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After backlash, publisher to retract article that surveyed parents of children with gender dysphoria, says coauthor
The move is “due to concerns about lack of informed consent,” according to tweets by one of the paper’s authors.
The article, “Rapid Onset Gender Dysphoria: Parent Reports on 1655 Possible Cases,” was published in March in the Archives of Sexual Behavior. It has not been cited in the scientific literature, according to Clarivate’s Web of Science, but Altmetric, which tracks the online attention papers receive, ranks the article in the top 1% of all articles of a similar age.
Rapid Onset Gender Dysphoria (ROGD) is, the article stated, a “controversial theory” that “common cultural beliefs, values, and preoccupations cause some adolescents (especially female adolescents) to attribute their social problems, feelings, and mental health issues to gender dysphoria,” and that “youth with ROGD falsely believe that they are transgender,” in part due to social influences.
Michael Bailey, a psychology professor at Northwestern University in Evanston, Ill., and the paper’s corresponding author, tweeted:
Bailey told Retraction Watch that he would “respond when [he] can” to our request for comment, following “new developments on our end.” Neither Springer Nature nor Kenneth Zucker, editor in chief of Archives of Sexual Behavior, has responded to similar requests.
The paper reported the results of a survey of parents who contacted the website ParentsofROGDKids.com, with which the first author is affiliated. According to the abstract, the authors found:
“Pre-existing mental health issues were common, and youths with these issues were more likely than those without them to have socially and medically transitioned. Parents reported that they had often felt pressured by clinicians to affirm their AYA [adolescent and young adult] child’s new gender and support their transition. According to the parents, AYA children’s mental health deteriorated considerably after social transition.”
Soon after publication, the paper attracted criticism that its method of gathering study participants was biased, and that the authors ignored information that didn’t support the theory of ROGD.
Archives of Sexual Behavior is the official publication of the International Academy of Sex Research, which tweeted on April 19:
The episode prompted a May 5 “Open Letter in Support of Dr. Kenneth Zucker and the Need to Promote Robust Scientific Debate” from the Foundation Against Intolerance and Racism that has now been signed by nearly 2000 people.
On May 10, the following publisher’s note was added to the article:
“readers are alerted that concerns have been raised regarding methodology as described in this article. The publisher is currently investigating this matter and a further response will follow the conclusion of this investigation.
Six days later, the publisher removed the article’s supplementary information “due to a lack of documented consent by study participants.”
The story may feel familiar to readers who recall what happened to another paper in 2018. In that paper, Brown University’s Lisa Littman coined the term ROGD. Following a backlash, Brown took down a press release touting the results, and the paper was eventually republished with corrections.
Bailey has been accused of mistreating transgender research participants, but an investigation by bioethicist Alice Dreger found that of the many accusations, “almost none appear to have been legitimate.”
In a post on UnHerd earlier this month, Bailey responded to the reported concerns about the study lacking approval by an Institutional Review Board (IRB), and that the way the participants were recruited biased the results.
IRB approval was not necessary, Bailey wrote, because Suzanna Diaz, the first author who collected the data, was not affiliated with an institution that required it. “Suzanna Diaz” is a pseudonym for “the mother of a gender dysphoric child she believes has ROGD” who wishes to remain anonymous for the sake of her family, Bailey wrote.
The paper included the following statement about its ethical approval:
“The first author and creator of the survey is not affiliated with any university or hospital. Thus, she did not seek approval from an IRB. After seeing a presentation of preliminary survey results by the first author, the second author suggested the data to be analyzed and submitted as an academic article (he was not involved in collecting the data). The second author consulted with his university’s IRB, who declined to certify the study because data were already collected. However, they advised that publishing the results was likely ethical provided data were deidentified. Editor’s note: After I reviewed the manuscript, I concluded that its publication is ethically appropriate, consistent with Springer policy.”
In his UnHerd post, Bailey quoted from the journal’s submission guidelines:
“If a study has not been granted ethics committee approval prior to commencing, retrospective ethics approval usually cannot be obtained and it may not be possible to consider the manuscript for peer review. The decision on whether to proceed to peer review in such cases is at the Editor’s discretion.”
“Regarding the methodological limitations of the study, these were addressed forthrightly and thoroughly in our article,” Bailey wrote.
Adam Marcus, a cofounder of Retraction Watch, is an editor at this news organization.
A version of this article first appeared on RetractionWatch.com.
The move is “due to concerns about lack of informed consent,” according to tweets by one of the paper’s authors.
The article, “Rapid Onset Gender Dysphoria: Parent Reports on 1655 Possible Cases,” was published in March in the Archives of Sexual Behavior. It has not been cited in the scientific literature, according to Clarivate’s Web of Science, but Altmetric, which tracks the online attention papers receive, ranks the article in the top 1% of all articles of a similar age.
Rapid Onset Gender Dysphoria (ROGD) is, the article stated, a “controversial theory” that “common cultural beliefs, values, and preoccupations cause some adolescents (especially female adolescents) to attribute their social problems, feelings, and mental health issues to gender dysphoria,” and that “youth with ROGD falsely believe that they are transgender,” in part due to social influences.
Michael Bailey, a psychology professor at Northwestern University in Evanston, Ill., and the paper’s corresponding author, tweeted:
Bailey told Retraction Watch that he would “respond when [he] can” to our request for comment, following “new developments on our end.” Neither Springer Nature nor Kenneth Zucker, editor in chief of Archives of Sexual Behavior, has responded to similar requests.
The paper reported the results of a survey of parents who contacted the website ParentsofROGDKids.com, with which the first author is affiliated. According to the abstract, the authors found:
“Pre-existing mental health issues were common, and youths with these issues were more likely than those without them to have socially and medically transitioned. Parents reported that they had often felt pressured by clinicians to affirm their AYA [adolescent and young adult] child’s new gender and support their transition. According to the parents, AYA children’s mental health deteriorated considerably after social transition.”
Soon after publication, the paper attracted criticism that its method of gathering study participants was biased, and that the authors ignored information that didn’t support the theory of ROGD.
Archives of Sexual Behavior is the official publication of the International Academy of Sex Research, which tweeted on April 19:
The episode prompted a May 5 “Open Letter in Support of Dr. Kenneth Zucker and the Need to Promote Robust Scientific Debate” from the Foundation Against Intolerance and Racism that has now been signed by nearly 2000 people.
On May 10, the following publisher’s note was added to the article:
“readers are alerted that concerns have been raised regarding methodology as described in this article. The publisher is currently investigating this matter and a further response will follow the conclusion of this investigation.
Six days later, the publisher removed the article’s supplementary information “due to a lack of documented consent by study participants.”
The story may feel familiar to readers who recall what happened to another paper in 2018. In that paper, Brown University’s Lisa Littman coined the term ROGD. Following a backlash, Brown took down a press release touting the results, and the paper was eventually republished with corrections.
Bailey has been accused of mistreating transgender research participants, but an investigation by bioethicist Alice Dreger found that of the many accusations, “almost none appear to have been legitimate.”
In a post on UnHerd earlier this month, Bailey responded to the reported concerns about the study lacking approval by an Institutional Review Board (IRB), and that the way the participants were recruited biased the results.
IRB approval was not necessary, Bailey wrote, because Suzanna Diaz, the first author who collected the data, was not affiliated with an institution that required it. “Suzanna Diaz” is a pseudonym for “the mother of a gender dysphoric child she believes has ROGD” who wishes to remain anonymous for the sake of her family, Bailey wrote.
The paper included the following statement about its ethical approval:
“The first author and creator of the survey is not affiliated with any university or hospital. Thus, she did not seek approval from an IRB. After seeing a presentation of preliminary survey results by the first author, the second author suggested the data to be analyzed and submitted as an academic article (he was not involved in collecting the data). The second author consulted with his university’s IRB, who declined to certify the study because data were already collected. However, they advised that publishing the results was likely ethical provided data were deidentified. Editor’s note: After I reviewed the manuscript, I concluded that its publication is ethically appropriate, consistent with Springer policy.”
In his UnHerd post, Bailey quoted from the journal’s submission guidelines:
“If a study has not been granted ethics committee approval prior to commencing, retrospective ethics approval usually cannot be obtained and it may not be possible to consider the manuscript for peer review. The decision on whether to proceed to peer review in such cases is at the Editor’s discretion.”
“Regarding the methodological limitations of the study, these were addressed forthrightly and thoroughly in our article,” Bailey wrote.
Adam Marcus, a cofounder of Retraction Watch, is an editor at this news organization.
A version of this article first appeared on RetractionWatch.com.
The move is “due to concerns about lack of informed consent,” according to tweets by one of the paper’s authors.
The article, “Rapid Onset Gender Dysphoria: Parent Reports on 1655 Possible Cases,” was published in March in the Archives of Sexual Behavior. It has not been cited in the scientific literature, according to Clarivate’s Web of Science, but Altmetric, which tracks the online attention papers receive, ranks the article in the top 1% of all articles of a similar age.
Rapid Onset Gender Dysphoria (ROGD) is, the article stated, a “controversial theory” that “common cultural beliefs, values, and preoccupations cause some adolescents (especially female adolescents) to attribute their social problems, feelings, and mental health issues to gender dysphoria,” and that “youth with ROGD falsely believe that they are transgender,” in part due to social influences.
Michael Bailey, a psychology professor at Northwestern University in Evanston, Ill., and the paper’s corresponding author, tweeted:
Bailey told Retraction Watch that he would “respond when [he] can” to our request for comment, following “new developments on our end.” Neither Springer Nature nor Kenneth Zucker, editor in chief of Archives of Sexual Behavior, has responded to similar requests.
The paper reported the results of a survey of parents who contacted the website ParentsofROGDKids.com, with which the first author is affiliated. According to the abstract, the authors found:
“Pre-existing mental health issues were common, and youths with these issues were more likely than those without them to have socially and medically transitioned. Parents reported that they had often felt pressured by clinicians to affirm their AYA [adolescent and young adult] child’s new gender and support their transition. According to the parents, AYA children’s mental health deteriorated considerably after social transition.”
Soon after publication, the paper attracted criticism that its method of gathering study participants was biased, and that the authors ignored information that didn’t support the theory of ROGD.
Archives of Sexual Behavior is the official publication of the International Academy of Sex Research, which tweeted on April 19:
The episode prompted a May 5 “Open Letter in Support of Dr. Kenneth Zucker and the Need to Promote Robust Scientific Debate” from the Foundation Against Intolerance and Racism that has now been signed by nearly 2000 people.
On May 10, the following publisher’s note was added to the article:
“readers are alerted that concerns have been raised regarding methodology as described in this article. The publisher is currently investigating this matter and a further response will follow the conclusion of this investigation.
Six days later, the publisher removed the article’s supplementary information “due to a lack of documented consent by study participants.”
The story may feel familiar to readers who recall what happened to another paper in 2018. In that paper, Brown University’s Lisa Littman coined the term ROGD. Following a backlash, Brown took down a press release touting the results, and the paper was eventually republished with corrections.
Bailey has been accused of mistreating transgender research participants, but an investigation by bioethicist Alice Dreger found that of the many accusations, “almost none appear to have been legitimate.”
In a post on UnHerd earlier this month, Bailey responded to the reported concerns about the study lacking approval by an Institutional Review Board (IRB), and that the way the participants were recruited biased the results.
IRB approval was not necessary, Bailey wrote, because Suzanna Diaz, the first author who collected the data, was not affiliated with an institution that required it. “Suzanna Diaz” is a pseudonym for “the mother of a gender dysphoric child she believes has ROGD” who wishes to remain anonymous for the sake of her family, Bailey wrote.
The paper included the following statement about its ethical approval:
“The first author and creator of the survey is not affiliated with any university or hospital. Thus, she did not seek approval from an IRB. After seeing a presentation of preliminary survey results by the first author, the second author suggested the data to be analyzed and submitted as an academic article (he was not involved in collecting the data). The second author consulted with his university’s IRB, who declined to certify the study because data were already collected. However, they advised that publishing the results was likely ethical provided data were deidentified. Editor’s note: After I reviewed the manuscript, I concluded that its publication is ethically appropriate, consistent with Springer policy.”
In his UnHerd post, Bailey quoted from the journal’s submission guidelines:
“If a study has not been granted ethics committee approval prior to commencing, retrospective ethics approval usually cannot be obtained and it may not be possible to consider the manuscript for peer review. The decision on whether to proceed to peer review in such cases is at the Editor’s discretion.”
“Regarding the methodological limitations of the study, these were addressed forthrightly and thoroughly in our article,” Bailey wrote.
Adam Marcus, a cofounder of Retraction Watch, is an editor at this news organization.
A version of this article first appeared on RetractionWatch.com.
Link between bipolar disorder and CVD mortality explained?
in new findings that may explain the “excessive and premature mortality” related to heart disease in this patient population.
The investigators found that higher reactive hyperemia index (RHI) scores, a measure of endothelial function, were tied to mood severity in patients with higher mania, but not depression scores. These findings persisted even after accounting for medications, obesity, and other cardiovascular risk factors (CVRFs).
“From a clinical perspective, these findings highlight the potential value of integrating vascular health in the assessment and management of youth with BD, and from a scientific perspective, these findings call for additional research focused on shared biological mechanisms linking vascular health and mood symptoms of BD,” senior investigator Benjamin Goldstein, MD, PhD, full professor of psychiatry, pharmacology, and psychological clinical science, University of Toronto, said in an interview.
The study was published online in the Journal of Clinical Psychiatry.
‘Excessively present’
BD is associated with “excessive and premature cardiovascular mortality” and CVD is “excessively present” in BD, exceeding what can be explained by traditional cardiovascular risk factors, psychiatric medications, and substance use, the researchers noted.
“In adults, more severe mood symptoms increase the risk of future CVD. Our focus on endothelial function rose due to the fact that CVD is rare in youth, whereas endothelial dysfunction – considered a precursor of CVD – can be assessed in youth,” said Dr. Goldstein, who holds the RBC Investments Chair in children’s mental health and developmental psychopathology at the Centre for Addiction and Mental Health, Toronto, where he is director of the Centre for Youth Bipolar Disorder.
For this reason, he and his colleagues were “interested in researching whether endothelial dysfunction is associated with mood symptoms in youth with BD.” Ultimately, the motivation was to “inspire new therapeutic opportunities that may improve both cardiovascular and mental health simultaneously.”
To investigate the question, the researchers studied 209 youth aged 13-20 years (n = 114 with BD and 94 healthy controls [HCs]).
In the BD group, there were 34 BD-euthymia, 36 BD-depressed, and 44 BD-hypomanic/mixed; and within the groups who had depression or hypomania/mixed features, 72 were experiencing clinically significant depression.
Participants had to be free of chronic inflammatory illness, use of medications that might be addressing traditional CVRFs, recent infectious diseases, or neurologic conditions.
Participants’ bipolar symptoms, psychosocial functioning, and family history were assessed. In addition, they were asked about treatment, physical and/or sexual abuse, smoking status, and socioeconomic status. Height, weight, waist circumference, blood pressure, and blood tests to assess CVRFs, including C-reactive protein (CRP), were also assessed. RHI was measured via pulse amplitude tonometry, with lower values indicating poorer endothelial function.
Positive affect beneficial?
Compared with HCs, there were fewer White participants in the BD group (78% vs. 55%; P < .001). The BD group also had higher Tanner stage development scores (stage 5: 65% vs. 35%; P = .03; V = 0.21), higher body mass index (BMI, 24.4 ± 4.6 vs. 22.0 ± 4.2; P < .001; d = 0.53), and higher CRP (1.94 ± 3.99 vs. 0.76 ± 0.86; P = .009; d = –0.40).
After controlling for age, sex, and BMI (F3,202 = 4.47; P = .005; np2 = 0.06), the researchers found significant between-group differences in RHI.
Post hoc pairwise comparisons showed RHI to be significantly lower in the BD-depressed versus the HC group (P = .04; d = 0.4). Moreover, the BD-hypomanic/mixed group had significantly higher RHI, compared with the other BD groups and the HC group.
RHI was associated with higher mania scores (beta, 0.26; P = .006), but there was no similar significant association with depression mood scores (beta, 0.01; P = .90).
The mood state differences in RHI and the RHI-mania association remained significant in sensitivity analyses examining the effect of current medication use as well as CVRFs, including lipids, CRP, and blood pressure on RHI.
“We found that youth with BD experiencing a depressive episode had lower endothelial function, whereas youth with BD experiencing a hypomanic/mixed episode had higher endothelial function, as compared to healthy youth,” Dr. Goldstein said.
There are several mechanisms potentially underlying the association between endothelial function and hypomania, the investigators noted. For example, positive affect is associated with increased endothelial function in normative samples, so hypomanic symptoms, including elation, may have similar beneficial associations, although those benefits likely do not extend to mania, which has been associated with cardiovascular risk.
They also point to several limitations in the study. The cross-sectional design “precludes making inferences regarding the temporal relationship between RHI and mood.” Moreover, the study focused only on hypomania, so “we cannot draw conclusions about mania.” In addition, the HC group had a “significantly higher proportion” of White participants, and a lower Tanner stage, so it “may not be a representative control sample.”
Nevertheless, the researchers concluded that the study “adds to the existing evidence for the potential value of integrating cardiovascular-related therapeutic approaches in BD,” noting that further research is needed to elucidate the mechanisms of the association.
Observable changes in youth
In a comment, Jess G Fiedorowicz, MD, PhD, head and chief, department of mental health, Ottawa Hospital Research Institute, noted that individuals with BD “have a much higher risk of CVD, which tends to develop earlier and shortens life expectancy by more than a decade.”
This cardiovascular risk “appears to be acquired over the long-term course of illness and proportionate to the persistence and severity of mood symptoms, which implies that mood syndromes, such as depression and mania, themselves may induce changes in the body relevant to CVD,” said Dr. Fiedorowicz, who is also a professor in the department of psychiatry and senior research chair in adult psychiatry at the Brain and Mind Research Institute, University of Ottawa, and was not involved with the study.
The study “adds to a growing body of evidence that mood syndromes may enact physiological changes that may be relevant to risk of CVD. One important aspect of this study is that this can even be observed in young sample,” he said.
This study was funded by the Canadian Institutes of Health Research and a Miner’s Lamp Innovation Fund from the University of Toronto. Dr. Goldstein and coauthors declare no relevant financial relationships. Dr. Fiedorowicz receives an honorarium from Elsevier for his work as editor-in-chief of the Journal of Psychosomatic Research.
A version of this article first appeared on Medscape.com.
in new findings that may explain the “excessive and premature mortality” related to heart disease in this patient population.
The investigators found that higher reactive hyperemia index (RHI) scores, a measure of endothelial function, were tied to mood severity in patients with higher mania, but not depression scores. These findings persisted even after accounting for medications, obesity, and other cardiovascular risk factors (CVRFs).
“From a clinical perspective, these findings highlight the potential value of integrating vascular health in the assessment and management of youth with BD, and from a scientific perspective, these findings call for additional research focused on shared biological mechanisms linking vascular health and mood symptoms of BD,” senior investigator Benjamin Goldstein, MD, PhD, full professor of psychiatry, pharmacology, and psychological clinical science, University of Toronto, said in an interview.
The study was published online in the Journal of Clinical Psychiatry.
‘Excessively present’
BD is associated with “excessive and premature cardiovascular mortality” and CVD is “excessively present” in BD, exceeding what can be explained by traditional cardiovascular risk factors, psychiatric medications, and substance use, the researchers noted.
“In adults, more severe mood symptoms increase the risk of future CVD. Our focus on endothelial function rose due to the fact that CVD is rare in youth, whereas endothelial dysfunction – considered a precursor of CVD – can be assessed in youth,” said Dr. Goldstein, who holds the RBC Investments Chair in children’s mental health and developmental psychopathology at the Centre for Addiction and Mental Health, Toronto, where he is director of the Centre for Youth Bipolar Disorder.
For this reason, he and his colleagues were “interested in researching whether endothelial dysfunction is associated with mood symptoms in youth with BD.” Ultimately, the motivation was to “inspire new therapeutic opportunities that may improve both cardiovascular and mental health simultaneously.”
To investigate the question, the researchers studied 209 youth aged 13-20 years (n = 114 with BD and 94 healthy controls [HCs]).
In the BD group, there were 34 BD-euthymia, 36 BD-depressed, and 44 BD-hypomanic/mixed; and within the groups who had depression or hypomania/mixed features, 72 were experiencing clinically significant depression.
Participants had to be free of chronic inflammatory illness, use of medications that might be addressing traditional CVRFs, recent infectious diseases, or neurologic conditions.
Participants’ bipolar symptoms, psychosocial functioning, and family history were assessed. In addition, they were asked about treatment, physical and/or sexual abuse, smoking status, and socioeconomic status. Height, weight, waist circumference, blood pressure, and blood tests to assess CVRFs, including C-reactive protein (CRP), were also assessed. RHI was measured via pulse amplitude tonometry, with lower values indicating poorer endothelial function.
Positive affect beneficial?
Compared with HCs, there were fewer White participants in the BD group (78% vs. 55%; P < .001). The BD group also had higher Tanner stage development scores (stage 5: 65% vs. 35%; P = .03; V = 0.21), higher body mass index (BMI, 24.4 ± 4.6 vs. 22.0 ± 4.2; P < .001; d = 0.53), and higher CRP (1.94 ± 3.99 vs. 0.76 ± 0.86; P = .009; d = –0.40).
After controlling for age, sex, and BMI (F3,202 = 4.47; P = .005; np2 = 0.06), the researchers found significant between-group differences in RHI.
Post hoc pairwise comparisons showed RHI to be significantly lower in the BD-depressed versus the HC group (P = .04; d = 0.4). Moreover, the BD-hypomanic/mixed group had significantly higher RHI, compared with the other BD groups and the HC group.
RHI was associated with higher mania scores (beta, 0.26; P = .006), but there was no similar significant association with depression mood scores (beta, 0.01; P = .90).
The mood state differences in RHI and the RHI-mania association remained significant in sensitivity analyses examining the effect of current medication use as well as CVRFs, including lipids, CRP, and blood pressure on RHI.
“We found that youth with BD experiencing a depressive episode had lower endothelial function, whereas youth with BD experiencing a hypomanic/mixed episode had higher endothelial function, as compared to healthy youth,” Dr. Goldstein said.
There are several mechanisms potentially underlying the association between endothelial function and hypomania, the investigators noted. For example, positive affect is associated with increased endothelial function in normative samples, so hypomanic symptoms, including elation, may have similar beneficial associations, although those benefits likely do not extend to mania, which has been associated with cardiovascular risk.
They also point to several limitations in the study. The cross-sectional design “precludes making inferences regarding the temporal relationship between RHI and mood.” Moreover, the study focused only on hypomania, so “we cannot draw conclusions about mania.” In addition, the HC group had a “significantly higher proportion” of White participants, and a lower Tanner stage, so it “may not be a representative control sample.”
Nevertheless, the researchers concluded that the study “adds to the existing evidence for the potential value of integrating cardiovascular-related therapeutic approaches in BD,” noting that further research is needed to elucidate the mechanisms of the association.
Observable changes in youth
In a comment, Jess G Fiedorowicz, MD, PhD, head and chief, department of mental health, Ottawa Hospital Research Institute, noted that individuals with BD “have a much higher risk of CVD, which tends to develop earlier and shortens life expectancy by more than a decade.”
