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Inpatient psychiatrist? Maybe I’ll be a vaccinator instead
Now that completion of residency is fast approaching, I am asked regularly what I plan to do when I become a Real Doctor on July 1. It feels like it wasn’t so long ago I was trying to decide if I should even go to medical school, then later, if I should go into psychiatry, family medicine, or emergency medicine. And here I am at another decision point, another of the regular, 4-year milestones in my journey to full physicianhood.
A surprising thing happened to me during my psychiatry training: I fell in love with acute care. Instead of outpatient care, I preferred the longer hours with patients who insist they are Jesus Christ, believe deeply they are being actively pursued by the FBI, and sometimes eat their own feces. I was in awe of the remarkable capacity of the human brain to convince a graduate-school educated man with bipolar disorder that it is acceptable to call in bomb threats to a hospital. To lead a patient on a conservatorship to believe that I am not a doctor but, instead, a seamstress or leave socks full of feces as presents for Santa Claus (lots of feces in inpatient psychiatry). To believe their spouses are not humans or hear voices telling them they should jump off a bridge, sustaining near-lethal injuries. I was hooked.
Psychiatry as a field is not for those requiring instant gratification. Other than Ativan challenges and the remarkably quick response some patients have to ECT, outcomes of our treatments are usually modest, and they take time. We often delude ourselves into thinking that bumping a patient’s fluoxetine from 10 mg to 20 mg will be The Thing that changes a patient’s life. We address our own sense of helplessness as much as that of our patients, who are desperate for something, for someone, to do something that will alter the course of their lives.
Of course, what I can offer my patients usually falls short of their lofty expectations of my prowess. I offer them compassion, validation, empathy. I offer them medications for which we usually have meager data and meager results. I cannot find them shelter but for a few nights, perhaps a week. I rarely, in settings in which primary diagnoses of substance use and personality disorders are forbidden by insurance companies, can help them with their addiction to methamphetamine. I cannot cure their maladaptive characterological pathology stemming from childhood attachment trauma. To address my own sense of failure as a healer, I resort to the bottom of Maslow’s hierarchy of needs, providing their choice of juice box, more blankets. I slow-roll their discharges overnight so that they can stay in the ER hallway instead of spending the night outside in the rare Southern California rain.
In my 3rd year of residency, we were thrown into a pandemic. I felt both terrified of getting COVID-19 in the hospital and inadequate as a physician. I did not want to be intubating patients, but even more, I dreaded the potential “psychiatry-friendly” assignment of calling the family members of those who had perished from the disease. Rumors circulated that certain versions of surge planning had the inpatient psychiatry unit transitioned to a COVID unit and psychiatry residents “redeployed” to cover medicine floors. Fortunately, we did not have to (or have not yet had to) endure this apocalyptic episode of worst-case scenario. I remained a psychiatrist-in-training, seeing occasional COVID patients but with full personal protective equipment and the ability to maintain some physical distance to complete my examinations. Coming home to my apartment building in scrubs, now acceptable attire on inpatient units – it always should have been since, as we have established, our units are filled with feces – I early on felt like a leper. Later on, I was treated with dignity and respect, like a hero.
My position as a non–frontline-physician was personally challenging. I wanted to help, felt like I should and could help. I am a helper-in-recovery who has spent years learning to achieve a balance of service and loyalty to others and my own desires. The initial guilt I felt at feeling appreciated during the nightly celebration of health care workers downtown ultimately dissipated. I was no hero, nor did I claim to be one. I made peace with my pandemic hobbies of sourdough bread-baking, Moscow mule-making, jigsaw-puzzling, and, briefly, running (before a calcaneal stress fracture reminded me that I am not built for land exercise). I went to work; I came home. My cat was happy.
Then, in rapid succession, vaccines were approved and distributed. My hospital had partnered with the county to administer them at a new superstation, and they were in desperate need of licensed humans to be vaccinators. They cared not that I had given very few (n = 3) injections and only during medical school. I watched the YouTube videos on the Z-track technique for IMs, learned about needle gauges, and went off to the baseball stadium.
I loved this new gig, disproportionately. The 8+ hours flew by, 100 vaccines given to occupants of cars who had eagerly waited hours for the privilege of being vaccinated by an almost-psychiatrist. It was not the technical expertise of sticking a needle into someone’s arm that gave me a dopamine rush, nor the microstress of preparing the syringes with a flimsy needle and a slight caffeine-induced tremor while trying to flick air bubbles out of the syringe without dropping the precious vaccine vial. It was not the travel nurse asking me why anyone – especially an overworked resident – would volunteer to do this for free, while she and others were making “stupid amounts of money” to do the same job.
What drove me to keep volunteering for no pay, only Cheez-Its available as sustenance, minimal gratitude from my employer, long hours on my feet doing a task that was rote and at which I probably would never completely excel? On my second shift, I realized why I found it so gratifying to be a vaccinator: There was a perfect 1:1 correspondence in what patients wanted at that moment and in what I had to offer them. They did not want me to fix their lives, secure them housing, or go back in time and remove them from abusive homes so they could grow up to be more functional, happier adults. They merely wanted a shot. They were profusely grateful, hopeful that this was the Beginning of the End. Nobody spat on me; nobody called me obscene names. Nobody was upset with me for involuntarily holding them against their will. My services were welcome, appreciated. I had lovely, superficial conversations with dozens of people. I felt connected to strangers in a way that has been sorely lacking since March 2020. Understandably mistaken for a nurse throughout the day, I felt more like a bona fide physician than I had in over a year.
I know the adrenaline rush will fade, that volunteer-vaccinating in my free time will eventually become less exciting to me. I know I won’t be able to convince my colleagues indefinitely that volunteering together is a great, institution-sanctioned bonding opportunity. I know the initial enthusiasm over vaccine distribution will fade as the pandemic continues to transform our everyday lives and threaten the health of millions, the economy, and the sanctity of normal human interactions. The gratitude and hopefulness may well be replaced with frustration over waiting hours in a car to get an injection from a psychiatrist, with fear that this promised panacea may not restore normalcy anytime soon. But right now, 11 months into a pandemic that has left our profession exhausted and jaded, the coprophilia and catatonia have temporarily lost their allure. So, I’m adding “vaccinator” to my list of pandemic hobbies.
Dr. Stone is a chief resident in psychiatry at the University of California, San Diego. Before deciding to become a physician, she obtained a master’s degree in public health and worked in health policy research studying empathy and patient-doctor interactions. She has a passion for public psychiatry and acute care, and she dabbles in physician wellness, medical education, and the interface of psychiatry and primary care. Dr. Stone has no disclosures.
Now that completion of residency is fast approaching, I am asked regularly what I plan to do when I become a Real Doctor on July 1. It feels like it wasn’t so long ago I was trying to decide if I should even go to medical school, then later, if I should go into psychiatry, family medicine, or emergency medicine. And here I am at another decision point, another of the regular, 4-year milestones in my journey to full physicianhood.
A surprising thing happened to me during my psychiatry training: I fell in love with acute care. Instead of outpatient care, I preferred the longer hours with patients who insist they are Jesus Christ, believe deeply they are being actively pursued by the FBI, and sometimes eat their own feces. I was in awe of the remarkable capacity of the human brain to convince a graduate-school educated man with bipolar disorder that it is acceptable to call in bomb threats to a hospital. To lead a patient on a conservatorship to believe that I am not a doctor but, instead, a seamstress or leave socks full of feces as presents for Santa Claus (lots of feces in inpatient psychiatry). To believe their spouses are not humans or hear voices telling them they should jump off a bridge, sustaining near-lethal injuries. I was hooked.
Psychiatry as a field is not for those requiring instant gratification. Other than Ativan challenges and the remarkably quick response some patients have to ECT, outcomes of our treatments are usually modest, and they take time. We often delude ourselves into thinking that bumping a patient’s fluoxetine from 10 mg to 20 mg will be The Thing that changes a patient’s life. We address our own sense of helplessness as much as that of our patients, who are desperate for something, for someone, to do something that will alter the course of their lives.
Of course, what I can offer my patients usually falls short of their lofty expectations of my prowess. I offer them compassion, validation, empathy. I offer them medications for which we usually have meager data and meager results. I cannot find them shelter but for a few nights, perhaps a week. I rarely, in settings in which primary diagnoses of substance use and personality disorders are forbidden by insurance companies, can help them with their addiction to methamphetamine. I cannot cure their maladaptive characterological pathology stemming from childhood attachment trauma. To address my own sense of failure as a healer, I resort to the bottom of Maslow’s hierarchy of needs, providing their choice of juice box, more blankets. I slow-roll their discharges overnight so that they can stay in the ER hallway instead of spending the night outside in the rare Southern California rain.
In my 3rd year of residency, we were thrown into a pandemic. I felt both terrified of getting COVID-19 in the hospital and inadequate as a physician. I did not want to be intubating patients, but even more, I dreaded the potential “psychiatry-friendly” assignment of calling the family members of those who had perished from the disease. Rumors circulated that certain versions of surge planning had the inpatient psychiatry unit transitioned to a COVID unit and psychiatry residents “redeployed” to cover medicine floors. Fortunately, we did not have to (or have not yet had to) endure this apocalyptic episode of worst-case scenario. I remained a psychiatrist-in-training, seeing occasional COVID patients but with full personal protective equipment and the ability to maintain some physical distance to complete my examinations. Coming home to my apartment building in scrubs, now acceptable attire on inpatient units – it always should have been since, as we have established, our units are filled with feces – I early on felt like a leper. Later on, I was treated with dignity and respect, like a hero.
My position as a non–frontline-physician was personally challenging. I wanted to help, felt like I should and could help. I am a helper-in-recovery who has spent years learning to achieve a balance of service and loyalty to others and my own desires. The initial guilt I felt at feeling appreciated during the nightly celebration of health care workers downtown ultimately dissipated. I was no hero, nor did I claim to be one. I made peace with my pandemic hobbies of sourdough bread-baking, Moscow mule-making, jigsaw-puzzling, and, briefly, running (before a calcaneal stress fracture reminded me that I am not built for land exercise). I went to work; I came home. My cat was happy.
Then, in rapid succession, vaccines were approved and distributed. My hospital had partnered with the county to administer them at a new superstation, and they were in desperate need of licensed humans to be vaccinators. They cared not that I had given very few (n = 3) injections and only during medical school. I watched the YouTube videos on the Z-track technique for IMs, learned about needle gauges, and went off to the baseball stadium.
I loved this new gig, disproportionately. The 8+ hours flew by, 100 vaccines given to occupants of cars who had eagerly waited hours for the privilege of being vaccinated by an almost-psychiatrist. It was not the technical expertise of sticking a needle into someone’s arm that gave me a dopamine rush, nor the microstress of preparing the syringes with a flimsy needle and a slight caffeine-induced tremor while trying to flick air bubbles out of the syringe without dropping the precious vaccine vial. It was not the travel nurse asking me why anyone – especially an overworked resident – would volunteer to do this for free, while she and others were making “stupid amounts of money” to do the same job.
What drove me to keep volunteering for no pay, only Cheez-Its available as sustenance, minimal gratitude from my employer, long hours on my feet doing a task that was rote and at which I probably would never completely excel? On my second shift, I realized why I found it so gratifying to be a vaccinator: There was a perfect 1:1 correspondence in what patients wanted at that moment and in what I had to offer them. They did not want me to fix their lives, secure them housing, or go back in time and remove them from abusive homes so they could grow up to be more functional, happier adults. They merely wanted a shot. They were profusely grateful, hopeful that this was the Beginning of the End. Nobody spat on me; nobody called me obscene names. Nobody was upset with me for involuntarily holding them against their will. My services were welcome, appreciated. I had lovely, superficial conversations with dozens of people. I felt connected to strangers in a way that has been sorely lacking since March 2020. Understandably mistaken for a nurse throughout the day, I felt more like a bona fide physician than I had in over a year.
I know the adrenaline rush will fade, that volunteer-vaccinating in my free time will eventually become less exciting to me. I know I won’t be able to convince my colleagues indefinitely that volunteering together is a great, institution-sanctioned bonding opportunity. I know the initial enthusiasm over vaccine distribution will fade as the pandemic continues to transform our everyday lives and threaten the health of millions, the economy, and the sanctity of normal human interactions. The gratitude and hopefulness may well be replaced with frustration over waiting hours in a car to get an injection from a psychiatrist, with fear that this promised panacea may not restore normalcy anytime soon. But right now, 11 months into a pandemic that has left our profession exhausted and jaded, the coprophilia and catatonia have temporarily lost their allure. So, I’m adding “vaccinator” to my list of pandemic hobbies.
Dr. Stone is a chief resident in psychiatry at the University of California, San Diego. Before deciding to become a physician, she obtained a master’s degree in public health and worked in health policy research studying empathy and patient-doctor interactions. She has a passion for public psychiatry and acute care, and she dabbles in physician wellness, medical education, and the interface of psychiatry and primary care. Dr. Stone has no disclosures.
Now that completion of residency is fast approaching, I am asked regularly what I plan to do when I become a Real Doctor on July 1. It feels like it wasn’t so long ago I was trying to decide if I should even go to medical school, then later, if I should go into psychiatry, family medicine, or emergency medicine. And here I am at another decision point, another of the regular, 4-year milestones in my journey to full physicianhood.
A surprising thing happened to me during my psychiatry training: I fell in love with acute care. Instead of outpatient care, I preferred the longer hours with patients who insist they are Jesus Christ, believe deeply they are being actively pursued by the FBI, and sometimes eat their own feces. I was in awe of the remarkable capacity of the human brain to convince a graduate-school educated man with bipolar disorder that it is acceptable to call in bomb threats to a hospital. To lead a patient on a conservatorship to believe that I am not a doctor but, instead, a seamstress or leave socks full of feces as presents for Santa Claus (lots of feces in inpatient psychiatry). To believe their spouses are not humans or hear voices telling them they should jump off a bridge, sustaining near-lethal injuries. I was hooked.
Psychiatry as a field is not for those requiring instant gratification. Other than Ativan challenges and the remarkably quick response some patients have to ECT, outcomes of our treatments are usually modest, and they take time. We often delude ourselves into thinking that bumping a patient’s fluoxetine from 10 mg to 20 mg will be The Thing that changes a patient’s life. We address our own sense of helplessness as much as that of our patients, who are desperate for something, for someone, to do something that will alter the course of their lives.
Of course, what I can offer my patients usually falls short of their lofty expectations of my prowess. I offer them compassion, validation, empathy. I offer them medications for which we usually have meager data and meager results. I cannot find them shelter but for a few nights, perhaps a week. I rarely, in settings in which primary diagnoses of substance use and personality disorders are forbidden by insurance companies, can help them with their addiction to methamphetamine. I cannot cure their maladaptive characterological pathology stemming from childhood attachment trauma. To address my own sense of failure as a healer, I resort to the bottom of Maslow’s hierarchy of needs, providing their choice of juice box, more blankets. I slow-roll their discharges overnight so that they can stay in the ER hallway instead of spending the night outside in the rare Southern California rain.
In my 3rd year of residency, we were thrown into a pandemic. I felt both terrified of getting COVID-19 in the hospital and inadequate as a physician. I did not want to be intubating patients, but even more, I dreaded the potential “psychiatry-friendly” assignment of calling the family members of those who had perished from the disease. Rumors circulated that certain versions of surge planning had the inpatient psychiatry unit transitioned to a COVID unit and psychiatry residents “redeployed” to cover medicine floors. Fortunately, we did not have to (or have not yet had to) endure this apocalyptic episode of worst-case scenario. I remained a psychiatrist-in-training, seeing occasional COVID patients but with full personal protective equipment and the ability to maintain some physical distance to complete my examinations. Coming home to my apartment building in scrubs, now acceptable attire on inpatient units – it always should have been since, as we have established, our units are filled with feces – I early on felt like a leper. Later on, I was treated with dignity and respect, like a hero.
My position as a non–frontline-physician was personally challenging. I wanted to help, felt like I should and could help. I am a helper-in-recovery who has spent years learning to achieve a balance of service and loyalty to others and my own desires. The initial guilt I felt at feeling appreciated during the nightly celebration of health care workers downtown ultimately dissipated. I was no hero, nor did I claim to be one. I made peace with my pandemic hobbies of sourdough bread-baking, Moscow mule-making, jigsaw-puzzling, and, briefly, running (before a calcaneal stress fracture reminded me that I am not built for land exercise). I went to work; I came home. My cat was happy.
Then, in rapid succession, vaccines were approved and distributed. My hospital had partnered with the county to administer them at a new superstation, and they were in desperate need of licensed humans to be vaccinators. They cared not that I had given very few (n = 3) injections and only during medical school. I watched the YouTube videos on the Z-track technique for IMs, learned about needle gauges, and went off to the baseball stadium.
I loved this new gig, disproportionately. The 8+ hours flew by, 100 vaccines given to occupants of cars who had eagerly waited hours for the privilege of being vaccinated by an almost-psychiatrist. It was not the technical expertise of sticking a needle into someone’s arm that gave me a dopamine rush, nor the microstress of preparing the syringes with a flimsy needle and a slight caffeine-induced tremor while trying to flick air bubbles out of the syringe without dropping the precious vaccine vial. It was not the travel nurse asking me why anyone – especially an overworked resident – would volunteer to do this for free, while she and others were making “stupid amounts of money” to do the same job.
What drove me to keep volunteering for no pay, only Cheez-Its available as sustenance, minimal gratitude from my employer, long hours on my feet doing a task that was rote and at which I probably would never completely excel? On my second shift, I realized why I found it so gratifying to be a vaccinator: There was a perfect 1:1 correspondence in what patients wanted at that moment and in what I had to offer them. They did not want me to fix their lives, secure them housing, or go back in time and remove them from abusive homes so they could grow up to be more functional, happier adults. They merely wanted a shot. They were profusely grateful, hopeful that this was the Beginning of the End. Nobody spat on me; nobody called me obscene names. Nobody was upset with me for involuntarily holding them against their will. My services were welcome, appreciated. I had lovely, superficial conversations with dozens of people. I felt connected to strangers in a way that has been sorely lacking since March 2020. Understandably mistaken for a nurse throughout the day, I felt more like a bona fide physician than I had in over a year.
I know the adrenaline rush will fade, that volunteer-vaccinating in my free time will eventually become less exciting to me. I know I won’t be able to convince my colleagues indefinitely that volunteering together is a great, institution-sanctioned bonding opportunity. I know the initial enthusiasm over vaccine distribution will fade as the pandemic continues to transform our everyday lives and threaten the health of millions, the economy, and the sanctity of normal human interactions. The gratitude and hopefulness may well be replaced with frustration over waiting hours in a car to get an injection from a psychiatrist, with fear that this promised panacea may not restore normalcy anytime soon. But right now, 11 months into a pandemic that has left our profession exhausted and jaded, the coprophilia and catatonia have temporarily lost their allure. So, I’m adding “vaccinator” to my list of pandemic hobbies.
Dr. Stone is a chief resident in psychiatry at the University of California, San Diego. Before deciding to become a physician, she obtained a master’s degree in public health and worked in health policy research studying empathy and patient-doctor interactions. She has a passion for public psychiatry and acute care, and she dabbles in physician wellness, medical education, and the interface of psychiatry and primary care. Dr. Stone has no disclosures.
Treatment of horizontal neck lines
The interplay of the neck subunits, as outlined in the recent article by Friedman and colleagues, requires multiple combination treatments, including fat removal, augmentation of deficient bony prominences, relaxation of hyperkinetic muscles, tissue tightening, suture anchoring, skin resurfacing, and treatment of dyschromia.
Horizontal neck lines are linear etched lines or furrows that commonly appear at a young age and are not caused by the aging process. The anatomy of the neck and the manner in which it bends contributes to their development at an early age. It is hypothesized that variable adipose tissue thickness and fibromuscular bands contribute to deepening of these lines in overweight patients. The widespread use of cell phones, laptops, and tablets has increased their prevalence and this has become one of the most common concerns of patients aged under 30 years in my clinic.
Various treatments have been recommended for neck rejuvenation, including hyaluronic acid and dilute calcium hydroxylapatite. In my experience, neither of these treatments adequately resolves the horizontal neck lines, and more importantly, prevents them from reoccurring. In addition, given the variability in skin and adipose thickness in the anterior neck, side effects including lumps, irregular correction, and the Tyndall effect, are common, particularly with incorrect choice of filler and injection depth.
The fibromuscular bands along the transverse neck lines pose one of the complexities in treatment with injectable filler. I have had significant improvement in the aesthetic outcome of my patients by using subcision along the transverse bands extensively prior to injection with hyaluronic acid fillers. The subcision is done with a 27-gauge needle to release the fibrous bands that tether the tissue down. If a patient has excess adipose tissue on either side of the bands, injectable fillers often do not improve the appearance of the lines and can make the neck appear heavier. The use of subcision followed by one to six treatments of deoxycholic acid in the adjacent adipose tissue prior to injection with a filler will help even out the contour of the neck, decrease adipose tissue bulges, release the fibrous bands, and fill the lines properly.
Working from home and on handheld devices has increased the appearance of neck lines in young populations. Despite the vast array of treatments in the aging neck, none have been very successful for this particular problem in the young. We need an improved understanding of these lines and better studies to investigate treatment options and long-term correction.
References:
Friedman O et al. J Cosmet Dermatol. 2021 Feb;20(2):569-76.
Brandt FS and Boker A. Dermatol Clin. 2004 Apr;22(2):159-66.
Tseng F and Yu H. Plast Reconstr Surg Glob Open. 2019 Aug 19;7(8):e2366.
Dibernardo BE. J Cosmet Laser Ther. 2013 Apr;15(2):56-64.
Jones D et al. Dermatol Surg. 2016 Oct;4 Suppl 1(Suppl 1):S235-42.
Lee SK and Kim HS. J Cosmet Dermatol. 2018 Aug;17(4):590-5.
Chao YY et al. Dermatol Surg. 2011 Oct;37(10):1542-5.
Han TY et al. Dermatol Surg. 2011 Sep;37(9):1291-6.
Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Talakoub. Write to them at dermnews@mdedge.com. They had no relevant disclosures.
The interplay of the neck subunits, as outlined in the recent article by Friedman and colleagues, requires multiple combination treatments, including fat removal, augmentation of deficient bony prominences, relaxation of hyperkinetic muscles, tissue tightening, suture anchoring, skin resurfacing, and treatment of dyschromia.
Horizontal neck lines are linear etched lines or furrows that commonly appear at a young age and are not caused by the aging process. The anatomy of the neck and the manner in which it bends contributes to their development at an early age. It is hypothesized that variable adipose tissue thickness and fibromuscular bands contribute to deepening of these lines in overweight patients. The widespread use of cell phones, laptops, and tablets has increased their prevalence and this has become one of the most common concerns of patients aged under 30 years in my clinic.
Various treatments have been recommended for neck rejuvenation, including hyaluronic acid and dilute calcium hydroxylapatite. In my experience, neither of these treatments adequately resolves the horizontal neck lines, and more importantly, prevents them from reoccurring. In addition, given the variability in skin and adipose thickness in the anterior neck, side effects including lumps, irregular correction, and the Tyndall effect, are common, particularly with incorrect choice of filler and injection depth.
The fibromuscular bands along the transverse neck lines pose one of the complexities in treatment with injectable filler. I have had significant improvement in the aesthetic outcome of my patients by using subcision along the transverse bands extensively prior to injection with hyaluronic acid fillers. The subcision is done with a 27-gauge needle to release the fibrous bands that tether the tissue down. If a patient has excess adipose tissue on either side of the bands, injectable fillers often do not improve the appearance of the lines and can make the neck appear heavier. The use of subcision followed by one to six treatments of deoxycholic acid in the adjacent adipose tissue prior to injection with a filler will help even out the contour of the neck, decrease adipose tissue bulges, release the fibrous bands, and fill the lines properly.
Working from home and on handheld devices has increased the appearance of neck lines in young populations. Despite the vast array of treatments in the aging neck, none have been very successful for this particular problem in the young. We need an improved understanding of these lines and better studies to investigate treatment options and long-term correction.
References:
Friedman O et al. J Cosmet Dermatol. 2021 Feb;20(2):569-76.
Brandt FS and Boker A. Dermatol Clin. 2004 Apr;22(2):159-66.
Tseng F and Yu H. Plast Reconstr Surg Glob Open. 2019 Aug 19;7(8):e2366.
Dibernardo BE. J Cosmet Laser Ther. 2013 Apr;15(2):56-64.
Jones D et al. Dermatol Surg. 2016 Oct;4 Suppl 1(Suppl 1):S235-42.
Lee SK and Kim HS. J Cosmet Dermatol. 2018 Aug;17(4):590-5.
Chao YY et al. Dermatol Surg. 2011 Oct;37(10):1542-5.
Han TY et al. Dermatol Surg. 2011 Sep;37(9):1291-6.
Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Talakoub. Write to them at dermnews@mdedge.com. They had no relevant disclosures.
