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BCBSMA Rolls Back Restrictive Anesthesia Policy
In a significant victory for patients and healthcare providers, . The change is retroactive to Jan. 1, 2024, so no claims will be rejected for payment.
The decision follows intense advocacy efforts by a coalition that included AGA, the American Society of Anesthesiologists (ASA), and the American College of Surgeons (ACS), with the Massachusetts Gastroenterology Association demonstrating exceptional leadership and the Massachusetts Society of Anesthesiologists (MSA) persevering throughout the process. The BCBSMA heeded the coalition’s warnings about the potential impact on cancer screening access and patient choice in GI care.
Physician leaders representing the societies played a crucial role in meetings with BCBSMA, contributing to this positive outcome. Member engagement, including contacting legislators, media outreach, and participation in the #Noto154 campaign, had a substantial impact.
BCBSMA informed the societies that all claims will be paid; however, documentation will still be required for patients presenting with ASA 1 and ASA 2. Providers may download a list of commonly used diagnosis codes documented with the administration of propofol. The AGA encourages members to still be mindful that BCBSMA will be monitoring the use of these codes for propofol administration. Members can see BCBSMA policy 154 for the complete list of diagnosis codes that support use of MAC. The societies have requested that BCBSMA provide education to providers on this requirement.
The AGA intends to closely monitor developments to ensure similar policies are not introduced nationally.
In a significant victory for patients and healthcare providers, . The change is retroactive to Jan. 1, 2024, so no claims will be rejected for payment.
The decision follows intense advocacy efforts by a coalition that included AGA, the American Society of Anesthesiologists (ASA), and the American College of Surgeons (ACS), with the Massachusetts Gastroenterology Association demonstrating exceptional leadership and the Massachusetts Society of Anesthesiologists (MSA) persevering throughout the process. The BCBSMA heeded the coalition’s warnings about the potential impact on cancer screening access and patient choice in GI care.
Physician leaders representing the societies played a crucial role in meetings with BCBSMA, contributing to this positive outcome. Member engagement, including contacting legislators, media outreach, and participation in the #Noto154 campaign, had a substantial impact.
BCBSMA informed the societies that all claims will be paid; however, documentation will still be required for patients presenting with ASA 1 and ASA 2. Providers may download a list of commonly used diagnosis codes documented with the administration of propofol. The AGA encourages members to still be mindful that BCBSMA will be monitoring the use of these codes for propofol administration. Members can see BCBSMA policy 154 for the complete list of diagnosis codes that support use of MAC. The societies have requested that BCBSMA provide education to providers on this requirement.
The AGA intends to closely monitor developments to ensure similar policies are not introduced nationally.
In a significant victory for patients and healthcare providers, . The change is retroactive to Jan. 1, 2024, so no claims will be rejected for payment.
The decision follows intense advocacy efforts by a coalition that included AGA, the American Society of Anesthesiologists (ASA), and the American College of Surgeons (ACS), with the Massachusetts Gastroenterology Association demonstrating exceptional leadership and the Massachusetts Society of Anesthesiologists (MSA) persevering throughout the process. The BCBSMA heeded the coalition’s warnings about the potential impact on cancer screening access and patient choice in GI care.
Physician leaders representing the societies played a crucial role in meetings with BCBSMA, contributing to this positive outcome. Member engagement, including contacting legislators, media outreach, and participation in the #Noto154 campaign, had a substantial impact.
BCBSMA informed the societies that all claims will be paid; however, documentation will still be required for patients presenting with ASA 1 and ASA 2. Providers may download a list of commonly used diagnosis codes documented with the administration of propofol. The AGA encourages members to still be mindful that BCBSMA will be monitoring the use of these codes for propofol administration. Members can see BCBSMA policy 154 for the complete list of diagnosis codes that support use of MAC. The societies have requested that BCBSMA provide education to providers on this requirement.
The AGA intends to closely monitor developments to ensure similar policies are not introduced nationally.
Dueling Gut Bacteria Impact Chronic HBV Progression
, according to investigators.
While Ruminococcus gnavus promotes immune tolerance and therefore HBV persistence, Akkermansia muciniphila stimulates the immune system, promoting viral clearance, reported lead author Huey-Huey Chua, MD, of the National Taiwan University College of Medicine and Children’s Hospital, Taipei, and colleagues.
These findings could lead to new therapeutic strategies, such as administration of the secretory products of A. muciniphila, or provision of probiotics and prebiotics that tip the balance toward this more beneficial bacterium, the investigators wrote in Cellular and Molecular Gastroenterology and Hepatology.
Their study, which included data from both human patients and mouse models of CHB, was grounded in prior research showing a link between gut microbiota and the age-dependence of HBV immunity.
“Sterilization of the gut microbiota using antibiotics prevents adult mice from rapidly clearing HBV and restores the tolerance phenotype, implying that the gut microbiota may transmit signals to break liver tolerance and evoke rapid HBV clearance,” Dr. Chua and colleagues wrote. “We hypothesized that the wax and wane of gut microbiota signatures may determine the progression of CHB. We aimed to delineate what the pivotal bacteria are and how they manipulate the progression of CHB.”
They began by analyzing fecal samples from 102 patients with CHB either in the immune-tolerant (IT) or immune-active (IA) phase of infection.
R. gnavus was the most abundant species among IT patients, whereas A. muciniphila was most abundant among patients in the IA phase. Higher levels of A. muciniphila were also associated with early hepatitis B e-antigen (HBeAG) loss, HBeAG seroconversion, and flares of aminotransferase. A mouse model echoed these findings.
Further experiments with mouse models revealed that R. gnavus modulates bile acids to promote HBV persistence and prolongation of the IT course. In opposition, A. muciniphila removes cholesterol and secretes metabolites that inhibit growth and function of R. gnavus.
“These novel findings will certainly confer a groundbreaking impact on the future therapy of CHB,” Dr. Chua and colleagues wrote.
They went on to describe several therapeutic strategies worth further investigation.
“A key step to promote switching from the IT to IA phase is to lessen the richness of R. gnavus and bile acid bioconversion from cholesterol,” they wrote. The secretory products of A. muciniphila that successfully ameliorate the burden of R. gnavus outgrowth can be provided as useful means to induce anti-HBV efficacy. Also, the development of targeted probiotics or prebiotics that can modulate the gut microbiota composition to favor the beneficial effects of A. muciniphila while inhibiting the detrimental effects of R. gnavus may have translational value for CHB.”
The study was supported by the Ministry of Science and Technology, Executive Yuan, Taiwan and the Center of Precision Medicine from Featured Areas Research Center Program within the Framework of the Higher Education Sprout Project by the Ministry of Education in Taiwan. The investigators disclosed no conflicts of interest.
Clinical observations have long indicated that chronic hepatitis B (CHB) patients with a prolonged immune-tolerant (IT) phase are at a higher risk of liver diseases, while those with an early transition to the immune-active (IA) phase are associated with a better clinical outcome. However, the underlying mechanisms remain unclear.
This study merits attention as it marks an important advancement in our understanding of how gut microbiota affects the immune response and, in turn, the progression of CHB, offering insights for potential A. muciniphila–based therapies. Nonetheless, the research is still in its infancy, and further studies, including longitudinal analysis to determine gut microbiota changes from IT to IA, are required. The prospect of A. muciniphila supplementation could be beneficial for CHB patients, warranting clinical trials. Continued research could lead to improved management and prevention of liver diseases in this patient population with CHB.
Qirong Jiang, MD, and Dawu Zeng, MD, are based in the Hepatology Research Institute, the First Affiliated Hospital, Fujian Medical University, Fuzhou, China. They report no conflicts of interest.
Clinical observations have long indicated that chronic hepatitis B (CHB) patients with a prolonged immune-tolerant (IT) phase are at a higher risk of liver diseases, while those with an early transition to the immune-active (IA) phase are associated with a better clinical outcome. However, the underlying mechanisms remain unclear.
This study merits attention as it marks an important advancement in our understanding of how gut microbiota affects the immune response and, in turn, the progression of CHB, offering insights for potential A. muciniphila–based therapies. Nonetheless, the research is still in its infancy, and further studies, including longitudinal analysis to determine gut microbiota changes from IT to IA, are required. The prospect of A. muciniphila supplementation could be beneficial for CHB patients, warranting clinical trials. Continued research could lead to improved management and prevention of liver diseases in this patient population with CHB.
Qirong Jiang, MD, and Dawu Zeng, MD, are based in the Hepatology Research Institute, the First Affiliated Hospital, Fujian Medical University, Fuzhou, China. They report no conflicts of interest.
Clinical observations have long indicated that chronic hepatitis B (CHB) patients with a prolonged immune-tolerant (IT) phase are at a higher risk of liver diseases, while those with an early transition to the immune-active (IA) phase are associated with a better clinical outcome. However, the underlying mechanisms remain unclear.
This study merits attention as it marks an important advancement in our understanding of how gut microbiota affects the immune response and, in turn, the progression of CHB, offering insights for potential A. muciniphila–based therapies. Nonetheless, the research is still in its infancy, and further studies, including longitudinal analysis to determine gut microbiota changes from IT to IA, are required. The prospect of A. muciniphila supplementation could be beneficial for CHB patients, warranting clinical trials. Continued research could lead to improved management and prevention of liver diseases in this patient population with CHB.
Qirong Jiang, MD, and Dawu Zeng, MD, are based in the Hepatology Research Institute, the First Affiliated Hospital, Fujian Medical University, Fuzhou, China. They report no conflicts of interest.
, according to investigators.
While Ruminococcus gnavus promotes immune tolerance and therefore HBV persistence, Akkermansia muciniphila stimulates the immune system, promoting viral clearance, reported lead author Huey-Huey Chua, MD, of the National Taiwan University College of Medicine and Children’s Hospital, Taipei, and colleagues.
These findings could lead to new therapeutic strategies, such as administration of the secretory products of A. muciniphila, or provision of probiotics and prebiotics that tip the balance toward this more beneficial bacterium, the investigators wrote in Cellular and Molecular Gastroenterology and Hepatology.
Their study, which included data from both human patients and mouse models of CHB, was grounded in prior research showing a link between gut microbiota and the age-dependence of HBV immunity.
“Sterilization of the gut microbiota using antibiotics prevents adult mice from rapidly clearing HBV and restores the tolerance phenotype, implying that the gut microbiota may transmit signals to break liver tolerance and evoke rapid HBV clearance,” Dr. Chua and colleagues wrote. “We hypothesized that the wax and wane of gut microbiota signatures may determine the progression of CHB. We aimed to delineate what the pivotal bacteria are and how they manipulate the progression of CHB.”
They began by analyzing fecal samples from 102 patients with CHB either in the immune-tolerant (IT) or immune-active (IA) phase of infection.