This cardiovascular risk “appears to be acquired over the long-term course of illness and proportionate to the persistence and severity of mood symptoms, which implies that mood syndromes, such as depression and mania, themselves may induce changes in the body relevant to CVD,” said Dr. Fiedorowicz, who is also a professor in the department of psychiatry and senior research chair in adult psychiatry at the Brain and Mind Research Institute, University of Ottawa, and was not involved with the study.
The study “adds to a growing body of evidence that mood syndromes may enact physiological changes that may be relevant to risk of CVD. One important aspect of this study is that this can even be observed in young sample,” he said.
This study was funded by the Canadian Institutes of Health Research and a Miner’s Lamp Innovation Fund from the University of Toronto. Dr. Goldstein and coauthors declare no relevant financial relationships. Dr. Fiedorowicz receives an honorarium from Elsevier for his work as editor-in-chief of the Journal of Psychosomatic Research.
A version of this article first appeared on Medscape.com.
in new findings that may explain the “excessive and premature mortality” related to heart disease in this patient population.
The investigators found that higher reactive hyperemia index (RHI) scores, a measure of endothelial function, were tied to mood severity in patients with higher mania, but not depression scores. These findings persisted even after accounting for medications, obesity, and other cardiovascular risk factors (CVRFs).
“From a clinical perspective, these findings highlight the potential value of integrating vascular health in the assessment and management of youth with BD, and from a scientific perspective, these findings call for additional research focused on shared biological mechanisms linking vascular health and mood symptoms of BD,” senior investigator Benjamin Goldstein, MD, PhD, full professor of psychiatry, pharmacology, and psychological clinical science, University of Toronto, said in an interview.
The study was published online in the Journal of Clinical Psychiatry.
‘Excessively present’
BD is associated with “excessive and premature cardiovascular mortality” and CVD is “excessively present” in BD, exceeding what can be explained by traditional cardiovascular risk factors, psychiatric medications, and substance use, the researchers noted.
“In adults, more severe mood symptoms increase the risk of future CVD. Our focus on endothelial function rose due to the fact that CVD is rare in youth, whereas endothelial dysfunction – considered a precursor of CVD – can be assessed in youth,” said Dr. Goldstein, who holds the RBC Investments Chair in children’s mental health and developmental psychopathology at the Centre for Addiction and Mental Health, Toronto, where he is director of the Centre for Youth Bipolar Disorder.
For this reason, he and his colleagues were “interested in researching whether endothelial dysfunction is associated with mood symptoms in youth with BD.” Ultimately, the motivation was to “inspire new therapeutic opportunities that may improve both cardiovascular and mental health simultaneously.”
To investigate the question, the researchers studied 209 youth aged 13-20 years (n = 114 with BD and 94 healthy controls [HCs]).
In the BD group, there were 34 BD-euthymia, 36 BD-depressed, and 44 BD-hypomanic/mixed; and within the groups who had depression or hypomania/mixed features, 72 were experiencing clinically significant depression.
Participants had to be free of chronic inflammatory illness, use of medications that might be addressing traditional CVRFs, recent infectious diseases, or neurologic conditions.
Participants’ bipolar symptoms, psychosocial functioning, and family history were assessed. In addition, they were asked about treatment, physical and/or sexual abuse, smoking status, and socioeconomic status. Height, weight, waist circumference, blood pressure, and blood tests to assess CVRFs, including C-reactive protein (CRP), were also assessed. RHI was measured via pulse amplitude tonometry, with lower values indicating poorer endothelial function.
Positive affect beneficial?
Compared with HCs, there were fewer White participants in the BD group (78% vs. 55%; P < .001). The BD group also had higher Tanner stage development scores (stage 5: 65% vs. 35%; P = .03; V = 0.21), higher body mass index (BMI, 24.4 ± 4.6 vs. 22.0 ± 4.2; P < .001; d = 0.53), and higher CRP (1.94 ± 3.99 vs. 0.76 ± 0.86; P = .009; d = –0.40).
After controlling for age, sex, and BMI (F3,202 = 4.47; P = .005; np2 = 0.06), the researchers found significant between-group differences in RHI.
Post hoc pairwise comparisons showed RHI to be significantly lower in the BD-depressed versus the HC group (P = .04; d = 0.4). Moreover, the BD-hypomanic/mixed group had significantly higher RHI, compared with the other BD groups and the HC group.
RHI was associated with higher mania scores (beta, 0.26; P = .006), but there was no similar significant association with depression mood scores (beta, 0.01; P = .90).
The mood state differences in RHI and the RHI-mania association remained significant in sensitivity analyses examining the effect of current medication use as well as CVRFs, including lipids, CRP, and blood pressure on RHI.
“We found that youth with BD experiencing a depressive episode had lower endothelial function, whereas youth with BD experiencing a hypomanic/mixed episode had higher endothelial function, as compared to healthy youth,” Dr. Goldstein said.
There are several mechanisms potentially underlying the association between endothelial function and hypomania, the investigators noted. For example, positive affect is associated with increased endothelial function in normative samples, so hypomanic symptoms, including elation, may have similar beneficial associations, although those benefits likely do not extend to mania, which has been associated with cardiovascular risk.
They also point to several limitations in the study. The cross-sectional design “precludes making inferences regarding the temporal relationship between RHI and mood.” Moreover, the study focused only on hypomania, so “we cannot draw conclusions about mania.” In addition, the HC group had a “significantly higher proportion” of White participants, and a lower Tanner stage, so it “may not be a representative control sample.”
Nevertheless, the researchers concluded that the study “adds to the existing evidence for the potential value of integrating cardiovascular-related therapeutic approaches in BD,” noting that further research is needed to elucidate the mechanisms of the association.
Observable changes in youth
In a comment, Jess G Fiedorowicz, MD, PhD, head and chief, department of mental health, Ottawa Hospital Research Institute, noted that individuals with BD “have a much higher risk of CVD, which tends to develop earlier and shortens life expectancy by more than a decade.”
This cardiovascular risk “appears to be acquired over the long-term course of illness and proportionate to the persistence and severity of mood symptoms, which implies that mood syndromes, such as depression and mania, themselves may induce changes in the body relevant to CVD,” said Dr. Fiedorowicz, who is also a professor in the department of psychiatry and senior research chair in adult psychiatry at the Brain and Mind Research Institute, University of Ottawa, and was not involved with the study.
The study “adds to a growing body of evidence that mood syndromes may enact physiological changes that may be relevant to risk of CVD. One important aspect of this study is that this can even be observed in young sample,” he said.
This study was funded by the Canadian Institutes of Health Research and a Miner’s Lamp Innovation Fund from the University of Toronto. Dr. Goldstein and coauthors declare no relevant financial relationships. Dr. Fiedorowicz receives an honorarium from Elsevier for his work as editor-in-chief of the Journal of Psychosomatic Research.
A version of this article first appeared on Medscape.com.
FROM THE JOURNAL OF CLINICAL PSYCHIATRY
Unraveling the mechanisms behind FMT efficacy needed to expand its use
A deeper understanding of the mechanisms underlying the success of fecal microbiota transplantation (FMT) is needed to further improve its effectiveness, according to two recent reviews published in Cell Host and Microbe.
how closely the donor’s microbial composition matches the patient’s existing microbiome, and the presence of nonbacterial gut inhabitants like viruses and fungi – affect FMT success, according to a press release.
FMT is most often used to treat recurrent Clostridioides difficile infections, which don’t always respond to antibiotics. Success rates range from 60% to 90%, depending on the administration route and study design, notes an international research team led by Abbas Yadegar, PhD, a medical bacteriologist at the Shahid Beheshti University of Medical Sciences in Tehran, Iran.
The understanding of how FMT works is incomplete, however, and the reasons some patients fail to benefit is unclear, note Dr. Yadegar and colleagues. Little attention has been paid to the role that other components of the patient’s microbiome, along with outside factors, play in the treatment’s success, they add.
“We wanted other researchers to look beyond changes in stool microbial composition and function, which have been the focus of research in the past few years,” Dr. Yadegar’s team said in a statement provided to this news organization.
Dr. Yadegar and colleagues’ review of more than 130 studies summarizes recent evidence on the mechanisms contributing to FMT success against recurrent C. difficile infection, highlights knowledge gaps, and proposes future research directions in the field.
Factors that influence FMT’s effectiveness and the potential the procedure holds for treatment of other diseases associated with gut dysbiosis are the subject of a review of 149 studies by a team of researchers led by Serena Porcari, MD, a gastroenterologist at the Fondazione Policlinico Universitario Gemelli and Università Cattolica del Sacro Cuore, in Rome.
“Our main goal was not only to unravel the different mechanisms of FMT efficacy but also to introduce some mindset shifts that are needed to bring FMT forward, mainly covering the gap that exists between basic scientists and clinicians,” Gianluca Ianiro, MD, PhD, a senior researcher in digestive diseases who works with Dr. Porcari and is the review’s lead author, told this news organization.
Engraftment may influence success
Engraftment of donor microbial strains in recipients appears to be key to the therapeutic success of FMT, both reviews note.
Three factors influence engraftment: the donor’s bacteria fitness relative to the recipient, the bacteria already present in the recipient, and whether antibiotics are used prior to FMT to open a niche for the incoming donor microbes, according to Dr. Yadegar and colleagues.
How to calculate strain engraftment has not yet been standardized in the field, and the number of strains detected in the recipient’s fecal sample is dependent on the depth of sequencing techniques, Dr. Porcari and colleagues note.
The use of whole-genome sequencing has enabled more precise evaluation of engraftment, they add.
“With this approach, microbial engraftment has been associated with clinical success, regardless of the disease, in a large metagenomic metanalysis of 24 FMT trials and almost 1,400 fecal samples,” Dr. Porcari and colleagues write. However, these results have not been replicated, likely because of differences between the studies.
More study on the topic is needed, both articles note.
“Because the recent metagenomics studies compared pre- and post-FMT only in cases with successful treatment outcomes, it is not possible to link engraftment to clinical outcomes,” Dr. Yadegar and colleagues write in their statement to this news organization.
A closer look at donor-recipient pairings
Clinicians usually enlist healthy, carefully screened individuals as FMT donors.
However, both research groups conclude that fine-scale taxonomic and metabolic analyses of donor and recipient microbiomes would better inform clinical decisions, especially when treating diseases other than C. difficile.
This may call for a more personalized approach to choosing donor-recipient pairings. Investigators should assess the patient’s diet and genetic background and how closely the donor’s microbiome matches that of the patient.
“Most studies focused on profiling stool samples before and after FMT without also including functional analyses; therefore, there are still a lot of aspects of host microbial interactions that remain unknown,” write Dr. Yadegar and colleagues in their statement.
Ecologic factors, including diet and host genetics, are often not included in clinical studies of C. difficile, but they “may potentially be the missing links” to treatment failure in the small portion of patients whose condition doesn’t respond to FMT, they write.
Pairing donor-recipient combinations on the basis of dietary patterns and preferences could improve FMT efficacy because the donor microbiota would be preadapted to the recipient’s diet, Dr. Yadegar and colleagues write. The team is examining how donor and recipient diet may affect outcomes.
Dr. Porcari and colleagues add that while some studies support the existence of shared characteristics that make up super-donors, others found that the optimal donor is more patient specific. They call for personalized selection strategies that employ microbiome sequencing tools rather than a “one stool fits all” approach.
Currently, many clinicians aren’t familiar with microbiome sequencing and analysis, but they’ll need to be in the near future, note Dr. Porcari and colleagues.
“Identifying microbiome characteristics that maximize strain engraftment in the FMT will allow clinicians to select the best donor for each single patient,” they write.
The possible role of viruses and fungi
In FMT research, investigators tend to focus on the bacteria in the human microbiome. However, viruses and fungi also appear to play a role, both articles note.
“Other microbial kingdoms that inhabit the intestine should be taken into account when considering predictors of post-FMT microbial transfer,” write Dr. Porcari and colleagues.
Although few studies have examined the gut virome’s impact on FMT effectiveness against C. difficile, the existing research, although limited, indicates that bacteriophage viruses could play a role, Dr. Yadegar and colleagues note. For example, high levels of donor-derived Caudoviralesbacteriophages in recipients were associated with FMT efficacy in one preliminary study, they write.
In a small human study, fecal filtrate from healthy donors who had bacteriophages but no live bacteria successfully treated five patients with recurrent C. difficile infection, Dr. Yadegar and colleagues write.
“Therefore, the idea that viruses may play a role is very provocative,” write Dr. Yadegar’s team in their statement.
It’s important to note that these studies are associative, which means they can’t definitively answer the question of how or whether viruses play a role, Dr. Yadegar’s team added.
Researchers “know even less about how fungi may or may not play a role,” write Dr. Yadegar and colleagues. However, in early research that involved patients who had successfully undergone FMT for C. difficile, there was higher relative abundance of Saccharomyces and Aspergillus, whereas Candida, if prominent, may impede response, they write in their article.
Additionally, to explore whether live bacteria are necessary for FMT to work, Dr. Yadegar and colleagues informed this news organization that they are conducting a study “comparing traditional FMT to a fecal filtrate that contains no live bacteria, but has all other components, to see if we can achieve similar success rates in recurrent C. difficile infection.”
Repeat treatment for sustained response
Dr. Yadegar’s team offered another important takeaway: A single FMT treatment will not sustain a positive response, especially when treating chronic noncommunicable conditions in which intestinal dysbiosis may play a role. Repeat treatment will be needed, as with other chronic conditions. This has been shown even in C. difficile infection.
“Recent studies have documented a significant advantage of repeated FMT over single FMT on the cure rates of recurrent C. difficile,” especially for patients with inflammatory bowel disorder, Dr. Yadegar’s team told this news organization.
“What we don’t know is which patient is likely to respond to microbial-based therapy, or what the dose or frequency should be, or which bacteria are responsible for the effects,” Dr. Yadegar and team said.
Dr. Porcari and colleagues are examining whether FMT could be refined to improve its success against other diseases. This may involve selecting specific donors, monitoring the gut microbiome of both donors and recipients, or using a specific means of delivery, such as lyophilized capsules, Dr. Ianiro said.
A response to FMT for chronic, noncommunicable disorders typically is not sustained long term, note Dr. Porcari and colleagues. However, they add that “sequential transplants have been applied in this setting with promising results, suggesting that chronic modulation of the patient microbiome may be beneficial in noncommunicable chronic disorders.” Dr. Porcari and colleagues point to the success of repeated, long-term FMT in studies of patients with ulcerative colitis and irritable bowel syndrome.
The use of cutting-edge technologies for microbiome assessment and a change in the view of FMT as only an acute, single-use therapy could improve FMT protocols and outcomes for noncommunicable conditions, they write.
Expanding FMT beyond C. difficile
Dr. Yadegar and colleagues’ article “really breaks down what is known about the mechanisms of FMT in C. difficile infection, which is important as other live biotherapeutic products are developed,” Colleen Kelly, MD, an associate professor of medicine at Brown University in Providence, R.I., who was not involved with the reviews, said in an interview.
Dr. Yadegar and colleagues concur. They note in a press release that as the mechanisms behind FMT success are understood, that information should be used to design new standardized therapies.
“Although highly effective, there are substantial drawbacks with [FMT], including infectious risks and sparse long-term safety data,” they write. “Better treatment options for recurrent C. difficile infections that are targeted, safe, and donor-independent are thus desired.”
In December 2022, the U.S. Food and Drug Administration approved the first fecal microbiota product, Rebyota, to prevent recurrence of C. difficile. More recently, in April 2023, the FDA approved Vowst, a pill for treating recurrent C. difficile infections.
Dr. Kelly also noted that the article by Dr. Yadegar and colleagues “may help us understand why a small percentage of patients fail to achieve cure after FMT.”
Regarding Dr. Porcari and colleagues’ article, Dr. Kelly said, “There is a lot of hope that FMT or other gut microbiome therapies will be beneficial for conditions outside of C. difficile.
“They do a good job reviewing the state of the science of FMT and highlight the many unknowns around the use of FMT in conditions outside of C. difficile,” added Dr. Kelly, who has been using FMT to treat C. difficile for more than 15 years.
Data supporting FMT for conditions such as ulcerative colitis and autism are compelling, Dr. Kelly acknowledged. But in her view, FMT isn’t ready for “prime time” outside of C. difficile – at least not yet.
“Academic investigators and those in industry are actively conducting research in many non–C. difficile indications, and I predict we will see the emergence of gut microbiome–based therapies for other indications within the next 5-10 years,” Dr. Kelly said.
Dr. Yadegar reports no relevant financial relationships. One coauthor of the Yadegar study has served on the adjudication board for Finch Therapeutics and has received consulting fees and a speaking honorarium from Rebiotix/Ferring Pharmaceuticals. Dr. Ianiro reports no relevant financial relationships. Dr. Kelly has consulted for Sebela Pharmaceuticals and is one of the principal investigators for the FMT National Patient Registry funded by the National Institute of Allergy and Infectious Diseases of the National Institutes of Health.
A version of this article originally appeared on Medscape.com.
A deeper understanding of the mechanisms underlying the success of fecal microbiota transplantation (FMT) is needed to further improve its effectiveness, according to two recent reviews published in Cell Host and Microbe.
how closely the donor’s microbial composition matches the patient’s existing microbiome, and the presence of nonbacterial gut inhabitants like viruses and fungi – affect FMT success, according to a press release.
FMT is most often used to treat recurrent Clostridioides difficile infections, which don’t always respond to antibiotics. Success rates range from 60% to 90%, depending on the administration route and study design, notes an international research team led by Abbas Yadegar, PhD, a medical bacteriologist at the Shahid Beheshti University of Medical Sciences in Tehran, Iran.
The understanding of how FMT works is incomplete, however, and the reasons some patients fail to benefit is unclear, note Dr. Yadegar and colleagues. Little attention has been paid to the role that other components of the patient’s microbiome, along with outside factors, play in the treatment’s success, they add.
“We wanted other researchers to look beyond changes in stool microbial composition and function, which have been the focus of research in the past few years,” Dr. Yadegar’s team said in a statement provided to this news organization.
Dr. Yadegar and colleagues’ review of more than 130 studies summarizes recent evidence on the mechanisms contributing to FMT success against recurrent C. difficile infection, highlights knowledge gaps, and proposes future research directions in the field.
Factors that influence FMT’s effectiveness and the potential the procedure holds for treatment of other diseases associated with gut dysbiosis are the subject of a review of 149 studies by a team of researchers led by Serena Porcari, MD, a gastroenterologist at the Fondazione Policlinico Universitario Gemelli and Università Cattolica del Sacro Cuore, in Rome.
“Our main goal was not only to unravel the different mechanisms of FMT efficacy but also to introduce some mindset shifts that are needed to bring FMT forward, mainly covering the gap that exists between basic scientists and clinicians,” Gianluca Ianiro, MD, PhD, a senior researcher in digestive diseases who works with Dr. Porcari and is the review’s lead author, told this news organization.
Engraftment may influence success
Engraftment of donor microbial strains in recipients appears to be key to the therapeutic success of FMT, both reviews note.
Three factors influence engraftment: the donor’s bacteria fitness relative to the recipient, the bacteria already present in the recipient, and whether antibiotics are used prior to FMT to open a niche for the incoming donor microbes, according to Dr. Yadegar and colleagues.
How to calculate strain engraftment has not yet been standardized in the field, and the number of strains detected in the recipient’s fecal sample is dependent on the depth of sequencing techniques, Dr. Porcari and colleagues note.
The use of whole-genome sequencing has enabled more precise evaluation of engraftment, they add.
“With this approach, microbial engraftment has been associated with clinical success, regardless of the disease, in a large metagenomic metanalysis of 24 FMT trials and almost 1,400 fecal samples,” Dr. Porcari and colleagues write. However, these results have not been replicated, likely because of differences between the studies.
More study on the topic is needed, both articles note.
“Because the recent metagenomics studies compared pre- and post-FMT only in cases with successful treatment outcomes, it is not possible to link engraftment to clinical outcomes,” Dr. Yadegar and colleagues write in their statement to this news organization.
A closer look at donor-recipient pairings
Clinicians usually enlist healthy, carefully screened individuals as FMT donors.
However, both research groups conclude that fine-scale taxonomic and metabolic analyses of donor and recipient microbiomes would better inform clinical decisions, especially when treating diseases other than C. difficile.
This may call for a more personalized approach to choosing donor-recipient pairings. Investigators should assess the patient’s diet and genetic background and how closely the donor’s microbiome matches that of the patient.
“Most studies focused on profiling stool samples before and after FMT without also including functional analyses; therefore, there are still a lot of aspects of host microbial interactions that remain unknown,” write Dr. Yadegar and colleagues in their statement.
Ecologic factors, including diet and host genetics, are often not included in clinical studies of C. difficile, but they “may potentially be the missing links” to treatment failure in the small portion of patients whose condition doesn’t respond to FMT, they write.
Pairing donor-recipient combinations on the basis of dietary patterns and preferences could improve FMT efficacy because the donor microbiota would be preadapted to the recipient’s diet, Dr. Yadegar and colleagues write. The team is examining how donor and recipient diet may affect outcomes.
Dr. Porcari and colleagues add that while some studies support the existence of shared characteristics that make up super-donors, others found that the optimal donor is more patient specific. They call for personalized selection strategies that employ microbiome sequencing tools rather than a “one stool fits all” approach.
Currently, many clinicians aren’t familiar with microbiome sequencing and analysis, but they’ll need to be in the near future, note Dr. Porcari and colleagues.
“Identifying microbiome characteristics that maximize strain engraftment in the FMT will allow clinicians to select the best donor for each single patient,” they write.
The possible role of viruses and fungi
In FMT research, investigators tend to focus on the bacteria in the human microbiome. However, viruses and fungi also appear to play a role, both articles note.
“Other microbial kingdoms that inhabit the intestine should be taken into account when considering predictors of post-FMT microbial transfer,” write Dr. Porcari and colleagues.
Although few studies have examined the gut virome’s impact on FMT effectiveness against C. difficile, the existing research, although limited, indicates that bacteriophage viruses could play a role, Dr. Yadegar and colleagues note. For example, high levels of donor-derived Caudoviralesbacteriophages in recipients were associated with FMT efficacy in one preliminary study, they write.
In a small human study, fecal filtrate from healthy donors who had bacteriophages but no live bacteria successfully treated five patients with recurrent C. difficile infection, Dr. Yadegar and colleagues write.
“Therefore, the idea that viruses may play a role is very provocative,” write Dr. Yadegar’s team in their statement.
It’s important to note that these studies are associative, which means they can’t definitively answer the question of how or whether viruses play a role, Dr. Yadegar’s team added.
Researchers “know even less about how fungi may or may not play a role,” write Dr. Yadegar and colleagues. However, in early research that involved patients who had successfully undergone FMT for C. difficile, there was higher relative abundance of Saccharomyces and Aspergillus, whereas Candida, if prominent, may impede response, they write in their article.
Additionally, to explore whether live bacteria are necessary for FMT to work, Dr. Yadegar and colleagues informed this news organization that they are conducting a study “comparing traditional FMT to a fecal filtrate that contains no live bacteria, but has all other components, to see if we can achieve similar success rates in recurrent C. difficile infection.”
Repeat treatment for sustained response
Dr. Yadegar’s team offered another important takeaway: A single FMT treatment will not sustain a positive response, especially when treating chronic noncommunicable conditions in which intestinal dysbiosis may play a role. Repeat treatment will be needed, as with other chronic conditions. This has been shown even in C. difficile infection.