The interplay of the neck subunits, as outlined in the recent article by Friedman and colleagues, requires multiple combination treatments, including fat removal, augmentation of deficient bony prominences, relaxation of hyperkinetic muscles, tissue tightening, suture anchoring, skin resurfacing, and treatment of dyschromia.
Horizontal neck lines are linear etched lines or furrows that commonly appear at a young age and are not caused by the aging process. The anatomy of the neck and the manner in which it bends contributes to their development at an early age. It is hypothesized that variable adipose tissue thickness and fibromuscular bands contribute to deepening of these lines in overweight patients. The widespread use of cell phones, laptops, and tablets has increased their prevalence and this has become one of the most common concerns of patients aged under 30 years in my clinic.
Various treatments have been recommended for neck rejuvenation, including hyaluronic acid and dilute calcium hydroxylapatite. In my experience, neither of these treatments adequately resolves the horizontal neck lines, and more importantly, prevents them from reoccurring. In addition, given the variability in skin and adipose thickness in the anterior neck, side effects including lumps, irregular correction, and the Tyndall effect, are common, particularly with incorrect choice of filler and injection depth.
The fibromuscular bands along the transverse neck lines pose one of the complexities in treatment with injectable filler. I have had significant improvement in the aesthetic outcome of my patients by using subcision along the transverse bands extensively prior to injection with hyaluronic acid fillers. The subcision is done with a 27-gauge needle to release the fibrous bands that tether the tissue down. If a patient has excess adipose tissue on either side of the bands, injectable fillers often do not improve the appearance of the lines and can make the neck appear heavier. The use of subcision followed by one to six treatments of deoxycholic acid in the adjacent adipose tissue prior to injection with a filler will help even out the contour of the neck, decrease adipose tissue bulges, release the fibrous bands, and fill the lines properly.
Working from home and on handheld devices has increased the appearance of neck lines in young populations. Despite the vast array of treatments in the aging neck, none have been very successful for this particular problem in the young. We need an improved understanding of these lines and better studies to investigate treatment options and long-term correction.
References:
Friedman O et al. J Cosmet Dermatol. 2021 Feb;20(2):569-76.
Brandt FS and Boker A. Dermatol Clin. 2004 Apr;22(2):159-66.
Tseng F and Yu H. Plast Reconstr Surg Glob Open. 2019 Aug 19;7(8):e2366.
Dibernardo BE. J Cosmet Laser Ther. 2013 Apr;15(2):56-64.
Jones D et al. Dermatol Surg. 2016 Oct;4 Suppl 1(Suppl 1):S235-42.
Lee SK and Kim HS. J Cosmet Dermatol. 2018 Aug;17(4):590-5.
Chao YY et al. Dermatol Surg. 2011 Oct;37(10):1542-5.
Han TY et al. Dermatol Surg. 2011 Sep;37(9):1291-6.
Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Talakoub. Write to them at dermnews@mdedge.com. They had no relevant disclosures.
Puppy love: Is losing a pet too hard for children?
The big news in the Wilkoff household is that Marilyn and I will be celebrating the arrival of a granddog into our nuclear family. Our younger daughter and her husband will be welcoming into their home a golden retriever puppy the first week in March. This may not seem like big news to some families and is certainly a step down on the priority list to the arrival of the four grandchildren that we already claim on our resume. But, you must understand that no one in our family has ever owned a dog.
Although my wife’s family had a dog, she apparently never really bonded with the canine. My pleas and occasional whining from our three children to get a dog were always met with my wife’s concerns about cleanliness and hygiene. We did have an antisocial cat who lived under a bed in the guest room or in the basement. His passing after 16 years when the kids were in college was not an event marked with any emotion beyond relief.
I think I harbored an unspoken concern about how I and our children might respond emotionally and psychologically to the inevitable death of what would likely have become our family’s best friend. Dispatching a belly-up goldfish after a month or two is small potatoes compared to putting down a tail-wagging, frisbee-catching, four-footed member of the family.
It turns out that my concerns about the mental health of our children may not have been unfounded. A recently published study from the Harvard Medical School and Massachusetts General Hospital found that children who had experienced the death of a loved pet were more likely to exhibit symptoms of psychopathology than were those who had loved a pet who was still alive (Crawford et al. Eur Child Adolesc Psychiatry. 2020 Sep 10. doi: 10.1007/s00787-020-01594-5). The observed effect of the loss was more pronounced in boys. There was also no statistical difference between the psychopathology symptoms of those children who had loved and lost and those children who had never loved a pet.
By the time I left for college I had grown up with five different dogs. I had endured the loss of sweet Mary, the boxer, when we moved to a small apartment and had to send her to a “farm.” I had watched 2-year-old Blackie experience a seizure that heralded his fatal bout with distemper. I shared the struggle with my parents as we made the decision to send my much loved inveterate car chasing “Butch” back to the pound.
However, I survived these losses and wonder whether they in some way prepared me for some of the emotional challenges that would come later in life. This study from Harvard sampled only children from birth to age 8 years. For those of us in primary care a more interesting study might be one that looked for any long-term associations between pet loss as a young child with adolescent and adult mental health. With the surge in pet ownership that has surfaced during the pandemic, there should be an abundance of clinical material to mine. The Harvard researchers’ findings should make us aware of the potential for psychopathology in a child who has suffered the loss of a pet. Each family must decide whether the plusses of pet ownership are worth the risk. However, I side with Tennyson who said it is better to have loved and lost than never to have loved at all.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.
The big news in the Wilkoff household is that Marilyn and I will be celebrating the arrival of a granddog into our nuclear family. Our younger daughter and her husband will be welcoming into their home a golden retriever puppy the first week in March. This may not seem like big news to some families and is certainly a step down on the priority list to the arrival of the four grandchildren that we already claim on our resume. But, you must understand that no one in our family has ever owned a dog.
Although my wife’s family had a dog, she apparently never really bonded with the canine. My pleas and occasional whining from our three children to get a dog were always met with my wife’s concerns about cleanliness and hygiene. We did have an antisocial cat who lived under a bed in the guest room or in the basement. His passing after 16 years when the kids were in college was not an event marked with any emotion beyond relief.
I think I harbored an unspoken concern about how I and our children might respond emotionally and psychologically to the inevitable death of what would likely have become our family’s best friend. Dispatching a belly-up goldfish after a month or two is small potatoes compared to putting down a tail-wagging, frisbee-catching, four-footed member of the family.
It turns out that my concerns about the mental health of our children may not have been unfounded. A recently published study from the Harvard Medical School and Massachusetts General Hospital found that children who had experienced the death of a loved pet were more likely to exhibit symptoms of psychopathology than were those who had loved a pet who was still alive (Crawford et al. Eur Child Adolesc Psychiatry. 2020 Sep 10. doi: 10.1007/s00787-020-01594-5). The observed effect of the loss was more pronounced in boys. There was also no statistical difference between the psychopathology symptoms of those children who had loved and lost and those children who had never loved a pet.
By the time I left for college I had grown up with five different dogs. I had endured the loss of sweet Mary, the boxer, when we moved to a small apartment and had to send her to a “farm.” I had watched 2-year-old Blackie experience a seizure that heralded his fatal bout with distemper. I shared the struggle with my parents as we made the decision to send my much loved inveterate car chasing “Butch” back to the pound.
However, I survived these losses and wonder whether they in some way prepared me for some of the emotional challenges that would come later in life. This study from Harvard sampled only children from birth to age 8 years. For those of us in primary care a more interesting study might be one that looked for any long-term associations between pet loss as a young child with adolescent and adult mental health. With the surge in pet ownership that has surfaced during the pandemic, there should be an abundance of clinical material to mine. The Harvard researchers’ findings should make us aware of the potential for psychopathology in a child who has suffered the loss of a pet. Each family must decide whether the plusses of pet ownership are worth the risk. However, I side with Tennyson who said it is better to have loved and lost than never to have loved at all.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.
The big news in the Wilkoff household is that Marilyn and I will be celebrating the arrival of a granddog into our nuclear family. Our younger daughter and her husband will be welcoming into their home a golden retriever puppy the first week in March. This may not seem like big news to some families and is certainly a step down on the priority list to the arrival of the four grandchildren that we already claim on our resume. But, you must understand that no one in our family has ever owned a dog.
Although my wife’s family had a dog, she apparently never really bonded with the canine. My pleas and occasional whining from our three children to get a dog were always met with my wife’s concerns about cleanliness and hygiene. We did have an antisocial cat who lived under a bed in the guest room or in the basement. His passing after 16 years when the kids were in college was not an event marked with any emotion beyond relief.
I think I harbored an unspoken concern about how I and our children might respond emotionally and psychologically to the inevitable death of what would likely have become our family’s best friend. Dispatching a belly-up goldfish after a month or two is small potatoes compared to putting down a tail-wagging, frisbee-catching, four-footed member of the family.
It turns out that my concerns about the mental health of our children may not have been unfounded. A recently published study from the Harvard Medical School and Massachusetts General Hospital found that children who had experienced the death of a loved pet were more likely to exhibit symptoms of psychopathology than were those who had loved a pet who was still alive (Crawford et al. Eur Child Adolesc Psychiatry. 2020 Sep 10. doi: 10.1007/s00787-020-01594-5). The observed effect of the loss was more pronounced in boys. There was also no statistical difference between the psychopathology symptoms of those children who had loved and lost and those children who had never loved a pet.
By the time I left for college I had grown up with five different dogs. I had endured the loss of sweet Mary, the boxer, when we moved to a small apartment and had to send her to a “farm.” I had watched 2-year-old Blackie experience a seizure that heralded his fatal bout with distemper. I shared the struggle with my parents as we made the decision to send my much loved inveterate car chasing “Butch” back to the pound.
However, I survived these losses and wonder whether they in some way prepared me for some of the emotional challenges that would come later in life. This study from Harvard sampled only children from birth to age 8 years. For those of us in primary care a more interesting study might be one that looked for any long-term associations between pet loss as a young child with adolescent and adult mental health. With the surge in pet ownership that has surfaced during the pandemic, there should be an abundance of clinical material to mine. The Harvard researchers’ findings should make us aware of the potential for psychopathology in a child who has suffered the loss of a pet. Each family must decide whether the plusses of pet ownership are worth the risk. However, I side with Tennyson who said it is better to have loved and lost than never to have loved at all.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.
The cutaneous benefits of bee venom, Part I: Atopic dermatitis and acne
Honeybees, Apis mellifera, play an important role in the web of life. We rely on bees for pollinating approximately one-third of our crops, including multiple fruits, vegetables, nuts, and seeds.1,2 Bees are also instrumental in the propagation of other plants, flower nectar, and flower pollen. A. mellifera, the European honeybee, is the main pollinator in Europe and North America, but other species, including A. cerana, A. dorsata, A. floria, A. andreniformis, A. koschevnikov, and A. laboriosa, yield honey.3 Honey, propolis, and royal jelly, along with beeswax and bee pollen, are among some of the celebrated bee products that have been found to confer health benefits to human beings.4,5 Bee venom, a toxin bees use for protection, is a convoluted combination of peptides and toxic proteins such as phospholipase A2 (PLA2) and melittin that has garnered significant scientific attention of late and is used to treat various inflammatory conditions.6-8 This column will focus on the investigation of the use of bee venom to treat atopic dermatitis (AD) and acne.
Atopic dermatitis
In 2013, Kim et al. assessed the impact of bee venom on AD-related symptoms in mice, finding that it attenuated the effects of AD-simulating compounds in 48 of 80 patients injected subcutaneously. They concluded that bee venom acted by suppressing mast cell degranulation and proinflammatory cytokine expression.9 Three years later, You et al. conducted a double-blind, randomized, base-controlled multicenter study of 136 patients with AD to ascertain the effects of a bee venom emollient. For 4 weeks, patients applied an emollient with bee venom and silk protein or a vehicle lacking bee venom twice daily. Eczema area and severity index (EASI) scores were significantly lower in the bee venom group, as were the visual analogue scale (VAS) scores. The investigators concluded that bee venom is an effective and safe therapeutic choice for treating patients with AD.10 Further, in 2018, Shin et al. demonstrated that PLA2 derived from bee venom mitigates atopic skin inflammation via the CD206 mannose receptor. They had previously shown in a mouse model that PLA2 from bee venom exerts such activity against AD-like lesions induced by 2,4-dinitrochlorobenzene (DNCB) and house dust mite (Dermatophagoides farinae) extract.11 Gu et al. observed later that year that intraperitoneal administration of bee venom eased the symptoms of ovalbumin-induced AD-like skin lesions in an experimental mouse model. Bee venom also lowered serum immunoglobulin E levels and suppressed infiltration of eosinophils and mast cells. They concluded that bee venom is a viable alternative for attenuating the allergic skin inflammation characteristic of AD.12 At the end of 2018, An et al. reported on the use of an in vivo female Balb/c mouse AD model in which 1-chloro-DNCB acted as inducer in cultures of human keratinocytes, stimulated by TNF-alpha/IFN-gamma. The investigators found that bee venom and melittin displayed robust antiatopic effects as evidenced by reduced lesions. The bee products were also found to have hindered elevated expression of various chemokines and proinflammatory cytokines. The authors suggested that bee venom and melittin appear to warrant consideration as a topical treatment for AD.13 In 2019, Kim et al. demonstrated in mice that bee venom eases the symptoms of AD by inactivating the complement system, particularly through CD55 induction, which might account for its effectiveness in AD treatment in humans, they suggested.6 Early in 2020, Lee et al. demonstrated in a Balb/c mouse model that bee venom appears to be a possible therapeutic macromolecule for treating phthalic anhydride-induced AD.7
Acne
In 2013, in vitro experiments by Han et al. showed that purified bee venom exhibited antimicrobial activity, in a concentration-dependent manner, against Cutibacterium acnes (or Propionibacterium acnes). They followed up with a small randomized, double-blind, controlled trial with 12 subjects who were treated with cosmetics with pure bee venom or cosmetics without it for two weeks. The group receiving bee venom experienced significantly fewer inflammatory and noninflammatory lesions, and a significant decline in adenosine triphosphate levels (a 57.5% reduction) was noted in subjects in the bee venom group, with a nonsignificant decrease of 4.7% observed in the control group. The investigators concluded the purified bee venom may be suitable as an antiacne agent.14 Using a mouse model, An et al. studied the therapeutic effects of bee venom against C. acnes–induced skin inflammation. They found that bee venom significantly diminished the volume of infiltrated inflammatory cells in the treated mice, compared with untreated mice. Bee venom also decreased expression levels of tumor necrosis factor (TNF)-α, and interleukin (IL)-1beta and suppressed Toll-like receptor (TLR)2 and CD14 expression in C. acnes–injected tissue. The investigators concluded that bee venom imparts notable anti-inflammatory activity and has potential for use in treating acne and as an anti-inflammatory agent in skin care.15
In 2015, Kim et al. studied the influence of bee venom against C. acnes–induced inflammation in human keratinocytes (HaCaT) and monocytes (THP-1). They found that bee venom successfully suppressed the secretion of interferon-gamma, IL-1beta, IL-8, and TNF-alpha. It also galvanized the expression of IL-8 and TLR2 in HaCaT cells but hampered their expression in heat-killed C. acnes. The researchers concluded that bee venom displays considerable anti-inflammatory activity against C. acnes and warrants consideration as an alternative to antibiotic acne treatment.16 It is worth noting that early that year, in a comprehensive database review to evaluate the effects and safety of a wide range of complementary treatments for acne, Cao et al. found, among 35 studies including parallel-group randomized controlled trials, that one trial indicated bee venom was superior to control in lowering the number of acne lesions.17
Conclusion
More research, in the form of randomized, controlled trials, is required before bee venom can be incorporated into the dermatologic armamentarium as a first-line therapy for common and vexing cutaneous conditions. Nevertheless, .
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann has written two textbooks and a New York Times Best Sellers book for consumers. Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Galderma, Revance, Evolus, and Burt’s Bees. She is the CEO of Skin Type Solutions Inc., a company that independently tests skin care products and makes recommendations to physicians on which skin care technologies are best. Write to her at dermnews@mdedge.com.
References
1. Walsh B. The plight of the honeybee: Mass deaths in bee colonies may mean disaster for farmers – and your favorite Foods. Time Magazine, 2013 Aug 19.
2. Klein AM et al. Proc Biol Sci. 2007 Feb 7;274(1608):303-13. doi: 10.1098/rspb.2006.3721.
3. Ediriweera ER and Premarathna NY. AYU. 2012 Apr;33(2):178-82. doi: 10.4103/0974-8520.105233.
4. Baumann, L. Honey/Propolis/Royal Jelly. In Cosmeceuticals and Cosmetic Ingredients. New York:McGraw-Hill; 2014:203-212.
5. Cornara L et al. Front Pharmacol. 2017 Jun 28;8:412. doi: 10.3389/fphar.2017.00412.
6. Kim Y et al. Toxins (Basel). 2019 Apr 26;11(5):239. doi: 10.3390/toxins11050239.
7. Lee YJ et al. Inflammopharmacology. 2020 Feb;28(1):253-63. doi: 10.1007/s10787-019-00646-w.
8. Lee G and Bae H. Molecules. 2016 May 11;21(5):616. doi: 10.3390/molecules21050616.
9. Kim KH et al. Int J Clin Exp Pathol. 2013 Nov 15;6(12):2896-903.
10. You CE et al. Ann Dermatol. 2016 Oct;28(5):593-9. doi: 10.5021/ad.2016.28.5.593.
11. Shin D et al. Toxins (Basel). 2018 Apr 2;10(4):146. doi: 10.3390/toxins10040146.
12. Gu H et al. Mol Med Rep. 2018 Oct;18(4):3711-8. doi: 10.3892/mmr.2018.9398.
13. An HJ et al. Br J Pharmacol. 2018 Dec;175(23):4310-24. doi: 10.1111/bph.14487.
14. Han SM et al. J Integr Med. 2013 Sep;11(5):320-6. doi: 10.3736/jintegrmed2013043.
15. An HJ et al. Int J Mol Med. 2014 Nov;34(5):1341-8. doi: 10.3892/ijmm.2014.1933.
16. Kim JY et al. Int J Mol Med. 2015 Jun;35(6):1651-6. doi: 10.3892/ijmm.2015.2180.
17. Cao H et al. Cochrane Database Syst Rev. 2015 Jan 19;1:CD009436. doi: 10.1002/14651858.CD009436.pub2.
Honeybees, Apis mellifera, play an important role in the web of life. We rely on bees for pollinating approximately one-third of our crops, including multiple fruits, vegetables, nuts, and seeds.1,2 Bees are also instrumental in the propagation of other plants, flower nectar, and flower pollen. A. mellifera, the European honeybee, is the main pollinator in Europe and North America, but other species, including A. cerana, A. dorsata, A. floria, A. andreniformis, A. koschevnikov, and A. laboriosa, yield honey.3 Honey, propolis, and royal jelly, along with beeswax and bee pollen, are among some of the celebrated bee products that have been found to confer health benefits to human beings.4,5 Bee venom, a toxin bees use for protection, is a convoluted combination of peptides and toxic proteins such as phospholipase A2 (PLA2) and melittin that has garnered significant scientific attention of late and is used to treat various inflammatory conditions.6-8 This column will focus on the investigation of the use of bee venom to treat atopic dermatitis (AD) and acne.
Atopic dermatitis
In 2013, Kim et al. assessed the impact of bee venom on AD-related symptoms in mice, finding that it attenuated the effects of AD-simulating compounds in 48 of 80 patients injected subcutaneously. They concluded that bee venom acted by suppressing mast cell degranulation and proinflammatory cytokine expression.9 Three years later, You et al. conducted a double-blind, randomized, base-controlled multicenter study of 136 patients with AD to ascertain the effects of a bee venom emollient. For 4 weeks, patients applied an emollient with bee venom and silk protein or a vehicle lacking bee venom twice daily. Eczema area and severity index (EASI) scores were significantly lower in the bee venom group, as were the visual analogue scale (VAS) scores. The investigators concluded that bee venom is an effective and safe therapeutic choice for treating patients with AD.10 Further, in 2018, Shin et al. demonstrated that PLA2 derived from bee venom mitigates atopic skin inflammation via the CD206 mannose receptor. They had previously shown in a mouse model that PLA2 from bee venom exerts such activity against AD-like lesions induced by 2,4-dinitrochlorobenzene (DNCB) and house dust mite (Dermatophagoides farinae) extract.11 Gu et al. observed later that year that intraperitoneal administration of bee venom eased the symptoms of ovalbumin-induced AD-like skin lesions in an experimental mouse model. Bee venom also lowered serum immunoglobulin E levels and suppressed infiltration of eosinophils and mast cells. They concluded that bee venom is a viable alternative for attenuating the allergic skin inflammation characteristic of AD.12 At the end of 2018, An et al. reported on the use of an in vivo female Balb/c mouse AD model in which 1-chloro-DNCB acted as inducer in cultures of human keratinocytes, stimulated by TNF-alpha/IFN-gamma. The investigators found that bee venom and melittin displayed robust antiatopic effects as evidenced by reduced lesions. The bee products were also found to have hindered elevated expression of various chemokines and proinflammatory cytokines. The authors suggested that bee venom and melittin appear to warrant consideration as a topical treatment for AD.13 In 2019, Kim et al. demonstrated in mice that bee venom eases the symptoms of AD by inactivating the complement system, particularly through CD55 induction, which might account for its effectiveness in AD treatment in humans, they suggested.6 Early in 2020, Lee et al. demonstrated in a Balb/c mouse model that bee venom appears to be a possible therapeutic macromolecule for treating phthalic anhydride-induced AD.7
Acne
In 2013, in vitro experiments by Han et al. showed that purified bee venom exhibited antimicrobial activity, in a concentration-dependent manner, against Cutibacterium acnes (or Propionibacterium acnes). They followed up with a small randomized, double-blind, controlled trial with 12 subjects who were treated with cosmetics with pure bee venom or cosmetics without it for two weeks. The group receiving bee venom experienced significantly fewer inflammatory and noninflammatory lesions, and a significant decline in adenosine triphosphate levels (a 57.5% reduction) was noted in subjects in the bee venom group, with a nonsignificant decrease of 4.7% observed in the control group. The investigators concluded the purified bee venom may be suitable as an antiacne agent.14 Using a mouse model, An et al. studied the therapeutic effects of bee venom against C. acnes–induced skin inflammation. They found that bee venom significantly diminished the volume of infiltrated inflammatory cells in the treated mice, compared with untreated mice. Bee venom also decreased expression levels of tumor necrosis factor (TNF)-α, and interleukin (IL)-1beta and suppressed Toll-like receptor (TLR)2 and CD14 expression in C. acnes–injected tissue. The investigators concluded that bee venom imparts notable anti-inflammatory activity and has potential for use in treating acne and as an anti-inflammatory agent in skin care.15
In 2015, Kim et al. studied the influence of bee venom against C. acnes–induced inflammation in human keratinocytes (HaCaT) and monocytes (THP-1). They found that bee venom successfully suppressed the secretion of interferon-gamma, IL-1beta, IL-8, and TNF-alpha. It also galvanized the expression of IL-8 and TLR2 in HaCaT cells but hampered their expression in heat-killed C. acnes. The researchers concluded that bee venom displays considerable anti-inflammatory activity against C. acnes and warrants consideration as an alternative to antibiotic acne treatment.16 It is worth noting that early that year, in a comprehensive database review to evaluate the effects and safety of a wide range of complementary treatments for acne, Cao et al. found, among 35 studies including parallel-group randomized controlled trials, that one trial indicated bee venom was superior to control in lowering the number of acne lesions.17
Conclusion
More research, in the form of randomized, controlled trials, is required before bee venom can be incorporated into the dermatologic armamentarium as a first-line therapy for common and vexing cutaneous conditions. Nevertheless, .
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann has written two textbooks and a New York Times Best Sellers book for consumers. Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Galderma, Revance, Evolus, and Burt’s Bees. She is the CEO of Skin Type Solutions Inc., a company that independently tests skin care products and makes recommendations to physicians on which skin care technologies are best. Write to her at dermnews@mdedge.com.
References
1. Walsh B. The plight of the honeybee: Mass deaths in bee colonies may mean disaster for farmers – and your favorite Foods. Time Magazine, 2013 Aug 19.
2. Klein AM et al. Proc Biol Sci. 2007 Feb 7;274(1608):303-13. doi: 10.1098/rspb.2006.3721.
3. Ediriweera ER and Premarathna NY. AYU. 2012 Apr;33(2):178-82. doi: 10.4103/0974-8520.105233.
4. Baumann, L. Honey/Propolis/Royal Jelly. In Cosmeceuticals and Cosmetic Ingredients. New York:McGraw-Hill; 2014:203-212.