R. gnavus was the most abundant species among IT patients, whereas A. muciniphila was most abundant among patients in the IA phase. Higher levels of A. muciniphila were also associated with early hepatitis B e-antigen (HBeAG) loss, HBeAG seroconversion, and flares of aminotransferase. A mouse model echoed these findings.
Further experiments with mouse models revealed that R. gnavus modulates bile acids to promote HBV persistence and prolongation of the IT course. In opposition, A. muciniphila removes cholesterol and secretes metabolites that inhibit growth and function of R. gnavus.
“These novel findings will certainly confer a groundbreaking impact on the future therapy of CHB,” Dr. Chua and colleagues wrote.
They went on to describe several therapeutic strategies worth further investigation.
“A key step to promote switching from the IT to IA phase is to lessen the richness of R. gnavus and bile acid bioconversion from cholesterol,” they wrote. The secretory products of A. muciniphila that successfully ameliorate the burden of R. gnavus outgrowth can be provided as useful means to induce anti-HBV efficacy. Also, the development of targeted probiotics or prebiotics that can modulate the gut microbiota composition to favor the beneficial effects of A. muciniphila while inhibiting the detrimental effects of R. gnavus may have translational value for CHB.”
The study was supported by the Ministry of Science and Technology, Executive Yuan, Taiwan and the Center of Precision Medicine from Featured Areas Research Center Program within the Framework of the Higher Education Sprout Project by the Ministry of Education in Taiwan. The investigators disclosed no conflicts of interest.
, according to investigators.
While Ruminococcus gnavus promotes immune tolerance and therefore HBV persistence, Akkermansia muciniphila stimulates the immune system, promoting viral clearance, reported lead author Huey-Huey Chua, MD, of the National Taiwan University College of Medicine and Children’s Hospital, Taipei, and colleagues.
These findings could lead to new therapeutic strategies, such as administration of the secretory products of A. muciniphila, or provision of probiotics and prebiotics that tip the balance toward this more beneficial bacterium, the investigators wrote in Cellular and Molecular Gastroenterology and Hepatology.
Their study, which included data from both human patients and mouse models of CHB, was grounded in prior research showing a link between gut microbiota and the age-dependence of HBV immunity.
“Sterilization of the gut microbiota using antibiotics prevents adult mice from rapidly clearing HBV and restores the tolerance phenotype, implying that the gut microbiota may transmit signals to break liver tolerance and evoke rapid HBV clearance,” Dr. Chua and colleagues wrote. “We hypothesized that the wax and wane of gut microbiota signatures may determine the progression of CHB. We aimed to delineate what the pivotal bacteria are and how they manipulate the progression of CHB.”
They began by analyzing fecal samples from 102 patients with CHB either in the immune-tolerant (IT) or immune-active (IA) phase of infection.
R. gnavus was the most abundant species among IT patients, whereas A. muciniphila was most abundant among patients in the IA phase. Higher levels of A. muciniphila were also associated with early hepatitis B e-antigen (HBeAG) loss, HBeAG seroconversion, and flares of aminotransferase. A mouse model echoed these findings.
Further experiments with mouse models revealed that R. gnavus modulates bile acids to promote HBV persistence and prolongation of the IT course. In opposition, A. muciniphila removes cholesterol and secretes metabolites that inhibit growth and function of R. gnavus.
“These novel findings will certainly confer a groundbreaking impact on the future therapy of CHB,” Dr. Chua and colleagues wrote.
They went on to describe several therapeutic strategies worth further investigation.
“A key step to promote switching from the IT to IA phase is to lessen the richness of R. gnavus and bile acid bioconversion from cholesterol,” they wrote. The secretory products of A. muciniphila that successfully ameliorate the burden of R. gnavus outgrowth can be provided as useful means to induce anti-HBV efficacy. Also, the development of targeted probiotics or prebiotics that can modulate the gut microbiota composition to favor the beneficial effects of A. muciniphila while inhibiting the detrimental effects of R. gnavus may have translational value for CHB.”
The study was supported by the Ministry of Science and Technology, Executive Yuan, Taiwan and the Center of Precision Medicine from Featured Areas Research Center Program within the Framework of the Higher Education Sprout Project by the Ministry of Education in Taiwan. The investigators disclosed no conflicts of interest.
FROM CELLULAR AND MOLECULAR GASTROENTEROLOGY AND HEPATOLOGY
First Impressions and Lessons Learned
“He was one of those fresh Jewish types you want to kill at sight ... she on the other hand looked Italian, a goaty slant to her eyes ... She looked dirty. So did he ... And she smelled, the usual smell of sweat and dirt you find among people who habitually do not wash or bathe ... People like that belong in clinics ... Just dumb oxen. Why the hell do they let them into the country? Half idiots at best.”
Who wrote that? Some hate-mongering pundit on a cable channel? A Twitter troll?
Nope. It was William Carlos Williams, MD, the patron saint of physician-writers.
You’re thinking “No! Not him!” We all read “The Use of Force” and “Red Wheelbarrow” in high school or college. But this blatant anti-Semitism and xenophobia?
The short story is “A Face of Stone” from his collection “The Doctor Stories” (highly recommended). When Williams was asked to remove those parts before publication, he refused because they’re a key part of the story. And I agree with him.
The point, as in so much of life, is the big picture. Despite his vivid disgust, he examines their infant, reassuring the mother that everything is okay, and later helping her with her leg pain and walking difficulties. At the end of the short story he realizes that his impressions were wrong and that people he started out hating are, well, just people who need help. And, as doctors, isn’t helping what we’re here to do?
It’s not just Williams, it’s all of us. First impressions aren’t always correct, but we rely on them — a lot. We’re programmed to. Our ancestors in the caves didn’t have much time to decided friend or foe when they encountered others.
So we initially judge people on their faces, expressions, hair, clothes, religious symbols (if present), jewelry ... The things that are registered by the brain in a split-second before the first words are exchanged.
All of us are constantly “scanning” others we encounter. In the office, store, restaurant, whatever. Usually those impressions are fleeting as we forget that person within a minute or two since we don’t see them again. But as doctors we do get to know them as patients, and so are constantly “updating” our mental files as new information comes in.
As Williams tells the story, he realizes that the “face of stone” isn’t that of the young mother he mentally derided — it’s his own face, turned that way by his first dismissive impression of the family, and then melted as he realizes he was wrong and learns from the experience to be a better doctor.
In vivid terms he reminds us that, although doctors, we are still susceptible to the same foibles, errors, and incorrect snap-judgments that all people are, but what matters is that we can, and have to, overcome them.
As a wall plaque in St. Mary’s General Hospital in Passaic, New Jersey, reminds us: “We walk the wards that Williams walked.”
We all do. Everyday. Everywhere.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
“He was one of those fresh Jewish types you want to kill at sight ... she on the other hand looked Italian, a goaty slant to her eyes ... She looked dirty. So did he ... And she smelled, the usual smell of sweat and dirt you find among people who habitually do not wash or bathe ... People like that belong in clinics ... Just dumb oxen. Why the hell do they let them into the country? Half idiots at best.”
Who wrote that? Some hate-mongering pundit on a cable channel? A Twitter troll?
Nope. It was William Carlos Williams, MD, the patron saint of physician-writers.
You’re thinking “No! Not him!” We all read “The Use of Force” and “Red Wheelbarrow” in high school or college. But this blatant anti-Semitism and xenophobia?
The short story is “A Face of Stone” from his collection “The Doctor Stories” (highly recommended). When Williams was asked to remove those parts before publication, he refused because they’re a key part of the story. And I agree with him.
The point, as in so much of life, is the big picture. Despite his vivid disgust, he examines their infant, reassuring the mother that everything is okay, and later helping her with her leg pain and walking difficulties. At the end of the short story he realizes that his impressions were wrong and that people he started out hating are, well, just people who need help. And, as doctors, isn’t helping what we’re here to do?
It’s not just Williams, it’s all of us. First impressions aren’t always correct, but we rely on them — a lot. We’re programmed to. Our ancestors in the caves didn’t have much time to decided friend or foe when they encountered others.
So we initially judge people on their faces, expressions, hair, clothes, religious symbols (if present), jewelry ... The things that are registered by the brain in a split-second before the first words are exchanged.
All of us are constantly “scanning” others we encounter. In the office, store, restaurant, whatever. Usually those impressions are fleeting as we forget that person within a minute or two since we don’t see them again. But as doctors we do get to know them as patients, and so are constantly “updating” our mental files as new information comes in.
As Williams tells the story, he realizes that the “face of stone” isn’t that of the young mother he mentally derided — it’s his own face, turned that way by his first dismissive impression of the family, and then melted as he realizes he was wrong and learns from the experience to be a better doctor.
In vivid terms he reminds us that, although doctors, we are still susceptible to the same foibles, errors, and incorrect snap-judgments that all people are, but what matters is that we can, and have to, overcome them.
As a wall plaque in St. Mary’s General Hospital in Passaic, New Jersey, reminds us: “We walk the wards that Williams walked.”
We all do. Everyday. Everywhere.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
“He was one of those fresh Jewish types you want to kill at sight ... she on the other hand looked Italian, a goaty slant to her eyes ... She looked dirty. So did he ... And she smelled, the usual smell of sweat and dirt you find among people who habitually do not wash or bathe ... People like that belong in clinics ... Just dumb oxen. Why the hell do they let them into the country? Half idiots at best.”
Who wrote that? Some hate-mongering pundit on a cable channel? A Twitter troll?
Nope. It was William Carlos Williams, MD, the patron saint of physician-writers.
You’re thinking “No! Not him!” We all read “The Use of Force” and “Red Wheelbarrow” in high school or college. But this blatant anti-Semitism and xenophobia?
The short story is “A Face of Stone” from his collection “The Doctor Stories” (highly recommended). When Williams was asked to remove those parts before publication, he refused because they’re a key part of the story. And I agree with him.
The point, as in so much of life, is the big picture. Despite his vivid disgust, he examines their infant, reassuring the mother that everything is okay, and later helping her with her leg pain and walking difficulties. At the end of the short story he realizes that his impressions were wrong and that people he started out hating are, well, just people who need help. And, as doctors, isn’t helping what we’re here to do?
It’s not just Williams, it’s all of us. First impressions aren’t always correct, but we rely on them — a lot. We’re programmed to. Our ancestors in the caves didn’t have much time to decided friend or foe when they encountered others.
So we initially judge people on their faces, expressions, hair, clothes, religious symbols (if present), jewelry ... The things that are registered by the brain in a split-second before the first words are exchanged.
All of us are constantly “scanning” others we encounter. In the office, store, restaurant, whatever. Usually those impressions are fleeting as we forget that person within a minute or two since we don’t see them again. But as doctors we do get to know them as patients, and so are constantly “updating” our mental files as new information comes in.
