC Chapel Hill: Religion and Spirituality, a page with a link to nondenominational and denomination-specific resources with various religious and spiritual communities’ beliefs regarding faith and LGBTQIA+ (Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual). lgbtq.unc.edu/resources/exploring-identities/religion-and-spirituality
- HRC: Explore Religion and Faith, a Human Rights Campaign page containing links to resources on religion and faith. It also has links to the Coming Home Series, guides aimed at those who hope to lead their faith communities toward a more welcoming stance and those seeking a path back to beloved traditions. www.hrc.org/explore/topic/religion-faith
References
1. Raising teens: A synthesis or research and a foundation for action. (Boston: Center for Health Communication, Harvard School of Public Health, 2001).
2. Faith in Our Families: Parents, Families and Friends Talk About Religion and Homosexuality (Washington, D.C.: Parents, Families and Friends of Lesbians and Gays, 1997)
3. Pediatrics. 2013 Jul;132(1):198-203.
4. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. (Washington, D.C.: National Academies Press, 2011)
5. Coming Home: To Faith, to Spirit, to Self. Pamphlet by the Human Rights Campaign.
JB is a 15-year-old female who presents to your office for a wellness check. Mom is concerned because she has seemed more depressed and withdrawn over the past few months. During the confidential portion of your visit, JB discloses that, while she has had boyfriends in the past, she is realizing that she is romantically and sexually attracted to females. Many members of her religious faith, which she is strongly connected to, believe that homosexuality is a sin. She has been secretly researching therapies to help her “not be gay” and asks you for advice.
Adolescence is a time of rapid growth and development. Two important developmental tasks of adolescence are to establish key aspects of identity and identify meaningful moral standards, values, and belief systems.1 For some LGBTQ adolescents, these tasks can become more complicated when the value system or religious faith in which they were raised views homosexuality or gender nonconformity as a sin.
- Identifying as lesbian, gay, bisexual, or transgender is normal, just different.
- LGBT people exist in almost every faith group across the country.
- Many religious groups have wrestled with homosexuality, gender identity, and religion and decided to be more welcoming to LGBT communities.
- Within most faiths, there are many interpretations of religious texts, such as the Bible and the Koran, on all issues, including homosexuality.
- While every religion has different teachings, almost all religions advocate love and compassion.
- Clergy and other faith leaders can be a source of support. However, every faith community is different and may not always be supportive. Safely investigate your individual community’s approach. You have the right to question and explore your faith, sexuality, and/or gender identity and reconcile these in a way that is true to you.
- Remember this is your journey. You get to decide the path and the pace.
- Recognize that this may involve working for change within your community or it may mean leaving it.
- Referral for “conversion” or “reparative therapy” is never indicated. Such therapy is not effective and may be harmful to LGBTQ individuals by increasing internalized stigma, distress, and depression.
Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus. She has no relevant financial disclosures. Email her at pdnews@frontlinemedcom.com.
Spirituality resources
- LGBTQ and Religion: Your Relationship with Religion is Completely Up to You, the FAQ Page by the Trevor Project, a national organization that provides crisis intervention and suicide prevention resources to LGBTQ young people ages 13-24 years. www.thetrevorproject.org/pages/lgbtq-and-religion
- Faith in Our Families: Parents, Families and Friends Talk About Religion and Homosexuality, a resource from PFLAG (Parents, Families, and Friends of Lesbians and Gays). www.pflag.org/sites/default/files/Faith%20In%20Our%20Families.pdf
- LGBT Center UNC Chapel Hill: Religion and Spirituality, a page with a link to nondenominational and denomination-specific resources with various religious and spiritual communities’ beliefs regarding faith and LGBTQIA+ (Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual). lgbtq.unc.edu/resources/exploring-identities/religion-and-spirituality
- HRC: Explore Religion and Faith, a Human Rights Campaign page containing links to resources on religion and faith. It also has links to the Coming Home Series, guides aimed at those who hope to lead their faith communities toward a more welcoming stance and those seeking a path back to beloved traditions. www.hrc.org/explore/topic/religion-faith
References
1. Raising teens: A synthesis or research and a foundation for action. (Boston: Center for Health Communication, Harvard School of Public Health, 2001).