5. Cornara L et al. Front Pharmacol. 2017 Jun 28;8:412. doi: 10.3389/fphar.2017.00412.
6. Kim Y et al. Toxins (Basel). 2019 Apr 26;11(5):239. doi: 10.3390/toxins11050239.
7. Lee YJ et al. Inflammopharmacology. 2020 Feb;28(1):253-63. doi: 10.1007/s10787-019-00646-w.
8. Lee G and Bae H. Molecules. 2016 May 11;21(5):616. doi: 10.3390/molecules21050616.
9. Kim KH et al. Int J Clin Exp Pathol. 2013 Nov 15;6(12):2896-903.
10. You CE et al. Ann Dermatol. 2016 Oct;28(5):593-9. doi: 10.5021/ad.2016.28.5.593.
11. Shin D et al. Toxins (Basel). 2018 Apr 2;10(4):146. doi: 10.3390/toxins10040146.
12. Gu H et al. Mol Med Rep. 2018 Oct;18(4):3711-8. doi: 10.3892/mmr.2018.9398.
13. An HJ et al. Br J Pharmacol. 2018 Dec;175(23):4310-24. doi: 10.1111/bph.14487.
14. Han SM et al. J Integr Med. 2013 Sep;11(5):320-6. doi: 10.3736/jintegrmed2013043.
15. An HJ et al. Int J Mol Med. 2014 Nov;34(5):1341-8. doi: 10.3892/ijmm.2014.1933.
16. Kim JY et al. Int J Mol Med. 2015 Jun;35(6):1651-6. doi: 10.3892/ijmm.2015.2180.
17. Cao H et al. Cochrane Database Syst Rev. 2015 Jan 19;1:CD009436. doi: 10.1002/14651858.CD009436.pub2.
Honeybees, Apis mellifera, play an important role in the web of life. We rely on bees for pollinating approximately one-third of our crops, including multiple fruits, vegetables, nuts, and seeds.1,2 Bees are also instrumental in the propagation of other plants, flower nectar, and flower pollen. A. mellifera, the European honeybee, is the main pollinator in Europe and North America, but other species, including A. cerana, A. dorsata, A. floria, A. andreniformis, A. koschevnikov, and A. laboriosa, yield honey.3 Honey, propolis, and royal jelly, along with beeswax and bee pollen, are among some of the celebrated bee products that have been found to confer health benefits to human beings.4,5 Bee venom, a toxin bees use for protection, is a convoluted combination of peptides and toxic proteins such as phospholipase A2 (PLA2) and melittin that has garnered significant scientific attention of late and is used to treat various inflammatory conditions.6-8 This column will focus on the investigation of the use of bee venom to treat atopic dermatitis (AD) and acne.
Atopic dermatitis
In 2013, Kim et al. assessed the impact of bee venom on AD-related symptoms in mice, finding that it attenuated the effects of AD-simulating compounds in 48 of 80 patients injected subcutaneously. They concluded that bee venom acted by suppressing mast cell degranulation and proinflammatory cytokine expression.9 Three years later, You et al. conducted a double-blind, randomized, base-controlled multicenter study of 136 patients with AD to ascertain the effects of a bee venom emollient. For 4 weeks, patients applied an emollient with bee venom and silk protein or a vehicle lacking bee venom twice daily. Eczema area and severity index (EASI) scores were significantly lower in the bee venom group, as were the visual analogue scale (VAS) scores. The investigators concluded that bee venom is an effective and safe therapeutic choice for treating patients with AD.10 Further, in 2018, Shin et al. demonstrated that PLA2 derived from bee venom mitigates atopic skin inflammation via the CD206 mannose receptor. They had previously shown in a mouse model that PLA2 from bee venom exerts such activity against AD-like lesions induced by 2,4-dinitrochlorobenzene (DNCB) and house dust mite (Dermatophagoides farinae) extract.11 Gu et al. observed later that year that intraperitoneal administration of bee venom eased the symptoms of ovalbumin-induced AD-like skin lesions in an experimental mouse model. Bee venom also lowered serum immunoglobulin E levels and suppressed infiltration of eosinophils and mast cells. They concluded that bee venom is a viable alternative for attenuating the allergic skin inflammation characteristic of AD.12 At the end of 2018, An et al. reported on the use of an in vivo female Balb/c mouse AD model in which 1-chloro-DNCB acted as inducer in cultures of human keratinocytes, stimulated by TNF-alpha/IFN-gamma. The investigators found that bee venom and melittin displayed robust antiatopic effects as evidenced by reduced lesions. The bee products were also found to have hindered elevated expression of various chemokines and proinflammatory cytokines. The authors suggested that bee venom and melittin appear to warrant consideration as a topical treatment for AD.13 In 2019, Kim et al. demonstrated in mice that bee venom eases the symptoms of AD by inactivating the complement system, particularly through CD55 induction, which might account for its effectiveness in AD treatment in humans, they suggested.6 Early in 2020, Lee et al. demonstrated in a Balb/c mouse model that bee venom appears to be a possible therapeutic macromolecule for treating phthalic anhydride-induced AD.7
Acne
In 2013, in vitro experiments by Han et al. showed that purified bee venom exhibited antimicrobial activity, in a concentration-dependent manner, against Cutibacterium acnes (or Propionibacterium acnes). They followed up with a small randomized, double-blind, controlled trial with 12 subjects who were treated with cosmetics with pure bee venom or cosmetics without it for two weeks. The group receiving bee venom experienced significantly fewer inflammatory and noninflammatory lesions, and a significant decline in adenosine triphosphate levels (a 57.5% reduction) was noted in subjects in the bee venom group, with a nonsignificant decrease of 4.7% observed in the control group. The investigators concluded the purified bee venom may be suitable as an antiacne agent.14 Using a mouse model, An et al. studied the therapeutic effects of bee venom against C. acnes–induced skin inflammation. They found that bee venom significantly diminished the volume of infiltrated inflammatory cells in the treated mice, compared with untreated mice. Bee venom also decreased expression levels of tumor necrosis factor (TNF)-α, and interleukin (IL)-1beta and suppressed Toll-like receptor (TLR)2 and CD14 expression in C. acnes–injected tissue. The investigators concluded that bee venom imparts notable anti-inflammatory activity and has potential for use in treating acne and as an anti-inflammatory agent in skin care.15
In 2015, Kim et al. studied the influence of bee venom against C. acnes–induced inflammation in human keratinocytes (HaCaT) and monocytes (THP-1). They found that bee venom successfully suppressed the secretion of interferon-gamma, IL-1beta, IL-8, and TNF-alpha. It also galvanized the expression of IL-8 and TLR2 in HaCaT cells but hampered their expression in heat-killed C. acnes. The researchers concluded that bee venom displays considerable anti-inflammatory activity against C. acnes and warrants consideration as an alternative to antibiotic acne treatment.16 It is worth noting that early that year, in a comprehensive database review to evaluate the effects and safety of a wide range of complementary treatments for acne, Cao et al. found, among 35 studies including parallel-group randomized controlled trials, that one trial indicated bee venom was superior to control in lowering the number of acne lesions.17
Conclusion
More research, in the form of randomized, controlled trials, is required before bee venom can be incorporated into the dermatologic armamentarium as a first-line therapy for common and vexing cutaneous conditions. Nevertheless, .
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann has written two textbooks and a New York Times Best Sellers book for consumers. Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Galderma, Revance, Evolus, and Burt’s Bees. She is the CEO of Skin Type Solutions Inc., a company that independently tests skin care products and makes recommendations to physicians on which skin care technologies are best. Write to her at dermnews@mdedge.com.
References
1. Walsh B. The plight of the honeybee: Mass deaths in bee colonies may mean disaster for farmers – and your favorite Foods. Time Magazine, 2013 Aug 19.
2. Klein AM et al. Proc Biol Sci. 2007 Feb 7;274(1608):303-13. doi: 10.1098/rspb.2006.3721.
3. Ediriweera ER and Premarathna NY. AYU. 2012 Apr;33(2):178-82. doi: 10.4103/0974-8520.105233.
4. Baumann, L. Honey/Propolis/Royal Jelly. In Cosmeceuticals and Cosmetic Ingredients. New York:McGraw-Hill; 2014:203-212.
5. Cornara L et al. Front Pharmacol. 2017 Jun 28;8:412. doi: 10.3389/fphar.2017.00412.
6. Kim Y et al. Toxins (Basel). 2019 Apr 26;11(5):239. doi: 10.3390/toxins11050239.
7. Lee YJ et al. Inflammopharmacology. 2020 Feb;28(1):253-63. doi: 10.1007/s10787-019-00646-w.
8. Lee G and Bae H. Molecules. 2016 May 11;21(5):616. doi: 10.3390/molecules21050616.
9. Kim KH et al. Int J Clin Exp Pathol. 2013 Nov 15;6(12):2896-903.
10. You CE et al. Ann Dermatol. 2016 Oct;28(5):593-9. doi: 10.5021/ad.2016.28.5.593.
11. Shin D et al. Toxins (Basel). 2018 Apr 2;10(4):146. doi: 10.3390/toxins10040146.
12. Gu H et al. Mol Med Rep. 2018 Oct;18(4):3711-8. doi: 10.3892/mmr.2018.9398.
13. An HJ et al. Br J Pharmacol. 2018 Dec;175(23):4310-24. doi: 10.1111/bph.14487.
14. Han SM et al. J Integr Med. 2013 Sep;11(5):320-6. doi: 10.3736/jintegrmed2013043.
15. An HJ et al. Int J Mol Med. 2014 Nov;34(5):1341-8. doi: 10.3892/ijmm.2014.1933.
16. Kim JY et al. Int J Mol Med. 2015 Jun;35(6):1651-6. doi: 10.3892/ijmm.2015.2180.
17. Cao H et al. Cochrane Database Syst Rev. 2015 Jan 19;1:CD009436. doi: 10.1002/14651858.CD009436.pub2.
The Veterans Health Administration Approach to COVID-19 Vaccine Allocation—Balancing Utility and Equity
The Veterans Health Administration (VHA) COVID-19 vaccine allocation plan showcases several lessons for government and health care leaders in planning for future pandemics.1 Many state governments—underresourced and overwhelmed with other COVID-19 demands—have struggled to get COVID-19 vaccines into the arms of their residents.2 In contrast, the VHA was able to mobilize early to identify vaccine allocation guidelines and proactively prepare facilities to vaccinate VHA staff and veterans as soon as vaccines were approved under Emergency Use Authorization by the US Food and Drug Administration.3,4
In August 2020, VHA formed a COVID-19 Vaccine Integrated Project Team, composed of 6 subgroups: communications, distribution, education, measurement, policy, prioritization, and vaccine safety. The National Center for Ethics in Health Care weighed in on the ethical justification for the developed vaccination risk stratification framework, which was informed by, but not identical to, that recommended by the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices.5
Prioritizing who gets early access to a potentially life-saving vaccine weighs heavily on those leaders charged with making such decisions. The ethics of scarce resource allocation and triage protocols that may be necessary in a pandemic are often in tension with the patient-centered clinical ethics that health care practitioners (HCPs) encounter. HCPs require assistance in appreciating the ethical rationale for this shift in focus from the preference of the individual to the common good. The same is true for the risk stratification criteria required when there is not sufficient vaccine for all those who could benefit from immunization. Decisions must be transparent to ensure widespread acceptance and trust in the vaccination process. The ethical reasoning and values that are the basis for allocation criteria must be clearly, compassionately, and consistently communicated to the public, as outlined below. Ethical questions or concerns involve a conflict between core values: one of the central tasks of ethical analysis is to identify the available ethical options to resolve value conflicts. Several ethical frameworks for vaccine allocation are available—each balances and weighs the primary values of equity, dignity, beneficence, and utility slightly differently.6
For example, utilitarian ethics looks to produce the most good and avoid the most harm for the greatest number of people. Within this framework, there can be different notions of “good,” for example, saving the most lives, the most life years, the most quality life years, or the lives of those who have more life “innings” ahead. The approach of the US Department of Veterans Affairs (VA) focuses on saving the most lives in combination with avoiding suffering from serious illness, minimizing contagion, and preserving the essential workforce. Frameworks that give primacy to 1 notion of the good (ie, saving the most lives) may deprioritize other beneficial outcomes, such as allowing earlier return to work, school, and leisure activities that many find integral to human flourishing. Other ethical theories and principles may be used to support various allocation frameworks. For example, a pragmatic ethics approach might emphasize the importance of adapting the approach based on the evolving science and innovation surrounding COVID-19. Having more than 1 ethically defensible approach is common; the goal in ethics work is to be open to diversity of thought and reflect on the strength of one’s reasoning in resolving a core values conflict. We identify 2 central tenets of pandemic ethics that inform vaccine allocation.
1. Pandemic Ethics Requires Proactive Planning and Reevaluation of Continually Evolving Facts
There is an oft quoted saying among bioethicists: “Good ethics begins with good facts.” One obvious challenge during the COVID-19 pandemic has been the difficulty accessing up-to-date facts to inform decision making. If a main goal of a vaccination plan is to minimize the incidence of serious or fatal COVID-19 disease and contagion, myriad data points are needed to identify the best way to do this. For example, if 2 doses of the same vaccine are needed, this impacts the logistics of identifying, inviting, and scheduling eligible individuals and staffing vaccine clinics as well as ensuring that sufficient personal protective equipment and rescue equipment/medication are available to treat allergic reactions. If the adverse effects of vaccines lead to staff absenteeism or vaccine hesitancy, this needs to be factored into logistics.7 Tailored messaging is important to reduce appointment no-shows and vaccine nonadopters.8 Transportation to vaccination sites is a relevant factor: how a vaccine is stored, thawed, and reconstituted and its shelf life impacts whether it can be transported after thawing and what must be provided on site.
Consideration of the multifaceted factors influencing a successful vaccination campaign requires proactive planning and the readiness to pivot when new information is revealed. For example, vaccine appointment no-shows should be anticipated along with a fair process for allocating unused vaccine that would otherwise be wasted. This is an example of responsible stewardship of a scarce and life-saving resource. A higher than anticipated no-show rate would require revisiting a facility’s approach to ensuring that waste is avoided while the process is perceived to be fair and transparent. Ethical theories and principles cannot do all the work here; mindful attention to detail and proactive, informed planning are critical. Fortunately, the VA is well resourced in this domain, whereas many state health departments floundered in their response, causing unnecessary vaccination delays.9
2. Utility: Necessary But Insufficient
Most ethical approaches recognize to some extent that seeking good and minimizing harm is of value. However, a strictly utilitarian approach is insufficient to address the core values in conflict surrounding how best to allocate limited doses of COVID-19 vaccine. For example, some may argue that prioritizing the elderly or those in long-term care facilities like VA’s community living centers because they have the highest COVID-19 mortality rate produces less net benefit than prioritizing younger veterans with comorbidities or certain higher risk essential workers. There are 2 important points to make here.
First, the VHA vaccination plan balances utility with other ethical principles, namely, treating people with equal concern, and addressing health inequities, including a focus on justice and valuing the worth and dignity of each person. Rather than giving everyone an equal chance via lottery, the prioritization plan recognizes that some people have greater need or would stand to better mitigate viral contagion and preserve the essential workforce if they were vaccinated earlier. However, the principle of justice requires that efforts are made to treat like cases the same to avoid perceptions of bias, and to demonstrate respect for the dignity of each individual by way of promoting a fair vaccination process.
This requires transparency, consistency, and delivery of respectful and accurate communication. For example, the VA recognizes that lifetime exposure to social injustice produces health inequities that make Black, Hispanic, and Native American persons more susceptible to contracting COVID-19 and suffering serious or fatal illness. The approach to addressing this inequity is by giving priority to those with higher risk factors. Again, this is an example of blending and balancing ethical principles of utility and justice—that is, recognizing and remedying social injustice is of value both because it will help achieve better outcomes for persons of color and because it is inherently worthwhile to oppose injustice.
However, contrary to some news reports, the VHA approach does not allocate by race/ethnicity alone, as it does by age.10,11 Doing so would present logistical challenges—for example, race/ethnicity is not an objective classification as is age, and reconciling individuals’ self-reports could create confusion or chaos that is antithetical to a fair, streamlined vaccination program. Putting veterans of color at the front of the vaccination line could backfire by amplifying worries that they are being exposed to vaccine that is not fully tested (a common contributor to vaccine hesitancy, particularly among communities of color familiar with prior exploitation and abuse in the name of science).
Discriminating based on race/ethnicity alone in the spirit of achieving equity would be precedent setting for the VA and would require a strong ethical justification. The decision to prioritize for vaccine based on risk factors strives to achieve this balance of equity and utility, as it encompasses VA staff and veterans of color by way of their status as essential workers or those with comorbidities. However, it is important to address race-based access barriers and vaccine hesitancy to satisfy the equity demands. This effort is underway (eg, engaging community champions and developing tailored educational resources to reach diverse communities).
In addition, pragmatic ethics recognizes that an overly granular, complicated allocation plan would be inefficient to implement. While it might be true that some veterans who are aged < 65 years may be at higher risk from COVID-19 than some elderly veterans, achieving the goals of fairness and transparency requires establishing a vaccine prioritization plan that is both ethically defensible and feasibly implementable (ie, achieves its goal of getting “needles into arms”). For example, veterans aged ≥ 65 years may be invited to schedule their vaccination before younger veterans, but any veteran may be accepted “on-call” for vaccine appointment no-shows via first-come, first-served or by lottery. Flexibility of response is crucial. This played out in adding flexibility around the decision to vaccinate veterans aged ≥ 75 years before those aged 65 to 74 years, after revisiting how this prioritization might affect feasibility and throughput and opting to allow the opportunity to include those aged ≥ 65 years.
There will no doubt be additional modifications to the vaccine allocation plan as more data become available. Since the danger of fueling suspicion and distrust is high (ie, that certain privileged people are jumping the line, as we heard reports of in some non-VA facilities).12 There is an obvious ethical duty to explain why the chosen approach is ethically defensible. VA facility leaders should be able to answer how their approach achieves the goals of avoiding serious or fatal illness, reducing contagion, and preserving the essential workforce while ensuring a fair, respectful, evidence-based, and transparent process.
1. US Department of Veterans Affairs. COVID-19 vaccination plan for the Veterans Health Administration. Version 2.0, Published December 14, 2020. Accessed February 3, 2021. https://www.publichealth.va.gov/docs/n-coronavirus/VHA-COVID-Vaccine-Plan-14Dec2020.pdf
2. Hennigann WJ, Park A, Ducharme J. The U.S. fumbled its early vaccine rollout. Will the Biden Administration put America back on track? TIME. January 21, 2021. Accessed February 3, 2021. https://time.com/5932028/vaccine-rollout-joe-biden/
3. US Food and Drug Administration. FDA take key action in fight against COVID-19 by issuing emergency use authorization for first COVID-19 vaccine [press release]. Published December 11, 2020. Accessed February 3, 2021. https://www.fda.gov/news-events/press-announcements/fda-takes-key-action-fight-against-covid-19-issuing-emergency-use-authorization-first-covid-19
4. US Food and Drug Administration. FDA takes additional action in fight against COVID-19 by Issuing emergency use authorization for second COVID-19 vaccine [press release]. Published December 18, 2020. Accessed February 3, 2021. https://www.fda.gov/news-events/press-announcements/fda-takes-additional-action-fight-against-covid-19-issuing-emergency-use-authorization-second-covid
5. McClung N, Chamberland M, Kinlaw K, et al. The Advisory Committee on Immunization Practices’ Ethical Principles for Allocating Initial Supplies of COVID-19 Vaccine-United States, 2020. Am J Transplant. 2021;21(1):420-425. doi:10.1111/ajt.16437
6. National Academies of Sciences, Engineering, and Medicine. 2020. Framework for equitable allocation of COVID-19 vaccine. The National Academies Press; 2020. doi:10.17226/25917
7 . Wood S, Schulman K. Beyond Politics - Promoting Covid-19 vaccination in the United States [published online ahead of print, 2021 Jan 6]. N Engl J Med. 2021;10.1056/NEJMms2033790. doi:10.1056/NEJMms2033790
8 . Matrajt L, Eaton J, Leung T, Brown ER. Vaccine optimization for COVID-19, who to vaccinate first? medRxiv . 2020 Aug 16. doi:10.1101/2020.08.14.20175257
9 . Makary M. Hospitals: stop playing vaccine games and show leadership. Published January 12, 2021. Accessed February 3, 2021. https://www.medpagetoday.com/blogs/marty-makary/90649
10 . Wentling N. Minority veterans to receive priority for coronavirus vaccines. Stars and Stripes. December 10, 2020. Accessed February 3, 2021. https://www.stripes.com/news/us/minority-veterans-to-receive-priority-for-coronavirus-vaccines-1.654624
11 . Kime, P. Minority veterans on VA’s priority list for COVID-19 vaccine distribution. Published December 8, 2020. Accessed February 3, 2021. https://www.military.com/daily-news/2020/12/08/minority-veterans-vas-priority-list-covid-19-vaccine-distribution.html
12 . Rosenthal, E. Yes, it matters that people are jumping the vaccine line. The New York Times . Published January 28, 2021. Accessed February 3, 2021. https://www.nytimes.com/2021/01/28/opinion/covid-vaccine-line.html
The Veterans Health Administration (VHA) COVID-19 vaccine allocation plan showcases several lessons for government and health care leaders in planning for future pandemics.1 Many state governments—underresourced and overwhelmed with other COVID-19 demands—have struggled to get COVID-19 vaccines into the arms of their residents.2 In contrast, the VHA was able to mobilize early to identify vaccine allocation guidelines and proactively prepare facilities to vaccinate VHA staff and veterans as soon as vaccines were approved under Emergency Use Authorization by the US Food and Drug Administration.3,4
In August 2020, VHA formed a COVID-19 Vaccine Integrated Project Team, composed of 6 subgroups: communications, distribution, education, measurement, policy, prioritization, and vaccine safety. The National Center for Ethics in Health Care weighed in on the ethical justification for the developed vaccination risk stratification framework, which was informed by, but not identical to, that recommended by the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices.5
Prioritizing who gets early access to a potentially life-saving vaccine weighs heavily on those leaders charged with making such decisions. The ethics of scarce resource allocation and triage protocols that may be necessary in a pandemic are often in tension with the patient-centered clinical ethics that health care practitioners (HCPs) encounter. HCPs require assistance in appreciating the ethical rationale for this shift in focus from the preference of the individual to the common good. The same is true for the risk stratification criteria required when there is not sufficient vaccine for all those who could benefit from immunization. Decisions must be transparent to ensure widespread acceptance and trust in the vaccination process. The ethical reasoning and values that are the basis for allocation criteria must be clearly, compassionately, and consistently communicated to the public, as outlined below. Ethical questions or concerns involve a conflict between core values: one of the central tasks of ethical analysis is to identify the available ethical options to resolve value conflicts. Several ethical frameworks for vaccine allocation are available—each balances and weighs the primary values of equity, dignity, beneficence, and utility slightly differently.6
For example, utilitarian ethics looks to produce the most good and avoid the most harm for the greatest number of people. Within this framework, there can be different notions of “good,” for example, saving the most lives, the most life years, the most quality life years, or the lives of those who have more life “innings” ahead. The approach of the US Department of Veterans Affairs (VA) focuses on saving the most lives in combination with avoiding suffering from serious illness, minimizing contagion, and preserving the essential workforce. Frameworks that give primacy to 1 notion of the good (ie, saving the most lives) may deprioritize other beneficial outcomes, such as allowing earlier return to work, school, and leisure activities that many find integral to human flourishing. Other ethical theories and principles may be used to support various allocation frameworks. For example, a pragmatic ethics approach might emphasize the importance of adapting the approach based on the evolving science and innovation surrounding COVID-19. Having more than 1 ethically defensible approach is common; the goal in ethics work is to be open to diversity of thought and reflect on the strength of one’s reasoning in resolving a core values conflict. We identify 2 central tenets of pandemic ethics that inform vaccine allocation.
1. Pandemic Ethics Requires Proactive Planning and Reevaluation of Continually Evolving Facts
There is an oft quoted saying among bioethicists: “Good ethics begins with good facts.” One obvious challenge during the COVID-19 pandemic has been the difficulty accessing up-to-date facts to inform decision making. If a main goal of a vaccination plan is to minimize the incidence of serious or fatal COVID-19 disease and contagion, myriad data points are needed to identify the best way to do this. For example, if 2 doses of the same vaccine are needed, this impacts the logistics of identifying, inviting, and scheduling eligible individuals and staffing vaccine clinics as well as ensuring that sufficient personal protective equipment and rescue equipment/medication are available to treat allergic reactions. If the adverse effects of vaccines lead to staff absenteeism or vaccine hesitancy, this needs to be factored into logistics.7 Tailored messaging is important to reduce appointment no-shows and vaccine nonadopters.8 Transportation to vaccination sites is a relevant factor: how a vaccine is stored, thawed, and reconstituted and its shelf life impacts whether it can be transported after thawing and what must be provided on site.