As Williams tells the story, he realizes that the “face of stone” isn’t that of the young mother he mentally derided — it’s his own face, turned that way by his first dismissive impression of the family, and then melted as he realizes he was wrong and learns from the experience to be a better doctor.
In vivid terms he reminds us that, although doctors, we are still susceptible to the same foibles, errors, and incorrect snap-judgments that all people are, but what matters is that we can, and have to, overcome them.
As a wall plaque in St. Mary’s General Hospital in Passaic, New Jersey, reminds us: “We walk the wards that Williams walked.”
We all do. Everyday. Everywhere.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
AAD Updates Guidelines for Managing Acne
. The guidelines also conditionally recommend the use of topical clascoterone, salicylic acid, azelaic acid, oral minocycline, sarecycline, combined oral contraceptives, and spironolactone.
The development updates the AAD’s 2016 guidelines for managing acne. “Since there have been several important new treatments introduced since the prior guidelines, it was determined that there was a need to update these guidelines,” John S. Barbieri, MD, MBA, who cochaired a 16-member multidisciplinary work group that assembled the guidelines, told this news organization.
For the new guidelines, which were published online January 30, 2023, in the Journal of the American Academy of Dermatology, Dr. Barbieri, a dermatologist who directs the Advanced Acne Therapeutics Clinic at Brigham and Women’s Hospital, Boston, guidelines cochair Rachel V. Reynolds, MD, a dermatologist at Beth Israel Deaconess Medical Center, Boston, and colleagues conducted a systematic review of evidence regarding the management of acne. Next, the work group applied the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach for assessing the certainty of the evidence and formulating and grading clinical recommendations based on relevant randomized trials in the medical literature.
In all, the work group made 18 recommendations and 5 good practice statements. They ranked 7 of the recommendations as “strong” based on the evidence reviewed, and the rest as “conditional.” The “strong” recommendations include the use of benzoyl peroxide, the use of topical retinoids, the use of topical antibiotics, a fixed dose of a combination topical antibiotic with benzoyl peroxide, a fixed dose of a combination topical retinoid with topical antibiotic, a fixed dose combination of a topical retinoid with benzoyl peroxide, and the use of doxycycline.
“Conditional” recommendations include those for the use of clascoterone, salicylic acid, azelaic acid, minocycline, sarecycline, doxycycline over azithromycin; combined oral contraceptive pills, spironolactone, and, for patients with severe acne, traditional daily dosing of isotretinoin over intermittent dosing of isotretinoin.
Meanwhile, good clinical practice statements contained in the document include using topical therapies combining multiple mechanisms of action, limiting systemic antibiotic use, combining topical and systemic antibiotics with benzoyl peroxide and other topical therapies, and adjuvant intralesional corticosteroid injections.
In Dr. Barbieri’s opinion, the recommendations regarding clascoterone and sarecycline represent important developments. “Clascoterone is the first FDA-approved treatment that can address hormonal causes of acne in both men and women,” he told this news organization. “Sarecycline is a narrow-spectrum tetracycline that might have some advantages over other tetracyclines such as doxycycline and minocycline. It will be important to payers to provide coverage to ensure that patients have access to these valuable new treatments.”
Dr. Barbieri added that while no evidence exists to suggest that minocycline is more effective than doxycycline, minocycline can be associated with rare but serious side effects, such as vestibular dysfunction, autoimmune hepatitis, drug-induced lupus, and drug reaction with eosinophilia and systemic symptoms (DRESS). “We should consider whether reducing use of minocycline might be beneficial to our overall care of patients with acne,” he said. “In addition, we discuss that use of trimethoprim-sulfamethoxazole should be limited due to risk of severe adverse reactions such as Stevens-Johnson syndrome/toxic epidermal necrolysis, and acute respiratory failure.”
Another highlight of the guidelines, he continued, are specific recommendations for young, healthy patients on isotretinoin or spironolactone, which “can help clinicians and patients who are interested in less frequent monitoring feel more comfortable with these approaches,” he said.
Many discussions among work group members dealt with how to best implement the GRADE approach to the project “while ensuring the guidelines were as clinically relevant and actionable as possible,” according to Dr. Barbieri. “I think an important issue going forward will be to consider how to update and modify the GRADE approach to fit the unique needs of creating evidence-based guidelines for the management of skin disease.”
The work group acknowledged limitations of the guidelines, including identification of “important evidence gaps on the use of microbiology and endocrinology testing in acne, the use of systemic antibiotics beyond tetracycline-class antibiotics, physical modalities, complementary and alternative therapies, dietary interventions for the treatment of acne, and cost-effectiveness of acne treatments,” they wrote. “RCTs with long-term follow-up and comparative effectiveness research are necessary to examine and compare patient-centered acne treatment outcomes.”
The AAD funded the project. Dr. Barbieri disclosed that he serves as investigator for the National Institutes of Health and the National Psoriasis Foundation. Many coauthors reported being a speaker for and/or a consultant and advisory board member to many pharmaceutical companies.
. The guidelines also conditionally recommend the use of topical clascoterone, salicylic acid, azelaic acid, oral minocycline, sarecycline, combined oral contraceptives, and spironolactone.
The development updates the AAD’s 2016 guidelines for managing acne. “Since there have been several important new treatments introduced since the prior guidelines, it was determined that there was a need to update these guidelines,” John S. Barbieri, MD, MBA, who cochaired a 16-member multidisciplinary work group that assembled the guidelines, told this news organization.
For the new guidelines, which were published online January 30, 2023, in the Journal of the American Academy of Dermatology, Dr. Barbieri, a dermatologist who directs the Advanced Acne Therapeutics Clinic at Brigham and Women’s Hospital, Boston, guidelines cochair Rachel V. Reynolds, MD, a dermatologist at Beth Israel Deaconess Medical Center, Boston, and colleagues conducted a systematic review of evidence regarding the management of acne. Next, the work group applied the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach for assessing the certainty of the evidence and formulating and grading clinical recommendations based on relevant randomized trials in the medical literature.
In all, the work group made 18 recommendations and 5 good practice statements. They ranked 7 of the recommendations as “strong” based on the evidence reviewed, and the rest as “conditional.” The “strong” recommendations include the use of benzoyl peroxide, the use of topical retinoids, the use of topical antibiotics, a fixed dose of a combination topical antibiotic with benzoyl peroxide, a fixed dose of a combination topical retinoid with topical antibiotic, a fixed dose combination of a topical retinoid with benzoyl peroxide, and the use of doxycycline.
“Conditional” recommendations include those for the use of clascoterone, salicylic acid, azelaic acid, minocycline, sarecycline, doxycycline over azithromycin; combined oral contraceptive pills, spironolactone, and, for patients with severe acne, traditional daily dosing of isotretinoin over intermittent dosing of isotretinoin.
Meanwhile, good clinical practice statements contained in the document include using topical therapies combining multiple mechanisms of action, limiting systemic antibiotic use, combining topical and systemic antibiotics with benzoyl peroxide and other topical therapies, and adjuvant intralesional corticosteroid injections.
In Dr. Barbieri’s opinion, the recommendations regarding clascoterone and sarecycline represent important developments. “Clascoterone is the first FDA-approved treatment that can address hormonal causes of acne in both men and women,” he told this news organization. “Sarecycline is a narrow-spectrum tetracycline that might have some advantages over other tetracyclines such as doxycycline and minocycline. It will be important to payers to provide coverage to ensure that patients have access to these valuable new treatments.”
Dr. Barbieri added that while no evidence exists to suggest that minocycline is more effective than doxycycline, minocycline can be associated with rare but serious side effects, such as vestibular dysfunction, autoimmune hepatitis, drug-induced lupus, and drug reaction with eosinophilia and systemic symptoms (DRESS). “We should consider whether reducing use of minocycline might be beneficial to our overall care of patients with acne,” he said. “In addition, we discuss that use of trimethoprim-sulfamethoxazole should be limited due to risk of severe adverse reactions such as Stevens-Johnson syndrome/toxic epidermal necrolysis, and acute respiratory failure.”
Another highlight of the guidelines, he continued, are specific recommendations for young, healthy patients on isotretinoin or spironolactone, which “can help clinicians and patients who are interested in less frequent monitoring feel more comfortable with these approaches,” he said.
Many discussions among work group members dealt with how to best implement the GRADE approach to the project “while ensuring the guidelines were as clinically relevant and actionable as possible,” according to Dr. Barbieri. “I think an important issue going forward will be to consider how to update and modify the GRADE approach to fit the unique needs of creating evidence-based guidelines for the management of skin disease.”
The work group acknowledged limitations of the guidelines, including identification of “important evidence gaps on the use of microbiology and endocrinology testing in acne, the use of systemic antibiotics beyond tetracycline-class antibiotics, physical modalities, complementary and alternative therapies, dietary interventions for the treatment of acne, and cost-effectiveness of acne treatments,” they wrote. “RCTs with long-term follow-up and comparative effectiveness research are necessary to examine and compare patient-centered acne treatment outcomes.”
The AAD funded the project. Dr. Barbieri disclosed that he serves as investigator for the National Institutes of Health and the National Psoriasis Foundation. Many coauthors reported being a speaker for and/or a consultant and advisory board member to many pharmaceutical companies.
. The guidelines also conditionally recommend the use of topical clascoterone, salicylic acid, azelaic acid, oral minocycline, sarecycline, combined oral contraceptives, and spironolactone.
The development updates the AAD’s 2016 guidelines for managing acne. “Since there have been several important new treatments introduced since the prior guidelines, it was determined that there was a need to update these guidelines,” John S. Barbieri, MD, MBA, who cochaired a 16-member multidisciplinary work group that assembled the guidelines, told this news organization.
For the new guidelines, which were published online January 30, 2023, in the Journal of the American Academy of Dermatology, Dr. Barbieri, a dermatologist who directs the Advanced Acne Therapeutics Clinic at Brigham and Women’s Hospital, Boston, guidelines cochair Rachel V. Reynolds, MD, a dermatologist at Beth Israel Deaconess Medical Center, Boston, and colleagues conducted a systematic review of evidence regarding the management of acne. Next, the work group applied the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach for assessing the certainty of the evidence and formulating and grading clinical recommendations based on relevant randomized trials in the medical literature.
In all, the work group made 18 recommendations and 5 good practice statements. They ranked 7 of the recommendations as “strong” based on the evidence reviewed, and the rest as “conditional.” The “strong” recommendations include the use of benzoyl peroxide, the use of topical retinoids, the use of topical antibiotics, a fixed dose of a combination topical antibiotic with benzoyl peroxide, a fixed dose of a combination topical retinoid with topical antibiotic, a fixed dose combination of a topical retinoid with benzoyl peroxide, and the use of doxycycline.