“Recent studies have documented a significant advantage of repeated FMT over single FMT on the cure rates of recurrent C. difficile,” especially for patients with inflammatory bowel disorder, Dr. Yadegar’s team told this news organization.
“What we don’t know is which patient is likely to respond to microbial-based therapy, or what the dose or frequency should be, or which bacteria are responsible for the effects,” Dr. Yadegar and team said.
Dr. Porcari and colleagues are examining whether FMT could be refined to improve its success against other diseases. This may involve selecting specific donors, monitoring the gut microbiome of both donors and recipients, or using a specific means of delivery, such as lyophilized capsules, Dr. Ianiro said.
A response to FMT for chronic, noncommunicable disorders typically is not sustained long term, note Dr. Porcari and colleagues. However, they add that “sequential transplants have been applied in this setting with promising results, suggesting that chronic modulation of the patient microbiome may be beneficial in noncommunicable chronic disorders.” Dr. Porcari and colleagues point to the success of repeated, long-term FMT in studies of patients with ulcerative colitis and irritable bowel syndrome.
The use of cutting-edge technologies for microbiome assessment and a change in the view of FMT as only an acute, single-use therapy could improve FMT protocols and outcomes for noncommunicable conditions, they write.
Expanding FMT beyond C. difficile
Dr. Yadegar and colleagues’ article “really breaks down what is known about the mechanisms of FMT in C. difficile infection, which is important as other live biotherapeutic products are developed,” Colleen Kelly, MD, an associate professor of medicine at Brown University in Providence, R.I., who was not involved with the reviews, said in an interview.
Dr. Yadegar and colleagues concur. They note in a press release that as the mechanisms behind FMT success are understood, that information should be used to design new standardized therapies.
“Although highly effective, there are substantial drawbacks with [FMT], including infectious risks and sparse long-term safety data,” they write. “Better treatment options for recurrent C. difficile infections that are targeted, safe, and donor-independent are thus desired.”
In December 2022, the U.S. Food and Drug Administration approved the first fecal microbiota product, Rebyota, to prevent recurrence of C. difficile. More recently, in April 2023, the FDA approved Vowst, a pill for treating recurrent C. difficile infections.
Dr. Kelly also noted that the article by Dr. Yadegar and colleagues “may help us understand why a small percentage of patients fail to achieve cure after FMT.”
Regarding Dr. Porcari and colleagues’ article, Dr. Kelly said, “There is a lot of hope that FMT or other gut microbiome therapies will be beneficial for conditions outside of C. difficile.
“They do a good job reviewing the state of the science of FMT and highlight the many unknowns around the use of FMT in conditions outside of C. difficile,” added Dr. Kelly, who has been using FMT to treat C. difficile for more than 15 years.
Data supporting FMT for conditions such as ulcerative colitis and autism are compelling, Dr. Kelly acknowledged. But in her view, FMT isn’t ready for “prime time” outside of C. difficile – at least not yet.
“Academic investigators and those in industry are actively conducting research in many non–C. difficile indications, and I predict we will see the emergence of gut microbiome–based therapies for other indications within the next 5-10 years,” Dr. Kelly said.
Dr. Yadegar reports no relevant financial relationships. One coauthor of the Yadegar study has served on the adjudication board for Finch Therapeutics and has received consulting fees and a speaking honorarium from Rebiotix/Ferring Pharmaceuticals. Dr. Ianiro reports no relevant financial relationships. Dr. Kelly has consulted for Sebela Pharmaceuticals and is one of the principal investigators for the FMT National Patient Registry funded by the National Institute of Allergy and Infectious Diseases of the National Institutes of Health.
A version of this article originally appeared on Medscape.com.
A deeper understanding of the mechanisms underlying the success of fecal microbiota transplantation (FMT) is needed to further improve its effectiveness, according to two recent reviews published in Cell Host and Microbe.
how closely the donor’s microbial composition matches the patient’s existing microbiome, and the presence of nonbacterial gut inhabitants like viruses and fungi – affect FMT success, according to a press release.
FMT is most often used to treat recurrent Clostridioides difficile infections, which don’t always respond to antibiotics. Success rates range from 60% to 90%, depending on the administration route and study design, notes an international research team led by Abbas Yadegar, PhD, a medical bacteriologist at the Shahid Beheshti University of Medical Sciences in Tehran, Iran.
The understanding of how FMT works is incomplete, however, and the reasons some patients fail to benefit is unclear, note Dr. Yadegar and colleagues. Little attention has been paid to the role that other components of the patient’s microbiome, along with outside factors, play in the treatment’s success, they add.
“We wanted other researchers to look beyond changes in stool microbial composition and function, which have been the focus of research in the past few years,” Dr. Yadegar’s team said in a statement provided to this news organization.
Dr. Yadegar and colleagues’ review of more than 130 studies summarizes recent evidence on the mechanisms contributing to FMT success against recurrent C. difficile infection, highlights knowledge gaps, and proposes future research directions in the field.
Factors that influence FMT’s effectiveness and the potential the procedure holds for treatment of other diseases associated with gut dysbiosis are the subject of a review of 149 studies by a team of researchers led by Serena Porcari, MD, a gastroenterologist at the Fondazione Policlinico Universitario Gemelli and Università Cattolica del Sacro Cuore, in Rome.
“Our main goal was not only to unravel the different mechanisms of FMT efficacy but also to introduce some mindset shifts that are needed to bring FMT forward, mainly covering the gap that exists between basic scientists and clinicians,” Gianluca Ianiro, MD, PhD, a senior researcher in digestive diseases who works with Dr. Porcari and is the review’s lead author, told this news organization.
Engraftment may influence success
Engraftment of donor microbial strains in recipients appears to be key to the therapeutic success of FMT, both reviews note.
Three factors influence engraftment: the donor’s bacteria fitness relative to the recipient, the bacteria already present in the recipient, and whether antibiotics are used prior to FMT to open a niche for the incoming donor microbes, according to Dr. Yadegar and colleagues.
How to calculate strain engraftment has not yet been standardized in the field, and the number of strains detected in the recipient’s fecal sample is dependent on the depth of sequencing techniques, Dr. Porcari and colleagues note.
The use of whole-genome sequencing has enabled more precise evaluation of engraftment, they add.
“With this approach, microbial engraftment has been associated with clinical success, regardless of the disease, in a large metagenomic metanalysis of 24 FMT trials and almost 1,400 fecal samples,” Dr. Porcari and colleagues write. However, these results have not been replicated, likely because of differences between the studies.
More study on the topic is needed, both articles note.
“Because the recent metagenomics studies compared pre- and post-FMT only in cases with successful treatment outcomes, it is not possible to link engraftment to clinical outcomes,” Dr. Yadegar and colleagues write in their statement to this news organization.
A closer look at donor-recipient pairings
Clinicians usually enlist healthy, carefully screened individuals as FMT donors.
However, both research groups conclude that fine-scale taxonomic and metabolic analyses of donor and recipient microbiomes would better inform clinical decisions, especially when treating diseases other than C. difficile.
This may call for a more personalized approach to choosing donor-recipient pairings. Investigators should assess the patient’s diet and genetic background and how closely the donor’s microbiome matches that of the patient.
“Most studies focused on profiling stool samples before and after FMT without also including functional analyses; therefore, there are still a lot of aspects of host microbial interactions that remain unknown,” write Dr. Yadegar and colleagues in their statement.
Ecologic factors, including diet and host genetics, are often not included in clinical studies of C. difficile, but they “may potentially be the missing links” to treatment failure in the small portion of patients whose condition doesn’t respond to FMT, they write.
Pairing donor-recipient combinations on the basis of dietary patterns and preferences could improve FMT efficacy because the donor microbiota would be preadapted to the recipient’s diet, Dr. Yadegar and colleagues write. The team is examining how donor and recipient diet may affect outcomes.
Dr. Porcari and colleagues add that while some studies support the existence of shared characteristics that make up super-donors, others found that the optimal donor is more patient specific. They call for personalized selection strategies that employ microbiome sequencing tools rather than a “one stool fits all” approach.
Currently, many clinicians aren’t familiar with microbiome sequencing and analysis, but they’ll need to be in the near future, note Dr. Porcari and colleagues.
“Identifying microbiome characteristics that maximize strain engraftment in the FMT will allow clinicians to select the best donor for each single patient,” they write.
The possible role of viruses and fungi
In FMT research, investigators tend to focus on the bacteria in the human microbiome. However, viruses and fungi also appear to play a role, both articles note.
“Other microbial kingdoms that inhabit the intestine should be taken into account when considering predictors of post-FMT microbial transfer,” write Dr. Porcari and colleagues.
Although few studies have examined the gut virome’s impact on FMT effectiveness against C. difficile, the existing research, although limited, indicates that bacteriophage viruses could play a role, Dr. Yadegar and colleagues note. For example, high levels of donor-derived Caudoviralesbacteriophages in recipients were associated with FMT efficacy in one preliminary study, they write.
In a small human study, fecal filtrate from healthy donors who had bacteriophages but no live bacteria successfully treated five patients with recurrent C. difficile infection, Dr. Yadegar and colleagues write.
“Therefore, the idea that viruses may play a role is very provocative,” write Dr. Yadegar’s team in their statement.
It’s important to note that these studies are associative, which means they can’t definitively answer the question of how or whether viruses play a role, Dr. Yadegar’s team added.
Researchers “know even less about how fungi may or may not play a role,” write Dr. Yadegar and colleagues. However, in early research that involved patients who had successfully undergone FMT for C. difficile, there was higher relative abundance of Saccharomyces and Aspergillus, whereas Candida, if prominent, may impede response, they write in their article.
Additionally, to explore whether live bacteria are necessary for FMT to work, Dr. Yadegar and colleagues informed this news organization that they are conducting a study “comparing traditional FMT to a fecal filtrate that contains no live bacteria, but has all other components, to see if we can achieve similar success rates in recurrent C. difficile infection.”
Repeat treatment for sustained response
Dr. Yadegar’s team offered another important takeaway: A single FMT treatment will not sustain a positive response, especially when treating chronic noncommunicable conditions in which intestinal dysbiosis may play a role. Repeat treatment will be needed, as with other chronic conditions. This has been shown even in C. difficile infection.
“Recent studies have documented a significant advantage of repeated FMT over single FMT on the cure rates of recurrent C. difficile,” especially for patients with inflammatory bowel disorder, Dr. Yadegar’s team told this news organization.
“What we don’t know is which patient is likely to respond to microbial-based therapy, or what the dose or frequency should be, or which bacteria are responsible for the effects,” Dr. Yadegar and team said.
Dr. Porcari and colleagues are examining whether FMT could be refined to improve its success against other diseases. This may involve selecting specific donors, monitoring the gut microbiome of both donors and recipients, or using a specific means of delivery, such as lyophilized capsules, Dr. Ianiro said.
A response to FMT for chronic, noncommunicable disorders typically is not sustained long term, note Dr. Porcari and colleagues. However, they add that “sequential transplants have been applied in this setting with promising results, suggesting that chronic modulation of the patient microbiome may be beneficial in noncommunicable chronic disorders.” Dr. Porcari and colleagues point to the success of repeated, long-term FMT in studies of patients with ulcerative colitis and irritable bowel syndrome.
The use of cutting-edge technologies for microbiome assessment and a change in the view of FMT as only an acute, single-use therapy could improve FMT protocols and outcomes for noncommunicable conditions, they write.
Expanding FMT beyond C. difficile
Dr. Yadegar and colleagues’ article “really breaks down what is known about the mechanisms of FMT in C. difficile infection, which is important as other live biotherapeutic products are developed,” Colleen Kelly, MD, an associate professor of medicine at Brown University in Providence, R.I., who was not involved with the reviews, said in an interview.
Dr. Yadegar and colleagues concur. They note in a press release that as the mechanisms behind FMT success are understood, that information should be used to design new standardized therapies.
“Although highly effective, there are substantial drawbacks with [FMT], including infectious risks and sparse long-term safety data,” they write. “Better treatment options for recurrent C. difficile infections that are targeted, safe, and donor-independent are thus desired.”
In December 2022, the U.S. Food and Drug Administration approved the first fecal microbiota product, Rebyota, to prevent recurrence of C. difficile. More recently, in April 2023, the FDA approved Vowst, a pill for treating recurrent C. difficile infections.
Dr. Kelly also noted that the article by Dr. Yadegar and colleagues “may help us understand why a small percentage of patients fail to achieve cure after FMT.”
Regarding Dr. Porcari and colleagues’ article, Dr. Kelly said, “There is a lot of hope that FMT or other gut microbiome therapies will be beneficial for conditions outside of C. difficile.
“They do a good job reviewing the state of the science of FMT and highlight the many unknowns around the use of FMT in conditions outside of C. difficile,” added Dr. Kelly, who has been using FMT to treat C. difficile for more than 15 years.
Data supporting FMT for conditions such as ulcerative colitis and autism are compelling, Dr. Kelly acknowledged. But in her view, FMT isn’t ready for “prime time” outside of C. difficile – at least not yet.
“Academic investigators and those in industry are actively conducting research in many non–C. difficile indications, and I predict we will see the emergence of gut microbiome–based therapies for other indications within the next 5-10 years,” Dr. Kelly said.
Dr. Yadegar reports no relevant financial relationships. One coauthor of the Yadegar study has served on the adjudication board for Finch Therapeutics and has received consulting fees and a speaking honorarium from Rebiotix/Ferring Pharmaceuticals. Dr. Ianiro reports no relevant financial relationships. Dr. Kelly has consulted for Sebela Pharmaceuticals and is one of the principal investigators for the FMT National Patient Registry funded by the National Institute of Allergy and Infectious Diseases of the National Institutes of Health.
A version of this article originally appeared on Medscape.com.
Should antibiotic treatment be used toward the end of life?
Diagnosing an infection is complex because of the presence of symptoms that are often nonspecific and that are common in patients in decline toward the end of life. Use of antibiotic therapy in this patient population is still controversial, because the clinical benefits are not clear and the risk of pointless overmedicalization is very high.
Etiology
For patients who are receiving palliative care, the following factors predispose to an infection:
- Increasing fragility.
- Bedbound status and anorexia/cachexia syndrome.
- Weakened immune defenses owing to disease or treatments.
- Changes to skin integrity, related to venous access sites and/or bladder catheterization.
Four-week cutoff
For patients who are expected to live for fewer than 4 weeks, evidence from the literature shows that antimicrobial therapy does not resolve a potential infection or improve the prognosis. Antibiotics should therefore be used only for improving symptom management.
In practice, the most common infections in patients receiving end-of-life care are in the urinary and respiratory tracts. Antibiotics are beneficial in the short term in managing symptoms associated with urinary tract infections (effective in 60%-92% of cases), so they should be considered if the patient is not in the agonal or pre-agonal phase of death.
Antibiotics are also beneficial in managing symptoms associated with respiratory tract infections (effective in up to 53% of cases), so they should be considered if the patient is not in the agonal or pre-agonal phase of death. However, the risk of futility is high. As an alternative, opioids and antitussives could provide greater benefit for patients with dyspnea and cough.
No benefit has been observed with the use of antibiotics to treat symptoms associated with sepsis, abscesses, and deep and complicated infections. Antibiotics are therefore deemed futile in these cases.
In unclear cases, the “2-day rule” is useful. This involves waiting for 2 days, and if the patient remains clinically stable, prescribing antibiotics. If the patient’s condition deteriorates rapidly and progressively, antibiotics should not be prescribed.
Alternatively, one can prescribe antibiotics immediately. If no clinical improvement is observed after 2 days, the antibiotics should be stopped, especially if deterioration of the patient’s condition is rapid and progressive.
Increased body temperature is somewhat common in the last days and hours of life and is not generally associated with symptoms. Fever in these cases is not an indication for the use of antimicrobial therapy.
The most common laboratory markers of infection (C-reactive protein level, erythrocyte sedimentation rate, leukocyte level) are not particularly useful in this patient population, because they are affected by the baseline condition as well as by any treatments given and the state of systemic inflammation, which is associated with the decline in overall health in the last few weeks of life.
The choice should be individualized and shared with patients and family members so that the clinical appropriateness of the therapeutic strategy is evident and that decisions regarding antibiotic treatment are not regarded as a failure to treat the patient.
The longer term
In deciding to start antibiotic therapy, consideration must be given to the patient’s overall health, the treatment objectives, the possibility that the antibiotic will resolve the infection or improve the patient’s symptoms, and the estimated prognosis, which must be sufficiently long to allow the antibiotic time to take effect.
This article was translated from Univadis Italy, which is part of the Medscape Professional Network. A version of this article appeared on Medscape.com.
Diagnosing an infection is complex because of the presence of symptoms that are often nonspecific and that are common in patients in decline toward the end of life. Use of antibiotic therapy in this patient population is still controversial, because the clinical benefits are not clear and the risk of pointless overmedicalization is very high.
Etiology
For patients who are receiving palliative care, the following factors predispose to an infection:
- Increasing fragility.
- Bedbound status and anorexia/cachexia syndrome.
- Weakened immune defenses owing to disease or treatments.
- Changes to skin integrity, related to venous access sites and/or bladder catheterization.
Four-week cutoff
For patients who are expected to live for fewer than 4 weeks, evidence from the literature shows that antimicrobial therapy does not resolve a potential infection or improve the prognosis. Antibiotics should therefore be used only for improving symptom management.
In practice, the most common infections in patients receiving end-of-life care are in the urinary and respiratory tracts. Antibiotics are beneficial in the short term in managing symptoms associated with urinary tract infections (effective in 60%-92% of cases), so they should be considered if the patient is not in the agonal or pre-agonal phase of death.
Antibiotics are also beneficial in managing symptoms associated with respiratory tract infections (effective in up to 53% of cases), so they should be considered if the patient is not in the agonal or pre-agonal phase of death. However, the risk of futility is high. As an alternative, opioids and antitussives could provide greater benefit for patients with dyspnea and cough.
No benefit has been observed with the use of antibiotics to treat symptoms associated with sepsis, abscesses, and deep and complicated infections. Antibiotics are therefore deemed futile in these cases.
In unclear cases, the “2-day rule” is useful. This involves waiting for 2 days, and if the patient remains clinically stable, prescribing antibiotics. If the patient’s condition deteriorates rapidly and progressively, antibiotics should not be prescribed.
Alternatively, one can prescribe antibiotics immediately. If no clinical improvement is observed after 2 days, the antibiotics should be stopped, especially if deterioration of the patient’s condition is rapid and progressive.
Increased body temperature is somewhat common in the last days and hours of life and is not generally associated with symptoms. Fever in these cases is not an indication for the use of antimicrobial therapy.
The most common laboratory markers of infection (C-reactive protein level, erythrocyte sedimentation rate, leukocyte level) are not particularly useful in this patient population, because they are affected by the baseline condition as well as by any treatments given and the state of systemic inflammation, which is associated with the decline in overall health in the last few weeks of life.
The choice should be individualized and shared with patients and family members so that the clinical appropriateness of the therapeutic strategy is evident and that decisions regarding antibiotic treatment are not regarded as a failure to treat the patient.
The longer term
In deciding to start antibiotic therapy, consideration must be given to the patient’s overall health, the treatment objectives, the possibility that the antibiotic will resolve the infection or improve the patient’s symptoms, and the estimated prognosis, which must be sufficiently long to allow the antibiotic time to take effect.
This article was translated from Univadis Italy, which is part of the Medscape Professional Network. A version of this article appeared on Medscape.com.
Diagnosing an infection is complex because of the presence of symptoms that are often nonspecific and that are common in patients in decline toward the end of life. Use of antibiotic therapy in this patient population is still controversial, because the clinical benefits are not clear and the risk of pointless overmedicalization is very high.
Etiology
For patients who are receiving palliative care, the following factors predispose to an infection:
- Increasing fragility.
- Bedbound status and anorexia/cachexia syndrome.
- Weakened immune defenses owing to disease or treatments.
- Changes to skin integrity, related to venous access sites and/or bladder catheterization.
Four-week cutoff
For patients who are expected to live for fewer than 4 weeks, evidence from the literature shows that antimicrobial therapy does not resolve a potential infection or improve the prognosis. Antibiotics should therefore be used only for improving symptom management.
In practice, the most common infections in patients receiving end-of-life care are in the urinary and respiratory tracts. Antibiotics are beneficial in the short term in managing symptoms associated with urinary tract infections (effective in 60%-92% of cases), so they should be considered if the patient is not in the agonal or pre-agonal phase of death.
Antibiotics are also beneficial in managing symptoms associated with respiratory tract infections (effective in up to 53% of cases), so they should be considered if the patient is not in the agonal or pre-agonal phase of death. However, the risk of futility is high. As an alternative, opioids and antitussives could provide greater benefit for patients with dyspnea and cough.
No benefit has been observed with the use of antibiotics to treat symptoms associated with sepsis, abscesses, and deep and complicated infections. Antibiotics are therefore deemed futile in these cases.
In unclear cases, the “2-day rule” is useful. This involves waiting for 2 days, and if the patient remains clinically stable, prescribing antibiotics. If the patient’s condition deteriorates rapidly and progressively, antibiotics should not be prescribed.
Alternatively, one can prescribe antibiotics immediately. If no clinical improvement is observed after 2 days, the antibiotics should be stopped, especially if deterioration of the patient’s condition is rapid and progressive.
Increased body temperature is somewhat common in the last days and hours of life and is not generally associated with symptoms. Fever in these cases is not an indication for the use of antimicrobial therapy.
The most common laboratory markers of infection (C-reactive protein level, erythrocyte sedimentation rate, leukocyte level) are not particularly useful in this patient population, because they are affected by the baseline condition as well as by any treatments given and the state of systemic inflammation, which is associated with the decline in overall health in the last few weeks of life.
The choice should be individualized and shared with patients and family members so that the clinical appropriateness of the therapeutic strategy is evident and that decisions regarding antibiotic treatment are not regarded as a failure to treat the patient.
The longer term
In deciding to start antibiotic therapy, consideration must be given to the patient’s overall health, the treatment objectives, the possibility that the antibiotic will resolve the infection or improve the patient’s symptoms, and the estimated prognosis, which must be sufficiently long to allow the antibiotic time to take effect.
This article was translated from Univadis Italy, which is part of the Medscape Professional Network. A version of this article appeared on Medscape.com.
The enemy of carcinogenic fumes is my friendly begonia
Sowing the seeds of cancer prevention
Are you looking to add to your quality of life, even though pets are not your speed? Might we suggest something with lower maintenance? Something a little greener?
Indoor plants can purify the air that comes from outside. Researchers at the University of Technology Sydney, in partnership with the plantscaping company Ambius, showed that a “green wall” made up of mixed indoor plants was able to suck up 97% of “the most toxic compounds” from the air in just 8 hours. We’re talking about lung-irritating, headache-inducing, cancer risk–boosting compounds from gasoline fumes, including benzene.
Public health initiatives often strive to reduce cardiovascular and obesity risks, but breathing seems pretty important too. According to the World Health Organization, household air pollution is responsible for about 2.5 million global premature deaths each year. And since 2020 we’ve become accustomed to spending more time inside and at home.
“This new research proves that plants should not just be seen as ‘nice to have,’ but rather a crucial part of every workplace wellness plan,” Ambius General Manager Johan Hodgson said in statement released by the university.
So don’t spend hundreds of dollars on a fancy air filtration system when a wall of plants can do that for next to nothing. Find what works for you and your space and become a plant parent today! Your lungs will thank you.