Consideration of the multifaceted factors influencing a successful vaccination campaign requires proactive planning and the readiness to pivot when new information is revealed. For example, vaccine appointment no-shows should be anticipated along with a fair process for allocating unused vaccine that would otherwise be wasted. This is an example of responsible stewardship of a scarce and life-saving resource. A higher than anticipated no-show rate would require revisiting a facility’s approach to ensuring that waste is avoided while the process is perceived to be fair and transparent. Ethical theories and principles cannot do all the work here; mindful attention to detail and proactive, informed planning are critical. Fortunately, the VA is well resourced in this domain, whereas many state health departments floundered in their response, causing unnecessary vaccination delays.9
2. Utility: Necessary But Insufficient
Most ethical approaches recognize to some extent that seeking good and minimizing harm is of value. However, a strictly utilitarian approach is insufficient to address the core values in conflict surrounding how best to allocate limited doses of COVID-19 vaccine. For example, some may argue that prioritizing the elderly or those in long-term care facilities like VA’s community living centers because they have the highest COVID-19 mortality rate produces less net benefit than prioritizing younger veterans with comorbidities or certain higher risk essential workers. There are 2 important points to make here.
First, the VHA vaccination plan balances utility with other ethical principles, namely, treating people with equal concern, and addressing health inequities, including a focus on justice and valuing the worth and dignity of each person. Rather than giving everyone an equal chance via lottery, the prioritization plan recognizes that some people have greater need or would stand to better mitigate viral contagion and preserve the essential workforce if they were vaccinated earlier. However, the principle of justice requires that efforts are made to treat like cases the same to avoid perceptions of bias, and to demonstrate respect for the dignity of each individual by way of promoting a fair vaccination process.
This requires transparency, consistency, and delivery of respectful and accurate communication. For example, the VA recognizes that lifetime exposure to social injustice produces health inequities that make Black, Hispanic, and Native American persons more susceptible to contracting COVID-19 and suffering serious or fatal illness. The approach to addressing this inequity is by giving priority to those with higher risk factors. Again, this is an example of blending and balancing ethical principles of utility and justice—that is, recognizing and remedying social injustice is of value both because it will help achieve better outcomes for persons of color and because it is inherently worthwhile to oppose injustice.
However, contrary to some news reports, the VHA approach does not allocate by race/ethnicity alone, as it does by age.10,11 Doing so would present logistical challenges—for example, race/ethnicity is not an objective classification as is age, and reconciling individuals’ self-reports could create confusion or chaos that is antithetical to a fair, streamlined vaccination program. Putting veterans of color at the front of the vaccination line could backfire by amplifying worries that they are being exposed to vaccine that is not fully tested (a common contributor to vaccine hesitancy, particularly among communities of color familiar with prior exploitation and abuse in the name of science).
Discriminating based on race/ethnicity alone in the spirit of achieving equity would be precedent setting for the VA and would require a strong ethical justification. The decision to prioritize for vaccine based on risk factors strives to achieve this balance of equity and utility, as it encompasses VA staff and veterans of color by way of their status as essential workers or those with comorbidities. However, it is important to address race-based access barriers and vaccine hesitancy to satisfy the equity demands. This effort is underway (eg, engaging community champions and developing tailored educational resources to reach diverse communities).
In addition, pragmatic ethics recognizes that an overly granular, complicated allocation plan would be inefficient to implement. While it might be true that some veterans who are aged < 65 years may be at higher risk from COVID-19 than some elderly veterans, achieving the goals of fairness and transparency requires establishing a vaccine prioritization plan that is both ethically defensible and feasibly implementable (ie, achieves its goal of getting “needles into arms”). For example, veterans aged ≥ 65 years may be invited to schedule their vaccination before younger veterans, but any veteran may be accepted “on-call” for vaccine appointment no-shows via first-come, first-served or by lottery. Flexibility of response is crucial. This played out in adding flexibility around the decision to vaccinate veterans aged ≥ 75 years before those aged 65 to 74 years, after revisiting how this prioritization might affect feasibility and throughput and opting to allow the opportunity to include those aged ≥ 65 years.
There will no doubt be additional modifications to the vaccine allocation plan as more data become available. Since the danger of fueling suspicion and distrust is high (ie, that certain privileged people are jumping the line, as we heard reports of in some non-VA facilities).12 There is an obvious ethical duty to explain why the chosen approach is ethically defensible. VA facility leaders should be able to answer how their approach achieves the goals of avoiding serious or fatal illness, reducing contagion, and preserving the essential workforce while ensuring a fair, respectful, evidence-based, and transparent process.
The Veterans Health Administration (VHA) COVID-19 vaccine allocation plan showcases several lessons for government and health care leaders in planning for future pandemics.1 Many state governments—underresourced and overwhelmed with other COVID-19 demands—have struggled to get COVID-19 vaccines into the arms of their residents.2 In contrast, the VHA was able to mobilize early to identify vaccine allocation guidelines and proactively prepare facilities to vaccinate VHA staff and veterans as soon as vaccines were approved under Emergency Use Authorization by the US Food and Drug Administration.3,4
In August 2020, VHA formed a COVID-19 Vaccine Integrated Project Team, composed of 6 subgroups: communications, distribution, education, measurement, policy, prioritization, and vaccine safety. The National Center for Ethics in Health Care weighed in on the ethical justification for the developed vaccination risk stratification framework, which was informed by, but not identical to, that recommended by the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices.5
Prioritizing who gets early access to a potentially life-saving vaccine weighs heavily on those leaders charged with making such decisions. The ethics of scarce resource allocation and triage protocols that may be necessary in a pandemic are often in tension with the patient-centered clinical ethics that health care practitioners (HCPs) encounter. HCPs require assistance in appreciating the ethical rationale for this shift in focus from the preference of the individual to the common good. The same is true for the risk stratification criteria required when there is not sufficient vaccine for all those who could benefit from immunization. Decisions must be transparent to ensure widespread acceptance and trust in the vaccination process. The ethical reasoning and values that are the basis for allocation criteria must be clearly, compassionately, and consistently communicated to the public, as outlined below. Ethical questions or concerns involve a conflict between core values: one of the central tasks of ethical analysis is to identify the available ethical options to resolve value conflicts. Several ethical frameworks for vaccine allocation are available—each balances and weighs the primary values of equity, dignity, beneficence, and utility slightly differently.6
For example, utilitarian ethics looks to produce the most good and avoid the most harm for the greatest number of people. Within this framework, there can be different notions of “good,” for example, saving the most lives, the most life years, the most quality life years, or the lives of those who have more life “innings” ahead. The approach of the US Department of Veterans Affairs (VA) focuses on saving the most lives in combination with avoiding suffering from serious illness, minimizing contagion, and preserving the essential workforce. Frameworks that give primacy to 1 notion of the good (ie, saving the most lives) may deprioritize other beneficial outcomes, such as allowing earlier return to work, school, and leisure activities that many find integral to human flourishing. Other ethical theories and principles may be used to support various allocation frameworks. For example, a pragmatic ethics approach might emphasize the importance of adapting the approach based on the evolving science and innovation surrounding COVID-19. Having more than 1 ethically defensible approach is common; the goal in ethics work is to be open to diversity of thought and reflect on the strength of one’s reasoning in resolving a core values conflict. We identify 2 central tenets of pandemic ethics that inform vaccine allocation.
1. Pandemic Ethics Requires Proactive Planning and Reevaluation of Continually Evolving Facts
There is an oft quoted saying among bioethicists: “Good ethics begins with good facts.” One obvious challenge during the COVID-19 pandemic has been the difficulty accessing up-to-date facts to inform decision making. If a main goal of a vaccination plan is to minimize the incidence of serious or fatal COVID-19 disease and contagion, myriad data points are needed to identify the best way to do this. For example, if 2 doses of the same vaccine are needed, this impacts the logistics of identifying, inviting, and scheduling eligible individuals and staffing vaccine clinics as well as ensuring that sufficient personal protective equipment and rescue equipment/medication are available to treat allergic reactions. If the adverse effects of vaccines lead to staff absenteeism or vaccine hesitancy, this needs to be factored into logistics.7 Tailored messaging is important to reduce appointment no-shows and vaccine nonadopters.8 Transportation to vaccination sites is a relevant factor: how a vaccine is stored, thawed, and reconstituted and its shelf life impacts whether it can be transported after thawing and what must be provided on site.
Consideration of the multifaceted factors influencing a successful vaccination campaign requires proactive planning and the readiness to pivot when new information is revealed. For example, vaccine appointment no-shows should be anticipated along with a fair process for allocating unused vaccine that would otherwise be wasted. This is an example of responsible stewardship of a scarce and life-saving resource. A higher than anticipated no-show rate would require revisiting a facility’s approach to ensuring that waste is avoided while the process is perceived to be fair and transparent. Ethical theories and principles cannot do all the work here; mindful attention to detail and proactive, informed planning are critical. Fortunately, the VA is well resourced in this domain, whereas many state health departments floundered in their response, causing unnecessary vaccination delays.9
2. Utility: Necessary But Insufficient
Most ethical approaches recognize to some extent that seeking good and minimizing harm is of value. However, a strictly utilitarian approach is insufficient to address the core values in conflict surrounding how best to allocate limited doses of COVID-19 vaccine. For example, some may argue that prioritizing the elderly or those in long-term care facilities like VA’s community living centers because they have the highest COVID-19 mortality rate produces less net benefit than prioritizing younger veterans with comorbidities or certain higher risk essential workers. There are 2 important points to make here.
First, the VHA vaccination plan balances utility with other ethical principles, namely, treating people with equal concern, and addressing health inequities, including a focus on justice and valuing the worth and dignity of each person. Rather than giving everyone an equal chance via lottery, the prioritization plan recognizes that some people have greater need or would stand to better mitigate viral contagion and preserve the essential workforce if they were vaccinated earlier. However, the principle of justice requires that efforts are made to treat like cases the same to avoid perceptions of bias, and to demonstrate respect for the dignity of each individual by way of promoting a fair vaccination process.
This requires transparency, consistency, and delivery of respectful and accurate communication. For example, the VA recognizes that lifetime exposure to social injustice produces health inequities that make Black, Hispanic, and Native American persons more susceptible to contracting COVID-19 and suffering serious or fatal illness. The approach to addressing this inequity is by giving priority to those with higher risk factors. Again, this is an example of blending and balancing ethical principles of utility and justice—that is, recognizing and remedying social injustice is of value both because it will help achieve better outcomes for persons of color and because it is inherently worthwhile to oppose injustice.
However, contrary to some news reports, the VHA approach does not allocate by race/ethnicity alone, as it does by age.10,11 Doing so would present logistical challenges—for example, race/ethnicity is not an objective classification as is age, and reconciling individuals’ self-reports could create confusion or chaos that is antithetical to a fair, streamlined vaccination program. Putting veterans of color at the front of the vaccination line could backfire by amplifying worries that they are being exposed to vaccine that is not fully tested (a common contributor to vaccine hesitancy, particularly among communities of color familiar with prior exploitation and abuse in the name of science).
Discriminating based on race/ethnicity alone in the spirit of achieving equity would be precedent setting for the VA and would require a strong ethical justification. The decision to prioritize for vaccine based on risk factors strives to achieve this balance of equity and utility, as it encompasses VA staff and veterans of color by way of their status as essential workers or those with comorbidities. However, it is important to address race-based access barriers and vaccine hesitancy to satisfy the equity demands. This effort is underway (eg, engaging community champions and developing tailored educational resources to reach diverse communities).
In addition, pragmatic ethics recognizes that an overly granular, complicated allocation plan would be inefficient to implement. While it might be true that some veterans who are aged < 65 years may be at higher risk from COVID-19 than some elderly veterans, achieving the goals of fairness and transparency requires establishing a vaccine prioritization plan that is both ethically defensible and feasibly implementable (ie, achieves its goal of getting “needles into arms”). For example, veterans aged ≥ 65 years may be invited to schedule their vaccination before younger veterans, but any veteran may be accepted “on-call” for vaccine appointment no-shows via first-come, first-served or by lottery. Flexibility of response is crucial. This played out in adding flexibility around the decision to vaccinate veterans aged ≥ 75 years before those aged 65 to 74 years, after revisiting how this prioritization might affect feasibility and throughput and opting to allow the opportunity to include those aged ≥ 65 years.
There will no doubt be additional modifications to the vaccine allocation plan as more data become available. Since the danger of fueling suspicion and distrust is high (ie, that certain privileged people are jumping the line, as we heard reports of in some non-VA facilities).12 There is an obvious ethical duty to explain why the chosen approach is ethically defensible. VA facility leaders should be able to answer how their approach achieves the goals of avoiding serious or fatal illness, reducing contagion, and preserving the essential workforce while ensuring a fair, respectful, evidence-based, and transparent process.
1. US Department of Veterans Affairs. COVID-19 vaccination plan for the Veterans Health Administration. Version 2.0, Published December 14, 2020. Accessed February 3, 2021. https://www.publichealth.va.gov/docs/n-coronavirus/VHA-COVID-Vaccine-Plan-14Dec2020.pdf
2. Hennigann WJ, Park A, Ducharme J. The U.S. fumbled its early vaccine rollout. Will the Biden Administration put America back on track? TIME. January 21, 2021. Accessed February 3, 2021. https://time.com/5932028/vaccine-rollout-joe-biden/
3. US Food and Drug Administration. FDA take key action in fight against COVID-19 by issuing emergency use authorization for first COVID-19 vaccine [press release]. Published December 11, 2020. Accessed February 3, 2021. https://www.fda.gov/news-events/press-announcements/fda-takes-key-action-fight-against-covid-19-issuing-emergency-use-authorization-first-covid-19
4. US Food and Drug Administration. FDA takes additional action in fight against COVID-19 by Issuing emergency use authorization for second COVID-19 vaccine [press release]. Published December 18, 2020. Accessed February 3, 2021. https://www.fda.gov/news-events/press-announcements/fda-takes-additional-action-fight-against-covid-19-issuing-emergency-use-authorization-second-covid
5. McClung N, Chamberland M, Kinlaw K, et al. The Advisory Committee on Immunization Practices’ Ethical Principles for Allocating Initial Supplies of COVID-19 Vaccine-United States, 2020. Am J Transplant. 2021;21(1):420-425. doi:10.1111/ajt.16437
6. National Academies of Sciences, Engineering, and Medicine. 2020. Framework for equitable allocation of COVID-19 vaccine. The National Academies Press; 2020. doi:10.17226/25917
7 . Wood S, Schulman K. Beyond Politics - Promoting Covid-19 vaccination in the United States [published online ahead of print, 2021 Jan 6]. N Engl J Med. 2021;10.1056/NEJMms2033790. doi:10.1056/NEJMms2033790
8 . Matrajt L, Eaton J, Leung T, Brown ER. Vaccine optimization for COVID-19, who to vaccinate first? medRxiv . 2020 Aug 16. doi:10.1101/2020.08.14.20175257
9 . Makary M. Hospitals: stop playing vaccine games and show leadership. Published January 12, 2021. Accessed February 3, 2021. https://www.medpagetoday.com/blogs/marty-makary/90649
10 . Wentling N. Minority veterans to receive priority for coronavirus vaccines. Stars and Stripes. December 10, 2020. Accessed February 3, 2021. https://www.stripes.com/news/us/minority-veterans-to-receive-priority-for-coronavirus-vaccines-1.654624
11 . Kime, P. Minority veterans on VA’s priority list for COVID-19 vaccine distribution. Published December 8, 2020. Accessed February 3, 2021. https://www.military.com/daily-news/2020/12/08/minority-veterans-vas-priority-list-covid-19-vaccine-distribution.html
12 . Rosenthal, E. Yes, it matters that people are jumping the vaccine line. The New York Times . Published January 28, 2021. Accessed February 3, 2021. https://www.nytimes.com/2021/01/28/opinion/covid-vaccine-line.html
1. US Department of Veterans Affairs. COVID-19 vaccination plan for the Veterans Health Administration. Version 2.0, Published December 14, 2020. Accessed February 3, 2021. https://www.publichealth.va.gov/docs/n-coronavirus/VHA-COVID-Vaccine-Plan-14Dec2020.pdf
2. Hennigann WJ, Park A, Ducharme J. The U.S. fumbled its early vaccine rollout. Will the Biden Administration put America back on track? TIME. January 21, 2021. Accessed February 3, 2021. https://time.com/5932028/vaccine-rollout-joe-biden/
3. US Food and Drug Administration. FDA take key action in fight against COVID-19 by issuing emergency use authorization for first COVID-19 vaccine [press release]. Published December 11, 2020. Accessed February 3, 2021. https://www.fda.gov/news-events/press-announcements/fda-takes-key-action-fight-against-covid-19-issuing-emergency-use-authorization-first-covid-19
4. US Food and Drug Administration. FDA takes additional action in fight against COVID-19 by Issuing emergency use authorization for second COVID-19 vaccine [press release]. Published December 18, 2020. Accessed February 3, 2021. https://www.fda.gov/news-events/press-announcements/fda-takes-additional-action-fight-against-covid-19-issuing-emergency-use-authorization-second-covid
5. McClung N, Chamberland M, Kinlaw K, et al. The Advisory Committee on Immunization Practices’ Ethical Principles for Allocating Initial Supplies of COVID-19 Vaccine-United States, 2020. Am J Transplant. 2021;21(1):420-425. doi:10.1111/ajt.16437
6. National Academies of Sciences, Engineering, and Medicine. 2020. Framework for equitable allocation of COVID-19 vaccine. The National Academies Press; 2020. doi:10.17226/25917
7 . Wood S, Schulman K. Beyond Politics - Promoting Covid-19 vaccination in the United States [published online ahead of print, 2021 Jan 6]. N Engl J Med. 2021;10.1056/NEJMms2033790. doi:10.1056/NEJMms2033790
8 . Matrajt L, Eaton J, Leung T, Brown ER. Vaccine optimization for COVID-19, who to vaccinate first? medRxiv . 2020 Aug 16. doi:10.1101/2020.08.14.20175257
9 . Makary M. Hospitals: stop playing vaccine games and show leadership. Published January 12, 2021. Accessed February 3, 2021. https://www.medpagetoday.com/blogs/marty-makary/90649
10 . Wentling N. Minority veterans to receive priority for coronavirus vaccines. Stars and Stripes. December 10, 2020. Accessed February 3, 2021. https://www.stripes.com/news/us/minority-veterans-to-receive-priority-for-coronavirus-vaccines-1.654624
11 . Kime, P. Minority veterans on VA’s priority list for COVID-19 vaccine distribution. Published December 8, 2020. Accessed February 3, 2021. https://www.military.com/daily-news/2020/12/08/minority-veterans-vas-priority-list-covid-19-vaccine-distribution.html
12 . Rosenthal, E. Yes, it matters that people are jumping the vaccine line. The New York Times . Published January 28, 2021. Accessed February 3, 2021. https://www.nytimes.com/2021/01/28/opinion/covid-vaccine-line.html
Believing in conspiracy theories is not delusional
When many people across the country, not to mention in public office, believe that the world is run by a group of Satanic pedophiles that includes top Democrats and Hollywood elites, and that former President Trump is leading a secret mission to bring these evildoers to justice, one can’t help but ask if they’re at least to some degree mentally impaired.
Conspiracy theories are often received with psychiatric connotations; associated with paranoid plan-hatchers, and nonbelieving outsiders. But whereas theories such as QAnon strain credibility for many people, we would argue that they are likely not the product of psychosis or mental illness; nor do conspiracy theories in general represent delusions.
For one thing, surveys have consistently revealed that about 50% of the population believes in at least one conspiracy theory. Furthermore, there are several substantive differences between conspiracy theory beliefs and delusions.
Some researchers consider conspiracy theories to be “a subset of false beliefs,” but most scholars, ourselves included, do not prejudge their validity or veracity. Real-life conspiracies, such as the CIA’s MK-Ultra program, have clearly occurred throughout history.
Our central contention is that belief in conspiracy theories is distinct from psychosis, and more closely resembles extreme but subculturally sanctioned religious or political beliefs. However, the line between believing in conspiracies and being delusional becomes blurred when the believer becomes part of the conspiracy theory and feels compelled to act on the belief as part of a personal mission.
Take Edgar Maddison Welch, a 28-year-old man who firmly believed the so-called “Pizzagate” conspiracy theory – the baseless claim that Hillary Clinton and Democratic elites were running a child sex-trafficking ring out of a Washington, DC, pizzeria. Seeing himself a potential savior of children, Mr. Welch drove 350 miles to the pizza shop from his home in North Carolina in December 2016 and fired three shots from an AR-15 style rifle into a locked closet door, ultimately surrendering to police. However, on questioning he quickly conceded, “The intel on this wasn’t 100%.”
Who believes in conspiracy theories?
Given that half the population believes in at least one conspiracy theory, it should come as little surprise that there is no reliable “profile” for believers. Although some studies have suggested associations with low education, right-wing political orientation, and certain personality traits like subclinical paranoia and schizotypy, such findings have been inconsistent and may vary across specific conspiracy theory. Associations between conspiracy belief and paranoia suggest overlap within a “conspiratorial mindset,” with recent evidence that “distrust of officialdom” is a key mediator between believing in conspiracies and political ideology.
Other quantitative “cognitive quirks” reported in those who believe in conspiracies are a need for certainty and control, a need for uniqueness, illusory pattern perception, and lack of analytical thinking. It’s unclear which of these factors may represent universal cognitive explanations for conspiratorial beliefs, vs. those that might be related to specific beliefs, such as the need for certainty during times of crisis and societal upheaval, when conspiracy theories tend to flourish.
Much of the research on conspiracy theory belief is based on the questionable premise that it’s best understood at the level of the individual’s psychopathology, or the “deficit model,” as it’s called. One of us (JMP) has instead proposed a two-component model that includes social and informational contexts. The first component – epistemic mistrust – involves mistrusting conventional, “authoritative” knowledge. The second involves biased information processing and exposure to misinformation, often transmitted by word of mouth, or through social networks. With this model, believing in conspiracy theories could be conceived as involving “delusion-like beliefs,” but not frank psychosis or full-blown delusions, as one might see, for example, in schizophrenia.
Indeed, many of the cognitive characteristics associated with conspiracy theory belief are universal, continuously distributed traits, varying in quantity, rather than all-or-none variables or distinct symptoms of mental illness.
Essentially, delusions are fixed, false, usually unshared beliefs, often based on subjective “inner” experience. (One rare exception is the so-called folie à deux, in which two people appear to “share” the same delusion; however, psychiatrists have long debated whether both individuals should be considered truly delusional). The delusion’s content is often “self-referential”; i.e., focused primarily on the believer.
In contrast, conspiracy theories are usually, but not necessarily, false. They are typically shared beliefs that don’t explicitly or directly involve the believer, and are based on evidence that one finds “out there,” such as on the Internet. This speaks to the highly communal nature of so many conspiracy theories – networks of like-minded individuals reinforcing one another’s beliefs in a particular socio-cultural context.
Conspiracy theory belief, COVID-19, and medical intervention
As for medical conspiracy theories, none have flourished recently more so than those involving the COVID-19 pandemic. As a recent editorial by Stein and colleagues noted, “Some conspiratorial claims include assertions that COVID‐19 is a hoax; arguments that the virus was created artificially and spread on purpose as a bioweapon; or allegations that governments are using the emergency situation to pursue their antidemocratic goals. … Other conspiracies argued that people in power are taking advantage of the pandemic as a plan to inject microchip quantum-dot spy software and monitor people.”
Stein and colleagues make the important point that a “key difference between COVID‐19 and the 1918 flu pandemic ... is that [now] a highly interconnected world, to a great extent on social media, is setting the stage for distributing information and misinformation about COVID‐19.”
Consider the following composite vignette: Mr. A is a 70-year-old retiree with a history of COPD who has been advised by his PCP to get vaccinated against COVID-19. He is extremely reluctant to do so, fearing that “the vaccine is going to change my DNA” and “might even give me COVID.” He has heard from friends on social media that vaccine developers “faked the results” and are “in cahoots with the federal government.” Mr. A has heard “experts” declare the vaccines safe, but does not trust them. Mr. A has no psychiatric or substance abuse history, and there are no cognitive, perceptual, or other abnormalities in Mr. A’s mental status exam.
Mr. A’s beliefs qualify as a “conspiracy theory,” but probably represent widely held misconceptions about COVID-19 vaccines, as well as widespread mistrust of pharmaceutical companies and the federal government. Based on the information provided, there is no basis for concluding that Mr. A is psychotic or delusional. His beliefs appear to be the result of “epistemic mistrust” of authoritative informational accounts, biased information processing, and exposure to misinformation.
How should the physician manage and care for patients like Mr. A? Absent frank delusions, there is no role for antipsychotic medication, though . In addition to providing accurate medical information to the patient, the physician should avoid arguing, or trying to “talk the patient out of” his or her belief. Instead, the focus should be on sustaining and strengthening the physician-patient alliance, establishing an atmosphere of respect and safety, clarifying differences in trusted sources of medical information, and allowing the patient time to process the physician’s recommendations.