“Conditional” recommendations include those for the use of clascoterone, salicylic acid, azelaic acid, minocycline, sarecycline, doxycycline over azithromycin; combined oral contraceptive pills, spironolactone, and, for patients with severe acne, traditional daily dosing of isotretinoin over intermittent dosing of isotretinoin.
Meanwhile, good clinical practice statements contained in the document include using topical therapies combining multiple mechanisms of action, limiting systemic antibiotic use, combining topical and systemic antibiotics with benzoyl peroxide and other topical therapies, and adjuvant intralesional corticosteroid injections.
In Dr. Barbieri’s opinion, the recommendations regarding clascoterone and sarecycline represent important developments. “Clascoterone is the first FDA-approved treatment that can address hormonal causes of acne in both men and women,” he told this news organization. “Sarecycline is a narrow-spectrum tetracycline that might have some advantages over other tetracyclines such as doxycycline and minocycline. It will be important to payers to provide coverage to ensure that patients have access to these valuable new treatments.”
Dr. Barbieri added that while no evidence exists to suggest that minocycline is more effective than doxycycline, minocycline can be associated with rare but serious side effects, such as vestibular dysfunction, autoimmune hepatitis, drug-induced lupus, and drug reaction with eosinophilia and systemic symptoms (DRESS). “We should consider whether reducing use of minocycline might be beneficial to our overall care of patients with acne,” he said. “In addition, we discuss that use of trimethoprim-sulfamethoxazole should be limited due to risk of severe adverse reactions such as Stevens-Johnson syndrome/toxic epidermal necrolysis, and acute respiratory failure.”
Another highlight of the guidelines, he continued, are specific recommendations for young, healthy patients on isotretinoin or spironolactone, which “can help clinicians and patients who are interested in less frequent monitoring feel more comfortable with these approaches,” he said.
Many discussions among work group members dealt with how to best implement the GRADE approach to the project “while ensuring the guidelines were as clinically relevant and actionable as possible,” according to Dr. Barbieri. “I think an important issue going forward will be to consider how to update and modify the GRADE approach to fit the unique needs of creating evidence-based guidelines for the management of skin disease.”
The work group acknowledged limitations of the guidelines, including identification of “important evidence gaps on the use of microbiology and endocrinology testing in acne, the use of systemic antibiotics beyond tetracycline-class antibiotics, physical modalities, complementary and alternative therapies, dietary interventions for the treatment of acne, and cost-effectiveness of acne treatments,” they wrote. “RCTs with long-term follow-up and comparative effectiveness research are necessary to examine and compare patient-centered acne treatment outcomes.”
The AAD funded the project. Dr. Barbieri disclosed that he serves as investigator for the National Institutes of Health and the National Psoriasis Foundation. Many coauthors reported being a speaker for and/or a consultant and advisory board member to many pharmaceutical companies.
FROM THE JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY
Higher vitamin B6 and folate intake tied to lower severe headache or migraine risk
Key clinical point: Higher dietary intakes of vitamin B6 and folate were significantly associated with a lower risk for severe headaches or migraines, with a synergistic interaction observed between vitamin B6 and folate intake and reduced migraine risk.
Major finding: Compared with the lowest quintile of dietary vitamin B6 (≤1.13 mg/day) and folate (≤240 μg/day) intake, the risk for severe headache or migraine was lower in the highest quintile of vitamin B6 (≥2.39 mg/day; adjusted odds ratio [aOR] 0.66; P = .01) and folate (≥502.01 μg/day; aOR 0.57; P = .002) intake. A synergistic interaction was observed between the high mass of vitamin B6 and folate intake and a lower risk for severe headache or migraine (synergy index 0.58; 95% CI 0.40-0.83).
Study details: This cross-sectional study included 7017 adult participants (age ≥ 20 years), of whom 1350 (19.23%) had migraine.
Disclosures: This study was supported by the National Natural Science Foundation of China, Natural Science Foundation of Jiangxi Province, and others. No conflicts of interests were declared.
Source: Tian S et al. Vitamin B6 and folate intake are associated with lower risk of severe headache or migraine in adults: An analysis based on NHANES 1999-2004. Nutr Res. 2023;121:51-60 (Nov 15). doi: 10.1016/j.nutres.2023.11.008
Key clinical point: Higher dietary intakes of vitamin B6 and folate were significantly associated with a lower risk for severe headaches or migraines, with a synergistic interaction observed between vitamin B6 and folate intake and reduced migraine risk.
Major finding: Compared with the lowest quintile of dietary vitamin B6 (≤1.13 mg/day) and folate (≤240 μg/day) intake, the risk for severe headache or migraine was lower in the highest quintile of vitamin B6 (≥2.39 mg/day; adjusted odds ratio [aOR] 0.66; P = .01) and folate (≥502.01 μg/day; aOR 0.57; P = .002) intake. A synergistic interaction was observed between the high mass of vitamin B6 and folate intake and a lower risk for severe headache or migraine (synergy index 0.58; 95% CI 0.40-0.83).
Study details: This cross-sectional study included 7017 adult participants (age ≥ 20 years), of whom 1350 (19.23%) had migraine.
Disclosures: This study was supported by the National Natural Science Foundation of China, Natural Science Foundation of Jiangxi Province, and others. No conflicts of interests were declared.
Source: Tian S et al. Vitamin B6 and folate intake are associated with lower risk of severe headache or migraine in adults: An analysis based on NHANES 1999-2004. Nutr Res. 2023;121:51-60 (Nov 15). doi: 10.1016/j.nutres.2023.11.008
Key clinical point: Higher dietary intakes of vitamin B6 and folate were significantly associated with a lower risk for severe headaches or migraines, with a synergistic interaction observed between vitamin B6 and folate intake and reduced migraine risk.
Major finding: Compared with the lowest quintile of dietary vitamin B6 (≤1.13 mg/day) and folate (≤240 μg/day) intake, the risk for severe headache or migraine was lower in the highest quintile of vitamin B6 (≥2.39 mg/day; adjusted odds ratio [aOR] 0.66; P = .01) and folate (≥502.01 μg/day; aOR 0.57; P = .002) intake. A synergistic interaction was observed between the high mass of vitamin B6 and folate intake and a lower risk for severe headache or migraine (synergy index 0.58; 95% CI 0.40-0.83).
Study details: This cross-sectional study included 7017 adult participants (age ≥ 20 years), of whom 1350 (19.23%) had migraine.
Disclosures: This study was supported by the National Natural Science Foundation of China, Natural Science Foundation of Jiangxi Province, and others. No conflicts of interests were declared.
Source: Tian S et al. Vitamin B6 and folate intake are associated with lower risk of severe headache or migraine in adults: An analysis based on NHANES 1999-2004. Nutr Res. 2023;121:51-60 (Nov 15). doi: 10.1016/j.nutres.2023.11.008
Physicians as First Responders I
When I was an intern and junior resident there was a fellow house officer who seemed to be a magnet for out-of-hospital emergencies. There were a couple of car accidents, a baby to be delivered, an elderly neighbor with alarming chest pain, and a little old lady with syncope, plus a few playground incidents that required more than a little on-site tending and triage. It got to the point where he felt he needed to raid the hospital supply closets to build himself a proper emergency kit.
Envious of his excitement I, of course, followed suit. However, my well-appointed plastic tackle box remained unopened on the floor behind the driver’s seat in my car. Sure, there were Band-Aids to be dispensed from time to time but mostly I was the on-site reassurer and triage consultant at the playground. I almost never suggested a trip to the emergency room. No little old ladies crumpled to the floor in front of me in the checkout line at the grocery store. No distracted teenage drivers plowed into telephone poles anywhere within earshot.
When I began my practice here on the midcoast of Maine, my protective aura traveled with me. I went looking for excitement by signing on as the team physician for the local high school football team. But, other than a few minor concussions, which in those days we “treated” with a “sit on the bench for awhile and I’ll ask you a few questions,” my first responder experiences continued to be boringly undramatic. Not even any obvious dislocations or angulated fractures on the playground or athletic fields I frequented.
My professional adventures were confined to the hospital, where every physician regardless of specialty training was required to take a shift covering the emergency room. Talk about a situation looking for trouble. The concept of physicians with specialty training in emergency room medicine had not yet occurred to anyone in rural Maine. Although there were anxiety-provoking nights waiting for the disasters to arrive, somehow the shit never hit the fan while I was on duty.
Finally, after several more years of this bad (or good) fortune I was on a bike ride out in the country alone on a back road and came upon a fresh single-vehicle-single-occupant accident. Steam and smoke coming out of the engine compartment, the young driver slumped over the steering wheel. I was able to pry the door open but couldn’t find a pulse. I thumped him three times on the chest and eventually could detect a pulse and he began to stir. When the ambulance arrived I dragged my bike into the back of the ambulance with me and monitored him on the way to the hospital. He did fine, only to die in another accident a few years later.
A recent article in one of our local newspapers described a fledgling program in which three emergency room physicians are being equipped with supplies and communication links that will allow them to respond to emergent situations in the field. The program is currently seeking to extend its funding for another year. Its advocates argue that the need is twofold. There is currently a regional shortage of fully trained first responder EMTs. And having an extra pair of hands in the field could ease the burden of the already overutilized emergency rooms.
I am sure the physicians who have signed on to become first responders are passionate about the need and probably enjoy the excitement of in-the-field professional experiences, much as my fellow house officer did. However, were I sitting on the committee that controls the funding of programs like this I would want to take a step back and consider whether using primary care physicians, who are already in short supply, as first responders made sense. Some of the scenarios may be dramatic and the physician’s contribution may be life saving. But I suspect in the long run these headline-making stories will be few and far between.
The argument that putting physicians in the field will make a significant dent in the emergency room overutilization crisis we have in this country doesn’t hold water. Extending outpatient office hours, education, and improved phone triage to name just a few would have a bigger impact. I suspect there are other countries and even some counties in this country that may already use physicians as first responders. It just doesn’t seem to be a model that will work well given the realities in most semirural and suburban locales.
The real question that must wait for another Letters From Maine column is how well prepared should all of us who have graduated from medical school be to function as first responders. There are thousands of us out there who initially had the training and could, with some updating, become a valuable source of first-responders. Where do issues like continuing education requirements and Good Samaritan protection fit into the equation? The answers in a future Letter.
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.
When I was an intern and junior resident there was a fellow house officer who seemed to be a magnet for out-of-hospital emergencies. There were a couple of car accidents, a baby to be delivered, an elderly neighbor with alarming chest pain, and a little old lady with syncope, plus a few playground incidents that required more than a little on-site tending and triage. It got to the point where he felt he needed to raid the hospital supply closets to build himself a proper emergency kit.