But officer, I had to swerve to miss the duodenal ampulla
Tiny video capsule endoscopes have been around for many years, but they have one big weakness: The ingestible cameras’ journey through the GI tract is passively driven by gravity and the natural movement of the body, so they often miss potential problem areas.
Not anymore. That flaw has been addressed by medical technology company AnX Robotica, which has taken endoscopy to the next level by adding that wondrous directional control device of the modern electronic age, a joystick.
The new system “uses an external magnet and hand-held video game style joysticks to move the capsule in three dimensions,” which allows physicians to “remotely drive a miniature video capsule to all regions of the stomach to visualize and photograph potential problem areas,” according to Andrew C. Meltzer, MD, of George Washington University and associates, who conducted a pilot study funded by AnX Robotica.
The video capsule provided a 95% rate of visualization in the stomachs of 40 patients who were examined at a medical office building by an emergency medicine physician who had no previous specialty training in endoscopy. “Capsules were driven by the ER physician and then the study reports were reviewed by an attending gastroenterologist who was physically off site,” the investigators said in a written statement.
The capsule operator did receive some additional training, and development of artificial intelligence to self-drive the capsule is in the works, but for now, we’re talking about a device controlled by a human using a joystick. And we all know that 50-year-olds are not especially known for their joystick skills. For that we need real experts. Yup, we need to put those joystick-controlled capsule endoscopes in the hands of teenage gamers. Who wants to go first?
Maybe AI isn’t ready for the big time after all
“How long before some intrepid stockholder says: ‘Hey, instead of paying doctors, why don’t we just use the free robot instead?’ ” Those words appeared on LOTME but a month ago. After all, the AI is supposed to be smarter and more empathetic than a doctor. And did we mention it’s free? Or at least extremely cheap. Cheaper than, say, a group of recently unionized health care workers.
In early May, the paid employees manning the National Eating Disorders Association emergency hotline voted to unionize, as they felt overwhelmed and underpaid. Apparently, paying six people an extra few thousand a year was too much for NEDA’s leadership, as they decided a few weeks later to fire those workers, fully closing down the hotline. Instead of talking to a real person, people “calling in” for support would be met with Tessa, a wellness chatbot that would hopefully guide them through their crisis. Key word, hopefully.
In perhaps the least surprising twist of the year, NEDA was forced to walk back its decision about a week after its initial announcement. It all started with a viral Instagram post from a woman who called in and received the following advice from Tessa: Lose 1-2 pounds a week, count calories and work for a 500- to 1,000-calorie deficit, weigh herself weekly, and restrict her diet. Unfortunately, all of these suggestions were things that led to the development of the woman’s eating disorder.
Naturally, NEDA responded in good grace, accusing the woman of lying. A NEDA vice president even left some nasty comments on the post, but hastily deleted them a day later when NEDA announced it was shutting down Tessa “until further notice for a complete investigation.” NEDA’s CEO insisted they hadn’t seen that behavior from Tessa before, calling it a “bug” and insisting the bot would only be down temporarily until the triggers causing the bug were fixed.
In the aftermath, several doctors and psychologists chimed in, terming the rush to automate human roles dangerous and risky. After all, much of what makes these hotlines effective is the volunteers speaking from their own experience. An unsupervised bot doesn’t seem to have what it takes to deal with a mental health crisis, but we’re betting that Tessa will be back. As a wise cephalopod once said: Nobody gives a care about the fate of labor as long as they can get their instant gratification.
You can’t spell existential without s-t-e-n-t
This week, we’re including a special “bonus” item that, to be honest, has nothing to do with stents. That’s why our editor is making us call this a “bonus” (and making us use quote marks, too): It doesn’t really have anything to do with stents or health care or those who practice health care. Actually, his exact words were, “You can’t just give the readers someone else’s ****ing list and expect to get paid for it.” Did we mention that he looks like Jack Nicklaus but acts like BoJack Horseman?
Anywaaay, we’re pretty sure that the list in question – “America’s Top 10 Most Googled Existential Questions” – says something about the human condition, just not about stents:
1. Why is the sky blue?
2. What do dreams mean?
3. What is the meaning of life?
4. Why am I so tired?
5. Who am I?
6. What is love?
7. Is a hot dog a sandwich?
8. What came first, the chicken or the egg?
9. What should I do?
10. Do animals have souls?
Sowing the seeds of cancer prevention
Are you looking to add to your quality of life, even though pets are not your speed? Might we suggest something with lower maintenance? Something a little greener?
Indoor plants can purify the air that comes from outside. Researchers at the University of Technology Sydney, in partnership with the plantscaping company Ambius, showed that a “green wall” made up of mixed indoor plants was able to suck up 97% of “the most toxic compounds” from the air in just 8 hours. We’re talking about lung-irritating, headache-inducing, cancer risk–boosting compounds from gasoline fumes, including benzene.
Public health initiatives often strive to reduce cardiovascular and obesity risks, but breathing seems pretty important too. According to the World Health Organization, household air pollution is responsible for about 2.5 million global premature deaths each year. And since 2020 we’ve become accustomed to spending more time inside and at home.
“This new research proves that plants should not just be seen as ‘nice to have,’ but rather a crucial part of every workplace wellness plan,” Ambius General Manager Johan Hodgson said in statement released by the university.
So don’t spend hundreds of dollars on a fancy air filtration system when a wall of plants can do that for next to nothing. Find what works for you and your space and become a plant parent today! Your lungs will thank you.
But officer, I had to swerve to miss the duodenal ampulla
Tiny video capsule endoscopes have been around for many years, but they have one big weakness: The ingestible cameras’ journey through the GI tract is passively driven by gravity and the natural movement of the body, so they often miss potential problem areas.
Not anymore. That flaw has been addressed by medical technology company AnX Robotica, which has taken endoscopy to the next level by adding that wondrous directional control device of the modern electronic age, a joystick.
The new system “uses an external magnet and hand-held video game style joysticks to move the capsule in three dimensions,” which allows physicians to “remotely drive a miniature video capsule to all regions of the stomach to visualize and photograph potential problem areas,” according to Andrew C. Meltzer, MD, of George Washington University and associates, who conducted a pilot study funded by AnX Robotica.
The video capsule provided a 95% rate of visualization in the stomachs of 40 patients who were examined at a medical office building by an emergency medicine physician who had no previous specialty training in endoscopy. “Capsules were driven by the ER physician and then the study reports were reviewed by an attending gastroenterologist who was physically off site,” the investigators said in a written statement.
The capsule operator did receive some additional training, and development of artificial intelligence to self-drive the capsule is in the works, but for now, we’re talking about a device controlled by a human using a joystick. And we all know that 50-year-olds are not especially known for their joystick skills. For that we need real experts. Yup, we need to put those joystick-controlled capsule endoscopes in the hands of teenage gamers. Who wants to go first?
Maybe AI isn’t ready for the big time after all
“How long before some intrepid stockholder says: ‘Hey, instead of paying doctors, why don’t we just use the free robot instead?’ ” Those words appeared on LOTME but a month ago. After all, the AI is supposed to be smarter and more empathetic than a doctor. And did we mention it’s free? Or at least extremely cheap. Cheaper than, say, a group of recently unionized health care workers.
In early May, the paid employees manning the National Eating Disorders Association emergency hotline voted to unionize, as they felt overwhelmed and underpaid. Apparently, paying six people an extra few thousand a year was too much for NEDA’s leadership, as they decided a few weeks later to fire those workers, fully closing down the hotline. Instead of talking to a real person, people “calling in” for support would be met with Tessa, a wellness chatbot that would hopefully guide them through their crisis. Key word, hopefully.
In perhaps the least surprising twist of the year, NEDA was forced to walk back its decision about a week after its initial announcement. It all started with a viral Instagram post from a woman who called in and received the following advice from Tessa: Lose 1-2 pounds a week, count calories and work for a 500- to 1,000-calorie deficit, weigh herself weekly, and restrict her diet. Unfortunately, all of these suggestions were things that led to the development of the woman’s eating disorder.
Naturally, NEDA responded in good grace, accusing the woman of lying. A NEDA vice president even left some nasty comments on the post, but hastily deleted them a day later when NEDA announced it was shutting down Tessa “until further notice for a complete investigation.” NEDA’s CEO insisted they hadn’t seen that behavior from Tessa before, calling it a “bug” and insisting the bot would only be down temporarily until the triggers causing the bug were fixed.
In the aftermath, several doctors and psychologists chimed in, terming the rush to automate human roles dangerous and risky. After all, much of what makes these hotlines effective is the volunteers speaking from their own experience. An unsupervised bot doesn’t seem to have what it takes to deal with a mental health crisis, but we’re betting that Tessa will be back. As a wise cephalopod once said: Nobody gives a care about the fate of labor as long as they can get their instant gratification.
You can’t spell existential without s-t-e-n-t
This week, we’re including a special “bonus” item that, to be honest, has nothing to do with stents. That’s why our editor is making us call this a “bonus” (and making us use quote marks, too): It doesn’t really have anything to do with stents or health care or those who practice health care. Actually, his exact words were, “You can’t just give the readers someone else’s ****ing list and expect to get paid for it.” Did we mention that he looks like Jack Nicklaus but acts like BoJack Horseman?
Anywaaay, we’re pretty sure that the list in question – “America’s Top 10 Most Googled Existential Questions” – says something about the human condition, just not about stents:
1. Why is the sky blue?
2. What do dreams mean?
3. What is the meaning of life?
4. Why am I so tired?
5. Who am I?
6. What is love?
7. Is a hot dog a sandwich?
8. What came first, the chicken or the egg?
9. What should I do?
10. Do animals have souls?
Sowing the seeds of cancer prevention
Are you looking to add to your quality of life, even though pets are not your speed? Might we suggest something with lower maintenance? Something a little greener?
Indoor plants can purify the air that comes from outside. Researchers at the University of Technology Sydney, in partnership with the plantscaping company Ambius, showed that a “green wall” made up of mixed indoor plants was able to suck up 97% of “the most toxic compounds” from the air in just 8 hours. We’re talking about lung-irritating, headache-inducing, cancer risk–boosting compounds from gasoline fumes, including benzene.
Public health initiatives often strive to reduce cardiovascular and obesity risks, but breathing seems pretty important too. According to the World Health Organization, household air pollution is responsible for about 2.5 million global premature deaths each year. And since 2020 we’ve become accustomed to spending more time inside and at home.
“This new research proves that plants should not just be seen as ‘nice to have,’ but rather a crucial part of every workplace wellness plan,” Ambius General Manager Johan Hodgson said in statement released by the university.
So don’t spend hundreds of dollars on a fancy air filtration system when a wall of plants can do that for next to nothing. Find what works for you and your space and become a plant parent today! Your lungs will thank you.
But officer, I had to swerve to miss the duodenal ampulla
Tiny video capsule endoscopes have been around for many years, but they have one big weakness: The ingestible cameras’ journey through the GI tract is passively driven by gravity and the natural movement of the body, so they often miss potential problem areas.
Not anymore. That flaw has been addressed by medical technology company AnX Robotica, which has taken endoscopy to the next level by adding that wondrous directional control device of the modern electronic age, a joystick.
The new system “uses an external magnet and hand-held video game style joysticks to move the capsule in three dimensions,” which allows physicians to “remotely drive a miniature video capsule to all regions of the stomach to visualize and photograph potential problem areas,” according to Andrew C. Meltzer, MD, of George Washington University and associates, who conducted a pilot study funded by AnX Robotica.
The video capsule provided a 95% rate of visualization in the stomachs of 40 patients who were examined at a medical office building by an emergency medicine physician who had no previous specialty training in endoscopy. “Capsules were driven by the ER physician and then the study reports were reviewed by an attending gastroenterologist who was physically off site,” the investigators said in a written statement.
The capsule operator did receive some additional training, and development of artificial intelligence to self-drive the capsule is in the works, but for now, we’re talking about a device controlled by a human using a joystick. And we all know that 50-year-olds are not especially known for their joystick skills. For that we need real experts. Yup, we need to put those joystick-controlled capsule endoscopes in the hands of teenage gamers. Who wants to go first?
Maybe AI isn’t ready for the big time after all
“How long before some intrepid stockholder says: ‘Hey, instead of paying doctors, why don’t we just use the free robot instead?’ ” Those words appeared on LOTME but a month ago. After all, the AI is supposed to be smarter and more empathetic than a doctor. And did we mention it’s free? Or at least extremely cheap. Cheaper than, say, a group of recently unionized health care workers.
In early May, the paid employees manning the National Eating Disorders Association emergency hotline voted to unionize, as they felt overwhelmed and underpaid. Apparently, paying six people an extra few thousand a year was too much for NEDA’s leadership, as they decided a few weeks later to fire those workers, fully closing down the hotline. Instead of talking to a real person, people “calling in” for support would be met with Tessa, a wellness chatbot that would hopefully guide them through their crisis. Key word, hopefully.
In perhaps the least surprising twist of the year, NEDA was forced to walk back its decision about a week after its initial announcement. It all started with a viral Instagram post from a woman who called in and received the following advice from Tessa: Lose 1-2 pounds a week, count calories and work for a 500- to 1,000-calorie deficit, weigh herself weekly, and restrict her diet. Unfortunately, all of these suggestions were things that led to the development of the woman’s eating disorder.
Naturally, NEDA responded in good grace, accusing the woman of lying. A NEDA vice president even left some nasty comments on the post, but hastily deleted them a day later when NEDA announced it was shutting down Tessa “until further notice for a complete investigation.” NEDA’s CEO insisted they hadn’t seen that behavior from Tessa before, calling it a “bug” and insisting the bot would only be down temporarily until the triggers causing the bug were fixed.
In the aftermath, several doctors and psychologists chimed in, terming the rush to automate human roles dangerous and risky. After all, much of what makes these hotlines effective is the volunteers speaking from their own experience. An unsupervised bot doesn’t seem to have what it takes to deal with a mental health crisis, but we’re betting that Tessa will be back. As a wise cephalopod once said: Nobody gives a care about the fate of labor as long as they can get their instant gratification.
You can’t spell existential without s-t-e-n-t
This week, we’re including a special “bonus” item that, to be honest, has nothing to do with stents. That’s why our editor is making us call this a “bonus” (and making us use quote marks, too): It doesn’t really have anything to do with stents or health care or those who practice health care. Actually, his exact words were, “You can’t just give the readers someone else’s ****ing list and expect to get paid for it.” Did we mention that he looks like Jack Nicklaus but acts like BoJack Horseman?
Anywaaay, we’re pretty sure that the list in question – “America’s Top 10 Most Googled Existential Questions” – says something about the human condition, just not about stents:
1. Why is the sky blue?
2. What do dreams mean?
3. What is the meaning of life?
4. Why am I so tired?
5. Who am I?
6. What is love?
7. Is a hot dog a sandwich?
8. What came first, the chicken or the egg?
9. What should I do?
10. Do animals have souls?
Cross-sectional Analysis of Matched Dermatology Residency Applicants Without US Home Programs
To the Editor:
Dermatology is one of the most competitive residencies for matching, with a 57.5% match rate in 2022.1 Our prior study of research-mentor relationships among matched dermatology applicants corroborated the importance of home programs (HPs) and program connections.2 Therefore, our current objective was to compare profiles of matched dermatology applicants without HPs vs those with HPs.
We searched websites of 139 dermatology programs nationwide and found 1736 matched applicants from 2016 to 2020; of them, 323 did not have HPs. We determined program rank by research output using Doximity Residency Navigator (https://www.doximity.com/residency/). Advanced degrees (ADs) of applicants were identified using program websites and LinkedIn. A PubMed search was conducted for number of articles published by each applicant before September 15 of their match year. For applicants without HPs, we identified the senior author on each publication. The senior author publishing with an applicant most often was considered the research mentor. Two-tailed independent t tests and χ2 tests were used to determine statistical significance (P<.05).
On average, matched applicants without HPs matched in lower-ranked (74.4) and smaller (12.4) programs compared with matched applicants with HPs (45.3 [P<.0001] and 15.1 [P<.0001], respectively)(eTable). The mean number of publications was similar between matched applicants with HPs and without HPs (5.64 and 4.80, respectively; P=.0525) as well as the percentage with ADs (14.7% and 11.5%, respectively; P=.0953). Overall, 14.8% of matched applicants without HPs matched at their mentors’ institutions.
Data were obtained for matched international applicants as a subset of non-HP applicants. Despite attending medical schools without associated HPs in the United States, international applicants matched at similarly ranked (44.3) and sized (15.0) programs, on average, compared with HP applicants. The mean number of publications was higher for international applicants (11.4) vs domestic applicants (5.33). International applicants more often had ADs (23.8%) and 60.1% of them held doctor of philosophy degrees. Overall, 40.5% of international applicants matched at their mentors’ institutions.
Our study suggests that matched dermatology applicants with and without HPs had similar achievements, on average, for the number of publications and percentage with ADs. However, non-HP applicants matched at lower-ranked programs than HP applicants. Therefore, applicants without HPs should strongly consider cultivating program connections, especially if they desire to match at higher-ranked dermatology programs. To illustrate, the rate of matching at research mentors’ institutions was approximately 3-times higher for international applicants than non-HP applicants overall. Despite the disadvantages of applying as international applicants, they were able to match at substantially higher-ranked dermatology programs than non-HP applicants. International applicants may have a longer time investment—the number of years from obtaining their medical degree or US medical license to matching—giving them time to produce quality research and develop meaningful relationships at an institution. Additionally, our prior study of the top 25 dermatology residencies showed that 26.2% of successful applicants matched at their research mentors’ institutions, with almost half of this subset matching at their HPs, where their mentors also practiced.2 Because of the potential benefits of having program connections, applicants without HPs should seek dermatology research mentors, especially via highly beneficial in-person networking opportunities (eg, away rotations, conferences) that had previously been limited during the COVID-19 pandemic.3 Formal mentorship programs giving priority to students without HPs recently have been developed, which only begins to address the inequities in the dermatology residency application process.4
Study limitations include lack of resident information on 15 program websites, missed publications due to applicant name changes, not accounting for abstracts and posters, and inability to collect data on unmatched applicants.
We hope that our study alleviates some concerns that applicants without HPs may have regarding applying for dermatology residency and encourages those with a genuine interest in dermatology to pursue the specialty, provided they find a strong research mentor. Residency programs should be cognizant of the unique challenges that non-HP applicants face for matching.
- National Resident Matching Program. Results and Data: 2022 Main Residency Match. National Resident Matching Program; May 2022. Accessed May 30, 2023. https://www.nrmp.org/wp-content/uploads/2022/11 /2022-Main-Match-Results-and-Data-Final-Revised.pdf
- Yeh C, Desai AD, Wilson BN, et al. Cross-sectional analysis of scholarly work and mentor relationships in matched dermatology residency applicants. J Am Acad Dermatol. 2022;86:1437-1439.
- Association of American Medical Colleges. Specialty recommendations on away rotations for 2021-22 academic year. Accessed May 24, 2023. https://students-residents.aamc.org/researching-residency-programs -and-building-application-strategy/specialty-response-covid-19
- derminterest Instagram page. DIGA is excited for the second year of our mentor-mentee program! Mentors are dermatology residents. Please keep in mind due to the current circumstances, dermatology residency 2021-2022 applicants without home programs will be prioritized as mentees. Please refrain from signing up if you were paired with a faculty mentor for the APD-DIGA Mentorship Program in May 2021. Contact @suryasweetie123 only if you have specific questions, otherwise all information is on our website and the link is here. Link is below and in our bio! #DIGA #derm #mentee #residencyapplication. Accessed May 24, 2023. https://www.instagram.com/p/CSrq0exMchY/
To the Editor:
Dermatology is one of the most competitive residencies for matching, with a 57.5% match rate in 2022.1 Our prior study of research-mentor relationships among matched dermatology applicants corroborated the importance of home programs (HPs) and program connections.2 Therefore, our current objective was to compare profiles of matched dermatology applicants without HPs vs those with HPs.
We searched websites of 139 dermatology programs nationwide and found 1736 matched applicants from 2016 to 2020; of them, 323 did not have HPs. We determined program rank by research output using Doximity Residency Navigator (https://www.doximity.com/residency/). Advanced degrees (ADs) of applicants were identified using program websites and LinkedIn. A PubMed search was conducted for number of articles published by each applicant before September 15 of their match year. For applicants without HPs, we identified the senior author on each publication. The senior author publishing with an applicant most often was considered the research mentor. Two-tailed independent t tests and χ2 tests were used to determine statistical significance (P<.05).
On average, matched applicants without HPs matched in lower-ranked (74.4) and smaller (12.4) programs compared with matched applicants with HPs (45.3 [P<.0001] and 15.1 [P<.0001], respectively)(eTable). The mean number of publications was similar between matched applicants with HPs and without HPs (5.64 and 4.80, respectively; P=.0525) as well as the percentage with ADs (14.7% and 11.5%, respectively; P=.0953). Overall, 14.8% of matched applicants without HPs matched at their mentors’ institutions.
Data were obtained for matched international applicants as a subset of non-HP applicants. Despite attending medical schools without associated HPs in the United States, international applicants matched at similarly ranked (44.3) and sized (15.0) programs, on average, compared with HP applicants. The mean number of publications was higher for international applicants (11.4) vs domestic applicants (5.33). International applicants more often had ADs (23.8%) and 60.1% of them held doctor of philosophy degrees. Overall, 40.5% of international applicants matched at their mentors’ institutions.
Our study suggests that matched dermatology applicants with and without HPs had similar achievements, on average, for the number of publications and percentage with ADs. However, non-HP applicants matched at lower-ranked programs than HP applicants. Therefore, applicants without HPs should strongly consider cultivating program connections, especially if they desire to match at higher-ranked dermatology programs. To illustrate, the rate of matching at research mentors’ institutions was approximately 3-times higher for international applicants than non-HP applicants overall. Despite the disadvantages of applying as international applicants, they were able to match at substantially higher-ranked dermatology programs than non-HP applicants. International applicants may have a longer time investment—the number of years from obtaining their medical degree or US medical license to matching—giving them time to produce quality research and develop meaningful relationships at an institution. Additionally, our prior study of the top 25 dermatology residencies showed that 26.2% of successful applicants matched at their research mentors’ institutions, with almost half of this subset matching at their HPs, where their mentors also practiced.2 Because of the potential benefits of having program connections, applicants without HPs should seek dermatology research mentors, especially via highly beneficial in-person networking opportunities (eg, away rotations, conferences) that had previously been limited during the COVID-19 pandemic.3 Formal mentorship programs giving priority to students without HPs recently have been developed, which only begins to address the inequities in the dermatology residency application process.4
Study limitations include lack of resident information on 15 program websites, missed publications due to applicant name changes, not accounting for abstracts and posters, and inability to collect data on unmatched applicants.
We hope that our study alleviates some concerns that applicants without HPs may have regarding applying for dermatology residency and encourages those with a genuine interest in dermatology to pursue the specialty, provided they find a strong research mentor. Residency programs should be cognizant of the unique challenges that non-HP applicants face for matching.
To the Editor:
Dermatology is one of the most competitive residencies for matching, with a 57.5% match rate in 2022.1 Our prior study of research-mentor relationships among matched dermatology applicants corroborated the importance of home programs (HPs) and program connections.2 Therefore, our current objective was to compare profiles of matched dermatology applicants without HPs vs those with HPs.