One-to-one engagement with health care providers has proved effective in reducing vaccine hesitancy and correcting misinformation. For patients with less fixed conspiracy theory beliefs, it may sometimes be helpful to gently offer alternative hypotheses to the patient’s conspiracy theory, using elements of cognitive-behavioral therapy (CBT). For example, a physician might ask, “Is it possible that the online source you read was mistaken about the vaccine changing your DNA?” while reminding patients that – contrary to popular belief – mRNA vaccines have been in development against cancer for several decades.
Challenging beliefs collaboratively and acknowledging areas of uncertainty, rather than confronting or arguing about false beliefs, can foster trust between physician and patient and, at the very least, open a dialogue regarding potential exposure to medical misinformation. “Inoculation” strategies that present and then dispel misinformation before patients become aware of it are among the best supported strategies for mitigating conspiracy theory belief. Ideally, physicians and health care systems should maintain an ongoing “inventory” of medical misinformation circulating online and “beat it to the punch” with reliable information.
Finally, because believing in conspiracy theories is often associated with a sense of uncertainty, and feeling that one’s life is “out of control,” medical interventions can be framed as ways of regaining control and appealing to patients’ values; for example, saying, “By getting the vaccine, you’ll be more likely to stay in good health, protect your family, and do all the things you want to do.”
Dr. Pies is professor of psychiatry and a lecturer on bioethics and humanities at State University of New York, Syracuse. Dr. Pierre is a health sciences clinical professor in the department of psychiatry and biobehavioral sciences at the University of California, Los Angeles. A version of this article first appeared on Medscape.com.
When many people across the country, not to mention in public office, believe that the world is run by a group of Satanic pedophiles that includes top Democrats and Hollywood elites, and that former President Trump is leading a secret mission to bring these evildoers to justice, one can’t help but ask if they’re at least to some degree mentally impaired.
Conspiracy theories are often received with psychiatric connotations; associated with paranoid plan-hatchers, and nonbelieving outsiders. But whereas theories such as QAnon strain credibility for many people, we would argue that they are likely not the product of psychosis or mental illness; nor do conspiracy theories in general represent delusions.
For one thing, surveys have consistently revealed that about 50% of the population believes in at least one conspiracy theory. Furthermore, there are several substantive differences between conspiracy theory beliefs and delusions.
Some researchers consider conspiracy theories to be “a subset of false beliefs,” but most scholars, ourselves included, do not prejudge their validity or veracity. Real-life conspiracies, such as the CIA’s MK-Ultra program, have clearly occurred throughout history.
Our central contention is that belief in conspiracy theories is distinct from psychosis, and more closely resembles extreme but subculturally sanctioned religious or political beliefs. However, the line between believing in conspiracies and being delusional becomes blurred when the believer becomes part of the conspiracy theory and feels compelled to act on the belief as part of a personal mission.
Take Edgar Maddison Welch, a 28-year-old man who firmly believed the so-called “Pizzagate” conspiracy theory – the baseless claim that Hillary Clinton and Democratic elites were running a child sex-trafficking ring out of a Washington, DC, pizzeria. Seeing himself a potential savior of children, Mr. Welch drove 350 miles to the pizza shop from his home in North Carolina in December 2016 and fired three shots from an AR-15 style rifle into a locked closet door, ultimately surrendering to police. However, on questioning he quickly conceded, “The intel on this wasn’t 100%.”
Who believes in conspiracy theories?
Given that half the population believes in at least one conspiracy theory, it should come as little surprise that there is no reliable “profile” for believers. Although some studies have suggested associations with low education, right-wing political orientation, and certain personality traits like subclinical paranoia and schizotypy, such findings have been inconsistent and may vary across specific conspiracy theory. Associations between conspiracy belief and paranoia suggest overlap within a “conspiratorial mindset,” with recent evidence that “distrust of officialdom” is a key mediator between believing in conspiracies and political ideology.
Other quantitative “cognitive quirks” reported in those who believe in conspiracies are a need for certainty and control, a need for uniqueness, illusory pattern perception, and lack of analytical thinking. It’s unclear which of these factors may represent universal cognitive explanations for conspiratorial beliefs, vs. those that might be related to specific beliefs, such as the need for certainty during times of crisis and societal upheaval, when conspiracy theories tend to flourish.
Much of the research on conspiracy theory belief is based on the questionable premise that it’s best understood at the level of the individual’s psychopathology, or the “deficit model,” as it’s called. One of us (JMP) has instead proposed a two-component model that includes social and informational contexts. The first component – epistemic mistrust – involves mistrusting conventional, “authoritative” knowledge. The second involves biased information processing and exposure to misinformation, often transmitted by word of mouth, or through social networks. With this model, believing in conspiracy theories could be conceived as involving “delusion-like beliefs,” but not frank psychosis or full-blown delusions, as one might see, for example, in schizophrenia.
Indeed, many of the cognitive characteristics associated with conspiracy theory belief are universal, continuously distributed traits, varying in quantity, rather than all-or-none variables or distinct symptoms of mental illness.
Essentially, delusions are fixed, false, usually unshared beliefs, often based on subjective “inner” experience. (One rare exception is the so-called folie à deux, in which two people appear to “share” the same delusion; however, psychiatrists have long debated whether both individuals should be considered truly delusional). The delusion’s content is often “self-referential”; i.e., focused primarily on the believer.
In contrast, conspiracy theories are usually, but not necessarily, false. They are typically shared beliefs that don’t explicitly or directly involve the believer, and are based on evidence that one finds “out there,” such as on the Internet. This speaks to the highly communal nature of so many conspiracy theories – networks of like-minded individuals reinforcing one another’s beliefs in a particular socio-cultural context.
Conspiracy theory belief, COVID-19, and medical intervention
As for medical conspiracy theories, none have flourished recently more so than those involving the COVID-19 pandemic. As a recent editorial by Stein and colleagues noted, “Some conspiratorial claims include assertions that COVID‐19 is a hoax; arguments that the virus was created artificially and spread on purpose as a bioweapon; or allegations that governments are using the emergency situation to pursue their antidemocratic goals. … Other conspiracies argued that people in power are taking advantage of the pandemic as a plan to inject microchip quantum-dot spy software and monitor people.”
Stein and colleagues make the important point that a “key difference between COVID‐19 and the 1918 flu pandemic ... is that [now] a highly interconnected world, to a great extent on social media, is setting the stage for distributing information and misinformation about COVID‐19.”
Consider the following composite vignette: Mr. A is a 70-year-old retiree with a history of COPD who has been advised by his PCP to get vaccinated against COVID-19. He is extremely reluctant to do so, fearing that “the vaccine is going to change my DNA” and “might even give me COVID.” He has heard from friends on social media that vaccine developers “faked the results” and are “in cahoots with the federal government.” Mr. A has heard “experts” declare the vaccines safe, but does not trust them. Mr. A has no psychiatric or substance abuse history, and there are no cognitive, perceptual, or other abnormalities in Mr. A’s mental status exam.
Mr. A’s beliefs qualify as a “conspiracy theory,” but probably represent widely held misconceptions about COVID-19 vaccines, as well as widespread mistrust of pharmaceutical companies and the federal government. Based on the information provided, there is no basis for concluding that Mr. A is psychotic or delusional. His beliefs appear to be the result of “epistemic mistrust” of authoritative informational accounts, biased information processing, and exposure to misinformation.
How should the physician manage and care for patients like Mr. A? Absent frank delusions, there is no role for antipsychotic medication, though . In addition to providing accurate medical information to the patient, the physician should avoid arguing, or trying to “talk the patient out of” his or her belief. Instead, the focus should be on sustaining and strengthening the physician-patient alliance, establishing an atmosphere of respect and safety, clarifying differences in trusted sources of medical information, and allowing the patient time to process the physician’s recommendations.
One-to-one engagement with health care providers has proved effective in reducing vaccine hesitancy and correcting misinformation. For patients with less fixed conspiracy theory beliefs, it may sometimes be helpful to gently offer alternative hypotheses to the patient’s conspiracy theory, using elements of cognitive-behavioral therapy (CBT). For example, a physician might ask, “Is it possible that the online source you read was mistaken about the vaccine changing your DNA?” while reminding patients that – contrary to popular belief – mRNA vaccines have been in development against cancer for several decades.
Challenging beliefs collaboratively and acknowledging areas of uncertainty, rather than confronting or arguing about false beliefs, can foster trust between physician and patient and, at the very least, open a dialogue regarding potential exposure to medical misinformation. “Inoculation” strategies that present and then dispel misinformation before patients become aware of it are among the best supported strategies for mitigating conspiracy theory belief. Ideally, physicians and health care systems should maintain an ongoing “inventory” of medical misinformation circulating online and “beat it to the punch” with reliable information.
Finally, because believing in conspiracy theories is often associated with a sense of uncertainty, and feeling that one’s life is “out of control,” medical interventions can be framed as ways of regaining control and appealing to patients’ values; for example, saying, “By getting the vaccine, you’ll be more likely to stay in good health, protect your family, and do all the things you want to do.”
Dr. Pies is professor of psychiatry and a lecturer on bioethics and humanities at State University of New York, Syracuse. Dr. Pierre is a health sciences clinical professor in the department of psychiatry and biobehavioral sciences at the University of California, Los Angeles. A version of this article first appeared on Medscape.com.
When many people across the country, not to mention in public office, believe that the world is run by a group of Satanic pedophiles that includes top Democrats and Hollywood elites, and that former President Trump is leading a secret mission to bring these evildoers to justice, one can’t help but ask if they’re at least to some degree mentally impaired.
Conspiracy theories are often received with psychiatric connotations; associated with paranoid plan-hatchers, and nonbelieving outsiders. But whereas theories such as QAnon strain credibility for many people, we would argue that they are likely not the product of psychosis or mental illness; nor do conspiracy theories in general represent delusions.
For one thing, surveys have consistently revealed that about 50% of the population believes in at least one conspiracy theory. Furthermore, there are several substantive differences between conspiracy theory beliefs and delusions.
Some researchers consider conspiracy theories to be “a subset of false beliefs,” but most scholars, ourselves included, do not prejudge their validity or veracity. Real-life conspiracies, such as the CIA’s MK-Ultra program, have clearly occurred throughout history.
Our central contention is that belief in conspiracy theories is distinct from psychosis, and more closely resembles extreme but subculturally sanctioned religious or political beliefs. However, the line between believing in conspiracies and being delusional becomes blurred when the believer becomes part of the conspiracy theory and feels compelled to act on the belief as part of a personal mission.
Take Edgar Maddison Welch, a 28-year-old man who firmly believed the so-called “Pizzagate” conspiracy theory – the baseless claim that Hillary Clinton and Democratic elites were running a child sex-trafficking ring out of a Washington, DC, pizzeria. Seeing himself a potential savior of children, Mr. Welch drove 350 miles to the pizza shop from his home in North Carolina in December 2016 and fired three shots from an AR-15 style rifle into a locked closet door, ultimately surrendering to police. However, on questioning he quickly conceded, “The intel on this wasn’t 100%.”
Who believes in conspiracy theories?
Given that half the population believes in at least one conspiracy theory, it should come as little surprise that there is no reliable “profile” for believers. Although some studies have suggested associations with low education, right-wing political orientation, and certain personality traits like subclinical paranoia and schizotypy, such findings have been inconsistent and may vary across specific conspiracy theory. Associations between conspiracy belief and paranoia suggest overlap within a “conspiratorial mindset,” with recent evidence that “distrust of officialdom” is a key mediator between believing in conspiracies and political ideology.
Other quantitative “cognitive quirks” reported in those who believe in conspiracies are a need for certainty and control, a need for uniqueness, illusory pattern perception, and lack of analytical thinking. It’s unclear which of these factors may represent universal cognitive explanations for conspiratorial beliefs, vs. those that might be related to specific beliefs, such as the need for certainty during times of crisis and societal upheaval, when conspiracy theories tend to flourish.
Much of the research on conspiracy theory belief is based on the questionable premise that it’s best understood at the level of the individual’s psychopathology, or the “deficit model,” as it’s called. One of us (JMP) has instead proposed a two-component model that includes social and informational contexts. The first component – epistemic mistrust – involves mistrusting conventional, “authoritative” knowledge. The second involves biased information processing and exposure to misinformation, often transmitted by word of mouth, or through social networks. With this model, believing in conspiracy theories could be conceived as involving “delusion-like beliefs,” but not frank psychosis or full-blown delusions, as one might see, for example, in schizophrenia.
Indeed, many of the cognitive characteristics associated with conspiracy theory belief are universal, continuously distributed traits, varying in quantity, rather than all-or-none variables or distinct symptoms of mental illness.
Essentially, delusions are fixed, false, usually unshared beliefs, often based on subjective “inner” experience. (One rare exception is the so-called folie à deux, in which two people appear to “share” the same delusion; however, psychiatrists have long debated whether both individuals should be considered truly delusional). The delusion’s content is often “self-referential”; i.e., focused primarily on the believer.
In contrast, conspiracy theories are usually, but not necessarily, false. They are typically shared beliefs that don’t explicitly or directly involve the believer, and are based on evidence that one finds “out there,” such as on the Internet. This speaks to the highly communal nature of so many conspiracy theories – networks of like-minded individuals reinforcing one another’s beliefs in a particular socio-cultural context.
Conspiracy theory belief, COVID-19, and medical intervention
As for medical conspiracy theories, none have flourished recently more so than those involving the COVID-19 pandemic. As a recent editorial by Stein and colleagues noted, “Some conspiratorial claims include assertions that COVID‐19 is a hoax; arguments that the virus was created artificially and spread on purpose as a bioweapon; or allegations that governments are using the emergency situation to pursue their antidemocratic goals. … Other conspiracies argued that people in power are taking advantage of the pandemic as a plan to inject microchip quantum-dot spy software and monitor people.”
Stein and colleagues make the important point that a “key difference between COVID‐19 and the 1918 flu pandemic ... is that [now] a highly interconnected world, to a great extent on social media, is setting the stage for distributing information and misinformation about COVID‐19.”
Consider the following composite vignette: Mr. A is a 70-year-old retiree with a history of COPD who has been advised by his PCP to get vaccinated against COVID-19. He is extremely reluctant to do so, fearing that “the vaccine is going to change my DNA” and “might even give me COVID.” He has heard from friends on social media that vaccine developers “faked the results” and are “in cahoots with the federal government.” Mr. A has heard “experts” declare the vaccines safe, but does not trust them. Mr. A has no psychiatric or substance abuse history, and there are no cognitive, perceptual, or other abnormalities in Mr. A’s mental status exam.
Mr. A’s beliefs qualify as a “conspiracy theory,” but probably represent widely held misconceptions about COVID-19 vaccines, as well as widespread mistrust of pharmaceutical companies and the federal government. Based on the information provided, there is no basis for concluding that Mr. A is psychotic or delusional. His beliefs appear to be the result of “epistemic mistrust” of authoritative informational accounts, biased information processing, and exposure to misinformation.
How should the physician manage and care for patients like Mr. A? Absent frank delusions, there is no role for antipsychotic medication, though . In addition to providing accurate medical information to the patient, the physician should avoid arguing, or trying to “talk the patient out of” his or her belief. Instead, the focus should be on sustaining and strengthening the physician-patient alliance, establishing an atmosphere of respect and safety, clarifying differences in trusted sources of medical information, and allowing the patient time to process the physician’s recommendations.
One-to-one engagement with health care providers has proved effective in reducing vaccine hesitancy and correcting misinformation. For patients with less fixed conspiracy theory beliefs, it may sometimes be helpful to gently offer alternative hypotheses to the patient’s conspiracy theory, using elements of cognitive-behavioral therapy (CBT). For example, a physician might ask, “Is it possible that the online source you read was mistaken about the vaccine changing your DNA?” while reminding patients that – contrary to popular belief – mRNA vaccines have been in development against cancer for several decades.
Challenging beliefs collaboratively and acknowledging areas of uncertainty, rather than confronting or arguing about false beliefs, can foster trust between physician and patient and, at the very least, open a dialogue regarding potential exposure to medical misinformation. “Inoculation” strategies that present and then dispel misinformation before patients become aware of it are among the best supported strategies for mitigating conspiracy theory belief. Ideally, physicians and health care systems should maintain an ongoing “inventory” of medical misinformation circulating online and “beat it to the punch” with reliable information.
Finally, because believing in conspiracy theories is often associated with a sense of uncertainty, and feeling that one’s life is “out of control,” medical interventions can be framed as ways of regaining control and appealing to patients’ values; for example, saying, “By getting the vaccine, you’ll be more likely to stay in good health, protect your family, and do all the things you want to do.”
Dr. Pies is professor of psychiatry and a lecturer on bioethics and humanities at State University of New York, Syracuse. Dr. Pierre is a health sciences clinical professor in the department of psychiatry and biobehavioral sciences at the University of California, Los Angeles. A version of this article first appeared on Medscape.com.
Cervical cancer screening: Should my practice switch to primary HPV testing?
How should I be approaching cervical cancer screening: with primary human papillomavirus (HPV) testing, or cotesting? We get this question all the time from clinicians. Although they have heard of the latest cervical cancer screening guidelines for stand-alone “primary” HPV testing, they are still ordering cervical cytology (Papanicolaou, or Pap, test) for women aged 21 to 29 years and cotesting (cervical cytology with HPV testing) for women with a cervix aged 30 and older.
Changes in cervical cancer testing guidance
Cervical cancer occurs in more than 13,000 women in the United States annually.1 High-risk types of HPV—the known cause of cervical cancer—also cause a large majority of cancers of the anus, vagina, vulva, and oropharynx.2
Cervical cancer screening programs in the United States have markedly decreased the incidence of and mortality from cervical cancer since introduction of the Pap smear in the 1950s. In 2000, HPV testing was approved by the US Food and Drug Administration (FDA) as a reflex test to a Pap smear result of atypical squamous cells of undetermined significance (ASC-US). HPV testing was then approved for use with cytology as a cotest in 2003 and subsequently as a primary stand-alone test in 2014.
Recently, the American Cancer Society (ACS) released new cervical screening guidelines that depart from prior guidelines.3 They recommend not to screen 21- to 24-year-olds and to start screening at age 25 until age 65 with the preferred strategy of primary HPV testing every 5 years, using an FDA-approved HPV test. Alternative screening strategies are cytology (Pap) every 3 years or cotesting every 5 years.
The 2018 US Preventive Services Task Force (USPSTF) guidelines differ from the ACS guidelines. The USPSTF recommends cytology every 3 years as the preferred method for women with a cervix who are aged 21 to 29 years and, for women with a cervix who are aged 30 to 65 years, the option for cytology every 3 years, primary HPV testing every 5 years, or cotesting every 5 years (TABLE).4
Why the reluctance to switch to HPV testing?
Despite FDA approval in 2014 for primary HPV testing and concurrent professional society guidance to use this testing strategy in women with a cervix who are aged 25 years and older, few practices in the United States have switched over to primary HPV testing for cervical cancer screening.5,6 Several reasons underlie this inertia:
- Many practices currently use HPV tests that are not FDA approved for primary HPV testing.
- Until recently, national screening guidelines did not recommend primary HPV testing as the preferred testing strategy.
- Long-established guidance on the importance of regular cervical cytology screening promoted by the ACS and others (which especially impacts women with a cervix older than age 50 who guide their younger daughters) will rely on significant re-education to move away from the established “Pap smear” cultural icon to a new approach.
- Last but not least, companies that manufacture HPV tests and laboratories integrated to offer such tests not yet approved for primary screening are promoting reliance on the prior proven cotest strategy. They have lobbied to preserve cotesting as a primary test, with some laboratory database studies showing gaps in detection with HPV test screening alone.7-9
Currently, the FDA-approved HPV tests for primary HPV screening include the Cobas HPV test (Roche) and the BD Onclarity HPV assay (Becton, Dickinson and Company). Both are DNA tests for 14 high-risk types of HPV that include genotyping for HPV 16 and 18.
Continue to: Follow the evidence...
Follow the evidence
Several trials in Europe and Canada provide supporting evidence for primary HPV testing, and many European countries have moved to primary HPV testing as their preferred screening method.10,11 The new ACS guidelines put us more in sync with the rest of the world, where HPV testing is the dominant strategy.
It is true that doing additional tests will find more disease; cotesting has been shown to very minimally increase detection of cervical intraepithelial neoplasia grade 2/3 (CIN 2/3) compared with HPV testing alone, but it incurs many more costs and procedures.12 The vast majority of cervical cancer is HPV positive, and cytology still can be used as a triage to primary HPV screening until tests with better sensitivity and/or specificity (such as dual stain and methylation) can be employed to reduce unnecessary “false-positive” driven procedures.
As mentioned, many strong forces are trying to keep cotesting as the preferred strategy. It is important for clinicians to recognize the corporate investment into screening platforms, relationships, and products that underlie some of these efforts so as not to be unfairly influenced by their lobbying. Data from well-conducted, high-quality studies should be the evidence on which one bases a cervical cancer screening strategy.
Innovation catalyzes change
We acknowledge that it is difficult to give up something you have been doing for decades, so there is natural resistance by both patients and clinicians to move the Pap smear into a secondary role. But the data support primary HPV testing as the best screening option from a public health perspective.
At some point, hopefully soon, primary HPV testing will receive approval for self-sampling; this has the potential to reach patients in rural or remote locations who may otherwise not get screened for cervical cancer.13
The 2019 risk-based management guidelines from the ASCCP (American Society for Colposcopy and Cervical Pathology) also incorporate the use of HPV-based screening and surveillance after abnormal tests or colposcopy. Therefore, switching to primary HPV screening will not impact your ability to follow patients appropriately based on clinical guidelines.
Our advice to clinicians is to switch to primary HPV screening now if possible. If that is not feasible, continue your current strategy until you can make the change. And, of course, we recommend that you implement an HPV vaccination program in your practice to maximize primary prevention of HPV-related cancers. ●
- Siegel RL, Miller KD, Jemal A. Cancer statistics, 2020. CA Cancer J Clin. 2020;70:7-30.
- Viens LJ, Henley SJ, Watson M, et al. Human papillomavirus-associated cancers–United States, 2008-2012. MMWR Morb Mortal Wkly Rep. 2016;65:661-666.
- Fontham ET, Wolf AM, Church TR, et al. Cervical cancer screening for individuals at average risk: 2020 guideline update from the American Cancer Society. CA Cancer J Clin. 2020;70:321-346.
- US Preventive Services Task Force; Curry SJ, KristAH, Owens DK, et al. Screening for cervical cancer: US Preventive Services Task Force recommendation statement. JAMA. 2018;320:674-686.
- Huh WK, Ault KA, Chelmow D, et al. Use of primary high-risk human papillomavirus testing for cervical cancer screening: interim clinical guidance. Obstet Gynecol. 2015;125:330-337.
- Cooper CP, Saraiya M. Cervical cancer screening intervals preferred by US women. Am J Prev Med. 2018;55:389-394.
- Austin RM, Onisko A, Zhao C. Enhanced detection of cervical cancer and precancer through use of imaged liquid-based cytology in routine cytology and HPV cotesting. Am J Clin Pathol. 2018;150:385-392.
- Kaufman HW, Alagia DP, Chen Z, et al. Contributions of liquid-based (Papanicolaou) cytology and human papillomavirus testing in cotesting for detection of cervical cancer and precancer in the United States. Am J Clin Pathol. 2020;154:510-516.
- Blatt AJ, Kennedy R, Luff RD, et al. Comparison of cervical cancer screening results among 256,648 women in multiple clinical practices. Cancer Cytopathol. 2015;123:282-288.
- Ronco G, Dillner J, Elfstrom KM, et al; International HPV Screening Working Group. Efficacy of HPV-based screening for prevention of invasive cervical cancer: follow-up of four European randomised controlled trials. Lancet. 2014;383:524-532.
- Ogilvie GS, van Niekerk D, Krajden M, et al. Effect of screening with primary cervical HPV testing vs cytology testing on high-grade cervical intraepithelial neoplasia at 48 months: the HPV FOCAL randomized clinical trial. JAMA. 2018;320:43-52.
- Kim JJ, Burger EA, Regan C, et al. Screening for cervical cancer in primary care: a decision analysis for the US Preventive Services Task Force. JAMA. 2018;320:706-714.
- Arbyn M, Smith SB, Temin S, et al; on behalf of the Collaboration on Self-Sampling and HPV Testing. Detecting cervical precancer and reaching underscreened women by using HPV testing on self samples: updated meta-analyses. BMJ. 2018;363:k4823.
Michelle J. Khan, MD, MPH
Clinical Associate Professor
Department of Obstetrics and Gynecology
Stanford University School of Medicine
Stanford, California
Neal M. Lonky, MD, MPH
Clinical Professor
Department of Obstetrics and Gynecology
University of California, Irvine, School of Medicine
Partner Emeritus and Lead Physician,
Southern California Permanente Medical Group
Contributing Editor, OBG Management
Dr. Lonky reports receiving grant or research support from AbbVie and Merck (through Kaiser), being a consultant to Nowarta Biopharma Inc, and being a founder/CEO of Histologics, LLC. Dr. Khan reports no financial relationships relevant to this article.