Envious of his excitement I, of course, followed suit. However, my well-appointed plastic tackle box remained unopened on the floor behind the driver’s seat in my car. Sure, there were Band-Aids to be dispensed from time to time but mostly I was the on-site reassurer and triage consultant at the playground. I almost never suggested a trip to the emergency room. No little old ladies crumpled to the floor in front of me in the checkout line at the grocery store. No distracted teenage drivers plowed into telephone poles anywhere within earshot.
When I began my practice here on the midcoast of Maine, my protective aura traveled with me. I went looking for excitement by signing on as the team physician for the local high school football team. But, other than a few minor concussions, which in those days we “treated” with a “sit on the bench for awhile and I’ll ask you a few questions,” my first responder experiences continued to be boringly undramatic. Not even any obvious dislocations or angulated fractures on the playground or athletic fields I frequented.
My professional adventures were confined to the hospital, where every physician regardless of specialty training was required to take a shift covering the emergency room. Talk about a situation looking for trouble. The concept of physicians with specialty training in emergency room medicine had not yet occurred to anyone in rural Maine. Although there were anxiety-provoking nights waiting for the disasters to arrive, somehow the shit never hit the fan while I was on duty.
Finally, after several more years of this bad (or good) fortune I was on a bike ride out in the country alone on a back road and came upon a fresh single-vehicle-single-occupant accident. Steam and smoke coming out of the engine compartment, the young driver slumped over the steering wheel. I was able to pry the door open but couldn’t find a pulse. I thumped him three times on the chest and eventually could detect a pulse and he began to stir. When the ambulance arrived I dragged my bike into the back of the ambulance with me and monitored him on the way to the hospital. He did fine, only to die in another accident a few years later.
A recent article in one of our local newspapers described a fledgling program in which three emergency room physicians are being equipped with supplies and communication links that will allow them to respond to emergent situations in the field. The program is currently seeking to extend its funding for another year. Its advocates argue that the need is twofold. There is currently a regional shortage of fully trained first responder EMTs. And having an extra pair of hands in the field could ease the burden of the already overutilized emergency rooms.
I am sure the physicians who have signed on to become first responders are passionate about the need and probably enjoy the excitement of in-the-field professional experiences, much as my fellow house officer did. However, were I sitting on the committee that controls the funding of programs like this I would want to take a step back and consider whether using primary care physicians, who are already in short supply, as first responders made sense. Some of the scenarios may be dramatic and the physician’s contribution may be life saving. But I suspect in the long run these headline-making stories will be few and far between.
The argument that putting physicians in the field will make a significant dent in the emergency room overutilization crisis we have in this country doesn’t hold water. Extending outpatient office hours, education, and improved phone triage to name just a few would have a bigger impact. I suspect there are other countries and even some counties in this country that may already use physicians as first responders. It just doesn’t seem to be a model that will work well given the realities in most semirural and suburban locales.
The real question that must wait for another Letters From Maine column is how well prepared should all of us who have graduated from medical school be to function as first responders. There are thousands of us out there who initially had the training and could, with some updating, become a valuable source of first-responders. Where do issues like continuing education requirements and Good Samaritan protection fit into the equation? The answers in a future Letter.
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.
When I was an intern and junior resident there was a fellow house officer who seemed to be a magnet for out-of-hospital emergencies. There were a couple of car accidents, a baby to be delivered, an elderly neighbor with alarming chest pain, and a little old lady with syncope, plus a few playground incidents that required more than a little on-site tending and triage. It got to the point where he felt he needed to raid the hospital supply closets to build himself a proper emergency kit.
Envious of his excitement I, of course, followed suit. However, my well-appointed plastic tackle box remained unopened on the floor behind the driver’s seat in my car. Sure, there were Band-Aids to be dispensed from time to time but mostly I was the on-site reassurer and triage consultant at the playground. I almost never suggested a trip to the emergency room. No little old ladies crumpled to the floor in front of me in the checkout line at the grocery store. No distracted teenage drivers plowed into telephone poles anywhere within earshot.
When I began my practice here on the midcoast of Maine, my protective aura traveled with me. I went looking for excitement by signing on as the team physician for the local high school football team. But, other than a few minor concussions, which in those days we “treated” with a “sit on the bench for awhile and I’ll ask you a few questions,” my first responder experiences continued to be boringly undramatic. Not even any obvious dislocations or angulated fractures on the playground or athletic fields I frequented.
My professional adventures were confined to the hospital, where every physician regardless of specialty training was required to take a shift covering the emergency room. Talk about a situation looking for trouble. The concept of physicians with specialty training in emergency room medicine had not yet occurred to anyone in rural Maine. Although there were anxiety-provoking nights waiting for the disasters to arrive, somehow the shit never hit the fan while I was on duty.
Finally, after several more years of this bad (or good) fortune I was on a bike ride out in the country alone on a back road and came upon a fresh single-vehicle-single-occupant accident. Steam and smoke coming out of the engine compartment, the young driver slumped over the steering wheel. I was able to pry the door open but couldn’t find a pulse. I thumped him three times on the chest and eventually could detect a pulse and he began to stir. When the ambulance arrived I dragged my bike into the back of the ambulance with me and monitored him on the way to the hospital. He did fine, only to die in another accident a few years later.
A recent article in one of our local newspapers described a fledgling program in which three emergency room physicians are being equipped with supplies and communication links that will allow them to respond to emergent situations in the field. The program is currently seeking to extend its funding for another year. Its advocates argue that the need is twofold. There is currently a regional shortage of fully trained first responder EMTs. And having an extra pair of hands in the field could ease the burden of the already overutilized emergency rooms.
I am sure the physicians who have signed on to become first responders are passionate about the need and probably enjoy the excitement of in-the-field professional experiences, much as my fellow house officer did. However, were I sitting on the committee that controls the funding of programs like this I would want to take a step back and consider whether using primary care physicians, who are already in short supply, as first responders made sense. Some of the scenarios may be dramatic and the physician’s contribution may be life saving. But I suspect in the long run these headline-making stories will be few and far between.
The argument that putting physicians in the field will make a significant dent in the emergency room overutilization crisis we have in this country doesn’t hold water. Extending outpatient office hours, education, and improved phone triage to name just a few would have a bigger impact. I suspect there are other countries and even some counties in this country that may already use physicians as first responders. It just doesn’t seem to be a model that will work well given the realities in most semirural and suburban locales.
The real question that must wait for another Letters From Maine column is how well prepared should all of us who have graduated from medical school be to function as first responders. There are thousands of us out there who initially had the training and could, with some updating, become a valuable source of first-responders. Where do issues like continuing education requirements and Good Samaritan protection fit into the equation? The answers in a future Letter.
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.
More Than 100K New Cutaneous Melanoma Diagnoses Expected in 2024
SAN DIEGO — According to data from the
“The incidence of melanoma seems to have continued to go up since the early 1990s,” David E. Kent, MD, a dermatologist at Skin Care Physicians of Georgia, Macon, said at the annual Cutaneous Malignancy Update. “The death rates have been flat and may have slightly decreased.”
In 2024, the ACS estimates that about 100,640 new melanomas will be diagnosed in the United States (59,170 in men and 41,470 in women), and about 8,290 people are expected to die of melanoma (5,430 men and 2,860 women). Meanwhile, the lifetime risk of melanoma is about 3% (1 in 33) for Whites, 0.1% (1 in 1,000) for Blacks, and 0.5% (1 in 200) for Hispanics. In 2019, there were an estimated 1.4 million people in the United States living with cutaneous melanoma, and the overall 5-year survival is 93.7%.
Epidemiologic studies show an increase in melanoma incidence, primarily among White populations. “This is believed to be due to sun exposure, changes in recreational behaviors, and tanning bed exposures,” said Dr. Kent, who holds a faculty position in the department of dermatology at the Medical College of Georgia, Augusta. Increased surveillance and diagnosis also play a role. In the medical literature, annual increases in melanoma incidence vary from 3%-7% per year, “which means that the rate is doubling every 10-20 years,” he said, noting that annual melanoma costs are approximately $3.3 billion.
While incidence rates are lower in non-White, non-Hispanic populations, poor outcomes are disproportionately higher in persons of color, according to a 2023 paper. Black individuals present at diagnosis with more advanced stage disease and are 1.5 times more likely to die from melanoma, he said, while Hispanics are 2.4 times more likely to present with stage III disease and 3.6 times more likely to have distant metastases. Persons of color also have higher rates of mucosal, acral lentiginous, and subungual melanoma.
Risk Factors
Known genetic risk factors for melanoma include having skin types I and II, particularly those with light hair, light eyes, and freckling, and those with a family history have a twofold increased risk. Also, up to 40% of genetic cases are from inherited mutations in CDKN2A, CDK4, BAP1 and MCR1. Other genetic-related risk factors include the number and size of nevi, having atypical nevus syndrome, DNA repair defects, large congenital nevi, and a personal history of melanoma.
Dr. Kent said that genetic testing for melanoma is warranted for individuals who meet criteria for the “rule of 3s.” He defined this as three primary melanomas in an individual, or three cases of melanoma in first- or second-degree relatives, or two cases of melanoma and one pancreatic cancer or astrocytoma in first or second-degree relatives, or one case of melanoma and two of pancreatic cancer/astrocytoma in first- or second-degree relatives.
The main environmental risk factor for melanoma is exposure to ultraviolet radiation. Individuals can track their UV exposure with a variety of wearable devices and apps, including SunSense One Digital UV Tracker, the SunSense App, the UV Index Widget, the SunSmart Global UV App, the SunKnown UV light photometer, and the EPA’s UV Index Mobile App. Other environment-related risk factors include having a high socioeconomic status (SES), being immunosuppressed, as well as exposure to heavy metals, insecticides, or hormones; and ones distance from the equator.
In a study published in 2023, researchers investigated the risk factors associated with first and second primary melanomas in 38,845 patients who were followed in Australia between 2011 and 2018. During a median follow-up of 7.4 years, 1212 patients (3.1%) had a single primary melanoma diagnosis and 245 (0.6%) had a secondary primary melanoma diagnosis. The researchers found that second melanomas were more likely than first melanomas to be in situ; for invasive tumors, second melanomas were more likely to be thin (defined as 1 mm or less) than first melanomas. In addition, having many self-reported moles at age 21 years was more strongly associated with second melanomas compared with first melanomas (hazard ratio, 6.36 vs 3.46, respectively; P = .01), as was having a high genetic predisposition (HR, 3.28 vs. 2.06; P = .03). Second melanomas were also more strongly associated with a history of multiple skin cancer excisions (HR, 2.63 vs 1.86; P = .05).