We searched websites of 139 dermatology programs nationwide and found 1736 matched applicants from 2016 to 2020; of them, 323 did not have HPs. We determined program rank by research output using Doximity Residency Navigator (https://www.doximity.com/residency/). Advanced degrees (ADs) of applicants were identified using program websites and LinkedIn. A PubMed search was conducted for number of articles published by each applicant before September 15 of their match year. For applicants without HPs, we identified the senior author on each publication. The senior author publishing with an applicant most often was considered the research mentor. Two-tailed independent t tests and χ2 tests were used to determine statistical significance (P<.05).
On average, matched applicants without HPs matched in lower-ranked (74.4) and smaller (12.4) programs compared with matched applicants with HPs (45.3 [P<.0001] and 15.1 [P<.0001], respectively)(eTable). The mean number of publications was similar between matched applicants with HPs and without HPs (5.64 and 4.80, respectively; P=.0525) as well as the percentage with ADs (14.7% and 11.5%, respectively; P=.0953). Overall, 14.8% of matched applicants without HPs matched at their mentors’ institutions.
Data were obtained for matched international applicants as a subset of non-HP applicants. Despite attending medical schools without associated HPs in the United States, international applicants matched at similarly ranked (44.3) and sized (15.0) programs, on average, compared with HP applicants. The mean number of publications was higher for international applicants (11.4) vs domestic applicants (5.33). International applicants more often had ADs (23.8%) and 60.1% of them held doctor of philosophy degrees. Overall, 40.5% of international applicants matched at their mentors’ institutions.
Our study suggests that matched dermatology applicants with and without HPs had similar achievements, on average, for the number of publications and percentage with ADs. However, non-HP applicants matched at lower-ranked programs than HP applicants. Therefore, applicants without HPs should strongly consider cultivating program connections, especially if they desire to match at higher-ranked dermatology programs. To illustrate, the rate of matching at research mentors’ institutions was approximately 3-times higher for international applicants than non-HP applicants overall. Despite the disadvantages of applying as international applicants, they were able to match at substantially higher-ranked dermatology programs than non-HP applicants. International applicants may have a longer time investment—the number of years from obtaining their medical degree or US medical license to matching—giving them time to produce quality research and develop meaningful relationships at an institution. Additionally, our prior study of the top 25 dermatology residencies showed that 26.2% of successful applicants matched at their research mentors’ institutions, with almost half of this subset matching at their HPs, where their mentors also practiced.2 Because of the potential benefits of having program connections, applicants without HPs should seek dermatology research mentors, especially via highly beneficial in-person networking opportunities (eg, away rotations, conferences) that had previously been limited during the COVID-19 pandemic.3 Formal mentorship programs giving priority to students without HPs recently have been developed, which only begins to address the inequities in the dermatology residency application process.4
Study limitations include lack of resident information on 15 program websites, missed publications due to applicant name changes, not accounting for abstracts and posters, and inability to collect data on unmatched applicants.
We hope that our study alleviates some concerns that applicants without HPs may have regarding applying for dermatology residency and encourages those with a genuine interest in dermatology to pursue the specialty, provided they find a strong research mentor. Residency programs should be cognizant of the unique challenges that non-HP applicants face for matching.
- National Resident Matching Program. Results and Data: 2022 Main Residency Match. National Resident Matching Program; May 2022. Accessed May 30, 2023. https://www.nrmp.org/wp-content/uploads/2022/11 /2022-Main-Match-Results-and-Data-Final-Revised.pdf
- Yeh C, Desai AD, Wilson BN, et al. Cross-sectional analysis of scholarly work and mentor relationships in matched dermatology residency applicants. J Am Acad Dermatol. 2022;86:1437-1439.
- Association of American Medical Colleges. Specialty recommendations on away rotations for 2021-22 academic year. Accessed May 24, 2023. https://students-residents.aamc.org/researching-residency-programs -and-building-application-strategy/specialty-response-covid-19
- derminterest Instagram page. DIGA is excited for the second year of our mentor-mentee program! Mentors are dermatology residents. Please keep in mind due to the current circumstances, dermatology residency 2021-2022 applicants without home programs will be prioritized as mentees. Please refrain from signing up if you were paired with a faculty mentor for the APD-DIGA Mentorship Program in May 2021. Contact @suryasweetie123 only if you have specific questions, otherwise all information is on our website and the link is here. Link is below and in our bio! #DIGA #derm #mentee #residencyapplication. Accessed May 24, 2023. https://www.instagram.com/p/CSrq0exMchY/
- National Resident Matching Program. Results and Data: 2022 Main Residency Match. National Resident Matching Program; May 2022. Accessed May 30, 2023. https://www.nrmp.org/wp-content/uploads/2022/11 /2022-Main-Match-Results-and-Data-Final-Revised.pdf
- Yeh C, Desai AD, Wilson BN, et al. Cross-sectional analysis of scholarly work and mentor relationships in matched dermatology residency applicants. J Am Acad Dermatol. 2022;86:1437-1439.
- Association of American Medical Colleges. Specialty recommendations on away rotations for 2021-22 academic year. Accessed May 24, 2023. https://students-residents.aamc.org/researching-residency-programs -and-building-application-strategy/specialty-response-covid-19
- derminterest Instagram page. DIGA is excited for the second year of our mentor-mentee program! Mentors are dermatology residents. Please keep in mind due to the current circumstances, dermatology residency 2021-2022 applicants without home programs will be prioritized as mentees. Please refrain from signing up if you were paired with a faculty mentor for the APD-DIGA Mentorship Program in May 2021. Contact @suryasweetie123 only if you have specific questions, otherwise all information is on our website and the link is here. Link is below and in our bio! #DIGA #derm #mentee #residencyapplication. Accessed May 24, 2023. https://www.instagram.com/p/CSrq0exMchY/
Practice Points
- Our study suggests that matched dermatology applicants with and without home programs (HPs) had similar achievements, on average, for number of publications and holding advanced degrees.
- Because of the potential benefits of having program connections for matching in dermatology, applicants without HPs should seek dermatology research mentors.
What’s Eating You? Triatoma and Arilus cristatus Bugs
Classification
Triatomine bugs (Triatoma) and the wheel bug (Arilus cristatus) are part of the family Reduviidae (order Hemiptera, a name that describes the sucking proboscis on the front of the insect’s head).1,2 Both arthropods are found in multiple countries and are especially common in warmer areas, including in the United States, where they can be seen from Texas to California.3,4 Because blood-feeding triatomines need a blood meal to survive while laying eggs and then throughout their 5 developmental nymph stages to undergo molting, they feed on mammals, such as opossums, raccoons, pack rats, and armadillos, whereas wheel bugs mainly prey on soft-bodied insects.1,4-6
Triatoma bugs seek cutaneous blood vessels using thermosensors in their antennae to locate blood flow under the skin for feeding. After inserting the proboscis, they release nitric oxide and an anticoagulant that allows for continuous blood flow while feeding.7 It has been reported that triatomine bugs are not able to bite through clothing, instead seeking exposed skin, particularly near mucous membranes, such as the hands, arms, feet, head, and trunk. The name kissing bug for triatomines was coined because bites near the mouth are common.6 The bite typically is painless and occurs mainly at night when the insect is most active. After obtaining a blood meal, triatomine bugs seek shelter and hide in mud and daub structures, cracks, crevices, and furniture.1,8
Unlike Triatoma species, A cristatus does not require a blood meal for development and survival, leading it to prey on soft-bodied insects. Piercing prey with the proboscis, wheel bugs inject a toxin to digest the contents and suck the digested contents through this apparatus.4 Because the wheel bug does not require a blood meal, it typically bites a human only for defense if it feels threatened. Unlike the painless bite of a triatomine bug, the bite of A cristatus is extremely painful; it has been described as the worst arthropod bite—worse than a hornet’s sting. The pain from the bite is caused by the toxin being injected into the skin; possible retention of the proboscis makes the pain worse.4,9 In addition, when A cristatus is disturbed, it exudes pungent material from a pair of bright orange subrectal glands while stridulating to repulse predators.9
Although Triatoma species and A cristatus have separate roles in nature and vastly different impacts on health, they often are mistaken for the same arthropod when seen in nature. Features that members of Reduviidae share include large bodies (relative to their overall length); long thin legs; a narrow head; wings; and a long sucking proboscis on the front of the head.10
Characteristics that differentiate Triatoma and A cristatus species include size, color, and distinctive markings. Most triatomine bugs are 12- to 36-mm long; are dark brown or black; and have what are called tiger-stripe orange markings on the peripheral two-thirds of the body (Figure 1).11 In contrast, wheel bugs commonly are bigger—measuring longer than 1.25 inches—and gray, with a cogwheel-like structure on the thorax (Figure 2).10
Dermatologic Presentation and Clinical Symptoms
The area of involved skin on patients presenting with Triatoma or A cristatus bites may resemble other insect bites. Many bites from Triatoma bugs and A cristatus initially present as an erythematous, raised, pruritic papule with a central punctum that is visible because of the involvement of the proboscis. However, other presentations of bites from both arthropods have been reported4,6,7: grouped vesicles on an erythematous base; indurated, giant, urticarial-type wheels measuring 10 to 15 mm in diameter; and hemorrhagic bullous nodules (Figure 3). Associated lymphangitis or lymphadenitis is typical of the latter 2 variations.6 These variations in presentation can be mistaken for other causes of similarly presenting lesions, such as shingles or spider bites, leading to delayed or missed diagnosis.
Patients may present with a single bite or multiple bites due to the feeding pattern of Triatoma bugs; if the host moves or disrupts its feeding, the arthropod takes multiple bites to finish feeding.8 In comparison, 4 common variations of wheel bug bites have been reported: (1) a painful bite without complications; (2) a cutaneous horn and papilloma at the site of toxin injection; (3) a necrotic ulcer around the central punctum caused by injected toxin; and (4) an abscess under the central punctum due to secondary infection.4
Anaphylaxis—Although the bites of Triatoma and A cristatus present differently, both can cause anaphylaxis. Triatoma is implicated more often than A cristatus as the cause of anaphylaxis.12 In fact, Triatoma bites are among the more common causes of anaphylaxis from bug bites, with multiple cases of these reactions reported in the literature.12,13
Symptoms of Triatoma anaphylaxis include acute-onset urticarial rash, flushing, dyspnea, wheezing, nausea, vomiting, and localized edema.2 The cause of anaphylaxis is proteins in Triatoma saliva, including 20-kDa procalin, which incites the systemic reaction. Other potential causes of anaphylaxis include serine protease, which has similarities to salivary protein and desmoglein in humans.11
The degree of reaction to a bite depends on the patient's sensitization to antigenic proteins in each insect’s saliva.4,6 Patients who have a bite from a triatomine bug are at risk for subsequent bites, as household infestation is likely due to the pliability of the insect, allowing it to hide in small spaces unnoticed.8 In the case of a bite from Triatoma or A cristatus, sensitization may lead to severe and worsening reactions with subsequent bites, which ultimately can result in life-threatening anaphylaxis.1,6
Treatment and Prevention
Treatment of Triatoma and A cristatus bites depends on the severity of the patient’s reaction to the bite. A local reaction to a bite from either insect can be treated supportively with local corticosteroids and antihistamines.3 If the patient is sensitized to proteins associated with a bite, standard anaphylaxis treatment such as epinephrine and intravenous antihistamines may be indicated.14 Secondary infection can be treated with antibiotics; a formed abscess might need to be drained or debrided.15
There’s No Place Like Home—Because Triatoma bugs have a pliable exoskeleton and can squeeze into small spaces, they commonly infest dwellings where they find multiple attractants: light, heat, carbon dioxide, and lactic acid.8 The more household occupants (including pets), the higher the levels of carbon dioxide and lactic acid, thus the greater the attraction. Infestation of a home can lead to the spread of diseases harbored by Triatoma, including Chagas disease, which is caused by the parasite Trypanosoma cruzi.5
Preventive measures can be taken to reduce the risk and extent of home infestation by Triatoma bugs, including insecticides, a solid foundation, window screens, air conditioning, sealing of cracks and crevices, outdoor light management, and removal of clutter throughout the house.8 Because Triatoma bugs cannot bite through clothing, protective clothing and bug repellent on exposed skin can be employed. Another degree of protection is offered by pest management, especially control of rodents by removing food, water, and nests in areas where triatomine bugs feed off of that population.8,14
Unlike triatomine bugs, wheel bugs tend not to invade houses; therefore, these preventive measures are unnecessary. If a wheel bug is identified, do not engage the arthropod due to the defensive nature of its attack.4,9 Such deliberate avoidance should ensure protection from the wheel bug’s painful bite.
Medical Complications
Although triatomine bugs and wheel bugs are in the same taxonomic family, subsequent infection is unique to Triatoma bugs because they need a blood meal to survive. Because Triatoma bugs feed on mammals, they present an increased opportunity for transmitting the causative agents of infection from hosts on which they have fed.12 The principal parasite transmitted by triatomines is T cruzi, which causes Chagas disease and lives in the gastrointestinal (GI) tract of the insect.5 When a triatomine bug seeks out a mucosal surface to bite, including the mouth, it defecates and urinates during or shortly after feeding, leading to contamination of the initial wound or mucosal surfaces. In addition, Triatoma bugs are vectors for transmission of Serratia marcescans, Bartonella henselae, and Mycobacterium leprae.16
Chagas Disease—This infection has 3 stages: acute, intermediate, and chronic.5 The acute stage can present with symptoms of conjunctivitis, fever, lymphadenopathy, hepatosplenomegaly, and anemia. The intermediate stage typically is asymptomatic. The chronic stage usually involves the heart and GI tract and causes cardiac aneurysms, cardiomegaly, megacolon, and megaesophagus. Initial symptoms can be a localized nodule (chagoma) at the inoculation site, fever, fatigue, lymphadenopathy, and hepatosplenomegaly.2 Unilateral palpebral edema with associated lymphadenopathy (Romaña sign) also can be seen—not to be confused with bilateral swelling in an acute reaction to an insect bite. Romaña sign is pathognomonic of T cruzi infection; bilateral palpebral swelling is typical of an allergic reaction.12
Identification of a triatomine bite is the first step in diagnosing Chagas disease, which can be life-threatening. Among chronic carriers of Chagas disease, 30% develop GI and cardiac symptoms, of which 20% to 30% develop cardiomyopathy, with serious symptoms that present 10 to 20 years after the asymptomatic intermediate phase.2
Chagas disease is endemic to Central and South America but is also seen in North America; 28,000 new cases are reported annually in South America and North America combined. Human migration from endemic areas and from rural to urban areas has promoted the spread of Chagas disease.2 However, patients in the United States have a relatively low risk for Chagas disease, largely because of the quality of housing construction and use of insecticides.
Treatment options for Chagas disease include nifurtimox and benznidazole. Without treatment, the host immune response typically controls acute replication of the parasite but will lead to a chronic state, ultimately involving the heart and GI tract.5
- Vetter R. Kissing bugs (Triatoma) and the skin. Dermatol Online J. 2001;7:6.
- Zemore ZM, Wills BK. Kissing bug bite. StatPearls [Internet]. StatPearlsPublishing; 2023.
- Edwards L, Lynch PJ. Anaphylactic reaction to kissing bug bites. Ariz Med. 1984;41:159-161.
- Smith FD, Miller NG, Carnazzo SJ, et al. Insect bite by Arilus cristatus, a North American reduviid. AMA Arch Derm. 1958;77:324-330. doi:10.1001/archderm.1958.01560030070011
- Nguyen T, Waseem M. Chagas disease. StatPearls [Internet]. StatPearls Publishing; 2022.
- Shields TL, Walsh EN. Kissing bug bite. AMA Arch Derm. 1956;74:14-21. doi:10.1001/archderm.1956.01550070016004
- Beatty NL, Klotz SA. The midnight bite! a kissing bug nightmare. Am J Med. 2018;131:E43-E44. doi:10.1016/j.amjmed.2017.10.013
- Klotz SA, Smith SL, Schmidt JO. Kissing bug intrusions into homes in the Southwest United States. Insects. 2021;12:654. doi:10.3390/insects12070654
- Aldrich JR, Chauhan KR, Zhang A, et al. Exocrine secretions of wheel bugs (Heteroptera: Reduviidae: Arilus spp.): clarification and chemistry. Z Naturforsch C J Biosci. 2013;68:522-526.
- Boggs J. They’re wheel bugs, NOT kissing bugs. Buckeye Yard and Garden onLine [Internet]. September 17, 2020. Accessed May 25, 2023. https://bygl.osu.edu/node/1688
- Weber RW. Allergen of the month—assassin bug. Ann Allergy Asthma Immunol. 2015;115:A9.
- Klotz JH, Dorn PL, Logan JL, et al. “Kissing bugs”: potential disease vectors and cause of anaphylaxis. Clin Infect Dis 2010;50:1629-1634. doi:10.1086/652769
- Anderson C, Belnap C. The kiss of death: a rare case of anaphylaxis to the bite of the “red margined kissing bug”. Hawaii J Med Public Health. 2015;74(9 suppl 2):33-35.
- Moffitt JE, Venarske D, Goddard J, et al. Allergic reactions to Triatoma bites. Ann Allergy Asthma Immunol. 2003;91:122-128. doi:10.1016/s1081-1206(10)62165-5
- Burnett JW, Calton GJ, Morgan RJ. Triatoma: the “kissing bug”. Cutis. 1987;39:399.
- Vieira CB, Praça YR, Bentes K, et al. Triatomines: Trypanosomatids, bacteria, and viruses potential vectors? Front Cell Infect Microbiol. 2018;8:405. doi:10.3389/fcimb.2018.00405
Classification
Triatomine bugs (Triatoma) and the wheel bug (Arilus cristatus) are part of the family Reduviidae (order Hemiptera, a name that describes the sucking proboscis on the front of the insect’s head).1,2 Both arthropods are found in multiple countries and are especially common in warmer areas, including in the United States, where they can be seen from Texas to California.3,4 Because blood-feeding triatomines need a blood meal to survive while laying eggs and then throughout their 5 developmental nymph stages to undergo molting, they feed on mammals, such as opossums, raccoons, pack rats, and armadillos, whereas wheel bugs mainly prey on soft-bodied insects.1,4-6
Triatoma bugs seek cutaneous blood vessels using thermosensors in their antennae to locate blood flow under the skin for feeding. After inserting the proboscis, they release nitric oxide and an anticoagulant that allows for continuous blood flow while feeding.7 It has been reported that triatomine bugs are not able to bite through clothing, instead seeking exposed skin, particularly near mucous membranes, such as the hands, arms, feet, head, and trunk. The name kissing bug for triatomines was coined because bites near the mouth are common.6 The bite typically is painless and occurs mainly at night when the insect is most active. After obtaining a blood meal, triatomine bugs seek shelter and hide in mud and daub structures, cracks, crevices, and furniture.1,8
Unlike Triatoma species, A cristatus does not require a blood meal for development and survival, leading it to prey on soft-bodied insects. Piercing prey with the proboscis, wheel bugs inject a toxin to digest the contents and suck the digested contents through this apparatus.4 Because the wheel bug does not require a blood meal, it typically bites a human only for defense if it feels threatened. Unlike the painless bite of a triatomine bug, the bite of A cristatus is extremely painful; it has been described as the worst arthropod bite—worse than a hornet’s sting. The pain from the bite is caused by the toxin being injected into the skin; possible retention of the proboscis makes the pain worse.4,9 In addition, when A cristatus is disturbed, it exudes pungent material from a pair of bright orange subrectal glands while stridulating to repulse predators.9
Although Triatoma species and A cristatus have separate roles in nature and vastly different impacts on health, they often are mistaken for the same arthropod when seen in nature. Features that members of Reduviidae share include large bodies (relative to their overall length); long thin legs; a narrow head; wings; and a long sucking proboscis on the front of the head.10
Characteristics that differentiate Triatoma and A cristatus species include size, color, and distinctive markings. Most triatomine bugs are 12- to 36-mm long; are dark brown or black; and have what are called tiger-stripe orange markings on the peripheral two-thirds of the body (Figure 1).11 In contrast, wheel bugs commonly are bigger—measuring longer than 1.25 inches—and gray, with a cogwheel-like structure on the thorax (Figure 2).10
Dermatologic Presentation and Clinical Symptoms
The area of involved skin on patients presenting with Triatoma or A cristatus bites may resemble other insect bites. Many bites from Triatoma bugs and A cristatus initially present as an erythematous, raised, pruritic papule with a central punctum that is visible because of the involvement of the proboscis. However, other presentations of bites from both arthropods have been reported4,6,7: grouped vesicles on an erythematous base; indurated, giant, urticarial-type wheels measuring 10 to 15 mm in diameter; and hemorrhagic bullous nodules (Figure 3). Associated lymphangitis or lymphadenitis is typical of the latter 2 variations.6 These variations in presentation can be mistaken for other causes of similarly presenting lesions, such as shingles or spider bites, leading to delayed or missed diagnosis.
Patients may present with a single bite or multiple bites due to the feeding pattern of Triatoma bugs; if the host moves or disrupts its feeding, the arthropod takes multiple bites to finish feeding.8 In comparison, 4 common variations of wheel bug bites have been reported: (1) a painful bite without complications; (2) a cutaneous horn and papilloma at the site of toxin injection; (3) a necrotic ulcer around the central punctum caused by injected toxin; and (4) an abscess under the central punctum due to secondary infection.4
Anaphylaxis—Although the bites of Triatoma and A cristatus present differently, both can cause anaphylaxis. Triatoma is implicated more often than A cristatus as the cause of anaphylaxis.12 In fact, Triatoma bites are among the more common causes of anaphylaxis from bug bites, with multiple cases of these reactions reported in the literature.12,13
Symptoms of Triatoma anaphylaxis include acute-onset urticarial rash, flushing, dyspnea, wheezing, nausea, vomiting, and localized edema.2 The cause of anaphylaxis is proteins in Triatoma saliva, including 20-kDa procalin, which incites the systemic reaction. Other potential causes of anaphylaxis include serine protease, which has similarities to salivary protein and desmoglein in humans.11
The degree of reaction to a bite depends on the patient's sensitization to antigenic proteins in each insect’s saliva.4,6 Patients who have a bite from a triatomine bug are at risk for subsequent bites, as household infestation is likely due to the pliability of the insect, allowing it to hide in small spaces unnoticed.8 In the case of a bite from Triatoma or A cristatus, sensitization may lead to severe and worsening reactions with subsequent bites, which ultimately can result in life-threatening anaphylaxis.1,6
Treatment and Prevention
Treatment of Triatoma and A cristatus bites depends on the severity of the patient’s reaction to the bite. A local reaction to a bite from either insect can be treated supportively with local corticosteroids and antihistamines.3 If the patient is sensitized to proteins associated with a bite, standard anaphylaxis treatment such as epinephrine and intravenous antihistamines may be indicated.14 Secondary infection can be treated with antibiotics; a formed abscess might need to be drained or debrided.15
There’s No Place Like Home—Because Triatoma bugs have a pliable exoskeleton and can squeeze into small spaces, they commonly infest dwellings where they find multiple attractants: light, heat, carbon dioxide, and lactic acid.8 The more household occupants (including pets), the higher the levels of carbon dioxide and lactic acid, thus the greater the attraction. Infestation of a home can lead to the spread of diseases harbored by Triatoma, including Chagas disease, which is caused by the parasite Trypanosoma cruzi.5
Preventive measures can be taken to reduce the risk and extent of home infestation by Triatoma bugs, including insecticides, a solid foundation, window screens, air conditioning, sealing of cracks and crevices, outdoor light management, and removal of clutter throughout the house.8 Because Triatoma bugs cannot bite through clothing, protective clothing and bug repellent on exposed skin can be employed. Another degree of protection is offered by pest management, especially control of rodents by removing food, water, and nests in areas where triatomine bugs feed off of that population.8,14
Unlike triatomine bugs, wheel bugs tend not to invade houses; therefore, these preventive measures are unnecessary. If a wheel bug is identified, do not engage the arthropod due to the defensive nature of its attack.4,9 Such deliberate avoidance should ensure protection from the wheel bug’s painful bite.