Michelle J. Khan, MD, MPH
Clinical Associate Professor
Department of Obstetrics and Gynecology
Stanford University School of Medicine
Stanford, California
Neal M. Lonky, MD, MPH
Clinical Professor
Department of Obstetrics and Gynecology
University of California, Irvine, School of Medicine
Partner Emeritus and Lead Physician,
Southern California Permanente Medical Group
Contributing Editor, OBG Management
Dr. Lonky reports receiving grant or research support from AbbVie and Merck (through Kaiser), being a consultant to Nowarta Biopharma Inc, and being a founder/CEO of Histologics, LLC. Dr. Khan reports no financial relationships relevant to this article.
Michelle J. Khan, MD, MPH
Clinical Associate Professor
Department of Obstetrics and Gynecology
Stanford University School of Medicine
Stanford, California
Neal M. Lonky, MD, MPH
Clinical Professor
Department of Obstetrics and Gynecology
University of California, Irvine, School of Medicine
Partner Emeritus and Lead Physician,
Southern California Permanente Medical Group
Contributing Editor, OBG Management
Dr. Lonky reports receiving grant or research support from AbbVie and Merck (through Kaiser), being a consultant to Nowarta Biopharma Inc, and being a founder/CEO of Histologics, LLC. Dr. Khan reports no financial relationships relevant to this article.
How should I be approaching cervical cancer screening: with primary human papillomavirus (HPV) testing, or cotesting? We get this question all the time from clinicians. Although they have heard of the latest cervical cancer screening guidelines for stand-alone “primary” HPV testing, they are still ordering cervical cytology (Papanicolaou, or Pap, test) for women aged 21 to 29 years and cotesting (cervical cytology with HPV testing) for women with a cervix aged 30 and older.
Changes in cervical cancer testing guidance
Cervical cancer occurs in more than 13,000 women in the United States annually.1 High-risk types of HPV—the known cause of cervical cancer—also cause a large majority of cancers of the anus, vagina, vulva, and oropharynx.2
Cervical cancer screening programs in the United States have markedly decreased the incidence of and mortality from cervical cancer since introduction of the Pap smear in the 1950s. In 2000, HPV testing was approved by the US Food and Drug Administration (FDA) as a reflex test to a Pap smear result of atypical squamous cells of undetermined significance (ASC-US). HPV testing was then approved for use with cytology as a cotest in 2003 and subsequently as a primary stand-alone test in 2014.
Recently, the American Cancer Society (ACS) released new cervical screening guidelines that depart from prior guidelines.3 They recommend not to screen 21- to 24-year-olds and to start screening at age 25 until age 65 with the preferred strategy of primary HPV testing every 5 years, using an FDA-approved HPV test. Alternative screening strategies are cytology (Pap) every 3 years or cotesting every 5 years.
The 2018 US Preventive Services Task Force (USPSTF) guidelines differ from the ACS guidelines. The USPSTF recommends cytology every 3 years as the preferred method for women with a cervix who are aged 21 to 29 years and, for women with a cervix who are aged 30 to 65 years, the option for cytology every 3 years, primary HPV testing every 5 years, or cotesting every 5 years (TABLE).4
Why the reluctance to switch to HPV testing?
Despite FDA approval in 2014 for primary HPV testing and concurrent professional society guidance to use this testing strategy in women with a cervix who are aged 25 years and older, few practices in the United States have switched over to primary HPV testing for cervical cancer screening.5,6 Several reasons underlie this inertia:
- Many practices currently use HPV tests that are not FDA approved for primary HPV testing.
- Until recently, national screening guidelines did not recommend primary HPV testing as the preferred testing strategy.
- Long-established guidance on the importance of regular cervical cytology screening promoted by the ACS and others (which especially impacts women with a cervix older than age 50 who guide their younger daughters) will rely on significant re-education to move away from the established “Pap smear” cultural icon to a new approach.
- Last but not least, companies that manufacture HPV tests and laboratories integrated to offer such tests not yet approved for primary screening are promoting reliance on the prior proven cotest strategy. They have lobbied to preserve cotesting as a primary test, with some laboratory database studies showing gaps in detection with HPV test screening alone.7-9
Currently, the FDA-approved HPV tests for primary HPV screening include the Cobas HPV test (Roche) and the BD Onclarity HPV assay (Becton, Dickinson and Company). Both are DNA tests for 14 high-risk types of HPV that include genotyping for HPV 16 and 18.
Continue to: Follow the evidence...
Follow the evidence
Several trials in Europe and Canada provide supporting evidence for primary HPV testing, and many European countries have moved to primary HPV testing as their preferred screening method.10,11 The new ACS guidelines put us more in sync with the rest of the world, where HPV testing is the dominant strategy.
It is true that doing additional tests will find more disease; cotesting has been shown to very minimally increase detection of cervical intraepithelial neoplasia grade 2/3 (CIN 2/3) compared with HPV testing alone, but it incurs many more costs and procedures.12 The vast majority of cervical cancer is HPV positive, and cytology still can be used as a triage to primary HPV screening until tests with better sensitivity and/or specificity (such as dual stain and methylation) can be employed to reduce unnecessary “false-positive” driven procedures.
As mentioned, many strong forces are trying to keep cotesting as the preferred strategy. It is important for clinicians to recognize the corporate investment into screening platforms, relationships, and products that underlie some of these efforts so as not to be unfairly influenced by their lobbying. Data from well-conducted, high-quality studies should be the evidence on which one bases a cervical cancer screening strategy.
Innovation catalyzes change
We acknowledge that it is difficult to give up something you have been doing for decades, so there is natural resistance by both patients and clinicians to move the Pap smear into a secondary role. But the data support primary HPV testing as the best screening option from a public health perspective.
At some point, hopefully soon, primary HPV testing will receive approval for self-sampling; this has the potential to reach patients in rural or remote locations who may otherwise not get screened for cervical cancer.13
The 2019 risk-based management guidelines from the ASCCP (American Society for Colposcopy and Cervical Pathology) also incorporate the use of HPV-based screening and surveillance after abnormal tests or colposcopy. Therefore, switching to primary HPV screening will not impact your ability to follow patients appropriately based on clinical guidelines.
Our advice to clinicians is to switch to primary HPV screening now if possible. If that is not feasible, continue your current strategy until you can make the change. And, of course, we recommend that you implement an HPV vaccination program in your practice to maximize primary prevention of HPV-related cancers. ●
How should I be approaching cervical cancer screening: with primary human papillomavirus (HPV) testing, or cotesting? We get this question all the time from clinicians. Although they have heard of the latest cervical cancer screening guidelines for stand-alone “primary” HPV testing, they are still ordering cervical cytology (Papanicolaou, or Pap, test) for women aged 21 to 29 years and cotesting (cervical cytology with HPV testing) for women with a cervix aged 30 and older.
Changes in cervical cancer testing guidance
Cervical cancer occurs in more than 13,000 women in the United States annually.1 High-risk types of HPV—the known cause of cervical cancer—also cause a large majority of cancers of the anus, vagina, vulva, and oropharynx.2
Cervical cancer screening programs in the United States have markedly decreased the incidence of and mortality from cervical cancer since introduction of the Pap smear in the 1950s. In 2000, HPV testing was approved by the US Food and Drug Administration (FDA) as a reflex test to a Pap smear result of atypical squamous cells of undetermined significance (ASC-US). HPV testing was then approved for use with cytology as a cotest in 2003 and subsequently as a primary stand-alone test in 2014.
Recently, the American Cancer Society (ACS) released new cervical screening guidelines that depart from prior guidelines.3 They recommend not to screen 21- to 24-year-olds and to start screening at age 25 until age 65 with the preferred strategy of primary HPV testing every 5 years, using an FDA-approved HPV test. Alternative screening strategies are cytology (Pap) every 3 years or cotesting every 5 years.
The 2018 US Preventive Services Task Force (USPSTF) guidelines differ from the ACS guidelines. The USPSTF recommends cytology every 3 years as the preferred method for women with a cervix who are aged 21 to 29 years and, for women with a cervix who are aged 30 to 65 years, the option for cytology every 3 years, primary HPV testing every 5 years, or cotesting every 5 years (TABLE).4
Why the reluctance to switch to HPV testing?
Despite FDA approval in 2014 for primary HPV testing and concurrent professional society guidance to use this testing strategy in women with a cervix who are aged 25 years and older, few practices in the United States have switched over to primary HPV testing for cervical cancer screening.5,6 Several reasons underlie this inertia:
- Many practices currently use HPV tests that are not FDA approved for primary HPV testing.
- Until recently, national screening guidelines did not recommend primary HPV testing as the preferred testing strategy.
- Long-established guidance on the importance of regular cervical cytology screening promoted by the ACS and others (which especially impacts women with a cervix older than age 50 who guide their younger daughters) will rely on significant re-education to move away from the established “Pap smear” cultural icon to a new approach.
- Last but not least, companies that manufacture HPV tests and laboratories integrated to offer such tests not yet approved for primary screening are promoting reliance on the prior proven cotest strategy. They have lobbied to preserve cotesting as a primary test, with some laboratory database studies showing gaps in detection with HPV test screening alone.7-9
Currently, the FDA-approved HPV tests for primary HPV screening include the Cobas HPV test (Roche) and the BD Onclarity HPV assay (Becton, Dickinson and Company). Both are DNA tests for 14 high-risk types of HPV that include genotyping for HPV 16 and 18.
Continue to: Follow the evidence...
Follow the evidence
Several trials in Europe and Canada provide supporting evidence for primary HPV testing, and many European countries have moved to primary HPV testing as their preferred screening method.10,11 The new ACS guidelines put us more in sync with the rest of the world, where HPV testing is the dominant strategy.
It is true that doing additional tests will find more disease; cotesting has been shown to very minimally increase detection of cervical intraepithelial neoplasia grade 2/3 (CIN 2/3) compared with HPV testing alone, but it incurs many more costs and procedures.12 The vast majority of cervical cancer is HPV positive, and cytology still can be used as a triage to primary HPV screening until tests with better sensitivity and/or specificity (such as dual stain and methylation) can be employed to reduce unnecessary “false-positive” driven procedures.
As mentioned, many strong forces are trying to keep cotesting as the preferred strategy. It is important for clinicians to recognize the corporate investment into screening platforms, relationships, and products that underlie some of these efforts so as not to be unfairly influenced by their lobbying. Data from well-conducted, high-quality studies should be the evidence on which one bases a cervical cancer screening strategy.
Innovation catalyzes change
We acknowledge that it is difficult to give up something you have been doing for decades, so there is natural resistance by both patients and clinicians to move the Pap smear into a secondary role. But the data support primary HPV testing as the best screening option from a public health perspective.
At some point, hopefully soon, primary HPV testing will receive approval for self-sampling; this has the potential to reach patients in rural or remote locations who may otherwise not get screened for cervical cancer.13
The 2019 risk-based management guidelines from the ASCCP (American Society for Colposcopy and Cervical Pathology) also incorporate the use of HPV-based screening and surveillance after abnormal tests or colposcopy. Therefore, switching to primary HPV screening will not impact your ability to follow patients appropriately based on clinical guidelines.
Our advice to clinicians is to switch to primary HPV screening now if possible. If that is not feasible, continue your current strategy until you can make the change. And, of course, we recommend that you implement an HPV vaccination program in your practice to maximize primary prevention of HPV-related cancers. ●
- Siegel RL, Miller KD, Jemal A. Cancer statistics, 2020. CA Cancer J Clin. 2020;70:7-30.
- Viens LJ, Henley SJ, Watson M, et al. Human papillomavirus-associated cancers–United States, 2008-2012. MMWR Morb Mortal Wkly Rep. 2016;65:661-666.
- Fontham ET, Wolf AM, Church TR, et al. Cervical cancer screening for individuals at average risk: 2020 guideline update from the American Cancer Society. CA Cancer J Clin. 2020;70:321-346.
- US Preventive Services Task Force; Curry SJ, KristAH, Owens DK, et al. Screening for cervical cancer: US Preventive Services Task Force recommendation statement. JAMA. 2018;320:674-686.
- Huh WK, Ault KA, Chelmow D, et al. Use of primary high-risk human papillomavirus testing for cervical cancer screening: interim clinical guidance. Obstet Gynecol. 2015;125:330-337.
- Cooper CP, Saraiya M. Cervical cancer screening intervals preferred by US women. Am J Prev Med. 2018;55:389-394.
- Austin RM, Onisko A, Zhao C. Enhanced detection of cervical cancer and precancer through use of imaged liquid-based cytology in routine cytology and HPV cotesting. Am J Clin Pathol. 2018;150:385-392.
- Kaufman HW, Alagia DP, Chen Z, et al. Contributions of liquid-based (Papanicolaou) cytology and human papillomavirus testing in cotesting for detection of cervical cancer and precancer in the United States. Am J Clin Pathol. 2020;154:510-516.
- Blatt AJ, Kennedy R, Luff RD, et al. Comparison of cervical cancer screening results among 256,648 women in multiple clinical practices. Cancer Cytopathol. 2015;123:282-288.
- Ronco G, Dillner J, Elfstrom KM, et al; International HPV Screening Working Group. Efficacy of HPV-based screening for prevention of invasive cervical cancer: follow-up of four European randomised controlled trials. Lancet. 2014;383:524-532.
- Ogilvie GS, van Niekerk D, Krajden M, et al. Effect of screening with primary cervical HPV testing vs cytology testing on high-grade cervical intraepithelial neoplasia at 48 months: the HPV FOCAL randomized clinical trial. JAMA. 2018;320:43-52.
- Kim JJ, Burger EA, Regan C, et al. Screening for cervical cancer in primary care: a decision analysis for the US Preventive Services Task Force. JAMA. 2018;320:706-714.
- Arbyn M, Smith SB, Temin S, et al; on behalf of the Collaboration on Self-Sampling and HPV Testing. Detecting cervical precancer and reaching underscreened women by using HPV testing on self samples: updated meta-analyses. BMJ. 2018;363:k4823.
- Siegel RL, Miller KD, Jemal A. Cancer statistics, 2020. CA Cancer J Clin. 2020;70:7-30.
- Viens LJ, Henley SJ, Watson M, et al. Human papillomavirus-associated cancers–United States, 2008-2012. MMWR Morb Mortal Wkly Rep. 2016;65:661-666.
- Fontham ET, Wolf AM, Church TR, et al. Cervical cancer screening for individuals at average risk: 2020 guideline update from the American Cancer Society. CA Cancer J Clin. 2020;70:321-346.
- US Preventive Services Task Force; Curry SJ, KristAH, Owens DK, et al. Screening for cervical cancer: US Preventive Services Task Force recommendation statement. JAMA. 2018;320:674-686.
- Huh WK, Ault KA, Chelmow D, et al. Use of primary high-risk human papillomavirus testing for cervical cancer screening: interim clinical guidance. Obstet Gynecol. 2015;125:330-337.
- Cooper CP, Saraiya M. Cervical cancer screening intervals preferred by US women. Am J Prev Med. 2018;55:389-394.
- Austin RM, Onisko A, Zhao C. Enhanced detection of cervical cancer and precancer through use of imaged liquid-based cytology in routine cytology and HPV cotesting. Am J Clin Pathol. 2018;150:385-392.
- Kaufman HW, Alagia DP, Chen Z, et al. Contributions of liquid-based (Papanicolaou) cytology and human papillomavirus testing in cotesting for detection of cervical cancer and precancer in the United States. Am J Clin Pathol. 2020;154:510-516.
- Blatt AJ, Kennedy R, Luff RD, et al. Comparison of cervical cancer screening results among 256,648 women in multiple clinical practices. Cancer Cytopathol. 2015;123:282-288.
- Ronco G, Dillner J, Elfstrom KM, et al; International HPV Screening Working Group. Efficacy of HPV-based screening for prevention of invasive cervical cancer: follow-up of four European randomised controlled trials. Lancet. 2014;383:524-532.
- Ogilvie GS, van Niekerk D, Krajden M, et al. Effect of screening with primary cervical HPV testing vs cytology testing on high-grade cervical intraepithelial neoplasia at 48 months: the HPV FOCAL randomized clinical trial. JAMA. 2018;320:43-52.
- Kim JJ, Burger EA, Regan C, et al. Screening for cervical cancer in primary care: a decision analysis for the US Preventive Services Task Force. JAMA. 2018;320:706-714.
- Arbyn M, Smith SB, Temin S, et al; on behalf of the Collaboration on Self-Sampling and HPV Testing. Detecting cervical precancer and reaching underscreened women by using HPV testing on self samples: updated meta-analyses. BMJ. 2018;363:k4823.
Cesarean myomectomy: Safe operation or surgical folly?
Uterine leiomyomata (fibroids) are the most common pelvic tumor of women. When women are planning to conceive, and their fibroid(s) are clinically significant, causing abnormal uterine bleeding or bulk symptoms, it is often optimal to remove the uterine tumor(s) before conception. Advances in minimally invasive surgery offer women the option of laparoscopic or robot-assisted myomectomy with a low rate of operative complications, including excessive blood loss and hysterectomy, and a low rate of postoperative complications, including major pelvic adhesions and uterine rupture during subsequent pregnancy.1-3 However, many women become pregnant when they have clinically significant fibroids, and at least one-third of these women will have a cesarean birth.
Important clinical issues are the relative benefits and risks of performing a myomectomy at the time of the cesarean birth, so called cesarean myomectomy. Cesarean myomectomy offers carefully selected women the opportunity to have a cesarean birth and myomectomy in one operation, thereby avoiding a second major operation. Over the past 6 decades, most experts in the United States and the United Kingdom have strongly recommended against myomectomy at the time of cesarean delivery because of the risk of excessive blood loss and hysterectomy. Recently, expert opinion has shifted, especially in continental Europe and Asia, and cesarean myomectomy is now viewed as an acceptable surgical option in a limited number of clinical situations, including removal of pedunculated fibroids, excision of large solitary subserosal fibroids, and to achieve optimal management of the hysterotomy incision.
Decades of expert guidance: Avoid cesarean myomectomy at all costs
Dr. K.S.J. Olah succinctly captured the standard teaching that cesarean myomectomy should be avoided in this personal vignette:
Many years ago as a trainee I removed a subserosal fibroid during a cesarean section that was hanging by a thin stalk on the back of the uterus. The berating I received was severe and disproportionate to the crime. The rule was that myomectomy performed at cesarean section was not just frowned upon but expressly forbidden. It has always been considered foolish to consider removing fibroids at cesarean section, mostly because of the associated morbidity and the risk of haemorrhage requiring hysterectomy.4
Dr. Olah quoted guidance from Shaw’s Textbook of Operative Gynaecology,5 “It should be stressed that myomectomy in pregnancy should be avoided at all costs, including at caesarean section.” However, large case series published over the past 10 years report that, in limited clinical situations, cesarean myomectomy is a viable surgical option, where benefit may outweigh risk.6-14 The current literature has many weaknesses, including failure to specifically identify the indication for the cesarean myomectomy and lack of controlled prospective clinical trials. In almost all cases, cesarean myomectomy is performed after delivery of the fetus and placenta.
Continue to: The pedunculated, FIGO type 7 fibroid...
The pedunculated, FIGO type 7 fibroid
The International Federation of Gynecology and Obstetrics (FIGO) leiomyoma classification system identifies subserosal pedunculated fibroids as type 7 (FIGURE).15 Pedunculated fibroids are attached to the uterus by a stalk that is ≤10% of the mean of the 3 diameters of the fibroid. When a clinically significant pedunculated fibroid, causing bulk symptoms, is encountered at cesarean birth, I recommend that it be removed. This will save many patients a second major operation to perform a myomectomy. The surgical risk of removing a pedunculated is low.
The solitary FIGO type 6 fibroid
Type 6 fibroids are subserosal fibroids with less than 50% of their mass being subserosal. The type 6 fibroid is relatively easy to enucleate from the uterus. Following removal of a type 6 fibroid, closure of the serosal defect is relatively straightforward. In carefully selected cases, if the type 6 fibroid is causing bulk symptoms, cesarean myomectomy may be indicated with a low risk of operative complications.
The FIGO type 2-5 fibroid
The type 2-5 fibroid is a transmural fibroid with significant mass abutting both the endometrial cavity and serosal surface. Excision of a type 2-5 fibroid is likely to result in a large transmyometrial defect that will be more difficult to close and could be associated with greater blood loss. Although data are limited, I would recommend against cesarean myomectomy for type 2-5 fibroids in most clinical situations.
Myomectomy to achieve optimal management of the cesarean hysterotomy incision
Many surgeons performing a cesarean birth for a woman with clinically significant fibroids will plan the hysterotomy incision to avoid the fibroids. However, following delivery and contraction of the uterus, proper closure of the hysterotomy incision may be very difficult without removing a fibroid that is abutting the hysterotomy incision. Surgeons have reported performing myomectomy on lower uterine segment fibroids before making the hysterotomy incision in order to facilitate the hysterotomy incision and closure.16 Myomectomy prior to delivery of the newborn must be associated with additional risks to the fetus. I would prefer to identify an optimal site to perform a hysterotomy, deliver the newborn and placenta, and then consider myomectomy.
Complications associated with cesarean myomectomy
The evidence concerning the complications of cesarean birth plus myomectomy compared with cesarean birth alone in women with fibroids is limited to case series. There are no reported controlled clinical trials to guide practice. The largest single case series reported on 1,242 women with fibroids who had a cesarean birth plus myomectomy compared with 3 control groups, including 200 women without fibroids who had a cesarean birth, 145 women with fibroids who had a cesarean birth and no myomectomy, and 51 women with fibroids who had a cesarean hysterectomy. The investigators reported no significant differences in preoperative to postoperative hemoglobin change, incidence of postoperative fever, or length of hospital stay among the 4 groups.8 The authors concluded that myomectomy during cesarean birth was a safe and effective procedure.
Continue to: A systematic review and meta-analysis reported...
A systematic review and meta-analysis reported on the results of 17 studies which included 4,702 women who had a cesarean myomectomy and 1,843 women with cesarean birth without myomectomy.17 The authors of the meta-analysis noted that most reported case series had excluded women with a high risk of bleeding, including women with placenta previa, placenta accreta, coagulation disorders, and a history of multiple myomectomy operations. The investigators reported that, compared with the control women, the women undergoing cesarean myomectomy had a statistically significant but clinically insignificant decrease in mean hemoglobin concentration (-0.27 g/dL), a significant increase in mean operative time (+15 minutes) and a significant increase in the length of hospital stay (+0.36 days). There was an increase in the need for blood transfusion (risk ratio, 1.45; 95% confidence interval, 1.05–1.99), but only 3% of women undergoing cesarean myomectomy received a blood transfusion. There was no significant difference between the two groups in the incidence of postoperative fever. The authors concluded that cesarean myomectomy is a safe procedure when performed by experienced surgeons with appropriate hemostatic techniques.
Techniques to reduce blood loss at the time of cesarean myomectomy
A detailed review of all the available techniques to reduce blood loss at the time of cesarean myomectomy is beyond the scope of this editorial. All gynecologists know that control of uterine blood flow through the uterine artery, infundibulopelvic vessels and internal iliac artery can help to reduce bleeding at the time of myomectomy. Tourniquets, vascular clamps, and artery ligation all have been reported to be useful at the time of cesarean myomectomy. In addition, intravenous infusion of oxytocin and tranexamic acid is often used at the time of cesarean myomectomy. Direct injection of uterotonics, including carbetocin, oxytocin, and vasopressin, into the uterus also has been reported. Cell saver blood salvage technology has been utilized in a limited number of cases of cesarean myomectomy.8,18,19
Medicine is not a static field
Discoveries and new data help guide advances in medical practice. After 6 decades of strict adherence to the advice that myomectomy in pregnancy should be avoided at all costs, including at caesarean delivery, new data indicate that in carefully selected cases cesarean myomectomy is an acceptable operation. ●
- Pitter MC, Gargiulo AR, Bonaventura LM, et al. Pregnancy outcomes following robot-assisted myomectomy. Hum Reprod. 2013;28:99-108.
- Pitter MC, Srouji SS, Gargiulo AR, et al. Fertility and symptom relief following robot-assisted laparoscopic myomectomy. Obstet Gynecol Int. 2015;2015:967568.
- Huberlant S, Lenot J, Neron M, et al. Fertility and obstetric outcomes after robot-assisted laparoscopic myomectomy. Int J Med Robot. 2020;16:e2059.
- Olah KSJ. Caesarean myomectomy: TE or not TE? BJOG. 2018;125:501.
- Shaw, et al. Textbook of Operative Gynaecology. Edinburgh: Churchill Livingston; 1977.