Dr. Kent noted that while sunscreen use protects against melanoma, a National Ambulatory Medical Care Survey in 2014 found that internists and pediatricians mentioned sunscreen at fewer than 0.1% of visits — even those with patients who have a diagnosis of skin disease. “Physicians need to do better,” he said at the meeting, which was hosted by the Scripps Cancer Center. “We as dermatologists have work to do to help educate them.”
Dr. Kent reported having no relevant disclosures.
SAN DIEGO — According to data from the
“The incidence of melanoma seems to have continued to go up since the early 1990s,” David E. Kent, MD, a dermatologist at Skin Care Physicians of Georgia, Macon, said at the annual Cutaneous Malignancy Update. “The death rates have been flat and may have slightly decreased.”
In 2024, the ACS estimates that about 100,640 new melanomas will be diagnosed in the United States (59,170 in men and 41,470 in women), and about 8,290 people are expected to die of melanoma (5,430 men and 2,860 women). Meanwhile, the lifetime risk of melanoma is about 3% (1 in 33) for Whites, 0.1% (1 in 1,000) for Blacks, and 0.5% (1 in 200) for Hispanics. In 2019, there were an estimated 1.4 million people in the United States living with cutaneous melanoma, and the overall 5-year survival is 93.7%.
Epidemiologic studies show an increase in melanoma incidence, primarily among White populations. “This is believed to be due to sun exposure, changes in recreational behaviors, and tanning bed exposures,” said Dr. Kent, who holds a faculty position in the department of dermatology at the Medical College of Georgia, Augusta. Increased surveillance and diagnosis also play a role. In the medical literature, annual increases in melanoma incidence vary from 3%-7% per year, “which means that the rate is doubling every 10-20 years,” he said, noting that annual melanoma costs are approximately $3.3 billion.
While incidence rates are lower in non-White, non-Hispanic populations, poor outcomes are disproportionately higher in persons of color, according to a 2023 paper. Black individuals present at diagnosis with more advanced stage disease and are 1.5 times more likely to die from melanoma, he said, while Hispanics are 2.4 times more likely to present with stage III disease and 3.6 times more likely to have distant metastases. Persons of color also have higher rates of mucosal, acral lentiginous, and subungual melanoma.
Risk Factors
Known genetic risk factors for melanoma include having skin types I and II, particularly those with light hair, light eyes, and freckling, and those with a family history have a twofold increased risk. Also, up to 40% of genetic cases are from inherited mutations in CDKN2A, CDK4, BAP1 and MCR1. Other genetic-related risk factors include the number and size of nevi, having atypical nevus syndrome, DNA repair defects, large congenital nevi, and a personal history of melanoma.
Dr. Kent said that genetic testing for melanoma is warranted for individuals who meet criteria for the “rule of 3s.” He defined this as three primary melanomas in an individual, or three cases of melanoma in first- or second-degree relatives, or two cases of melanoma and one pancreatic cancer or astrocytoma in first or second-degree relatives, or one case of melanoma and two of pancreatic cancer/astrocytoma in first- or second-degree relatives.
The main environmental risk factor for melanoma is exposure to ultraviolet radiation. Individuals can track their UV exposure with a variety of wearable devices and apps, including SunSense One Digital UV Tracker, the SunSense App, the UV Index Widget, the SunSmart Global UV App, the SunKnown UV light photometer, and the EPA’s UV Index Mobile App. Other environment-related risk factors include having a high socioeconomic status (SES), being immunosuppressed, as well as exposure to heavy metals, insecticides, or hormones; and ones distance from the equator.
In a study published in 2023, researchers investigated the risk factors associated with first and second primary melanomas in 38,845 patients who were followed in Australia between 2011 and 2018. During a median follow-up of 7.4 years, 1212 patients (3.1%) had a single primary melanoma diagnosis and 245 (0.6%) had a secondary primary melanoma diagnosis. The researchers found that second melanomas were more likely than first melanomas to be in situ; for invasive tumors, second melanomas were more likely to be thin (defined as 1 mm or less) than first melanomas. In addition, having many self-reported moles at age 21 years was more strongly associated with second melanomas compared with first melanomas (hazard ratio, 6.36 vs 3.46, respectively; P = .01), as was having a high genetic predisposition (HR, 3.28 vs. 2.06; P = .03). Second melanomas were also more strongly associated with a history of multiple skin cancer excisions (HR, 2.63 vs 1.86; P = .05).
Dr. Kent noted that while sunscreen use protects against melanoma, a National Ambulatory Medical Care Survey in 2014 found that internists and pediatricians mentioned sunscreen at fewer than 0.1% of visits — even those with patients who have a diagnosis of skin disease. “Physicians need to do better,” he said at the meeting, which was hosted by the Scripps Cancer Center. “We as dermatologists have work to do to help educate them.”
Dr. Kent reported having no relevant disclosures.
SAN DIEGO — According to data from the
“The incidence of melanoma seems to have continued to go up since the early 1990s,” David E. Kent, MD, a dermatologist at Skin Care Physicians of Georgia, Macon, said at the annual Cutaneous Malignancy Update. “The death rates have been flat and may have slightly decreased.”
In 2024, the ACS estimates that about 100,640 new melanomas will be diagnosed in the United States (59,170 in men and 41,470 in women), and about 8,290 people are expected to die of melanoma (5,430 men and 2,860 women). Meanwhile, the lifetime risk of melanoma is about 3% (1 in 33) for Whites, 0.1% (1 in 1,000) for Blacks, and 0.5% (1 in 200) for Hispanics. In 2019, there were an estimated 1.4 million people in the United States living with cutaneous melanoma, and the overall 5-year survival is 93.7%.
Epidemiologic studies show an increase in melanoma incidence, primarily among White populations. “This is believed to be due to sun exposure, changes in recreational behaviors, and tanning bed exposures,” said Dr. Kent, who holds a faculty position in the department of dermatology at the Medical College of Georgia, Augusta. Increased surveillance and diagnosis also play a role. In the medical literature, annual increases in melanoma incidence vary from 3%-7% per year, “which means that the rate is doubling every 10-20 years,” he said, noting that annual melanoma costs are approximately $3.3 billion.
While incidence rates are lower in non-White, non-Hispanic populations, poor outcomes are disproportionately higher in persons of color, according to a 2023 paper. Black individuals present at diagnosis with more advanced stage disease and are 1.5 times more likely to die from melanoma, he said, while Hispanics are 2.4 times more likely to present with stage III disease and 3.6 times more likely to have distant metastases. Persons of color also have higher rates of mucosal, acral lentiginous, and subungual melanoma.
Risk Factors
Known genetic risk factors for melanoma include having skin types I and II, particularly those with light hair, light eyes, and freckling, and those with a family history have a twofold increased risk. Also, up to 40% of genetic cases are from inherited mutations in CDKN2A, CDK4, BAP1 and MCR1. Other genetic-related risk factors include the number and size of nevi, having atypical nevus syndrome, DNA repair defects, large congenital nevi, and a personal history of melanoma.
Dr. Kent said that genetic testing for melanoma is warranted for individuals who meet criteria for the “rule of 3s.” He defined this as three primary melanomas in an individual, or three cases of melanoma in first- or second-degree relatives, or two cases of melanoma and one pancreatic cancer or astrocytoma in first or second-degree relatives, or one case of melanoma and two of pancreatic cancer/astrocytoma in first- or second-degree relatives.
The main environmental risk factor for melanoma is exposure to ultraviolet radiation. Individuals can track their UV exposure with a variety of wearable devices and apps, including SunSense One Digital UV Tracker, the SunSense App, the UV Index Widget, the SunSmart Global UV App, the SunKnown UV light photometer, and the EPA’s UV Index Mobile App. Other environment-related risk factors include having a high socioeconomic status (SES), being immunosuppressed, as well as exposure to heavy metals, insecticides, or hormones; and ones distance from the equator.
In a study published in 2023, researchers investigated the risk factors associated with first and second primary melanomas in 38,845 patients who were followed in Australia between 2011 and 2018. During a median follow-up of 7.4 years, 1212 patients (3.1%) had a single primary melanoma diagnosis and 245 (0.6%) had a secondary primary melanoma diagnosis. The researchers found that second melanomas were more likely than first melanomas to be in situ; for invasive tumors, second melanomas were more likely to be thin (defined as 1 mm or less) than first melanomas. In addition, having many self-reported moles at age 21 years was more strongly associated with second melanomas compared with first melanomas (hazard ratio, 6.36 vs 3.46, respectively; P = .01), as was having a high genetic predisposition (HR, 3.28 vs. 2.06; P = .03). Second melanomas were also more strongly associated with a history of multiple skin cancer excisions (HR, 2.63 vs 1.86; P = .05).
Dr. Kent noted that while sunscreen use protects against melanoma, a National Ambulatory Medical Care Survey in 2014 found that internists and pediatricians mentioned sunscreen at fewer than 0.1% of visits — even those with patients who have a diagnosis of skin disease. “Physicians need to do better,” he said at the meeting, which was hosted by the Scripps Cancer Center. “We as dermatologists have work to do to help educate them.”
Dr. Kent reported having no relevant disclosures.
FROM MELANOMA 2024
AGA updates polypectomy guidance
The new guidance document, authored by Andrew P. Copland, MD, of the University of Virginia Health System, Charlottesville, and colleagues, includes 12 pieces of best practice advice pertaining to polyp removal, including the need for evaluation, considerations for selecting a resection strategy, and reasons for referral.
“Polypectomy techniques are continually evolving with improvements in the ability to assess polyps for high-risk features and with development of appropriate procedures for complete and safe polyp resection,” the authors wrote in Clinical Gastroenterology and Hepatology. “This clinical practice update provides guidance in characterizing polyps and choosing appropriate polypectomy techniques for polyps 2 cm or less in size, which comprise most polyps encountered by most endoscopists.”
To begin, they advised a “structured visual assessment using high-definition white light and/or electronic chromoendoscopy and with photodocumentation” for all polyps identified during routine colonoscopy, with close attention to any features suggesting submucosal invasion.
Next, in a series of statements, the guidance document steers appropriate use of various cold and hot polypectomy techniques.
Cold snare polypectomy should be used for polyps less than 10 mm in size, while cold forceps may be considered for polyps 1-3 mm in diameter. Cold resection techniques should also be used for serrated polyps, with use of submucosal injection, if needed, for polyps greater than 10 mm with unclear margins.
For polyps of intermediate size (10-19 mm), both cold and hot snare polypectomy should be considered, alongside endoscopic mucosal resection for polyps, Dr. Copland and colleagues wrote, noting that hot snare polypectomy should be used for removal of pedunculated lesions greater than 10 mm in size.
In contrast, the update advises against use of hot forceps polypectomy in any scenario.