Medical Complications
Although triatomine bugs and wheel bugs are in the same taxonomic family, subsequent infection is unique to Triatoma bugs because they need a blood meal to survive. Because Triatoma bugs feed on mammals, they present an increased opportunity for transmitting the causative agents of infection from hosts on which they have fed.12 The principal parasite transmitted by triatomines is T cruzi, which causes Chagas disease and lives in the gastrointestinal (GI) tract of the insect.5 When a triatomine bug seeks out a mucosal surface to bite, including the mouth, it defecates and urinates during or shortly after feeding, leading to contamination of the initial wound or mucosal surfaces. In addition, Triatoma bugs are vectors for transmission of Serratia marcescans, Bartonella henselae, and Mycobacterium leprae.16
Chagas Disease—This infection has 3 stages: acute, intermediate, and chronic.5 The acute stage can present with symptoms of conjunctivitis, fever, lymphadenopathy, hepatosplenomegaly, and anemia. The intermediate stage typically is asymptomatic. The chronic stage usually involves the heart and GI tract and causes cardiac aneurysms, cardiomegaly, megacolon, and megaesophagus. Initial symptoms can be a localized nodule (chagoma) at the inoculation site, fever, fatigue, lymphadenopathy, and hepatosplenomegaly.2 Unilateral palpebral edema with associated lymphadenopathy (Romaña sign) also can be seen—not to be confused with bilateral swelling in an acute reaction to an insect bite. Romaña sign is pathognomonic of T cruzi infection; bilateral palpebral swelling is typical of an allergic reaction.12
Identification of a triatomine bite is the first step in diagnosing Chagas disease, which can be life-threatening. Among chronic carriers of Chagas disease, 30% develop GI and cardiac symptoms, of which 20% to 30% develop cardiomyopathy, with serious symptoms that present 10 to 20 years after the asymptomatic intermediate phase.2
Chagas disease is endemic to Central and South America but is also seen in North America; 28,000 new cases are reported annually in South America and North America combined. Human migration from endemic areas and from rural to urban areas has promoted the spread of Chagas disease.2 However, patients in the United States have a relatively low risk for Chagas disease, largely because of the quality of housing construction and use of insecticides.
Treatment options for Chagas disease include nifurtimox and benznidazole. Without treatment, the host immune response typically controls acute replication of the parasite but will lead to a chronic state, ultimately involving the heart and GI tract.5
Classification
Triatomine bugs (Triatoma) and the wheel bug (Arilus cristatus) are part of the family Reduviidae (order Hemiptera, a name that describes the sucking proboscis on the front of the insect’s head).1,2 Both arthropods are found in multiple countries and are especially common in warmer areas, including in the United States, where they can be seen from Texas to California.3,4 Because blood-feeding triatomines need a blood meal to survive while laying eggs and then throughout their 5 developmental nymph stages to undergo molting, they feed on mammals, such as opossums, raccoons, pack rats, and armadillos, whereas wheel bugs mainly prey on soft-bodied insects.1,4-6
Triatoma bugs seek cutaneous blood vessels using thermosensors in their antennae to locate blood flow under the skin for feeding. After inserting the proboscis, they release nitric oxide and an anticoagulant that allows for continuous blood flow while feeding.7 It has been reported that triatomine bugs are not able to bite through clothing, instead seeking exposed skin, particularly near mucous membranes, such as the hands, arms, feet, head, and trunk. The name kissing bug for triatomines was coined because bites near the mouth are common.6 The bite typically is painless and occurs mainly at night when the insect is most active. After obtaining a blood meal, triatomine bugs seek shelter and hide in mud and daub structures, cracks, crevices, and furniture.1,8
Unlike Triatoma species, A cristatus does not require a blood meal for development and survival, leading it to prey on soft-bodied insects. Piercing prey with the proboscis, wheel bugs inject a toxin to digest the contents and suck the digested contents through this apparatus.4 Because the wheel bug does not require a blood meal, it typically bites a human only for defense if it feels threatened. Unlike the painless bite of a triatomine bug, the bite of A cristatus is extremely painful; it has been described as the worst arthropod bite—worse than a hornet’s sting. The pain from the bite is caused by the toxin being injected into the skin; possible retention of the proboscis makes the pain worse.4,9 In addition, when A cristatus is disturbed, it exudes pungent material from a pair of bright orange subrectal glands while stridulating to repulse predators.9
Although Triatoma species and A cristatus have separate roles in nature and vastly different impacts on health, they often are mistaken for the same arthropod when seen in nature. Features that members of Reduviidae share include large bodies (relative to their overall length); long thin legs; a narrow head; wings; and a long sucking proboscis on the front of the head.10
Characteristics that differentiate Triatoma and A cristatus species include size, color, and distinctive markings. Most triatomine bugs are 12- to 36-mm long; are dark brown or black; and have what are called tiger-stripe orange markings on the peripheral two-thirds of the body (Figure 1).11 In contrast, wheel bugs commonly are bigger—measuring longer than 1.25 inches—and gray, with a cogwheel-like structure on the thorax (Figure 2).10
Dermatologic Presentation and Clinical Symptoms
The area of involved skin on patients presenting with Triatoma or A cristatus bites may resemble other insect bites. Many bites from Triatoma bugs and A cristatus initially present as an erythematous, raised, pruritic papule with a central punctum that is visible because of the involvement of the proboscis. However, other presentations of bites from both arthropods have been reported4,6,7: grouped vesicles on an erythematous base; indurated, giant, urticarial-type wheels measuring 10 to 15 mm in diameter; and hemorrhagic bullous nodules (Figure 3). Associated lymphangitis or lymphadenitis is typical of the latter 2 variations.6 These variations in presentation can be mistaken for other causes of similarly presenting lesions, such as shingles or spider bites, leading to delayed or missed diagnosis.
Patients may present with a single bite or multiple bites due to the feeding pattern of Triatoma bugs; if the host moves or disrupts its feeding, the arthropod takes multiple bites to finish feeding.8 In comparison, 4 common variations of wheel bug bites have been reported: (1) a painful bite without complications; (2) a cutaneous horn and papilloma at the site of toxin injection; (3) a necrotic ulcer around the central punctum caused by injected toxin; and (4) an abscess under the central punctum due to secondary infection.4
Anaphylaxis—Although the bites of Triatoma and A cristatus present differently, both can cause anaphylaxis. Triatoma is implicated more often than A cristatus as the cause of anaphylaxis.12 In fact, Triatoma bites are among the more common causes of anaphylaxis from bug bites, with multiple cases of these reactions reported in the literature.12,13
Symptoms of Triatoma anaphylaxis include acute-onset urticarial rash, flushing, dyspnea, wheezing, nausea, vomiting, and localized edema.2 The cause of anaphylaxis is proteins in Triatoma saliva, including 20-kDa procalin, which incites the systemic reaction. Other potential causes of anaphylaxis include serine protease, which has similarities to salivary protein and desmoglein in humans.11
The degree of reaction to a bite depends on the patient's sensitization to antigenic proteins in each insect’s saliva.4,6 Patients who have a bite from a triatomine bug are at risk for subsequent bites, as household infestation is likely due to the pliability of the insect, allowing it to hide in small spaces unnoticed.8 In the case of a bite from Triatoma or A cristatus, sensitization may lead to severe and worsening reactions with subsequent bites, which ultimately can result in life-threatening anaphylaxis.1,6
Treatment and Prevention
Treatment of Triatoma and A cristatus bites depends on the severity of the patient’s reaction to the bite. A local reaction to a bite from either insect can be treated supportively with local corticosteroids and antihistamines.3 If the patient is sensitized to proteins associated with a bite, standard anaphylaxis treatment such as epinephrine and intravenous antihistamines may be indicated.14 Secondary infection can be treated with antibiotics; a formed abscess might need to be drained or debrided.15
There’s No Place Like Home—Because Triatoma bugs have a pliable exoskeleton and can squeeze into small spaces, they commonly infest dwellings where they find multiple attractants: light, heat, carbon dioxide, and lactic acid.8 The more household occupants (including pets), the higher the levels of carbon dioxide and lactic acid, thus the greater the attraction. Infestation of a home can lead to the spread of diseases harbored by Triatoma, including Chagas disease, which is caused by the parasite Trypanosoma cruzi.5
Preventive measures can be taken to reduce the risk and extent of home infestation by Triatoma bugs, including insecticides, a solid foundation, window screens, air conditioning, sealing of cracks and crevices, outdoor light management, and removal of clutter throughout the house.8 Because Triatoma bugs cannot bite through clothing, protective clothing and bug repellent on exposed skin can be employed. Another degree of protection is offered by pest management, especially control of rodents by removing food, water, and nests in areas where triatomine bugs feed off of that population.8,14
Unlike triatomine bugs, wheel bugs tend not to invade houses; therefore, these preventive measures are unnecessary. If a wheel bug is identified, do not engage the arthropod due to the defensive nature of its attack.4,9 Such deliberate avoidance should ensure protection from the wheel bug’s painful bite.
Medical Complications
Although triatomine bugs and wheel bugs are in the same taxonomic family, subsequent infection is unique to Triatoma bugs because they need a blood meal to survive. Because Triatoma bugs feed on mammals, they present an increased opportunity for transmitting the causative agents of infection from hosts on which they have fed.12 The principal parasite transmitted by triatomines is T cruzi, which causes Chagas disease and lives in the gastrointestinal (GI) tract of the insect.5 When a triatomine bug seeks out a mucosal surface to bite, including the mouth, it defecates and urinates during or shortly after feeding, leading to contamination of the initial wound or mucosal surfaces. In addition, Triatoma bugs are vectors for transmission of Serratia marcescans, Bartonella henselae, and Mycobacterium leprae.16
Chagas Disease—This infection has 3 stages: acute, intermediate, and chronic.5 The acute stage can present with symptoms of conjunctivitis, fever, lymphadenopathy, hepatosplenomegaly, and anemia. The intermediate stage typically is asymptomatic. The chronic stage usually involves the heart and GI tract and causes cardiac aneurysms, cardiomegaly, megacolon, and megaesophagus. Initial symptoms can be a localized nodule (chagoma) at the inoculation site, fever, fatigue, lymphadenopathy, and hepatosplenomegaly.2 Unilateral palpebral edema with associated lymphadenopathy (Romaña sign) also can be seen—not to be confused with bilateral swelling in an acute reaction to an insect bite. Romaña sign is pathognomonic of T cruzi infection; bilateral palpebral swelling is typical of an allergic reaction.12
Identification of a triatomine bite is the first step in diagnosing Chagas disease, which can be life-threatening. Among chronic carriers of Chagas disease, 30% develop GI and cardiac symptoms, of which 20% to 30% develop cardiomyopathy, with serious symptoms that present 10 to 20 years after the asymptomatic intermediate phase.2
Chagas disease is endemic to Central and South America but is also seen in North America; 28,000 new cases are reported annually in South America and North America combined. Human migration from endemic areas and from rural to urban areas has promoted the spread of Chagas disease.2 However, patients in the United States have a relatively low risk for Chagas disease, largely because of the quality of housing construction and use of insecticides.
Treatment options for Chagas disease include nifurtimox and benznidazole. Without treatment, the host immune response typically controls acute replication of the parasite but will lead to a chronic state, ultimately involving the heart and GI tract.5
- Vetter R. Kissing bugs (Triatoma) and the skin. Dermatol Online J. 2001;7:6.
- Zemore ZM, Wills BK. Kissing bug bite. StatPearls [Internet]. StatPearlsPublishing; 2023.
- Edwards L, Lynch PJ. Anaphylactic reaction to kissing bug bites. Ariz Med. 1984;41:159-161.
- Smith FD, Miller NG, Carnazzo SJ, et al. Insect bite by Arilus cristatus, a North American reduviid. AMA Arch Derm. 1958;77:324-330. doi:10.1001/archderm.1958.01560030070011
- Nguyen T, Waseem M. Chagas disease. StatPearls [Internet]. StatPearls Publishing; 2022.
- Shields TL, Walsh EN. Kissing bug bite. AMA Arch Derm. 1956;74:14-21. doi:10.1001/archderm.1956.01550070016004
- Beatty NL, Klotz SA. The midnight bite! a kissing bug nightmare. Am J Med. 2018;131:E43-E44. doi:10.1016/j.amjmed.2017.10.013
- Klotz SA, Smith SL, Schmidt JO. Kissing bug intrusions into homes in the Southwest United States. Insects. 2021;12:654. doi:10.3390/insects12070654
- Aldrich JR, Chauhan KR, Zhang A, et al. Exocrine secretions of wheel bugs (Heteroptera: Reduviidae: Arilus spp.): clarification and chemistry. Z Naturforsch C J Biosci. 2013;68:522-526.
- Boggs J. They’re wheel bugs, NOT kissing bugs. Buckeye Yard and Garden onLine [Internet]. September 17, 2020. Accessed May 25, 2023. https://bygl.osu.edu/node/1688
- Weber RW. Allergen of the month—assassin bug. Ann Allergy Asthma Immunol. 2015;115:A9.
- Klotz JH, Dorn PL, Logan JL, et al. “Kissing bugs”: potential disease vectors and cause of anaphylaxis. Clin Infect Dis 2010;50:1629-1634. doi:10.1086/652769
- Anderson C, Belnap C. The kiss of death: a rare case of anaphylaxis to the bite of the “red margined kissing bug”. Hawaii J Med Public Health. 2015;74(9 suppl 2):33-35.
- Moffitt JE, Venarske D, Goddard J, et al. Allergic reactions to Triatoma bites. Ann Allergy Asthma Immunol. 2003;91:122-128. doi:10.1016/s1081-1206(10)62165-5
- Burnett JW, Calton GJ, Morgan RJ. Triatoma: the “kissing bug”. Cutis. 1987;39:399.
- Vieira CB, Praça YR, Bentes K, et al. Triatomines: Trypanosomatids, bacteria, and viruses potential vectors? Front Cell Infect Microbiol. 2018;8:405. doi:10.3389/fcimb.2018.00405
- Vetter R. Kissing bugs (Triatoma) and the skin. Dermatol Online J. 2001;7:6.
- Zemore ZM, Wills BK. Kissing bug bite. StatPearls [Internet]. StatPearlsPublishing; 2023.
- Edwards L, Lynch PJ. Anaphylactic reaction to kissing bug bites. Ariz Med. 1984;41:159-161.
- Smith FD, Miller NG, Carnazzo SJ, et al. Insect bite by Arilus cristatus, a North American reduviid. AMA Arch Derm. 1958;77:324-330. doi:10.1001/archderm.1958.01560030070011
- Nguyen T, Waseem M. Chagas disease. StatPearls [Internet]. StatPearls Publishing; 2022.
- Shields TL, Walsh EN. Kissing bug bite. AMA Arch Derm. 1956;74:14-21. doi:10.1001/archderm.1956.01550070016004
- Beatty NL, Klotz SA. The midnight bite! a kissing bug nightmare. Am J Med. 2018;131:E43-E44. doi:10.1016/j.amjmed.2017.10.013
- Klotz SA, Smith SL, Schmidt JO. Kissing bug intrusions into homes in the Southwest United States. Insects. 2021;12:654. doi:10.3390/insects12070654
- Aldrich JR, Chauhan KR, Zhang A, et al. Exocrine secretions of wheel bugs (Heteroptera: Reduviidae: Arilus spp.): clarification and chemistry. Z Naturforsch C J Biosci. 2013;68:522-526.
- Boggs J. They’re wheel bugs, NOT kissing bugs. Buckeye Yard and Garden onLine [Internet]. September 17, 2020. Accessed May 25, 2023. https://bygl.osu.edu/node/1688
- Weber RW. Allergen of the month—assassin bug. Ann Allergy Asthma Immunol. 2015;115:A9.
- Klotz JH, Dorn PL, Logan JL, et al. “Kissing bugs”: potential disease vectors and cause of anaphylaxis. Clin Infect Dis 2010;50:1629-1634. doi:10.1086/652769
- Anderson C, Belnap C. The kiss of death: a rare case of anaphylaxis to the bite of the “red margined kissing bug”. Hawaii J Med Public Health. 2015;74(9 suppl 2):33-35.
- Moffitt JE, Venarske D, Goddard J, et al. Allergic reactions to Triatoma bites. Ann Allergy Asthma Immunol. 2003;91:122-128. doi:10.1016/s1081-1206(10)62165-5
- Burnett JW, Calton GJ, Morgan RJ. Triatoma: the “kissing bug”. Cutis. 1987;39:399.
- Vieira CB, Praça YR, Bentes K, et al. Triatomines: Trypanosomatids, bacteria, and viruses potential vectors? Front Cell Infect Microbiol. 2018;8:405. doi:10.3389/fcimb.2018.00405
Practice Points
- Triatomine bugs (Triatoma) and the wheel bug (Arilus cristatus) are found throughout North America with a concentration in southern regions.
- Bites of triatomine bugs can cause anaphylaxis; prevention of bites to diminish household infestation is important because sensitization can result in increased severity of anaphylaxis upon subsequent exposure.
- Chagas disease—caused by transmission of the parasite Trypanosoma cruzi—can be a complication of a Triatoma bite in endemic areas; treatments include nifurtimox and benznidazole.
- Left undiagnosed and untreated, Chagas disease can have long-lasting implications for cardiac and gastrointestinal pathology.
Guidelines on Away Rotations in Dermatology Programs
Medical students often perform away rotations (also called visiting electives) to gain exposure to educational experiences in a particular specialty, learn about a program, and show interest in a certain program. Away rotations also allow applicants to meet and form relationships with mentors and faculty outside of their home institution. For residency programs, away rotations provide an opportunity for a holistic review of applicants by allowing program directors to get to know potential residency applicants and assess their performance in the clinical environment and among the program’s team. In a National Resident Matching Program survey, program directors (n=17) reported that prior knowledge of an applicant is an important factor in selecting applicants to interview (82.4%) and rank (58.8%).1
In this article, we discuss the importance of away rotations in dermatology and provide an overview of the Organization of Program Director Associations (OPDA) and Association of Professors of Dermatology (APD) guidelines for away rotations.
Importance of the Away Rotation in the Match
According to the Association of American Medical Colleges, 86.7% of dermatology applicants (N=345) completed one or more away rotations (mean, 2.7) in 2020.2 Winterton et al3 reported that 47% of dermatology applicants (N=45) matched at a program where they completed an away rotation. Prior to the COVID-19 pandemic, the number of applicants matching to their home program was reported as 26.7% (N=641), which jumped to 40.3% (N=231) in the 2020-2021 cycle.4 Given that the majority of dermatology applicants reportedly match either at their home program or at programs where they completed an away rotation, the benefits of away rotations are high, particularly in a competitive specialty such as dermatology and particularly for applicants without a dermatology program at their home institution. However, it must be acknowledged that correlation does not necessarily mean causation, as away rotations have not necessarily been shown to increase applicants’ chances of matching for the most competitive specialties.5
OPDA Guidelines for Away Rotations
In 2021, the Coalition of Physician Accountability’s Undergraduate Medical Education-Graduate Medical Education Review Committee recommended creating a workgroup to explore the function and value of away rotations for medical students, programs, and institutions, with a particular focus on issues of equity (eg, accessibility, assessment, opportunity) for underrepresented in medicine students and those with financial disadvantages.6 The OPDA workgroup evaluated the advantages and disadvantages of away rotations across specialties. The disadvantages included that away rotations may decrease resources to students at their own institution, particularly if faculty time and energy are funneled/dedicated to away rotators instead of internal rotators, and may impart bias into the recruitment process. Additionally, there is a consideration of equity given the considerable cost and time commitment of travel and housing for students at another institution. In 2022, the estimated cost of an away rotation in dermatology ranged from $1390 to $5500 per rotation.7 Visiting scholarships may be available at some institutions but typically are reserved for underrepresented in medicine students.8 Virtual rotations offered at some programs offset the cost-prohibitiveness of an in-person away rotation; however, they are not universally offered and may be limited in allowing for meaningful interactions between students and program faculty and residents.
The OPDA away rotation workgroup recommended that (1) each specialty publish guidelines regarding the necessity and number of recommended away rotations; (2) specialties publish explicit language regarding the use of program preference signals to programs where students rotated; (3) programs be transparent about the purpose and value of an away rotation, including explicitly stating whether a formal interview is guaranteed; and (4) the Association of American Medical Colleges create a repository of these specialty-specific recommendations.9
APD Guidelines for Away Rotations
In response to the OPDA recommendations, the APD Residency Program Directors Section developed dermatology-specific guidelines for away rotations and established guidelines in other specialties.10 The APD recommends completing up to 2 away rotations, or 3 for those without a home program, if desired. This number was chosen in acknowledgment of the importance of external program experiences, along with the recognition of the financial and time restrictions associated with away rotations as well as the limited number of spots for rotating students. Away rotations are not mandatory. The APD guidelines explain the purpose and value of an away rotation while also noting that these rotations do not necessarily guarantee a formal interview and recommending that programs be transparent about their policies on interview invitations, which may vary.10
Final Thoughts
Publishing specialty-specific guidelines on away rotations is one step toward streamlining the process as well as increasing transparency on the importance of these external program experiences in the application process and residency match. Ideally, away rotations provide a valuable educational experience in which students and program directors get to know each other in a mutually beneficial manner; however, away rotations are not required for securing an interview or matching at a program, and there also are recognized disadvantages to away rotations, particularly with regard to equity, that we must continue to weigh as a specialty. The APD will continue its collaborative work to evaluate our application processes to support a sustainable and equitable system.
- National Resident Matching Program. Results of the 2021 NRMP program director survey. Published August 2021. Accessed May 17, 2023. https://www.nrmp.org/wp-content/uploads/2021/11/2021-PD-Survey-Report-for-WWW.pdf
- Association of American Medical Colleges. Away rotations of U.S. medical school graduates by intended specialty, 2020 AAMC Medical School Graduation Questionnaire (GQ). Published September 24, 2020. Accessed May 17, 2023. https://students-residents.aamc.org/media/9496/download
- Winterton M, Ahn J, Bernstein J. The prevalence and cost of medical student visiting rotations. BMC Med Educ. 2016;16:291. doi:10.1186/s12909-016-0805-z
- Dowdle TS, Ryan MP, Wagner RF. Internal and geographic dermatology match trends in the age of COVID-19. J Am Acad Dermatol. 2021;85:1364-1366. doi:10.1016/j.jaad.2021.08.004
- Griffith M, DeMasi SC, McGrath AJ, et al. Time to reevaluate the away rotation: improving return on investment for students and schools. Acad Med. 2019;94:496-500. doi:10.1097/ACM.0000000000002505
- Coalition for Physician Accountability. The Coalition for Physician Accountability’s Undergraduate Medication Education-Graduate Medical Education Review Committee (UGRC): recommendations for comprehensive improvement in the UME-GME transition. Published August 26, 2021. Accessed May 18, 2023. https://physicianaccountability.org/wp-content/uploads/2021/08/UGRC-Coalition-Report-FINAL.pdf
- Cucka B, Grant-Kels JM. Ethical implications of the high cost of medical student visiting dermatology rotations. Clin Dermatol. 2022;40:539-540.