2. Faith in Our Families: Parents, Families and Friends Talk About Religion and Homosexuality (Washington, D.C.: Parents, Families and Friends of Lesbians and Gays, 1997)
3. Pediatrics. 2013 Jul;132(1):198-203.
4. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. (Washington, D.C.: National Academies Press, 2011)
5. Coming Home: To Faith, to Spirit, to Self. Pamphlet by the Human Rights Campaign.
Student Hospitalist Scholars: Discovering a passion for research
Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-2018 year, offering two options for students to receive funding and engage in scholarly work during their first, second, and third years of medical school. As a part of the program, recipients are required to write about their experience on a biweekly basis.
When I decided to leave the business world to pursue a career in medicine, I envisioned myself in a clinic or an operating room helping the people in my community with the knowledge and skills acquired in my medical training. The thought of becoming a researcher had never even crossed my mind.
I grew up in Scottsdale, Arizona, a city which has no major academic medical centers. Prior to entering medical school, I was enrolled in a postbaccalaureate program at Johns Hopkins University, where I took the basic science classes necessary to apply. I was quite surprised to learn that, even at this level of education, I was required to participate in a research project. This experience changed the way I envisioned my entire career as a physician.
I am now a fourth year medical student and a pioneer of the “new curriculum” at Weill Cornell Medical College. In contrast to the traditional medical school curriculum, Cornell carved out 6 months of protected research time for all medical students by condensing the preclinical curriculum from 2 years to 1.5 years. I learned how much I enjoyed research at Johns Hopkins, which is one of the main reasons I applied here.
Despite my interest in research, I still struggled with the ultimate career question: What kind of doctor do I want to be?
After completing my medicine clerkship, I remember feeling intellectually stimulated in a way I hadn’t experienced in the previous years. While this may have had to do with the subject matter, I attribute much of this feeling to my clerkship director whose passion for medicine and teaching was contagious. I ultimately chose Ernie Esquivel, MD, to be my research mentor because of how much he impacted my education.
Together we came up with a project to study the utility of bone biopsies in the management of osteomyelitis. We are doing this by analyzing changes from empiric to final antibiotics after bone biopsy results become available to determine how clinicians use this information to guide their management of the disease. We were also interested in analyzing predictors of positive bone cultures in this population. The success of this project will mostly be based on our ability to perform these analyses, regardless of what the results may be. We hypothesize that, in fact, bone biopsy results are not likely to have a significant impact on antibiotic management of osteomyelitis in nonvertebral bones.
I was one of the lucky few to be awarded a grant from the Society of Hospital Medicine, which will be instrumental in the success of the project. This grant will not only support my ongoing research efforts but will also afford me the opportunity to attend the annual SHM conference and become integrated into the medical community in a way that would otherwise never be possible.
Cole Hirschfeld is originally from Phoenix, Ariz. He received undergraduate degrees in finance and entrepreneurship from the University of Arizona and went on to work in the finance industry for 2 years before deciding to change careers and attend medical school. He is now a fourth year medical student at Weill Cornell Medical College and plans to apply for residency in internal medicine.
Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-2018 year, offering two options for students to receive funding and engage in scholarly work during their first, second, and third years of medical school. As a part of the program, recipients are required to write about their experience on a biweekly basis.
When I decided to leave the business world to pursue a career in medicine, I envisioned myself in a clinic or an operating room helping the people in my community with the knowledge and skills acquired in my medical training. The thought of becoming a researcher had never even crossed my mind.
I grew up in Scottsdale, Arizona, a city which has no major academic medical centers. Prior to entering medical school, I was enrolled in a postbaccalaureate program at Johns Hopkins University, where I took the basic science classes necessary to apply. I was quite surprised to learn that, even at this level of education, I was required to participate in a research project. This experience changed the way I envisioned my entire career as a physician.
I am now a fourth year medical student and a pioneer of the “new curriculum” at Weill Cornell Medical College. In contrast to the traditional medical school curriculum, Cornell carved out 6 months of protected research time for all medical students by condensing the preclinical curriculum from 2 years to 1.5 years. I learned how much I enjoyed research at Johns Hopkins, which is one of the main reasons I applied here.