“Hot forceps polypectomy for diminutive and small polyps is associated with higher incomplete polyp removal rates compared with cold snare polypectomy,” the update panelists wrote. “It is also associated with higher risks of postpolypectomy hemorrhage, particularly in the right colon with higher risks of deep thermal injury. Therefore, the use of hot forceps polypectomy is discouraged.”
In another best practice advice statement, the panelists advised against routine use of clips to close resection sites for polyps less than 20 mm. For larger polyps, they advised “selective use” of clips, most suitably in the proximal colon.
Alternatively, patients with polyps at least 20 mm in size should be considered for referral to endoscopic referral centers, along with patients who have polyps in “challenging” locations, and those with a recurrent polyp at a prior polypectomy site.
Patients with nonpedunculated polyps that exhibit “clear evidence of submucosally invasive cancer” should be referred for surgical evaluation, they added. On a similar note, the update advises tattooing lesions that may need to be located at a future surgery or endoscopy.
Finally, Dr. Copland and colleagues advised all endoscopists to understand appropriate selection of electrosurgical generator settings for various polypectomy or postpolypectomy thermal techniques.
“Ongoing research will allow further tailoring of polypectomy techniques to improve patient outcomes,” they concluded.This clinical practice update was commissioned and approved by the AGA Institute. The working group disclosed relationships with Olympus, Boston Scientific, GIE Medical, and others.
The new guidance document, authored by Andrew P. Copland, MD, of the University of Virginia Health System, Charlottesville, and colleagues, includes 12 pieces of best practice advice pertaining to polyp removal, including the need for evaluation, considerations for selecting a resection strategy, and reasons for referral.
“Polypectomy techniques are continually evolving with improvements in the ability to assess polyps for high-risk features and with development of appropriate procedures for complete and safe polyp resection,” the authors wrote in Clinical Gastroenterology and Hepatology. “This clinical practice update provides guidance in characterizing polyps and choosing appropriate polypectomy techniques for polyps 2 cm or less in size, which comprise most polyps encountered by most endoscopists.”
To begin, they advised a “structured visual assessment using high-definition white light and/or electronic chromoendoscopy and with photodocumentation” for all polyps identified during routine colonoscopy, with close attention to any features suggesting submucosal invasion.
Next, in a series of statements, the guidance document steers appropriate use of various cold and hot polypectomy techniques.
Cold snare polypectomy should be used for polyps less than 10 mm in size, while cold forceps may be considered for polyps 1-3 mm in diameter. Cold resection techniques should also be used for serrated polyps, with use of submucosal injection, if needed, for polyps greater than 10 mm with unclear margins.
For polyps of intermediate size (10-19 mm), both cold and hot snare polypectomy should be considered, alongside endoscopic mucosal resection for polyps, Dr. Copland and colleagues wrote, noting that hot snare polypectomy should be used for removal of pedunculated lesions greater than 10 mm in size.
In contrast, the update advises against use of hot forceps polypectomy in any scenario.
“Hot forceps polypectomy for diminutive and small polyps is associated with higher incomplete polyp removal rates compared with cold snare polypectomy,” the update panelists wrote. “It is also associated with higher risks of postpolypectomy hemorrhage, particularly in the right colon with higher risks of deep thermal injury. Therefore, the use of hot forceps polypectomy is discouraged.”
In another best practice advice statement, the panelists advised against routine use of clips to close resection sites for polyps less than 20 mm. For larger polyps, they advised “selective use” of clips, most suitably in the proximal colon.
Alternatively, patients with polyps at least 20 mm in size should be considered for referral to endoscopic referral centers, along with patients who have polyps in “challenging” locations, and those with a recurrent polyp at a prior polypectomy site.
Patients with nonpedunculated polyps that exhibit “clear evidence of submucosally invasive cancer” should be referred for surgical evaluation, they added. On a similar note, the update advises tattooing lesions that may need to be located at a future surgery or endoscopy.
Finally, Dr. Copland and colleagues advised all endoscopists to understand appropriate selection of electrosurgical generator settings for various polypectomy or postpolypectomy thermal techniques.
“Ongoing research will allow further tailoring of polypectomy techniques to improve patient outcomes,” they concluded.This clinical practice update was commissioned and approved by the AGA Institute. The working group disclosed relationships with Olympus, Boston Scientific, GIE Medical, and others.
The new guidance document, authored by Andrew P. Copland, MD, of the University of Virginia Health System, Charlottesville, and colleagues, includes 12 pieces of best practice advice pertaining to polyp removal, including the need for evaluation, considerations for selecting a resection strategy, and reasons for referral.
“Polypectomy techniques are continually evolving with improvements in the ability to assess polyps for high-risk features and with development of appropriate procedures for complete and safe polyp resection,” the authors wrote in Clinical Gastroenterology and Hepatology. “This clinical practice update provides guidance in characterizing polyps and choosing appropriate polypectomy techniques for polyps 2 cm or less in size, which comprise most polyps encountered by most endoscopists.”
To begin, they advised a “structured visual assessment using high-definition white light and/or electronic chromoendoscopy and with photodocumentation” for all polyps identified during routine colonoscopy, with close attention to any features suggesting submucosal invasion.
Next, in a series of statements, the guidance document steers appropriate use of various cold and hot polypectomy techniques.
Cold snare polypectomy should be used for polyps less than 10 mm in size, while cold forceps may be considered for polyps 1-3 mm in diameter. Cold resection techniques should also be used for serrated polyps, with use of submucosal injection, if needed, for polyps greater than 10 mm with unclear margins.
For polyps of intermediate size (10-19 mm), both cold and hot snare polypectomy should be considered, alongside endoscopic mucosal resection for polyps, Dr. Copland and colleagues wrote, noting that hot snare polypectomy should be used for removal of pedunculated lesions greater than 10 mm in size.
In contrast, the update advises against use of hot forceps polypectomy in any scenario.
“Hot forceps polypectomy for diminutive and small polyps is associated with higher incomplete polyp removal rates compared with cold snare polypectomy,” the update panelists wrote. “It is also associated with higher risks of postpolypectomy hemorrhage, particularly in the right colon with higher risks of deep thermal injury. Therefore, the use of hot forceps polypectomy is discouraged.”
In another best practice advice statement, the panelists advised against routine use of clips to close resection sites for polyps less than 20 mm. For larger polyps, they advised “selective use” of clips, most suitably in the proximal colon.
Alternatively, patients with polyps at least 20 mm in size should be considered for referral to endoscopic referral centers, along with patients who have polyps in “challenging” locations, and those with a recurrent polyp at a prior polypectomy site.
Patients with nonpedunculated polyps that exhibit “clear evidence of submucosally invasive cancer” should be referred for surgical evaluation, they added. On a similar note, the update advises tattooing lesions that may need to be located at a future surgery or endoscopy.
Finally, Dr. Copland and colleagues advised all endoscopists to understand appropriate selection of electrosurgical generator settings for various polypectomy or postpolypectomy thermal techniques.
“Ongoing research will allow further tailoring of polypectomy techniques to improve patient outcomes,” they concluded.This clinical practice update was commissioned and approved by the AGA Institute. The working group disclosed relationships with Olympus, Boston Scientific, GIE Medical, and others.
FROM CLINICAL GASTROENTEROLOGY AND HEPATOLOGY
Iron Overload in Non-HFE Liver Disease: Not all Iron is Ready to Strike
Pathological iron overload with end-organ damage in hemochromatosis occurs in individuals who are homozygous for the major mutation C282Y. Phenotypic hemochromatosis occurs much less frequently in compound heterozygotes with one C282Y mutation and one H63D mutation. Iron overload can be confirmed by magnetic resonance imaging, which shows a loss of signal intensity in affected tissues and avoids the need for liver biopsy.
The serum ferritin level, an acute phase reactant, may be elevated for reasons other than iron overload, including infection and malignancy; in such cases, the iron saturation is usually normal. In patients with liver disease, iron overload is not restricted to patients with genetic hemochromatosis. In nonalcoholic fatty liver disease (NAFLD), up to one-third of patients have an elevated iron saturation (> 45%) and an elevated serum ferritin level. Iron accumulation in NAFLD can occur in hepatocytes, the reticuloendothelial system, or both. Deposition of iron in the reticuloendothelial system has been implicated in more severe liver disease (steatohepatitis and fibrosis) in NAFLD. Hepatic iron accumulation is also frequent in alcohol-associated liver disease. In chronic hepatitis B and C, accumulation of hepatic iron is also recognized.
Dr. Martin is chief of the division of digestive health and liver diseases at the Miller School of Medicine, University of Miami, where he is the Mandel Chair of Gastroenterology. Dr. Friedman is the Anton R. Fried, MD, Chair of the department of medicine at Newton-Wellesley Hospital in Newton, Massachusetts, and assistant chief of medicine at Massachusetts General Hospital, and a professor of medicine at Harvard Medical School and Tufts University School of Medicine, all in Boston. The authors disclosed no conflicts. Previously published in Gastro Hep Advances. 2023 Oct 12. doi: 10.1016/j.gastha.2023.10.004.
Pathological iron overload with end-organ damage in hemochromatosis occurs in individuals who are homozygous for the major mutation C282Y. Phenotypic hemochromatosis occurs much less frequently in compound heterozygotes with one C282Y mutation and one H63D mutation. Iron overload can be confirmed by magnetic resonance imaging, which shows a loss of signal intensity in affected tissues and avoids the need for liver biopsy.
The serum ferritin level, an acute phase reactant, may be elevated for reasons other than iron overload, including infection and malignancy; in such cases, the iron saturation is usually normal. In patients with liver disease, iron overload is not restricted to patients with genetic hemochromatosis. In nonalcoholic fatty liver disease (NAFLD), up to one-third of patients have an elevated iron saturation (> 45%) and an elevated serum ferritin level. Iron accumulation in NAFLD can occur in hepatocytes, the reticuloendothelial system, or both. Deposition of iron in the reticuloendothelial system has been implicated in more severe liver disease (steatohepatitis and fibrosis) in NAFLD. Hepatic iron accumulation is also frequent in alcohol-associated liver disease. In chronic hepatitis B and C, accumulation of hepatic iron is also recognized.
Dr. Martin is chief of the division of digestive health and liver diseases at the Miller School of Medicine, University of Miami, where he is the Mandel Chair of Gastroenterology. Dr. Friedman is the Anton R. Fried, MD, Chair of the department of medicine at Newton-Wellesley Hospital in Newton, Massachusetts, and assistant chief of medicine at Massachusetts General Hospital, and a professor of medicine at Harvard Medical School and Tufts University School of Medicine, all in Boston. The authors disclosed no conflicts. Previously published in Gastro Hep Advances. 2023 Oct 12. doi: 10.1016/j.gastha.2023.10.004.