- Burton CA, Grimes DA, March CM. Surgical management of leiomyomata during pregnancy. Obstet Gynecol. 1989;74:707-709.
- Ortac F, Gungor M, Sonmezer M. Myomectomy during cesarean section. Int J Gynaecol Obstet. 1999;67:189-193.
- Li H, Du J, Jin L, et al. Myomectomy during cesarean section. Acta Obstetricia et Gynecologica. 2009;88:183-186.
- Kwon DH, Song JE, Yoon KR, et al. Obstet Gynecol Sci. 2014;57:367-372.
- Senturk MB, Polat M, Dogan O, et al. Outcome of cesarean myomectomy: is it a safe procedure? Geburtshilfe Frauenheilkd. 2017;77:1200-1206.
- Chauhan AR. Cesarean myomectomy: necessity or opportunity? J Obstet Gynecol India. 2018;68:432-436.
- Sparic R, Kadija S, Stefanovic A, et al. Cesarean myomectomy in modern obstetrics: more light and fewer shadows. J Obstet Gynaecol Res. 2017;43:798-804.
- Ramya T, Sabnis SS, Chitra TV, et al. Cesarean myomectomy: an experience from a tertiary care teaching hospital. J Obstet Gynaecol India. 2019;69:426-430.
- Zhao R, Wang X, Zou L, et al. Outcomes of myomectomy at the time of cesarean section among pregnant women with uterine fibroids: a retrospective cohort study. Biomed Res Int. 2019;7576934.
- Munro MG, Critchley HOD, Fraser IS; FIGO Menstrual Disorders Committee. The two FIGO systems for normal and abnormal uterine bleeding symptoms and classification of causes of abnormal uterine bleeding in the reproductive years: 2018 revisions. In J Gynaecol Obstet. 2018;143:393.
- Omar SZ, Sivanesaratnam V, Damodaran P. Large lower segment myoma—myomectomy at lower segment caesarean section—a report of two cases. Singapore Med J. 1999;40:109-110.
- Goyal M, Dawood AS, Elbohoty SB, et al. Cesarean myomectomy in the last ten years; A true shift from contraindication to indication: a systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2021;256:145-157.
- Lin JY, Lee WL, Wang PH, et al. Uterine artery occlusion and myomectomy for treatment of pregnant women with uterine leiomyomas who are undergoing caesarean section. J Obstet Gynecol Res. 2010;36:284-290.
- Alfred E, Joy G, Uduak O, et al. Cesarean myomectomy outcome in a Nigerian hospital district hospital. J Basic Clin Reprod Sci. 2013;2:115-118.
Robert L. Barbieri, MD
Chair Emeritus, Department of Obstetrics and Gynecology
Interim Chief, Obstetrics
Brigham and Women’s Hospital
Kate Macy Ladd Distinguished Professor of Obstetrics,
Gynecology and Reproductive Biology
Harvard Medical School
Boston, Massachusetts
Dr. Barbieri reports no financial relationships relevant to this article.
Robert L. Barbieri, MD
Chair Emeritus, Department of Obstetrics and Gynecology
Interim Chief, Obstetrics
Brigham and Women’s Hospital
Kate Macy Ladd Distinguished Professor of Obstetrics,
Gynecology and Reproductive Biology
Harvard Medical School
Boston, Massachusetts
Dr. Barbieri reports no financial relationships relevant to this article.
Robert L. Barbieri, MD
Chair Emeritus, Department of Obstetrics and Gynecology
Interim Chief, Obstetrics
Brigham and Women’s Hospital
Kate Macy Ladd Distinguished Professor of Obstetrics,
Gynecology and Reproductive Biology
Harvard Medical School
Boston, Massachusetts
Dr. Barbieri reports no financial relationships relevant to this article.
Uterine leiomyomata (fibroids) are the most common pelvic tumor of women. When women are planning to conceive, and their fibroid(s) are clinically significant, causing abnormal uterine bleeding or bulk symptoms, it is often optimal to remove the uterine tumor(s) before conception. Advances in minimally invasive surgery offer women the option of laparoscopic or robot-assisted myomectomy with a low rate of operative complications, including excessive blood loss and hysterectomy, and a low rate of postoperative complications, including major pelvic adhesions and uterine rupture during subsequent pregnancy.1-3 However, many women become pregnant when they have clinically significant fibroids, and at least one-third of these women will have a cesarean birth.
Important clinical issues are the relative benefits and risks of performing a myomectomy at the time of the cesarean birth, so called cesarean myomectomy. Cesarean myomectomy offers carefully selected women the opportunity to have a cesarean birth and myomectomy in one operation, thereby avoiding a second major operation. Over the past 6 decades, most experts in the United States and the United Kingdom have strongly recommended against myomectomy at the time of cesarean delivery because of the risk of excessive blood loss and hysterectomy. Recently, expert opinion has shifted, especially in continental Europe and Asia, and cesarean myomectomy is now viewed as an acceptable surgical option in a limited number of clinical situations, including removal of pedunculated fibroids, excision of large solitary subserosal fibroids, and to achieve optimal management of the hysterotomy incision.
Decades of expert guidance: Avoid cesarean myomectomy at all costs
Dr. K.S.J. Olah succinctly captured the standard teaching that cesarean myomectomy should be avoided in this personal vignette:
Many years ago as a trainee I removed a subserosal fibroid during a cesarean section that was hanging by a thin stalk on the back of the uterus. The berating I received was severe and disproportionate to the crime. The rule was that myomectomy performed at cesarean section was not just frowned upon but expressly forbidden. It has always been considered foolish to consider removing fibroids at cesarean section, mostly because of the associated morbidity and the risk of haemorrhage requiring hysterectomy.4
Dr. Olah quoted guidance from Shaw’s Textbook of Operative Gynaecology,5 “It should be stressed that myomectomy in pregnancy should be avoided at all costs, including at caesarean section.” However, large case series published over the past 10 years report that, in limited clinical situations, cesarean myomectomy is a viable surgical option, where benefit may outweigh risk.6-14 The current literature has many weaknesses, including failure to specifically identify the indication for the cesarean myomectomy and lack of controlled prospective clinical trials. In almost all cases, cesarean myomectomy is performed after delivery of the fetus and placenta.
Continue to: The pedunculated, FIGO type 7 fibroid...
The pedunculated, FIGO type 7 fibroid
The International Federation of Gynecology and Obstetrics (FIGO) leiomyoma classification system identifies subserosal pedunculated fibroids as type 7 (FIGURE).15 Pedunculated fibroids are attached to the uterus by a stalk that is ≤10% of the mean of the 3 diameters of the fibroid. When a clinically significant pedunculated fibroid, causing bulk symptoms, is encountered at cesarean birth, I recommend that it be removed. This will save many patients a second major operation to perform a myomectomy. The surgical risk of removing a pedunculated is low.
The solitary FIGO type 6 fibroid
Type 6 fibroids are subserosal fibroids with less than 50% of their mass being subserosal. The type 6 fibroid is relatively easy to enucleate from the uterus. Following removal of a type 6 fibroid, closure of the serosal defect is relatively straightforward. In carefully selected cases, if the type 6 fibroid is causing bulk symptoms, cesarean myomectomy may be indicated with a low risk of operative complications.
The FIGO type 2-5 fibroid
The type 2-5 fibroid is a transmural fibroid with significant mass abutting both the endometrial cavity and serosal surface. Excision of a type 2-5 fibroid is likely to result in a large transmyometrial defect that will be more difficult to close and could be associated with greater blood loss. Although data are limited, I would recommend against cesarean myomectomy for type 2-5 fibroids in most clinical situations.
Myomectomy to achieve optimal management of the cesarean hysterotomy incision
Many surgeons performing a cesarean birth for a woman with clinically significant fibroids will plan the hysterotomy incision to avoid the fibroids. However, following delivery and contraction of the uterus, proper closure of the hysterotomy incision may be very difficult without removing a fibroid that is abutting the hysterotomy incision. Surgeons have reported performing myomectomy on lower uterine segment fibroids before making the hysterotomy incision in order to facilitate the hysterotomy incision and closure.16 Myomectomy prior to delivery of the newborn must be associated with additional risks to the fetus. I would prefer to identify an optimal site to perform a hysterotomy, deliver the newborn and placenta, and then consider myomectomy.
Complications associated with cesarean myomectomy
The evidence concerning the complications of cesarean birth plus myomectomy compared with cesarean birth alone in women with fibroids is limited to case series. There are no reported controlled clinical trials to guide practice. The largest single case series reported on 1,242 women with fibroids who had a cesarean birth plus myomectomy compared with 3 control groups, including 200 women without fibroids who had a cesarean birth, 145 women with fibroids who had a cesarean birth and no myomectomy, and 51 women with fibroids who had a cesarean hysterectomy. The investigators reported no significant differences in preoperative to postoperative hemoglobin change, incidence of postoperative fever, or length of hospital stay among the 4 groups.8 The authors concluded that myomectomy during cesarean birth was a safe and effective procedure.
Continue to: A systematic review and meta-analysis reported...
A systematic review and meta-analysis reported on the results of 17 studies which included 4,702 women who had a cesarean myomectomy and 1,843 women with cesarean birth without myomectomy.17 The authors of the meta-analysis noted that most reported case series had excluded women with a high risk of bleeding, including women with placenta previa, placenta accreta, coagulation disorders, and a history of multiple myomectomy operations. The investigators reported that, compared with the control women, the women undergoing cesarean myomectomy had a statistically significant but clinically insignificant decrease in mean hemoglobin concentration (-0.27 g/dL), a significant increase in mean operative time (+15 minutes) and a significant increase in the length of hospital stay (+0.36 days). There was an increase in the need for blood transfusion (risk ratio, 1.45; 95% confidence interval, 1.05–1.99), but only 3% of women undergoing cesarean myomectomy received a blood transfusion. There was no significant difference between the two groups in the incidence of postoperative fever. The authors concluded that cesarean myomectomy is a safe procedure when performed by experienced surgeons with appropriate hemostatic techniques.
Techniques to reduce blood loss at the time of cesarean myomectomy
A detailed review of all the available techniques to reduce blood loss at the time of cesarean myomectomy is beyond the scope of this editorial. All gynecologists know that control of uterine blood flow through the uterine artery, infundibulopelvic vessels and internal iliac artery can help to reduce bleeding at the time of myomectomy. Tourniquets, vascular clamps, and artery ligation all have been reported to be useful at the time of cesarean myomectomy. In addition, intravenous infusion of oxytocin and tranexamic acid is often used at the time of cesarean myomectomy. Direct injection of uterotonics, including carbetocin, oxytocin, and vasopressin, into the uterus also has been reported. Cell saver blood salvage technology has been utilized in a limited number of cases of cesarean myomectomy.8,18,19
Medicine is not a static field
Discoveries and new data help guide advances in medical practice. After 6 decades of strict adherence to the advice that myomectomy in pregnancy should be avoided at all costs, including at caesarean delivery, new data indicate that in carefully selected cases cesarean myomectomy is an acceptable operation. ●
Uterine leiomyomata (fibroids) are the most common pelvic tumor of women. When women are planning to conceive, and their fibroid(s) are clinically significant, causing abnormal uterine bleeding or bulk symptoms, it is often optimal to remove the uterine tumor(s) before conception. Advances in minimally invasive surgery offer women the option of laparoscopic or robot-assisted myomectomy with a low rate of operative complications, including excessive blood loss and hysterectomy, and a low rate of postoperative complications, including major pelvic adhesions and uterine rupture during subsequent pregnancy.1-3 However, many women become pregnant when they have clinically significant fibroids, and at least one-third of these women will have a cesarean birth.
Important clinical issues are the relative benefits and risks of performing a myomectomy at the time of the cesarean birth, so called cesarean myomectomy. Cesarean myomectomy offers carefully selected women the opportunity to have a cesarean birth and myomectomy in one operation, thereby avoiding a second major operation. Over the past 6 decades, most experts in the United States and the United Kingdom have strongly recommended against myomectomy at the time of cesarean delivery because of the risk of excessive blood loss and hysterectomy. Recently, expert opinion has shifted, especially in continental Europe and Asia, and cesarean myomectomy is now viewed as an acceptable surgical option in a limited number of clinical situations, including removal of pedunculated fibroids, excision of large solitary subserosal fibroids, and to achieve optimal management of the hysterotomy incision.
Decades of expert guidance: Avoid cesarean myomectomy at all costs
Dr. K.S.J. Olah succinctly captured the standard teaching that cesarean myomectomy should be avoided in this personal vignette:
Many years ago as a trainee I removed a subserosal fibroid during a cesarean section that was hanging by a thin stalk on the back of the uterus. The berating I received was severe and disproportionate to the crime. The rule was that myomectomy performed at cesarean section was not just frowned upon but expressly forbidden. It has always been considered foolish to consider removing fibroids at cesarean section, mostly because of the associated morbidity and the risk of haemorrhage requiring hysterectomy.4
Dr. Olah quoted guidance from Shaw’s Textbook of Operative Gynaecology,5 “It should be stressed that myomectomy in pregnancy should be avoided at all costs, including at caesarean section.” However, large case series published over the past 10 years report that, in limited clinical situations, cesarean myomectomy is a viable surgical option, where benefit may outweigh risk.6-14 The current literature has many weaknesses, including failure to specifically identify the indication for the cesarean myomectomy and lack of controlled prospective clinical trials. In almost all cases, cesarean myomectomy is performed after delivery of the fetus and placenta.
Continue to: The pedunculated, FIGO type 7 fibroid...
The pedunculated, FIGO type 7 fibroid
The International Federation of Gynecology and Obstetrics (FIGO) leiomyoma classification system identifies subserosal pedunculated fibroids as type 7 (FIGURE).15 Pedunculated fibroids are attached to the uterus by a stalk that is ≤10% of the mean of the 3 diameters of the fibroid. When a clinically significant pedunculated fibroid, causing bulk symptoms, is encountered at cesarean birth, I recommend that it be removed. This will save many patients a second major operation to perform a myomectomy. The surgical risk of removing a pedunculated is low.
The solitary FIGO type 6 fibroid
Type 6 fibroids are subserosal fibroids with less than 50% of their mass being subserosal. The type 6 fibroid is relatively easy to enucleate from the uterus. Following removal of a type 6 fibroid, closure of the serosal defect is relatively straightforward. In carefully selected cases, if the type 6 fibroid is causing bulk symptoms, cesarean myomectomy may be indicated with a low risk of operative complications.
The FIGO type 2-5 fibroid
The type 2-5 fibroid is a transmural fibroid with significant mass abutting both the endometrial cavity and serosal surface. Excision of a type 2-5 fibroid is likely to result in a large transmyometrial defect that will be more difficult to close and could be associated with greater blood loss. Although data are limited, I would recommend against cesarean myomectomy for type 2-5 fibroids in most clinical situations.
Myomectomy to achieve optimal management of the cesarean hysterotomy incision
Many surgeons performing a cesarean birth for a woman with clinically significant fibroids will plan the hysterotomy incision to avoid the fibroids. However, following delivery and contraction of the uterus, proper closure of the hysterotomy incision may be very difficult without removing a fibroid that is abutting the hysterotomy incision. Surgeons have reported performing myomectomy on lower uterine segment fibroids before making the hysterotomy incision in order to facilitate the hysterotomy incision and closure.16 Myomectomy prior to delivery of the newborn must be associated with additional risks to the fetus. I would prefer to identify an optimal site to perform a hysterotomy, deliver the newborn and placenta, and then consider myomectomy.
Complications associated with cesarean myomectomy
The evidence concerning the complications of cesarean birth plus myomectomy compared with cesarean birth alone in women with fibroids is limited to case series. There are no reported controlled clinical trials to guide practice. The largest single case series reported on 1,242 women with fibroids who had a cesarean birth plus myomectomy compared with 3 control groups, including 200 women without fibroids who had a cesarean birth, 145 women with fibroids who had a cesarean birth and no myomectomy, and 51 women with fibroids who had a cesarean hysterectomy. The investigators reported no significant differences in preoperative to postoperative hemoglobin change, incidence of postoperative fever, or length of hospital stay among the 4 groups.8 The authors concluded that myomectomy during cesarean birth was a safe and effective procedure.
Continue to: A systematic review and meta-analysis reported...
A systematic review and meta-analysis reported on the results of 17 studies which included 4,702 women who had a cesarean myomectomy and 1,843 women with cesarean birth without myomectomy.17 The authors of the meta-analysis noted that most reported case series had excluded women with a high risk of bleeding, including women with placenta previa, placenta accreta, coagulation disorders, and a history of multiple myomectomy operations. The investigators reported that, compared with the control women, the women undergoing cesarean myomectomy had a statistically significant but clinically insignificant decrease in mean hemoglobin concentration (-0.27 g/dL), a significant increase in mean operative time (+15 minutes) and a significant increase in the length of hospital stay (+0.36 days). There was an increase in the need for blood transfusion (risk ratio, 1.45; 95% confidence interval, 1.05–1.99), but only 3% of women undergoing cesarean myomectomy received a blood transfusion. There was no significant difference between the two groups in the incidence of postoperative fever. The authors concluded that cesarean myomectomy is a safe procedure when performed by experienced surgeons with appropriate hemostatic techniques.
Techniques to reduce blood loss at the time of cesarean myomectomy
A detailed review of all the available techniques to reduce blood loss at the time of cesarean myomectomy is beyond the scope of this editorial. All gynecologists know that control of uterine blood flow through the uterine artery, infundibulopelvic vessels and internal iliac artery can help to reduce bleeding at the time of myomectomy. Tourniquets, vascular clamps, and artery ligation all have been reported to be useful at the time of cesarean myomectomy. In addition, intravenous infusion of oxytocin and tranexamic acid is often used at the time of cesarean myomectomy. Direct injection of uterotonics, including carbetocin, oxytocin, and vasopressin, into the uterus also has been reported. Cell saver blood salvage technology has been utilized in a limited number of cases of cesarean myomectomy.8,18,19
Medicine is not a static field
Discoveries and new data help guide advances in medical practice. After 6 decades of strict adherence to the advice that myomectomy in pregnancy should be avoided at all costs, including at caesarean delivery, new data indicate that in carefully selected cases cesarean myomectomy is an acceptable operation. ●
- Pitter MC, Gargiulo AR, Bonaventura LM, et al. Pregnancy outcomes following robot-assisted myomectomy. Hum Reprod. 2013;28:99-108.
- Pitter MC, Srouji SS, Gargiulo AR, et al. Fertility and symptom relief following robot-assisted laparoscopic myomectomy. Obstet Gynecol Int. 2015;2015:967568.
- Huberlant S, Lenot J, Neron M, et al. Fertility and obstetric outcomes after robot-assisted laparoscopic myomectomy. Int J Med Robot. 2020;16:e2059.
- Olah KSJ. Caesarean myomectomy: TE or not TE? BJOG. 2018;125:501.
- Shaw, et al. Textbook of Operative Gynaecology. Edinburgh: Churchill Livingston; 1977.
- Burton CA, Grimes DA, March CM. Surgical management of leiomyomata during pregnancy. Obstet Gynecol. 1989;74:707-709.
- Ortac F, Gungor M, Sonmezer M. Myomectomy during cesarean section. Int J Gynaecol Obstet. 1999;67:189-193.
- Li H, Du J, Jin L, et al. Myomectomy during cesarean section. Acta Obstetricia et Gynecologica. 2009;88:183-186.
- Kwon DH, Song JE, Yoon KR, et al. Obstet Gynecol Sci. 2014;57:367-372.
- Senturk MB, Polat M, Dogan O, et al. Outcome of cesarean myomectomy: is it a safe procedure? Geburtshilfe Frauenheilkd. 2017;77:1200-1206.
- Chauhan AR. Cesarean myomectomy: necessity or opportunity? J Obstet Gynecol India. 2018;68:432-436.
- Sparic R, Kadija S, Stefanovic A, et al. Cesarean myomectomy in modern obstetrics: more light and fewer shadows. J Obstet Gynaecol Res. 2017;43:798-804.
- Ramya T, Sabnis SS, Chitra TV, et al. Cesarean myomectomy: an experience from a tertiary care teaching hospital. J Obstet Gynaecol India. 2019;69:426-430.
- Zhao R, Wang X, Zou L, et al. Outcomes of myomectomy at the time of cesarean section among pregnant women with uterine fibroids: a retrospective cohort study. Biomed Res Int. 2019;7576934.
- Munro MG, Critchley HOD, Fraser IS; FIGO Menstrual Disorders Committee. The two FIGO systems for normal and abnormal uterine bleeding symptoms and classification of causes of abnormal uterine bleeding in the reproductive years: 2018 revisions. In J Gynaecol Obstet. 2018;143:393.
- Omar SZ, Sivanesaratnam V, Damodaran P. Large lower segment myoma—myomectomy at lower segment caesarean section—a report of two cases. Singapore Med J. 1999;40:109-110.
- Goyal M, Dawood AS, Elbohoty SB, et al. Cesarean myomectomy in the last ten years; A true shift from contraindication to indication: a systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2021;256:145-157.
- Lin JY, Lee WL, Wang PH, et al. Uterine artery occlusion and myomectomy for treatment of pregnant women with uterine leiomyomas who are undergoing caesarean section. J Obstet Gynecol Res. 2010;36:284-290.
- Alfred E, Joy G, Uduak O, et al. Cesarean myomectomy outcome in a Nigerian hospital district hospital. J Basic Clin Reprod Sci. 2013;2:115-118.
- Pitter MC, Gargiulo AR, Bonaventura LM, et al. Pregnancy outcomes following robot-assisted myomectomy. Hum Reprod. 2013;28:99-108.
- Pitter MC, Srouji SS, Gargiulo AR, et al. Fertility and symptom relief following robot-assisted laparoscopic myomectomy. Obstet Gynecol Int. 2015;2015:967568.
- Huberlant S, Lenot J, Neron M, et al. Fertility and obstetric outcomes after robot-assisted laparoscopic myomectomy. Int J Med Robot. 2020;16:e2059.
- Olah KSJ. Caesarean myomectomy: TE or not TE? BJOG. 2018;125:501.
- Shaw, et al. Textbook of Operative Gynaecology. Edinburgh: Churchill Livingston; 1977.
- Burton CA, Grimes DA, March CM. Surgical management of leiomyomata during pregnancy. Obstet Gynecol. 1989;74:707-709.
- Ortac F, Gungor M, Sonmezer M. Myomectomy during cesarean section. Int J Gynaecol Obstet. 1999;67:189-193.
- Li H, Du J, Jin L, et al. Myomectomy during cesarean section. Acta Obstetricia et Gynecologica. 2009;88:183-186.
- Kwon DH, Song JE, Yoon KR, et al. Obstet Gynecol Sci. 2014;57:367-372.
- Senturk MB, Polat M, Dogan O, et al. Outcome of cesarean myomectomy: is it a safe procedure? Geburtshilfe Frauenheilkd. 2017;77:1200-1206.
- Chauhan AR. Cesarean myomectomy: necessity or opportunity? J Obstet Gynecol India. 2018;68:432-436.
- Sparic R, Kadija S, Stefanovic A, et al. Cesarean myomectomy in modern obstetrics: more light and fewer shadows. J Obstet Gynaecol Res. 2017;43:798-804.
- Ramya T, Sabnis SS, Chitra TV, et al. Cesarean myomectomy: an experience from a tertiary care teaching hospital. J Obstet Gynaecol India. 2019;69:426-430.
- Zhao R, Wang X, Zou L, et al. Outcomes of myomectomy at the time of cesarean section among pregnant women with uterine fibroids: a retrospective cohort study. Biomed Res Int. 2019;7576934.
- Munro MG, Critchley HOD, Fraser IS; FIGO Menstrual Disorders Committee. The two FIGO systems for normal and abnormal uterine bleeding symptoms and classification of causes of abnormal uterine bleeding in the reproductive years: 2018 revisions. In J Gynaecol Obstet. 2018;143:393.
- Omar SZ, Sivanesaratnam V, Damodaran P. Large lower segment myoma—myomectomy at lower segment caesarean section—a report of two cases. Singapore Med J. 1999;40:109-110.
- Goyal M, Dawood AS, Elbohoty SB, et al. Cesarean myomectomy in the last ten years; A true shift from contraindication to indication: a systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2021;256:145-157.
- Lin JY, Lee WL, Wang PH, et al. Uterine artery occlusion and myomectomy for treatment of pregnant women with uterine leiomyomas who are undergoing caesarean section. J Obstet Gynecol Res. 2010;36:284-290.
- Alfred E, Joy G, Uduak O, et al. Cesarean myomectomy outcome in a Nigerian hospital district hospital. J Basic Clin Reprod Sci. 2013;2:115-118.
Nature or nurture in primary care?
Does the name Bruce Lipton sound familiar to you? Until a few years ago the only bell that it rang with me was that I had a high school classmate named Bruce Lipton. I recall that his father owned the local grocery store and he was one of the most prolific pranksters in a class with a long history of prank playing. If the name dredges up any associations for you it may because you have heard of a PhD biologist who has written and lectured extensively on epigenetics. You may have even read his most widely published book, “The Biology of Belief.” It turns out the Epigenetics Guy and my high school prankster classmate are one and the same.