- Dahak S, Fernandez JM, Rosman IS. Funded dermatology visiting elective rotations for medical students who are underrepresented in medicine: a cross-sectional analysis [published online November 15, 2022]. J Am Acad Dermatol. 2023;88:941-943.
- Council of Medical Specialty Societies. The Organization of Program Director Associations (OPDA): away rotations workgroup. Published July 26, 2022. Accessed May 18, 2023. https://cmss.org/wp-content/uploads/2022/08/OPDA-Work-Group-on-Away-Rotations-7.26.2022-1.pdf
- Association of Professors of Dermatology. Recommendations regarding away electives. Published December 14, 2022. Accessed May 18, 2023. https://www.dermatologyprofessors.org/files/APD%20recommendations%20on%20away%20rotations%202023-2024.pdf
Medical students often perform away rotations (also called visiting electives) to gain exposure to educational experiences in a particular specialty, learn about a program, and show interest in a certain program. Away rotations also allow applicants to meet and form relationships with mentors and faculty outside of their home institution. For residency programs, away rotations provide an opportunity for a holistic review of applicants by allowing program directors to get to know potential residency applicants and assess their performance in the clinical environment and among the program’s team. In a National Resident Matching Program survey, program directors (n=17) reported that prior knowledge of an applicant is an important factor in selecting applicants to interview (82.4%) and rank (58.8%).1
In this article, we discuss the importance of away rotations in dermatology and provide an overview of the Organization of Program Director Associations (OPDA) and Association of Professors of Dermatology (APD) guidelines for away rotations.
Importance of the Away Rotation in the Match
According to the Association of American Medical Colleges, 86.7% of dermatology applicants (N=345) completed one or more away rotations (mean, 2.7) in 2020.2 Winterton et al3 reported that 47% of dermatology applicants (N=45) matched at a program where they completed an away rotation. Prior to the COVID-19 pandemic, the number of applicants matching to their home program was reported as 26.7% (N=641), which jumped to 40.3% (N=231) in the 2020-2021 cycle.4 Given that the majority of dermatology applicants reportedly match either at their home program or at programs where they completed an away rotation, the benefits of away rotations are high, particularly in a competitive specialty such as dermatology and particularly for applicants without a dermatology program at their home institution. However, it must be acknowledged that correlation does not necessarily mean causation, as away rotations have not necessarily been shown to increase applicants’ chances of matching for the most competitive specialties.5
OPDA Guidelines for Away Rotations
In 2021, the Coalition of Physician Accountability’s Undergraduate Medical Education-Graduate Medical Education Review Committee recommended creating a workgroup to explore the function and value of away rotations for medical students, programs, and institutions, with a particular focus on issues of equity (eg, accessibility, assessment, opportunity) for underrepresented in medicine students and those with financial disadvantages.6 The OPDA workgroup evaluated the advantages and disadvantages of away rotations across specialties. The disadvantages included that away rotations may decrease resources to students at their own institution, particularly if faculty time and energy are funneled/dedicated to away rotators instead of internal rotators, and may impart bias into the recruitment process. Additionally, there is a consideration of equity given the considerable cost and time commitment of travel and housing for students at another institution. In 2022, the estimated cost of an away rotation in dermatology ranged from $1390 to $5500 per rotation.7 Visiting scholarships may be available at some institutions but typically are reserved for underrepresented in medicine students.8 Virtual rotations offered at some programs offset the cost-prohibitiveness of an in-person away rotation; however, they are not universally offered and may be limited in allowing for meaningful interactions between students and program faculty and residents.
The OPDA away rotation workgroup recommended that (1) each specialty publish guidelines regarding the necessity and number of recommended away rotations; (2) specialties publish explicit language regarding the use of program preference signals to programs where students rotated; (3) programs be transparent about the purpose and value of an away rotation, including explicitly stating whether a formal interview is guaranteed; and (4) the Association of American Medical Colleges create a repository of these specialty-specific recommendations.9
APD Guidelines for Away Rotations
In response to the OPDA recommendations, the APD Residency Program Directors Section developed dermatology-specific guidelines for away rotations and established guidelines in other specialties.10 The APD recommends completing up to 2 away rotations, or 3 for those without a home program, if desired. This number was chosen in acknowledgment of the importance of external program experiences, along with the recognition of the financial and time restrictions associated with away rotations as well as the limited number of spots for rotating students. Away rotations are not mandatory. The APD guidelines explain the purpose and value of an away rotation while also noting that these rotations do not necessarily guarantee a formal interview and recommending that programs be transparent about their policies on interview invitations, which may vary.10
Final Thoughts
Publishing specialty-specific guidelines on away rotations is one step toward streamlining the process as well as increasing transparency on the importance of these external program experiences in the application process and residency match. Ideally, away rotations provide a valuable educational experience in which students and program directors get to know each other in a mutually beneficial manner; however, away rotations are not required for securing an interview or matching at a program, and there also are recognized disadvantages to away rotations, particularly with regard to equity, that we must continue to weigh as a specialty. The APD will continue its collaborative work to evaluate our application processes to support a sustainable and equitable system.
Medical students often perform away rotations (also called visiting electives) to gain exposure to educational experiences in a particular specialty, learn about a program, and show interest in a certain program. Away rotations also allow applicants to meet and form relationships with mentors and faculty outside of their home institution. For residency programs, away rotations provide an opportunity for a holistic review of applicants by allowing program directors to get to know potential residency applicants and assess their performance in the clinical environment and among the program’s team. In a National Resident Matching Program survey, program directors (n=17) reported that prior knowledge of an applicant is an important factor in selecting applicants to interview (82.4%) and rank (58.8%).1
In this article, we discuss the importance of away rotations in dermatology and provide an overview of the Organization of Program Director Associations (OPDA) and Association of Professors of Dermatology (APD) guidelines for away rotations.
Importance of the Away Rotation in the Match
According to the Association of American Medical Colleges, 86.7% of dermatology applicants (N=345) completed one or more away rotations (mean, 2.7) in 2020.2 Winterton et al3 reported that 47% of dermatology applicants (N=45) matched at a program where they completed an away rotation. Prior to the COVID-19 pandemic, the number of applicants matching to their home program was reported as 26.7% (N=641), which jumped to 40.3% (N=231) in the 2020-2021 cycle.4 Given that the majority of dermatology applicants reportedly match either at their home program or at programs where they completed an away rotation, the benefits of away rotations are high, particularly in a competitive specialty such as dermatology and particularly for applicants without a dermatology program at their home institution. However, it must be acknowledged that correlation does not necessarily mean causation, as away rotations have not necessarily been shown to increase applicants’ chances of matching for the most competitive specialties.5
OPDA Guidelines for Away Rotations
In 2021, the Coalition of Physician Accountability’s Undergraduate Medical Education-Graduate Medical Education Review Committee recommended creating a workgroup to explore the function and value of away rotations for medical students, programs, and institutions, with a particular focus on issues of equity (eg, accessibility, assessment, opportunity) for underrepresented in medicine students and those with financial disadvantages.6 The OPDA workgroup evaluated the advantages and disadvantages of away rotations across specialties. The disadvantages included that away rotations may decrease resources to students at their own institution, particularly if faculty time and energy are funneled/dedicated to away rotators instead of internal rotators, and may impart bias into the recruitment process. Additionally, there is a consideration of equity given the considerable cost and time commitment of travel and housing for students at another institution. In 2022, the estimated cost of an away rotation in dermatology ranged from $1390 to $5500 per rotation.7 Visiting scholarships may be available at some institutions but typically are reserved for underrepresented in medicine students.8 Virtual rotations offered at some programs offset the cost-prohibitiveness of an in-person away rotation; however, they are not universally offered and may be limited in allowing for meaningful interactions between students and program faculty and residents.
The OPDA away rotation workgroup recommended that (1) each specialty publish guidelines regarding the necessity and number of recommended away rotations; (2) specialties publish explicit language regarding the use of program preference signals to programs where students rotated; (3) programs be transparent about the purpose and value of an away rotation, including explicitly stating whether a formal interview is guaranteed; and (4) the Association of American Medical Colleges create a repository of these specialty-specific recommendations.9
APD Guidelines for Away Rotations
In response to the OPDA recommendations, the APD Residency Program Directors Section developed dermatology-specific guidelines for away rotations and established guidelines in other specialties.10 The APD recommends completing up to 2 away rotations, or 3 for those without a home program, if desired. This number was chosen in acknowledgment of the importance of external program experiences, along with the recognition of the financial and time restrictions associated with away rotations as well as the limited number of spots for rotating students. Away rotations are not mandatory. The APD guidelines explain the purpose and value of an away rotation while also noting that these rotations do not necessarily guarantee a formal interview and recommending that programs be transparent about their policies on interview invitations, which may vary.10
Final Thoughts
Publishing specialty-specific guidelines on away rotations is one step toward streamlining the process as well as increasing transparency on the importance of these external program experiences in the application process and residency match. Ideally, away rotations provide a valuable educational experience in which students and program directors get to know each other in a mutually beneficial manner; however, away rotations are not required for securing an interview or matching at a program, and there also are recognized disadvantages to away rotations, particularly with regard to equity, that we must continue to weigh as a specialty. The APD will continue its collaborative work to evaluate our application processes to support a sustainable and equitable system.
- National Resident Matching Program. Results of the 2021 NRMP program director survey. Published August 2021. Accessed May 17, 2023. https://www.nrmp.org/wp-content/uploads/2021/11/2021-PD-Survey-Report-for-WWW.pdf
- Association of American Medical Colleges. Away rotations of U.S. medical school graduates by intended specialty, 2020 AAMC Medical School Graduation Questionnaire (GQ). Published September 24, 2020. Accessed May 17, 2023. https://students-residents.aamc.org/media/9496/download
- Winterton M, Ahn J, Bernstein J. The prevalence and cost of medical student visiting rotations. BMC Med Educ. 2016;16:291. doi:10.1186/s12909-016-0805-z
- Dowdle TS, Ryan MP, Wagner RF. Internal and geographic dermatology match trends in the age of COVID-19. J Am Acad Dermatol. 2021;85:1364-1366. doi:10.1016/j.jaad.2021.08.004
- Griffith M, DeMasi SC, McGrath AJ, et al. Time to reevaluate the away rotation: improving return on investment for students and schools. Acad Med. 2019;94:496-500. doi:10.1097/ACM.0000000000002505
- Coalition for Physician Accountability. The Coalition for Physician Accountability’s Undergraduate Medication Education-Graduate Medical Education Review Committee (UGRC): recommendations for comprehensive improvement in the UME-GME transition. Published August 26, 2021. Accessed May 18, 2023. https://physicianaccountability.org/wp-content/uploads/2021/08/UGRC-Coalition-Report-FINAL.pdf
- Cucka B, Grant-Kels JM. Ethical implications of the high cost of medical student visiting dermatology rotations. Clin Dermatol. 2022;40:539-540.
- Dahak S, Fernandez JM, Rosman IS. Funded dermatology visiting elective rotations for medical students who are underrepresented in medicine: a cross-sectional analysis [published online November 15, 2022]. J Am Acad Dermatol. 2023;88:941-943.
- Council of Medical Specialty Societies. The Organization of Program Director Associations (OPDA): away rotations workgroup. Published July 26, 2022. Accessed May 18, 2023. https://cmss.org/wp-content/uploads/2022/08/OPDA-Work-Group-on-Away-Rotations-7.26.2022-1.pdf
- Association of Professors of Dermatology. Recommendations regarding away electives. Published December 14, 2022. Accessed May 18, 2023. https://www.dermatologyprofessors.org/files/APD%20recommendations%20on%20away%20rotations%202023-2024.pdf
- National Resident Matching Program. Results of the 2021 NRMP program director survey. Published August 2021. Accessed May 17, 2023. https://www.nrmp.org/wp-content/uploads/2021/11/2021-PD-Survey-Report-for-WWW.pdf
- Association of American Medical Colleges. Away rotations of U.S. medical school graduates by intended specialty, 2020 AAMC Medical School Graduation Questionnaire (GQ). Published September 24, 2020. Accessed May 17, 2023. https://students-residents.aamc.org/media/9496/download
- Winterton M, Ahn J, Bernstein J. The prevalence and cost of medical student visiting rotations. BMC Med Educ. 2016;16:291. doi:10.1186/s12909-016-0805-z
- Dowdle TS, Ryan MP, Wagner RF. Internal and geographic dermatology match trends in the age of COVID-19. J Am Acad Dermatol. 2021;85:1364-1366. doi:10.1016/j.jaad.2021.08.004
- Griffith M, DeMasi SC, McGrath AJ, et al. Time to reevaluate the away rotation: improving return on investment for students and schools. Acad Med. 2019;94:496-500. doi:10.1097/ACM.0000000000002505
- Coalition for Physician Accountability. The Coalition for Physician Accountability’s Undergraduate Medication Education-Graduate Medical Education Review Committee (UGRC): recommendations for comprehensive improvement in the UME-GME transition. Published August 26, 2021. Accessed May 18, 2023. https://physicianaccountability.org/wp-content/uploads/2021/08/UGRC-Coalition-Report-FINAL.pdf
- Cucka B, Grant-Kels JM. Ethical implications of the high cost of medical student visiting dermatology rotations. Clin Dermatol. 2022;40:539-540.
- Dahak S, Fernandez JM, Rosman IS. Funded dermatology visiting elective rotations for medical students who are underrepresented in medicine: a cross-sectional analysis [published online November 15, 2022]. J Am Acad Dermatol. 2023;88:941-943.
- Council of Medical Specialty Societies. The Organization of Program Director Associations (OPDA): away rotations workgroup. Published July 26, 2022. Accessed May 18, 2023. https://cmss.org/wp-content/uploads/2022/08/OPDA-Work-Group-on-Away-Rotations-7.26.2022-1.pdf
- Association of Professors of Dermatology. Recommendations regarding away electives. Published December 14, 2022. Accessed May 18, 2023. https://www.dermatologyprofessors.org/files/APD%20recommendations%20on%20away%20rotations%202023-2024.pdf
Practice Points
- Away rotations are an important tool for both applicants and residency programs during the application process.
- The Association of Professors of Dermatology (APD) recommends completing up to 2 external program experiences, or 3 if the student has no home program, ideally to be completed early in the fourth year of medical school prior to interview invitations.
- Away rotations may have considerable cost and time restrictions on applicants, which the APD recognizes and weighs in its recommendations. There may be program-specific scholarships and opportunities available to help with the cost of away rotations.
Community workers may address psychiatrist shortage
SAN FRANCISCO – promises to bring timely, evidence-based health services to those with little to no access to effective care.
The current shortage of mental health clinicians is driven by increased demand from a population more willing to seek psychiatric help and clinicians leaving the workforce. Both factors were exacerbated by the COVID-19 pandemic.
“It would be costly to address the problem through additional specialist training, and doing so would take decades to see any changes,” project director Milton L. Wainberg, MD, professor of clinical psychiatry at Columbia University, New York, and New York State Psychiatric Institute, said in an interview.
A better solution is to train members of the community to be the entry point to the mental health care system, a strategy that has been proven effective.
Details of the project were discussed at the annual meeting of the American Psychiatric Association.
Half of the United States population will be diagnosed with a mental or substance use disorder in their lifetime, but only about half of those will receive proper treatment. That percentage is even greater among lower-income groups and minorities, said Dr. Wainberg.
Despite the availability of multiple evidence-based therapies, there has been no reduction in the global prevalence of psychiatric illness since 1990 – the first time this burden was determined, he said.
Unfeasible model
“The historic paradigm of ongoing long-term care is costly and not a feasible public mental health model. There is no evidence that it works, and there is increasing demand for brief interventions,” said Dr. Wainberg.
The new initiative – called ENGAGE – has its origins in parts of Africa, where nurses had to be trained during the AIDS crisis as there weren’t enough doctors to roll out antiretroviral therapy.
In the United States, the program trains and certifies community workers who are passionate about their community. “Members of the community want to learn how to help their neighbors,” said Dr. Wainberg. “When we give them the opportunity to learn skills that can actually change community members’ symptoms, they are excited.”
The training involves a didactic component and an experiential component, in which trainees work with at least three cases under supervision to demonstrate competency. Technical assistance and other supports, such as refresher training, are offered for a year after training.
Workers ask three initial questions to quickly determine if a person has a mental health disorder. Asking 10 additional questions tells the worker if the person has a common mental health disorder like depression, anxiety, or posttraumatic stress disorder (PTSD), a substance use disorder involving alcohol or drugs, suicide risk, or a severe disorder requiring referral to a mental health specialist.
Those who do not require a referral are offered an intervention personalized to their need.
The training costs $5,000 per person. “We calculated for New York State it would cost only $18 million to train everybody we need,” said Dr. Wainberg.
Cost effective
He stressed the program, which is funded by the New York Office of Mental Health, is cost effective. Just like patients don’t need to see a plastic surgeon to have a small mole removed, they don’t always need to see a psychiatrist for run-of-the-mill mild depression, he said.
To date, 20 workers have been trained and have started to meet with clients in clinics in four New York City neighborhoods/boroughs (Harlem, Brooklyn, the Bronx, and Washington Heights). Additional clinics in West Harlem and Staten Island are expected to begin training soon.
Dr. Wainberg has been inundated with interest in the initiative. “Over the last 3 months I have been having 15 meetings a day” with parties interested in getting more information or wanting to know how to start such a program.
He plans to examine the program’s effectiveness in a number of areas, including patient symptoms, timeliness of services, access, sustainability, and cost. And he aims to expand the project beyond New York.
Mental health specialists shouldn’t worry about becoming irrelevant with the addition of community workers, as the demand is so great, said Dr. Wainberg. “There will always be a need for the kind of care mental health specialists are trained for. This initiative aims to expand capacity for those with less severe symptoms, who might not need an intensive level of intervention.”
Unique program
In a comment, Jonathan E. Alpert, MD, PhD, chair of the department of psychiatry and behavioral sciences, Montefiore Medical Center and Albert Einstein College of Medicine, New York, said the project is “unique” and an “excellent” idea.
“This is one of the first pilots that I know of in this country to train lay-members of the community to screen for mental illness and substance use disorders and even to provide evidence-based treatment for people who may have more mild symptoms and might not yet need to see a professional but otherwise would not have access to care.”
Dr. Alpert noted the current challenges of accessing care for a mental health or substance abuse disorder. “Many clinics have wait lists of 3-6 months.”
Another issue is the “stigma and lack of trust” among minority communities when it comes to formal mental health treatments. “Having lay-members who know the community, who look like the community, who understand the community, and who are available for screening and treatment is exceptionally important.”
Although this pilot program will have to be assessed for effectiveness, “the concept behind it is very important,” said Dr. Alpert. “If you’re relying on MDs and PhDs to provide mental health services, there just aren’t enough of us to go around.”
Dr. Wainberg and Dr. Alpert report no relevant financial relationships.
A version of this article first appeared on Medscape.com.
SAN FRANCISCO – promises to bring timely, evidence-based health services to those with little to no access to effective care.
The current shortage of mental health clinicians is driven by increased demand from a population more willing to seek psychiatric help and clinicians leaving the workforce. Both factors were exacerbated by the COVID-19 pandemic.
“It would be costly to address the problem through additional specialist training, and doing so would take decades to see any changes,” project director Milton L. Wainberg, MD, professor of clinical psychiatry at Columbia University, New York, and New York State Psychiatric Institute, said in an interview.
A better solution is to train members of the community to be the entry point to the mental health care system, a strategy that has been proven effective.
Details of the project were discussed at the annual meeting of the American Psychiatric Association.
Half of the United States population will be diagnosed with a mental or substance use disorder in their lifetime, but only about half of those will receive proper treatment. That percentage is even greater among lower-income groups and minorities, said Dr. Wainberg.
Despite the availability of multiple evidence-based therapies, there has been no reduction in the global prevalence of psychiatric illness since 1990 – the first time this burden was determined, he said.
Unfeasible model
“The historic paradigm of ongoing long-term care is costly and not a feasible public mental health model. There is no evidence that it works, and there is increasing demand for brief interventions,” said Dr. Wainberg.
The new initiative – called ENGAGE – has its origins in parts of Africa, where nurses had to be trained during the AIDS crisis as there weren’t enough doctors to roll out antiretroviral therapy.
In the United States, the program trains and certifies community workers who are passionate about their community. “Members of the community want to learn how to help their neighbors,” said Dr. Wainberg. “When we give them the opportunity to learn skills that can actually change community members’ symptoms, they are excited.”
The training involves a didactic component and an experiential component, in which trainees work with at least three cases under supervision to demonstrate competency. Technical assistance and other supports, such as refresher training, are offered for a year after training.
Workers ask three initial questions to quickly determine if a person has a mental health disorder. Asking 10 additional questions tells the worker if the person has a common mental health disorder like depression, anxiety, or posttraumatic stress disorder (PTSD), a substance use disorder involving alcohol or drugs, suicide risk, or a severe disorder requiring referral to a mental health specialist.
Those who do not require a referral are offered an intervention personalized to their need.
The training costs $5,000 per person. “We calculated for New York State it would cost only $18 million to train everybody we need,” said Dr. Wainberg.
Cost effective
He stressed the program, which is funded by the New York Office of Mental Health, is cost effective. Just like patients don’t need to see a plastic surgeon to have a small mole removed, they don’t always need to see a psychiatrist for run-of-the-mill mild depression, he said.
To date, 20 workers have been trained and have started to meet with clients in clinics in four New York City neighborhoods/boroughs (Harlem, Brooklyn, the Bronx, and Washington Heights). Additional clinics in West Harlem and Staten Island are expected to begin training soon.
Dr. Wainberg has been inundated with interest in the initiative. “Over the last 3 months I have been having 15 meetings a day” with parties interested in getting more information or wanting to know how to start such a program.
He plans to examine the program’s effectiveness in a number of areas, including patient symptoms, timeliness of services, access, sustainability, and cost. And he aims to expand the project beyond New York.
Mental health specialists shouldn’t worry about becoming irrelevant with the addition of community workers, as the demand is so great, said Dr. Wainberg. “There will always be a need for the kind of care mental health specialists are trained for. This initiative aims to expand capacity for those with less severe symptoms, who might not need an intensive level of intervention.”
Unique program
In a comment, Jonathan E. Alpert, MD, PhD, chair of the department of psychiatry and behavioral sciences, Montefiore Medical Center and Albert Einstein College of Medicine, New York, said the project is “unique” and an “excellent” idea.
“This is one of the first pilots that I know of in this country to train lay-members of the community to screen for mental illness and substance use disorders and even to provide evidence-based treatment for people who may have more mild symptoms and might not yet need to see a professional but otherwise would not have access to care.”
Dr. Alpert noted the current challenges of accessing care for a mental health or substance abuse disorder. “Many clinics have wait lists of 3-6 months.”
Another issue is the “stigma and lack of trust” among minority communities when it comes to formal mental health treatments. “Having lay-members who know the community, who look like the community, who understand the community, and who are available for screening and treatment is exceptionally important.”