Despite my interest in research, I still struggled with the ultimate career question: What kind of doctor do I want to be?
After completing my medicine clerkship, I remember feeling intellectually stimulated in a way I hadn’t experienced in the previous years. While this may have had to do with the subject matter, I attribute much of this feeling to my clerkship director whose passion for medicine and teaching was contagious. I ultimately chose Ernie Esquivel, MD, to be my research mentor because of how much he impacted my education.
Together we came up with a project to study the utility of bone biopsies in the management of osteomyelitis. We are doing this by analyzing changes from empiric to final antibiotics after bone biopsy results become available to determine how clinicians use this information to guide their management of the disease. We were also interested in analyzing predictors of positive bone cultures in this population. The success of this project will mostly be based on our ability to perform these analyses, regardless of what the results may be. We hypothesize that, in fact, bone biopsy results are not likely to have a significant impact on antibiotic management of osteomyelitis in nonvertebral bones.
I was one of the lucky few to be awarded a grant from the Society of Hospital Medicine, which will be instrumental in the success of the project. This grant will not only support my ongoing research efforts but will also afford me the opportunity to attend the annual SHM conference and become integrated into the medical community in a way that would otherwise never be possible.
Cole Hirschfeld is originally from Phoenix, Ariz. He received undergraduate degrees in finance and entrepreneurship from the University of Arizona and went on to work in the finance industry for 2 years before deciding to change careers and attend medical school. He is now a fourth year medical student at Weill Cornell Medical College and plans to apply for residency in internal medicine.
Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-2018 year, offering two options for students to receive funding and engage in scholarly work during their first, second, and third years of medical school. As a part of the program, recipients are required to write about their experience on a biweekly basis.
When I decided to leave the business world to pursue a career in medicine, I envisioned myself in a clinic or an operating room helping the people in my community with the knowledge and skills acquired in my medical training. The thought of becoming a researcher had never even crossed my mind.
I grew up in Scottsdale, Arizona, a city which has no major academic medical centers. Prior to entering medical school, I was enrolled in a postbaccalaureate program at Johns Hopkins University, where I took the basic science classes necessary to apply. I was quite surprised to learn that, even at this level of education, I was required to participate in a research project. This experience changed the way I envisioned my entire career as a physician.
I am now a fourth year medical student and a pioneer of the “new curriculum” at Weill Cornell Medical College. In contrast to the traditional medical school curriculum, Cornell carved out 6 months of protected research time for all medical students by condensing the preclinical curriculum from 2 years to 1.5 years. I learned how much I enjoyed research at Johns Hopkins, which is one of the main reasons I applied here.
Despite my interest in research, I still struggled with the ultimate career question: What kind of doctor do I want to be?
After completing my medicine clerkship, I remember feeling intellectually stimulated in a way I hadn’t experienced in the previous years. While this may have had to do with the subject matter, I attribute much of this feeling to my clerkship director whose passion for medicine and teaching was contagious. I ultimately chose Ernie Esquivel, MD, to be my research mentor because of how much he impacted my education.
Together we came up with a project to study the utility of bone biopsies in the management of osteomyelitis. We are doing this by analyzing changes from empiric to final antibiotics after bone biopsy results become available to determine how clinicians use this information to guide their management of the disease. We were also interested in analyzing predictors of positive bone cultures in this population. The success of this project will mostly be based on our ability to perform these analyses, regardless of what the results may be. We hypothesize that, in fact, bone biopsy results are not likely to have a significant impact on antibiotic management of osteomyelitis in nonvertebral bones.
I was one of the lucky few to be awarded a grant from the Society of Hospital Medicine, which will be instrumental in the success of the project. This grant will not only support my ongoing research efforts but will also afford me the opportunity to attend the annual SHM conference and become integrated into the medical community in a way that would otherwise never be possible.
Cole Hirschfeld is originally from Phoenix, Ariz. He received undergraduate degrees in finance and entrepreneurship from the University of Arizona and went on to work in the finance industry for 2 years before deciding to change careers and attend medical school. He is now a fourth year medical student at Weill Cornell Medical College and plans to apply for residency in internal medicine.