After decades of separation – he is in California and I’m here in Maine – we have reconnected via Zoom mini reunions that our class has organized to combat the isolation that has descended on us with the pandemic. While I haven’t read his books, I have watched and listened to some of his podcasts and lectures. The devilish twinkle in his eye in the 1950s and 1960s has provided the scaffolding on which he has built a charismatic and persuasive presentation style.
Bruce was no dummy in school but his early career as a cell biologist doing research in stem-cell function was a surprise to all of us. But then high school reunions are often full of surprises and should serve as good reminders of the danger of profiling and pigeon-holing adolescents.
Professor Lipton’s take on epigenetics boils down to the notion that our genome should merely be considered a blueprint and not the final determinant of who we are and what illnesses befall us. His research and observations suggest to him that there are an uncountable number extragenomic factors, including environmental conditions and our belief systems, that can influence how that blueprint is read and the resulting expression of the genes we have inherited.
At face value, Bruce’s basic premise falls very close to some of the conclusions I have toyed with in an attempt to explain what I have observed doing primary care pediatrics. For example, I have trouble blaming the meteoric rise of the ADHD phenomenon on a genetic mutation. I suspect there are likely to be extragenomic forces coming into play, such as sleep deprivation and changing child-rearing practices. In my Oct. 9, 2020, Letters from Maine column I referred to a Swedish twins study that suggested children from a family with a strong history of depression were more likely to develop depression when raised in an adopted family that experienced domestic turmoil. His philosophy also fits with my sense that I have more control over my own health outcomes than many other people.
However, Professor Lipton and I part company (just philosophically that is) when he slips into hyperbole and applies what he terms as the New Biology too broadly. He may be correct that the revolutionary changes which came in the wake of Watson and Crick’s double helix discovery have resulted in a view of pathophysiology that is overly focused on what we are learning about our genome. On the other hand it is refreshing to hear someone with his charismatic and persuasive skills question the status quo.
If you haven’t listened to what he has to say I urge you to browse the Internet and sample some of his talks. I am sure you will find what he has to say stimulating. I doubt you will buy his whole package but I suspect you may find some bits you can agree with.
It still boils down to the old nature versus nurture argument. He’s all in for nurture. I’m still more comfortable straddling the fence.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.
Does the name Bruce Lipton sound familiar to you? Until a few years ago the only bell that it rang with me was that I had a high school classmate named Bruce Lipton. I recall that his father owned the local grocery store and he was one of the most prolific pranksters in a class with a long history of prank playing. If the name dredges up any associations for you it may because you have heard of a PhD biologist who has written and lectured extensively on epigenetics. You may have even read his most widely published book, “The Biology of Belief.” It turns out the Epigenetics Guy and my high school prankster classmate are one and the same.
After decades of separation – he is in California and I’m here in Maine – we have reconnected via Zoom mini reunions that our class has organized to combat the isolation that has descended on us with the pandemic. While I haven’t read his books, I have watched and listened to some of his podcasts and lectures. The devilish twinkle in his eye in the 1950s and 1960s has provided the scaffolding on which he has built a charismatic and persuasive presentation style.
Bruce was no dummy in school but his early career as a cell biologist doing research in stem-cell function was a surprise to all of us. But then high school reunions are often full of surprises and should serve as good reminders of the danger of profiling and pigeon-holing adolescents.
Professor Lipton’s take on epigenetics boils down to the notion that our genome should merely be considered a blueprint and not the final determinant of who we are and what illnesses befall us. His research and observations suggest to him that there are an uncountable number extragenomic factors, including environmental conditions and our belief systems, that can influence how that blueprint is read and the resulting expression of the genes we have inherited.
At face value, Bruce’s basic premise falls very close to some of the conclusions I have toyed with in an attempt to explain what I have observed doing primary care pediatrics. For example, I have trouble blaming the meteoric rise of the ADHD phenomenon on a genetic mutation. I suspect there are likely to be extragenomic forces coming into play, such as sleep deprivation and changing child-rearing practices. In my Oct. 9, 2020, Letters from Maine column I referred to a Swedish twins study that suggested children from a family with a strong history of depression were more likely to develop depression when raised in an adopted family that experienced domestic turmoil. His philosophy also fits with my sense that I have more control over my own health outcomes than many other people.
However, Professor Lipton and I part company (just philosophically that is) when he slips into hyperbole and applies what he terms as the New Biology too broadly. He may be correct that the revolutionary changes which came in the wake of Watson and Crick’s double helix discovery have resulted in a view of pathophysiology that is overly focused on what we are learning about our genome. On the other hand it is refreshing to hear someone with his charismatic and persuasive skills question the status quo.
If you haven’t listened to what he has to say I urge you to browse the Internet and sample some of his talks. I am sure you will find what he has to say stimulating. I doubt you will buy his whole package but I suspect you may find some bits you can agree with.
It still boils down to the old nature versus nurture argument. He’s all in for nurture. I’m still more comfortable straddling the fence.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.
Does the name Bruce Lipton sound familiar to you? Until a few years ago the only bell that it rang with me was that I had a high school classmate named Bruce Lipton. I recall that his father owned the local grocery store and he was one of the most prolific pranksters in a class with a long history of prank playing. If the name dredges up any associations for you it may because you have heard of a PhD biologist who has written and lectured extensively on epigenetics. You may have even read his most widely published book, “The Biology of Belief.” It turns out the Epigenetics Guy and my high school prankster classmate are one and the same.
After decades of separation – he is in California and I’m here in Maine – we have reconnected via Zoom mini reunions that our class has organized to combat the isolation that has descended on us with the pandemic. While I haven’t read his books, I have watched and listened to some of his podcasts and lectures. The devilish twinkle in his eye in the 1950s and 1960s has provided the scaffolding on which he has built a charismatic and persuasive presentation style.
Bruce was no dummy in school but his early career as a cell biologist doing research in stem-cell function was a surprise to all of us. But then high school reunions are often full of surprises and should serve as good reminders of the danger of profiling and pigeon-holing adolescents.
Professor Lipton’s take on epigenetics boils down to the notion that our genome should merely be considered a blueprint and not the final determinant of who we are and what illnesses befall us. His research and observations suggest to him that there are an uncountable number extragenomic factors, including environmental conditions and our belief systems, that can influence how that blueprint is read and the resulting expression of the genes we have inherited.
At face value, Bruce’s basic premise falls very close to some of the conclusions I have toyed with in an attempt to explain what I have observed doing primary care pediatrics. For example, I have trouble blaming the meteoric rise of the ADHD phenomenon on a genetic mutation. I suspect there are likely to be extragenomic forces coming into play, such as sleep deprivation and changing child-rearing practices. In my Oct. 9, 2020, Letters from Maine column I referred to a Swedish twins study that suggested children from a family with a strong history of depression were more likely to develop depression when raised in an adopted family that experienced domestic turmoil. His philosophy also fits with my sense that I have more control over my own health outcomes than many other people.
However, Professor Lipton and I part company (just philosophically that is) when he slips into hyperbole and applies what he terms as the New Biology too broadly. He may be correct that the revolutionary changes which came in the wake of Watson and Crick’s double helix discovery have resulted in a view of pathophysiology that is overly focused on what we are learning about our genome. On the other hand it is refreshing to hear someone with his charismatic and persuasive skills question the status quo.
If you haven’t listened to what he has to say I urge you to browse the Internet and sample some of his talks. I am sure you will find what he has to say stimulating. I doubt you will buy his whole package but I suspect you may find some bits you can agree with.
It still boils down to the old nature versus nurture argument. He’s all in for nurture. I’m still more comfortable straddling the fence.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.
Home Phototherapy During the COVID-19 Pandemic
Office-based phototherapy practices have closed or are operating below capacity because of the coronavirus disease 2019 (COVID-19) pandemic.1 Social distancing measures to reduce virus transmission are a significant driving factor.1-3 In the age of biologics, other options requiring fewer patient visits are available, such as UVB phototherapy. UV phototherapy is considered first line when more than 10% of the body surface area is affected.4 Although phototherapy often is performed in the office, it also may be delivered at home.2 Home-based phototherapy is safe, effective, and similar in cost to office-based phototherapy.4 Currently, there are limited COVID-19–specific guidelines for home-based phototherapy.
The risks and sequelae of COVID-19 are still being investigated, with cases varying by location. As such, local and national public health recommendations are evolving. Dermatologists must make individualized decisions about practice services, as local restrictions differ. As office-based phototherapy services may struggle to implement mitigation strategies, home-based phototherapy is an increasingly viable treatment option.1,4,5 Patient benefits of home therapy include improved treatment compliance; greater patient satisfaction; reduced travel/waiting time; and reduced long-term cost, including co-pays, depending on insurance coverage.2,4
We aim to provide recommendations on home-based phototherapy during the pandemic. Throughout the decision-making process, careful consideration of safety, risks, benefits, and treatment options for physicians, staff, and patients will be vital to the successful implementation of home-based phototherapy. Our recommendations are based on maximizing benefits and minimizing risks.
Considerations for Physicians
Physicians should take the following steps when assessing if home phototherapy is an option for each patient.1,2,4
• Determine patient eligibility for phototherapy treatment if currently not on phototherapy
• Carefully review patient and provider requirements for home phototherapy supplier
• Review patient history of treatment compliance
• Determine insurance coverage and consider exclusion criteria
• Review prior treatments
• Provide education on side effects
• Provide education on signs of adequate treatment response
• Indicate the type of UV light and unit on the prescription
• Consider whether the patient is in the maintenance or initiation phase when providing recommendations
• Work with the supplier if the light therapy unit is denied by submitting an appeal or prescribing a different unit
• Follow up with telemedicine to assess treatment effectiveness and monitor for adverse effects
Considerations for Patients
Counsel patients to weigh the risks and benefits of home phototherapy prescription and usage.1,2,4
• Evaluate cost
• Carefully review patient and provider requirements for home phototherapy supplier
• Ensure a complete understanding of treatment schedule
• Properly utilize protective equipment (eg, genital shields for men, eye shields for all)
• Avoid sharing phototherapy units with household members
• Disinfect and maintain units
• Maintain proper ventilation of spaces
• Maintain treatment log
• Attend follow-up
Treatment Alternatives
For patients with severe psoriasis, there are alternative treatments to office and home phototherapy. Biologics, immunosuppressive therapies, and other treatment options may be considered on a case-by-case basis.3,4,6 Currently, recommendations for the risk of COVID-19 with biologics or systemic immunosuppressive therapies remains inconsistent and should be carefully considered when providing alternative treatments.7-11
Final Thoughts
As restrictions are lifted according to local public health measures, prepandemic office phototherapy practices may resume operations. Home phototherapy is a practical and effective alternative for treatment of psoriasis when access to the office setting is limited.
- Lim HW, Feldman SR, Van Voorhees AS, et al. Recommendations for phototherapy during the COVID-19 pandemic. J Am Acad Dermatol. 2020;83:287-288.
Anderson KL, Feldman SR. A guide to prescribing home phototherapy for patients with psoriasis: the appropriate patient, the type of unit, the treatment regimen, and the potential obstacles. J Am Acad Dermatol. 2015;72:868.E1-878.E1. - Palmore TN, Smith BA. Coronavirus disease 2019 (COVID-19): infection control in health care and home settings. UpToDate. Updated January 7, 2021. Accessed January 25, 2021.https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19-infection-control-in-health-care-and-home-settings
- Koek MB, Buskens E, van Weelden H, et al. Home versus outpatient ultraviolet B phototherapy for mild to severe psoriasis: pragmatic multicentre randomised controlled non-inferiority trial (PLUTO study). BMJ. 2009;338:b1542.
- Sadeghinia A, Daneshpazhooh M. Immunosuppressive drugs for patients with psoriasis during the COVID-19 pandemic era. a review [published online November 3, 2020]. Dermatol Ther. 2020:E14498. doi:10.1111/dth.14498
- Damiani G, Pacifico A, Bragazzi NL, et al. Biologics increase the risk of SARS-CoV-2 infection and hospitalization, but not ICU admission and death: real-life data from a large cohort during red-zone declaration. Dermatol Ther. 2020;33:E13475.
- Lebwohl M, Rivera-Oyola R, Murrell DF. Should biologics for psoriasis be interrupted in the era of COVID-19? J Am Acad Dermatol. 2020;82:1217-1218.
- Mehta P, Ciurtin C, Scully M, et al. JAK inhibitors in COVID-19: the need for vigilance regarding increased inherent thrombotic risk. Eur Respir J. 2020;56:2001919.
- Walz L, Cohen AJ, Rebaza AP, et al. JAK-inhibitor and type I interferon ability to produce favorable clinical outcomes in COVID-19 patients: a systematic review and meta-analysis. BMC Infect Dis. 2021;21:47.
- Carugno A, Gambini DM, Raponi F, et al. COVID-19 and biologics for psoriasis: a high-epidemic area experience-Bergamo, Lombardy, Italy. J Am Acad Dermatol. 2020;83:292-294.
- Gisondi P, Piaserico S, Naldi L, et al. Incidence rates of hospitalization and death from COVID-19 in patients with psoriasis receiving biological treatment: a Northern Italy experience [published online November 5, 2020]. J Allergy Clin Immunol. doi:10.1016/j.jaci.2020.10.032
Office-based phototherapy practices have closed or are operating below capacity because of the coronavirus disease 2019 (COVID-19) pandemic.1 Social distancing measures to reduce virus transmission are a significant driving factor.1-3 In the age of biologics, other options requiring fewer patient visits are available, such as UVB phototherapy. UV phototherapy is considered first line when more than 10% of the body surface area is affected.4 Although phototherapy often is performed in the office, it also may be delivered at home.2 Home-based phototherapy is safe, effective, and similar in cost to office-based phototherapy.4 Currently, there are limited COVID-19–specific guidelines for home-based phototherapy.
The risks and sequelae of COVID-19 are still being investigated, with cases varying by location. As such, local and national public health recommendations are evolving. Dermatologists must make individualized decisions about practice services, as local restrictions differ. As office-based phototherapy services may struggle to implement mitigation strategies, home-based phototherapy is an increasingly viable treatment option.1,4,5 Patient benefits of home therapy include improved treatment compliance; greater patient satisfaction; reduced travel/waiting time; and reduced long-term cost, including co-pays, depending on insurance coverage.2,4
We aim to provide recommendations on home-based phototherapy during the pandemic. Throughout the decision-making process, careful consideration of safety, risks, benefits, and treatment options for physicians, staff, and patients will be vital to the successful implementation of home-based phototherapy. Our recommendations are based on maximizing benefits and minimizing risks.
Considerations for Physicians
Physicians should take the following steps when assessing if home phototherapy is an option for each patient.1,2,4
• Determine patient eligibility for phototherapy treatment if currently not on phototherapy
• Carefully review patient and provider requirements for home phototherapy supplier
• Review patient history of treatment compliance
• Determine insurance coverage and consider exclusion criteria
• Review prior treatments
• Provide education on side effects
• Provide education on signs of adequate treatment response
• Indicate the type of UV light and unit on the prescription
• Consider whether the patient is in the maintenance or initiation phase when providing recommendations
• Work with the supplier if the light therapy unit is denied by submitting an appeal or prescribing a different unit
• Follow up with telemedicine to assess treatment effectiveness and monitor for adverse effects
Considerations for Patients
Counsel patients to weigh the risks and benefits of home phototherapy prescription and usage.1,2,4
• Evaluate cost
• Carefully review patient and provider requirements for home phototherapy supplier
• Ensure a complete understanding of treatment schedule
• Properly utilize protective equipment (eg, genital shields for men, eye shields for all)
• Avoid sharing phototherapy units with household members
• Disinfect and maintain units
• Maintain proper ventilation of spaces
• Maintain treatment log
• Attend follow-up
Treatment Alternatives
For patients with severe psoriasis, there are alternative treatments to office and home phototherapy. Biologics, immunosuppressive therapies, and other treatment options may be considered on a case-by-case basis.3,4,6 Currently, recommendations for the risk of COVID-19 with biologics or systemic immunosuppressive therapies remains inconsistent and should be carefully considered when providing alternative treatments.7-11
Final Thoughts
As restrictions are lifted according to local public health measures, prepandemic office phototherapy practices may resume operations. Home phototherapy is a practical and effective alternative for treatment of psoriasis when access to the office setting is limited.
Office-based phototherapy practices have closed or are operating below capacity because of the coronavirus disease 2019 (COVID-19) pandemic.1 Social distancing measures to reduce virus transmission are a significant driving factor.1-3 In the age of biologics, other options requiring fewer patient visits are available, such as UVB phototherapy. UV phototherapy is considered first line when more than 10% of the body surface area is affected.4 Although phototherapy often is performed in the office, it also may be delivered at home.2 Home-based phototherapy is safe, effective, and similar in cost to office-based phototherapy.4 Currently, there are limited COVID-19–specific guidelines for home-based phototherapy.
The risks and sequelae of COVID-19 are still being investigated, with cases varying by location. As such, local and national public health recommendations are evolving. Dermatologists must make individualized decisions about practice services, as local restrictions differ. As office-based phototherapy services may struggle to implement mitigation strategies, home-based phototherapy is an increasingly viable treatment option.1,4,5 Patient benefits of home therapy include improved treatment compliance; greater patient satisfaction; reduced travel/waiting time; and reduced long-term cost, including co-pays, depending on insurance coverage.2,4
We aim to provide recommendations on home-based phototherapy during the pandemic. Throughout the decision-making process, careful consideration of safety, risks, benefits, and treatment options for physicians, staff, and patients will be vital to the successful implementation of home-based phototherapy. Our recommendations are based on maximizing benefits and minimizing risks.
Considerations for Physicians
Physicians should take the following steps when assessing if home phototherapy is an option for each patient.1,2,4
• Determine patient eligibility for phototherapy treatment if currently not on phototherapy
• Carefully review patient and provider requirements for home phototherapy supplier
• Review patient history of treatment compliance
• Determine insurance coverage and consider exclusion criteria
• Review prior treatments
• Provide education on side effects
• Provide education on signs of adequate treatment response
• Indicate the type of UV light and unit on the prescription
• Consider whether the patient is in the maintenance or initiation phase when providing recommendations
• Work with the supplier if the light therapy unit is denied by submitting an appeal or prescribing a different unit
• Follow up with telemedicine to assess treatment effectiveness and monitor for adverse effects
Considerations for Patients
Counsel patients to weigh the risks and benefits of home phototherapy prescription and usage.1,2,4
• Evaluate cost
• Carefully review patient and provider requirements for home phototherapy supplier
• Ensure a complete understanding of treatment schedule
• Properly utilize protective equipment (eg, genital shields for men, eye shields for all)
• Avoid sharing phototherapy units with household members
• Disinfect and maintain units
• Maintain proper ventilation of spaces
• Maintain treatment log
• Attend follow-up
Treatment Alternatives
For patients with severe psoriasis, there are alternative treatments to office and home phototherapy. Biologics, immunosuppressive therapies, and other treatment options may be considered on a case-by-case basis.3,4,6 Currently, recommendations for the risk of COVID-19 with biologics or systemic immunosuppressive therapies remains inconsistent and should be carefully considered when providing alternative treatments.7-11
Final Thoughts
As restrictions are lifted according to local public health measures, prepandemic office phototherapy practices may resume operations. Home phototherapy is a practical and effective alternative for treatment of psoriasis when access to the office setting is limited.
- Lim HW, Feldman SR, Van Voorhees AS, et al. Recommendations for phototherapy during the COVID-19 pandemic. J Am Acad Dermatol. 2020;83:287-288.
Anderson KL, Feldman SR. A guide to prescribing home phototherapy for patients with psoriasis: the appropriate patient, the type of unit, the treatment regimen, and the potential obstacles. J Am Acad Dermatol. 2015;72:868.E1-878.E1. - Palmore TN, Smith BA. Coronavirus disease 2019 (COVID-19): infection control in health care and home settings. UpToDate. Updated January 7, 2021. Accessed January 25, 2021.https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19-infection-control-in-health-care-and-home-settings
- Koek MB, Buskens E, van Weelden H, et al. Home versus outpatient ultraviolet B phototherapy for mild to severe psoriasis: pragmatic multicentre randomised controlled non-inferiority trial (PLUTO study). BMJ. 2009;338:b1542.
- Sadeghinia A, Daneshpazhooh M. Immunosuppressive drugs for patients with psoriasis during the COVID-19 pandemic era. a review [published online November 3, 2020]. Dermatol Ther. 2020:E14498. doi:10.1111/dth.14498
- Damiani G, Pacifico A, Bragazzi NL, et al. Biologics increase the risk of SARS-CoV-2 infection and hospitalization, but not ICU admission and death: real-life data from a large cohort during red-zone declaration. Dermatol Ther. 2020;33:E13475.
- Lebwohl M, Rivera-Oyola R, Murrell DF. Should biologics for psoriasis be interrupted in the era of COVID-19? J Am Acad Dermatol. 2020;82:1217-1218.
- Mehta P, Ciurtin C, Scully M, et al. JAK inhibitors in COVID-19: the need for vigilance regarding increased inherent thrombotic risk. Eur Respir J. 2020;56:2001919.
- Walz L, Cohen AJ, Rebaza AP, et al. JAK-inhibitor and type I interferon ability to produce favorable clinical outcomes in COVID-19 patients: a systematic review and meta-analysis. BMC Infect Dis. 2021;21:47.
- Carugno A, Gambini DM, Raponi F, et al. COVID-19 and biologics for psoriasis: a high-epidemic area experience-Bergamo, Lombardy, Italy. J Am Acad Dermatol. 2020;83:292-294.
- Gisondi P, Piaserico S, Naldi L, et al. Incidence rates of hospitalization and death from COVID-19 in patients with psoriasis receiving biological treatment: a Northern Italy experience [published online November 5, 2020]. J Allergy Clin Immunol. doi:10.1016/j.jaci.2020.10.032
- Lim HW, Feldman SR, Van Voorhees AS, et al. Recommendations for phototherapy during the COVID-19 pandemic. J Am Acad Dermatol. 2020;83:287-288.
Anderson KL, Feldman SR. A guide to prescribing home phototherapy for patients with psoriasis: the appropriate patient, the type of unit, the treatment regimen, and the potential obstacles. J Am Acad Dermatol. 2015;72:868.E1-878.E1. - Palmore TN, Smith BA. Coronavirus disease 2019 (COVID-19): infection control in health care and home settings. UpToDate. Updated January 7, 2021. Accessed January 25, 2021.https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19-infection-control-in-health-care-and-home-settings
- Koek MB, Buskens E, van Weelden H, et al. Home versus outpatient ultraviolet B phototherapy for mild to severe psoriasis: pragmatic multicentre randomised controlled non-inferiority trial (PLUTO study). BMJ. 2009;338:b1542.
- Sadeghinia A, Daneshpazhooh M. Immunosuppressive drugs for patients with psoriasis during the COVID-19 pandemic era. a review [published online November 3, 2020]. Dermatol Ther. 2020:E14498. doi:10.1111/dth.14498
- Damiani G, Pacifico A, Bragazzi NL, et al. Biologics increase the risk of SARS-CoV-2 infection and hospitalization, but not ICU admission and death: real-life data from a large cohort during red-zone declaration. Dermatol Ther. 2020;33:E13475.
- Lebwohl M, Rivera-Oyola R, Murrell DF. Should biologics for psoriasis be interrupted in the era of COVID-19? J Am Acad Dermatol. 2020;82:1217-1218.
- Mehta P, Ciurtin C, Scully M, et al. JAK inhibitors in COVID-19: the need for vigilance regarding increased inherent thrombotic risk. Eur Respir J. 2020;56:2001919.
- Walz L, Cohen AJ, Rebaza AP, et al. JAK-inhibitor and type I interferon ability to produce favorable clinical outcomes in COVID-19 patients: a systematic review and meta-analysis. BMC Infect Dis. 2021;21:47.
- Carugno A, Gambini DM, Raponi F, et al. COVID-19 and biologics for psoriasis: a high-epidemic area experience-Bergamo, Lombardy, Italy. J Am Acad Dermatol. 2020;83:292-294.
- Gisondi P, Piaserico S, Naldi L, et al. Incidence rates of hospitalization and death from COVID-19 in patients with psoriasis receiving biological treatment: a Northern Italy experience [published online November 5, 2020]. J Allergy Clin Immunol. doi:10.1016/j.jaci.2020.10.032
Practice Points
- Home phototherapy is a safe and effective option for patients with psoriasis during the coronavirus disease 2019 (COVID-19) pandemic.
- Although a consensus has not been reached with systemic immunosuppressive therapies for patients with psoriasis and the risk of COVID-19, we continue to recommend caution and careful monitoring of clinical outcomes for patients.