Although this pilot program will have to be assessed for effectiveness, “the concept behind it is very important,” said Dr. Alpert. “If you’re relying on MDs and PhDs to provide mental health services, there just aren’t enough of us to go around.”
Dr. Wainberg and Dr. Alpert report no relevant financial relationships.
A version of this article first appeared on Medscape.com.
SAN FRANCISCO – promises to bring timely, evidence-based health services to those with little to no access to effective care.
The current shortage of mental health clinicians is driven by increased demand from a population more willing to seek psychiatric help and clinicians leaving the workforce. Both factors were exacerbated by the COVID-19 pandemic.
“It would be costly to address the problem through additional specialist training, and doing so would take decades to see any changes,” project director Milton L. Wainberg, MD, professor of clinical psychiatry at Columbia University, New York, and New York State Psychiatric Institute, said in an interview.
A better solution is to train members of the community to be the entry point to the mental health care system, a strategy that has been proven effective.
Details of the project were discussed at the annual meeting of the American Psychiatric Association.
Half of the United States population will be diagnosed with a mental or substance use disorder in their lifetime, but only about half of those will receive proper treatment. That percentage is even greater among lower-income groups and minorities, said Dr. Wainberg.
Despite the availability of multiple evidence-based therapies, there has been no reduction in the global prevalence of psychiatric illness since 1990 – the first time this burden was determined, he said.
Unfeasible model
“The historic paradigm of ongoing long-term care is costly and not a feasible public mental health model. There is no evidence that it works, and there is increasing demand for brief interventions,” said Dr. Wainberg.
The new initiative – called ENGAGE – has its origins in parts of Africa, where nurses had to be trained during the AIDS crisis as there weren’t enough doctors to roll out antiretroviral therapy.
In the United States, the program trains and certifies community workers who are passionate about their community. “Members of the community want to learn how to help their neighbors,” said Dr. Wainberg. “When we give them the opportunity to learn skills that can actually change community members’ symptoms, they are excited.”
The training involves a didactic component and an experiential component, in which trainees work with at least three cases under supervision to demonstrate competency. Technical assistance and other supports, such as refresher training, are offered for a year after training.
Workers ask three initial questions to quickly determine if a person has a mental health disorder. Asking 10 additional questions tells the worker if the person has a common mental health disorder like depression, anxiety, or posttraumatic stress disorder (PTSD), a substance use disorder involving alcohol or drugs, suicide risk, or a severe disorder requiring referral to a mental health specialist.
Those who do not require a referral are offered an intervention personalized to their need.
The training costs $5,000 per person. “We calculated for New York State it would cost only $18 million to train everybody we need,” said Dr. Wainberg.
Cost effective
He stressed the program, which is funded by the New York Office of Mental Health, is cost effective. Just like patients don’t need to see a plastic surgeon to have a small mole removed, they don’t always need to see a psychiatrist for run-of-the-mill mild depression, he said.
To date, 20 workers have been trained and have started to meet with clients in clinics in four New York City neighborhoods/boroughs (Harlem, Brooklyn, the Bronx, and Washington Heights). Additional clinics in West Harlem and Staten Island are expected to begin training soon.
Dr. Wainberg has been inundated with interest in the initiative. “Over the last 3 months I have been having 15 meetings a day” with parties interested in getting more information or wanting to know how to start such a program.
He plans to examine the program’s effectiveness in a number of areas, including patient symptoms, timeliness of services, access, sustainability, and cost. And he aims to expand the project beyond New York.
Mental health specialists shouldn’t worry about becoming irrelevant with the addition of community workers, as the demand is so great, said Dr. Wainberg. “There will always be a need for the kind of care mental health specialists are trained for. This initiative aims to expand capacity for those with less severe symptoms, who might not need an intensive level of intervention.”
Unique program
In a comment, Jonathan E. Alpert, MD, PhD, chair of the department of psychiatry and behavioral sciences, Montefiore Medical Center and Albert Einstein College of Medicine, New York, said the project is “unique” and an “excellent” idea.
“This is one of the first pilots that I know of in this country to train lay-members of the community to screen for mental illness and substance use disorders and even to provide evidence-based treatment for people who may have more mild symptoms and might not yet need to see a professional but otherwise would not have access to care.”
Dr. Alpert noted the current challenges of accessing care for a mental health or substance abuse disorder. “Many clinics have wait lists of 3-6 months.”
Another issue is the “stigma and lack of trust” among minority communities when it comes to formal mental health treatments. “Having lay-members who know the community, who look like the community, who understand the community, and who are available for screening and treatment is exceptionally important.”
Although this pilot program will have to be assessed for effectiveness, “the concept behind it is very important,” said Dr. Alpert. “If you’re relying on MDs and PhDs to provide mental health services, there just aren’t enough of us to go around.”
Dr. Wainberg and Dr. Alpert report no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM APA 2023
Finding a home in psychiatry: A medical student’s story
Perched on a meditation cushion with the day’s first light creeping up the Himalayan foothills around me, I felt more at ease within myself than I could ever recall over my previous 19 years.
My immersion in daily conversations within the Tibetan monastic community on achieving a more harmonious relationship to our thoughts and feelings awoke a consideration of myself and my inner life in a way that I’d never truly contemplated before. These reflections gave me a vocabulary and a toolkit for navigating my own internal landscape that I have used ever since.
However, upon returning home, I was forced to acknowledge how fortunate I had been, and that these tools and the underlying spirit of inquiry are not commonplace in our society. Despite great strides in shifting views toward mental illness over the past few decades, our public discourse rarely captures the nuances of the mental health crisis that our culture has faced well before COVID-19 catalyzed even greater distress. We all pay the price of this cultural deficit to varying degrees, and I became captivated by the notion that things could be different.
I followed that thread of inquiry through the practices of Buddhist studies, massage therapy, yoga instruction, and refugee aid before coming to psychiatry as the unlikely yet ideal crucible for integrating my experiences in these spaces. Since arriving at medical school, however, my vision of myself as a psychiatrist has changed dramatically as my aspirations have collided with the realities of clinical experience and been tempered by the wisdom of mentors, colleagues, and patients, opening up a space for a deeper appreciation of what psychiatry might offer.
Clinical experience changes perspective
Short on clinical experience, I had previously imagined my future practice primarily as one of mindful listening and finding presence with each patient as a kind ear, supplemented by the ability to prescribe medication. Since then, working with patients has offered me insight into the ways in which my personality, perception, and potential access to a range of affective stances can serve as tools for skillfully developing the therapeutic encounter.
Moreover, “challenging” patients have taught me that my role is not always to offer unbounded empathetic support, but to potentially initiate compassionately tactful confrontation, shifting my sense of my role in the therapeutic relationship.
This is a lofty goal, which might entail modeling the successful navigation of potential ruptures and the subsequent repair of relationships so that they can live more adaptably in the world.
However, while I can support their envisioning of a realistic future for themselves and facilitate their acquisition of the tools needed to get there, my role is significant yet limited. This has been a hard truth to reckon with, but one that’s opened up pathways to greater empathy and a deeper understanding of each patient’s struggles. As a result, my view of pathology as a state has shifted to one of a dynamic process that emerges through the interaction of their genes, environment, life history, pharmacological supplements, psychodynamic tendencies, diet, and more.
Yet, while holding this reality of the complexities of mental illness, clinical decision-making often hinges on making binary choices regarding diagnoses, medications, and criteria for legal determinations. Developing this capacity to simultaneously practice different ways of knowing and sit with uncertainty excites me tremendously, not only equipping me to balance clinical practice with the demands of the modern health care system, but also nourishing the roots of a rich and ethical life.
Psychiatry calls to me for this expectation of sustaining an appropriate tension between uncertainty and decisiveness. It also inspires a deeper dive into the history of the field in order to learn the roots of its theories and perspectives so I can better understand how those inform contemporary practice in ways that are both helpful and harmful.
From individual to community
In tandem with this outer work of learning to appropriately position myself within individual patient relationships, the broader health care system, and the legacy of the field, I’ve also sought to develop a better understanding of how my own history, beliefs, and motivations shape my collaborative efforts.
Through my mindfulness practice and participation in exploratory psychoanalysis, I’ve caught glimpses of my own countertransference investments and opened up space for seeing how patients might experience me as a clinician. This has allowed for tuning in to my own response to them, identifying where in the typology of personality structures our reciprocal experiences might exist, and learning to manage those feelings to ultimately foster empathy through the interaction.
This has shifted my sense of the work from solely mindfully listening and thoughtfully responding to honing deliberate ways of both listening and responding in a way that is directly informed by the person sitting in front of me so I can best support them in creating change.
Given the responsibility inherent to this work, I have treated my medical education as an opportunity to build a foundation for stepping into this role. This has involved going beyond exploring these dynamics within individual clinician-patient relationships and carried over into my experiences with community-based research and program development. It has asked me to recognize the perceptual frames and prioritization of values that I bring to any given project.
This process has sharpened my aim of discovering each community’s understanding of their mental health needs so that I’m not implicitly imposing my own notions of psychological wholeness and “wellness” on others.
Working with San Diego’s Somali and Spanish-speaking populations has helped me to better understand each community’s own conceptualization of their strengths and needs, teaching me how to engage in reciprocal partnerships that honor each of our areas of expertise. Investing myself in medical school curricular reform represents the flip side of this coin, serving as an attempt to better understand my own medical community, how we think about health, and how we can best care for ourselves.
These experiences have offered opportunities to refine my skills in appreciative inquiry, coalition building, navigating institutional dynamics, and initiating and sustaining change within complex systems to carry the lessons of psychiatry beyond explicitly clinical spaces.
Toward integrative care
Ultimately, I view my community-based research and academic program development as outgrowths of my commitment to clinical psychiatry and my desire to learn how to provide people with the tools for changing their relationship to themselves, others, and their communities.
Equipped with formal medical training as the bedrock of this skill set, I have actively sought out opportunities to draw from practices that are outside the scope of the formal curriculum. These range from psychoanalysis and narrative medicine to cultural psychiatry and psychological anthropology, as well as my background in bodywork and mindfulness education. I’m eager to dive more fully into psychiatric practice as I work to integrate these disparate knowledge bases with the biomedical and psychodynamic views of the mind to develop a strengths-based practice that tends to patients’ bodies, minds, and spirits by bringing forth their own knowledge of themselves and their lives as they imagine what could be.
These realizations bring me back to that Himalayan sunrise more than a decade ago. They affirm that my heart lies with traversing disciplines to provide integrative psychiatric care in the community and developing infrastructure that supports these efforts. I’m filled with enthusiasm by the breadth of what psychiatry training offers as I continue expanding my capacity to support patients in this lifelong healing journey.
Alec Terrana is a rising fourth-year medical student at the University of California, San Diego, who intends to apply into psychiatry residency programs. He’s invested in exploring how we can more effectively conceptualize and measure mental health outcomes within San Diego’s Somali and Spanish-speaking communities, as well as advancing mindfulness and compassion training in undergraduate medical education. His professional interests also include implementation science, cultural psychiatry, psychodynamics, and strengthening public mental health infrastructure.
Perched on a meditation cushion with the day’s first light creeping up the Himalayan foothills around me, I felt more at ease within myself than I could ever recall over my previous 19 years.
My immersion in daily conversations within the Tibetan monastic community on achieving a more harmonious relationship to our thoughts and feelings awoke a consideration of myself and my inner life in a way that I’d never truly contemplated before. These reflections gave me a vocabulary and a toolkit for navigating my own internal landscape that I have used ever since.
However, upon returning home, I was forced to acknowledge how fortunate I had been, and that these tools and the underlying spirit of inquiry are not commonplace in our society. Despite great strides in shifting views toward mental illness over the past few decades, our public discourse rarely captures the nuances of the mental health crisis that our culture has faced well before COVID-19 catalyzed even greater distress. We all pay the price of this cultural deficit to varying degrees, and I became captivated by the notion that things could be different.
I followed that thread of inquiry through the practices of Buddhist studies, massage therapy, yoga instruction, and refugee aid before coming to psychiatry as the unlikely yet ideal crucible for integrating my experiences in these spaces. Since arriving at medical school, however, my vision of myself as a psychiatrist has changed dramatically as my aspirations have collided with the realities of clinical experience and been tempered by the wisdom of mentors, colleagues, and patients, opening up a space for a deeper appreciation of what psychiatry might offer.
Clinical experience changes perspective
Short on clinical experience, I had previously imagined my future practice primarily as one of mindful listening and finding presence with each patient as a kind ear, supplemented by the ability to prescribe medication. Since then, working with patients has offered me insight into the ways in which my personality, perception, and potential access to a range of affective stances can serve as tools for skillfully developing the therapeutic encounter.
Moreover, “challenging” patients have taught me that my role is not always to offer unbounded empathetic support, but to potentially initiate compassionately tactful confrontation, shifting my sense of my role in the therapeutic relationship.
This is a lofty goal, which might entail modeling the successful navigation of potential ruptures and the subsequent repair of relationships so that they can live more adaptably in the world.
However, while I can support their envisioning of a realistic future for themselves and facilitate their acquisition of the tools needed to get there, my role is significant yet limited. This has been a hard truth to reckon with, but one that’s opened up pathways to greater empathy and a deeper understanding of each patient’s struggles. As a result, my view of pathology as a state has shifted to one of a dynamic process that emerges through the interaction of their genes, environment, life history, pharmacological supplements, psychodynamic tendencies, diet, and more.
Yet, while holding this reality of the complexities of mental illness, clinical decision-making often hinges on making binary choices regarding diagnoses, medications, and criteria for legal determinations. Developing this capacity to simultaneously practice different ways of knowing and sit with uncertainty excites me tremendously, not only equipping me to balance clinical practice with the demands of the modern health care system, but also nourishing the roots of a rich and ethical life.
Psychiatry calls to me for this expectation of sustaining an appropriate tension between uncertainty and decisiveness. It also inspires a deeper dive into the history of the field in order to learn the roots of its theories and perspectives so I can better understand how those inform contemporary practice in ways that are both helpful and harmful.
From individual to community
In tandem with this outer work of learning to appropriately position myself within individual patient relationships, the broader health care system, and the legacy of the field, I’ve also sought to develop a better understanding of how my own history, beliefs, and motivations shape my collaborative efforts.
Through my mindfulness practice and participation in exploratory psychoanalysis, I’ve caught glimpses of my own countertransference investments and opened up space for seeing how patients might experience me as a clinician. This has allowed for tuning in to my own response to them, identifying where in the typology of personality structures our reciprocal experiences might exist, and learning to manage those feelings to ultimately foster empathy through the interaction.
This has shifted my sense of the work from solely mindfully listening and thoughtfully responding to honing deliberate ways of both listening and responding in a way that is directly informed by the person sitting in front of me so I can best support them in creating change.
Given the responsibility inherent to this work, I have treated my medical education as an opportunity to build a foundation for stepping into this role. This has involved going beyond exploring these dynamics within individual clinician-patient relationships and carried over into my experiences with community-based research and program development. It has asked me to recognize the perceptual frames and prioritization of values that I bring to any given project.
This process has sharpened my aim of discovering each community’s understanding of their mental health needs so that I’m not implicitly imposing my own notions of psychological wholeness and “wellness” on others.
Working with San Diego’s Somali and Spanish-speaking populations has helped me to better understand each community’s own conceptualization of their strengths and needs, teaching me how to engage in reciprocal partnerships that honor each of our areas of expertise. Investing myself in medical school curricular reform represents the flip side of this coin, serving as an attempt to better understand my own medical community, how we think about health, and how we can best care for ourselves.
These experiences have offered opportunities to refine my skills in appreciative inquiry, coalition building, navigating institutional dynamics, and initiating and sustaining change within complex systems to carry the lessons of psychiatry beyond explicitly clinical spaces.
Toward integrative care
Ultimately, I view my community-based research and academic program development as outgrowths of my commitment to clinical psychiatry and my desire to learn how to provide people with the tools for changing their relationship to themselves, others, and their communities.
Equipped with formal medical training as the bedrock of this skill set, I have actively sought out opportunities to draw from practices that are outside the scope of the formal curriculum. These range from psychoanalysis and narrative medicine to cultural psychiatry and psychological anthropology, as well as my background in bodywork and mindfulness education. I’m eager to dive more fully into psychiatric practice as I work to integrate these disparate knowledge bases with the biomedical and psychodynamic views of the mind to develop a strengths-based practice that tends to patients’ bodies, minds, and spirits by bringing forth their own knowledge of themselves and their lives as they imagine what could be.
These realizations bring me back to that Himalayan sunrise more than a decade ago. They affirm that my heart lies with traversing disciplines to provide integrative psychiatric care in the community and developing infrastructure that supports these efforts. I’m filled with enthusiasm by the breadth of what psychiatry training offers as I continue expanding my capacity to support patients in this lifelong healing journey.
Alec Terrana is a rising fourth-year medical student at the University of California, San Diego, who intends to apply into psychiatry residency programs. He’s invested in exploring how we can more effectively conceptualize and measure mental health outcomes within San Diego’s Somali and Spanish-speaking communities, as well as advancing mindfulness and compassion training in undergraduate medical education. His professional interests also include implementation science, cultural psychiatry, psychodynamics, and strengthening public mental health infrastructure.
Perched on a meditation cushion with the day’s first light creeping up the Himalayan foothills around me, I felt more at ease within myself than I could ever recall over my previous 19 years.
My immersion in daily conversations within the Tibetan monastic community on achieving a more harmonious relationship to our thoughts and feelings awoke a consideration of myself and my inner life in a way that I’d never truly contemplated before. These reflections gave me a vocabulary and a toolkit for navigating my own internal landscape that I have used ever since.
However, upon returning home, I was forced to acknowledge how fortunate I had been, and that these tools and the underlying spirit of inquiry are not commonplace in our society. Despite great strides in shifting views toward mental illness over the past few decades, our public discourse rarely captures the nuances of the mental health crisis that our culture has faced well before COVID-19 catalyzed even greater distress. We all pay the price of this cultural deficit to varying degrees, and I became captivated by the notion that things could be different.
I followed that thread of inquiry through the practices of Buddhist studies, massage therapy, yoga instruction, and refugee aid before coming to psychiatry as the unlikely yet ideal crucible for integrating my experiences in these spaces. Since arriving at medical school, however, my vision of myself as a psychiatrist has changed dramatically as my aspirations have collided with the realities of clinical experience and been tempered by the wisdom of mentors, colleagues, and patients, opening up a space for a deeper appreciation of what psychiatry might offer.
Clinical experience changes perspective
Short on clinical experience, I had previously imagined my future practice primarily as one of mindful listening and finding presence with each patient as a kind ear, supplemented by the ability to prescribe medication. Since then, working with patients has offered me insight into the ways in which my personality, perception, and potential access to a range of affective stances can serve as tools for skillfully developing the therapeutic encounter.
Moreover, “challenging” patients have taught me that my role is not always to offer unbounded empathetic support, but to potentially initiate compassionately tactful confrontation, shifting my sense of my role in the therapeutic relationship.
This is a lofty goal, which might entail modeling the successful navigation of potential ruptures and the subsequent repair of relationships so that they can live more adaptably in the world.
However, while I can support their envisioning of a realistic future for themselves and facilitate their acquisition of the tools needed to get there, my role is significant yet limited. This has been a hard truth to reckon with, but one that’s opened up pathways to greater empathy and a deeper understanding of each patient’s struggles. As a result, my view of pathology as a state has shifted to one of a dynamic process that emerges through the interaction of their genes, environment, life history, pharmacological supplements, psychodynamic tendencies, diet, and more.
Yet, while holding this reality of the complexities of mental illness, clinical decision-making often hinges on making binary choices regarding diagnoses, medications, and criteria for legal determinations. Developing this capacity to simultaneously practice different ways of knowing and sit with uncertainty excites me tremendously, not only equipping me to balance clinical practice with the demands of the modern health care system, but also nourishing the roots of a rich and ethical life.
Psychiatry calls to me for this expectation of sustaining an appropriate tension between uncertainty and decisiveness. It also inspires a deeper dive into the history of the field in order to learn the roots of its theories and perspectives so I can better understand how those inform contemporary practice in ways that are both helpful and harmful.
From individual to community
In tandem with this outer work of learning to appropriately position myself within individual patient relationships, the broader health care system, and the legacy of the field, I’ve also sought to develop a better understanding of how my own history, beliefs, and motivations shape my collaborative efforts.
Through my mindfulness practice and participation in exploratory psychoanalysis, I’ve caught glimpses of my own countertransference investments and opened up space for seeing how patients might experience me as a clinician. This has allowed for tuning in to my own response to them, identifying where in the typology of personality structures our reciprocal experiences might exist, and learning to manage those feelings to ultimately foster empathy through the interaction.
This has shifted my sense of the work from solely mindfully listening and thoughtfully responding to honing deliberate ways of both listening and responding in a way that is directly informed by the person sitting in front of me so I can best support them in creating change.
Given the responsibility inherent to this work, I have treated my medical education as an opportunity to build a foundation for stepping into this role. This has involved going beyond exploring these dynamics within individual clinician-patient relationships and carried over into my experiences with community-based research and program development. It has asked me to recognize the perceptual frames and prioritization of values that I bring to any given project.
This process has sharpened my aim of discovering each community’s understanding of their mental health needs so that I’m not implicitly imposing my own notions of psychological wholeness and “wellness” on others.
Working with San Diego’s Somali and Spanish-speaking populations has helped me to better understand each community’s own conceptualization of their strengths and needs, teaching me how to engage in reciprocal partnerships that honor each of our areas of expertise. Investing myself in medical school curricular reform represents the flip side of this coin, serving as an attempt to better understand my own medical community, how we think about health, and how we can best care for ourselves.
These experiences have offered opportunities to refine my skills in appreciative inquiry, coalition building, navigating institutional dynamics, and initiating and sustaining change within complex systems to carry the lessons of psychiatry beyond explicitly clinical spaces.
Toward integrative care
Ultimately, I view my community-based research and academic program development as outgrowths of my commitment to clinical psychiatry and my desire to learn how to provide people with the tools for changing their relationship to themselves, others, and their communities.
Equipped with formal medical training as the bedrock of this skill set, I have actively sought out opportunities to draw from practices that are outside the scope of the formal curriculum. These range from psychoanalysis and narrative medicine to cultural psychiatry and psychological anthropology, as well as my background in bodywork and mindfulness education. I’m eager to dive more fully into psychiatric practice as I work to integrate these disparate knowledge bases with the biomedical and psychodynamic views of the mind to develop a strengths-based practice that tends to patients’ bodies, minds, and spirits by bringing forth their own knowledge of themselves and their lives as they imagine what could be.
These realizations bring me back to that Himalayan sunrise more than a decade ago. They affirm that my heart lies with traversing disciplines to provide integrative psychiatric care in the community and developing infrastructure that supports these efforts. I’m filled with enthusiasm by the breadth of what psychiatry training offers as I continue expanding my capacity to support patients in this lifelong healing journey.
Alec Terrana is a rising fourth-year medical student at the University of California, San Diego, who intends to apply into psychiatry residency programs. He’s invested in exploring how we can more effectively conceptualize and measure mental health outcomes within San Diego’s Somali and Spanish-speaking communities, as well as advancing mindfulness and compassion training in undergraduate medical education. His professional interests also include implementation science, cultural psychiatry, psychodynamics, and strengthening public mental health infrastructure.