Pathological iron overload with end-organ damage in hemochromatosis occurs in individuals who are homozygous for the major mutation C282Y. Phenotypic hemochromatosis occurs much less frequently in compound heterozygotes with one C282Y mutation and one H63D mutation. Iron overload can be confirmed by magnetic resonance imaging, which shows a loss of signal intensity in affected tissues and avoids the need for liver biopsy.
The serum ferritin level, an acute phase reactant, may be elevated for reasons other than iron overload, including infection and malignancy; in such cases, the iron saturation is usually normal. In patients with liver disease, iron overload is not restricted to patients with genetic hemochromatosis. In nonalcoholic fatty liver disease (NAFLD), up to one-third of patients have an elevated iron saturation (> 45%) and an elevated serum ferritin level. Iron accumulation in NAFLD can occur in hepatocytes, the reticuloendothelial system, or both. Deposition of iron in the reticuloendothelial system has been implicated in more severe liver disease (steatohepatitis and fibrosis) in NAFLD. Hepatic iron accumulation is also frequent in alcohol-associated liver disease. In chronic hepatitis B and C, accumulation of hepatic iron is also recognized.
Dr. Martin is chief of the division of digestive health and liver diseases at the Miller School of Medicine, University of Miami, where he is the Mandel Chair of Gastroenterology. Dr. Friedman is the Anton R. Fried, MD, Chair of the department of medicine at Newton-Wellesley Hospital in Newton, Massachusetts, and assistant chief of medicine at Massachusetts General Hospital, and a professor of medicine at Harvard Medical School and Tufts University School of Medicine, all in Boston. The authors disclosed no conflicts. Previously published in Gastro Hep Advances. 2023 Oct 12. doi: 10.1016/j.gastha.2023.10.004.
How Do Anogenital Injuries Relate to Rape Accusations?
Violence against women by partners is a serious human rights violation and a significant global public health issue. Overall, an estimated 27% of women aged 15-49 years who have been in a relationship have experienced physical or sexual violence (SV) at the hands of a partner. According to 2019 data from the US Department of Justice, SV in the United States occurs every 73 seconds, with child victims every 9 minutes. Lifetime rates of SV are around 17%-18% for women and 3% for men.
The emergency department remains the most common place where patients who have experienced SV seek comprehensive care, including emergency contraception, prophylaxis against sexually transmitted infections, forensic evidence collection for rape cases, and treatment for injuries.
Physical injuries from SV are not always detectable. Studies report variable percentages, ranging from 30%-80% of patients with traumatic SV injuries. Evidence regarding their severity is conflicting.
The presence or absence of anogenital injuries following SV is a factor that can influence both victims’ willingness to report a crime and the judicial decision-making process regarding accusations and convictions.
Rape Myths
The mythology of rape has been under discussion for more than 50 years, encompassing concerns that rape myths reinforce ideas about what does and does not constitute SV and who is a credible victim.
Rape myths, classically defined in the 1980s, are “prejudiced, stereotyped, and false beliefs about rape, rape victims, and rapists,” designed to “deny or minimize perceived harm or blame victims for their victimization.” The concept remains relevant to contemporary societal beliefs and concerns.
A systematic review analyzed elements of rape myths related to victim characteristics and their impact on credibility and blame attribution in the investigative process. Victims who knew the (male) perpetrator and were deemed provocative based on attire were assigned greater blame. In addition, detail and consistency in victims› statements and the presence of physical evidence and injuries increased credibility. However, in certain situations, rape myths may lead to blaming victims who do not fit the “real victim” stereotype, thus resulting in secondary victimization or revictimization.
Anogenital Injuries
Anogenital injuries can occur in relation to consensual sexual activity (CSA), and SV may not be associated with injuries. Therefore, the presence of anogenital injuries does not “prove” SV nor does their absence exclude rape.
This statement is supported by a systematic review and meta-analysis investigating the prevalence of anogenital injuries in women following SV and CSA, using consistent examination techniques for better forensic evidence evaluation in criminal proceedings.
The following two groups were defined for comparison: SV, indicating any nonconsensual sexual contact with the survivor’s anogenital area, and CSA, representing the same type of sexual contact with participants’ consent.
The outcome measure was the presence of anogenital injury (defined as any genital, anal, or perineal injury detected using described techniques in each study). With no universal definition of genital trauma, the result assessment was dichotomous: The presence or absence of injury.
The systematic search yielded 1401 results, and 10 cohort studies published from 1997 to 2022 met the inclusion criteria. The study participants were 3165 women, with 59% (1874/3165) surviving SV.
Anogenital injuries were found in 48% of women who experienced SV (901/1874) and in 31% of those with CSA (394/1291). Anogenital injuries were significantly more likely in women who had experienced SV, compared with those with CSA (risk ratio, 1.59; P < .001). However, both groups had cases where anogenital injuries were either detected or not.
Some SV survivors had no identified anogenital injuries, and women examined after CSA had detectable anogenital injuries. Subgroup analysis for high-quality studies showed no significant differences between groups. These data support the hypothesis that the presence of anogenital injuries does not prove SV, and the absence of injuries does not disprove it.
Point for Practice
Numerous myths reinforce cultural attitudes toward reporting SV. One myth suggests that physical violence, and thus injuries, are inevitable accompaniments to rape. If the victim does not react physically, it might be argued that it was not really rape, or without physical trauma, one might be less inclined to believe that a rape occurred.
Physicians and healthcare professionals involved in the care and support of SV survivors must explicitly reassure them that the lack of anogenital injury evidence does not diminish the credibility of their account.
This article was translated from Univadis Italy, which is part of the Medscape Professional Network. A version of this article appeared on Medscape.com.
Violence against women by partners is a serious human rights violation and a significant global public health issue. Overall, an estimated 27% of women aged 15-49 years who have been in a relationship have experienced physical or sexual violence (SV) at the hands of a partner. According to 2019 data from the US Department of Justice, SV in the United States occurs every 73 seconds, with child victims every 9 minutes. Lifetime rates of SV are around 17%-18% for women and 3% for men.
The emergency department remains the most common place where patients who have experienced SV seek comprehensive care, including emergency contraception, prophylaxis against sexually transmitted infections, forensic evidence collection for rape cases, and treatment for injuries.
Physical injuries from SV are not always detectable. Studies report variable percentages, ranging from 30%-80% of patients with traumatic SV injuries. Evidence regarding their severity is conflicting.
The presence or absence of anogenital injuries following SV is a factor that can influence both victims’ willingness to report a crime and the judicial decision-making process regarding accusations and convictions.
Rape Myths
The mythology of rape has been under discussion for more than 50 years, encompassing concerns that rape myths reinforce ideas about what does and does not constitute SV and who is a credible victim.
Rape myths, classically defined in the 1980s, are “prejudiced, stereotyped, and false beliefs about rape, rape victims, and rapists,” designed to “deny or minimize perceived harm or blame victims for their victimization.” The concept remains relevant to contemporary societal beliefs and concerns.
A systematic review analyzed elements of rape myths related to victim characteristics and their impact on credibility and blame attribution in the investigative process. Victims who knew the (male) perpetrator and were deemed provocative based on attire were assigned greater blame. In addition, detail and consistency in victims› statements and the presence of physical evidence and injuries increased credibility. However, in certain situations, rape myths may lead to blaming victims who do not fit the “real victim” stereotype, thus resulting in secondary victimization or revictimization.
Anogenital Injuries
Anogenital injuries can occur in relation to consensual sexual activity (CSA), and SV may not be associated with injuries. Therefore, the presence of anogenital injuries does not “prove” SV nor does their absence exclude rape.
This statement is supported by a systematic review and meta-analysis investigating the prevalence of anogenital injuries in women following SV and CSA, using consistent examination techniques for better forensic evidence evaluation in criminal proceedings.
The following two groups were defined for comparison: SV, indicating any nonconsensual sexual contact with the survivor’s anogenital area, and CSA, representing the same type of sexual contact with participants’ consent.
The outcome measure was the presence of anogenital injury (defined as any genital, anal, or perineal injury detected using described techniques in each study). With no universal definition of genital trauma, the result assessment was dichotomous: The presence or absence of injury.
The systematic search yielded 1401 results, and 10 cohort studies published from 1997 to 2022 met the inclusion criteria. The study participants were 3165 women, with 59% (1874/3165) surviving SV.
Anogenital injuries were found in 48% of women who experienced SV (901/1874) and in 31% of those with CSA (394/1291). Anogenital injuries were significantly more likely in women who had experienced SV, compared with those with CSA (risk ratio, 1.59; P < .001). However, both groups had cases where anogenital injuries were either detected or not.
Some SV survivors had no identified anogenital injuries, and women examined after CSA had detectable anogenital injuries. Subgroup analysis for high-quality studies showed no significant differences between groups. These data support the hypothesis that the presence of anogenital injuries does not prove SV, and the absence of injuries does not disprove it.
Point for Practice
Numerous myths reinforce cultural attitudes toward reporting SV. One myth suggests that physical violence, and thus injuries, are inevitable accompaniments to rape. If the victim does not react physically, it might be argued that it was not really rape, or without physical trauma, one might be less inclined to believe that a rape occurred.
Physicians and healthcare professionals involved in the care and support of SV survivors must explicitly reassure them that the lack of anogenital injury evidence does not diminish the credibility of their account.
This article was translated from Univadis Italy, which is part of the Medscape Professional Network. A version of this article appeared on Medscape.com.
Violence against women by partners is a serious human rights violation and a significant global public health issue. Overall, an estimated 27% of women aged 15-49 years who have been in a relationship have experienced physical or sexual violence (SV) at the hands of a partner. According to 2019 data from the US Department of Justice, SV in the United States occurs every 73 seconds, with child victims every 9 minutes. Lifetime rates of SV are around 17%-18% for women and 3% for men.
The emergency department remains the most common place where patients who have experienced SV seek comprehensive care, including emergency contraception, prophylaxis against sexually transmitted infections, forensic evidence collection for rape cases, and treatment for injuries.
Physical injuries from SV are not always detectable. Studies report variable percentages, ranging from 30%-80% of patients with traumatic SV injuries. Evidence regarding their severity is conflicting.
The presence or absence of anogenital injuries following SV is a factor that can influence both victims’ willingness to report a crime and the judicial decision-making process regarding accusations and convictions.
Rape Myths
The mythology of rape has been under discussion for more than 50 years, encompassing concerns that rape myths reinforce ideas about what does and does not constitute SV and who is a credible victim.
Rape myths, classically defined in the 1980s, are “prejudiced, stereotyped, and false beliefs about rape, rape victims, and rapists,” designed to “deny or minimize perceived harm or blame victims for their victimization.” The concept remains relevant to contemporary societal beliefs and concerns.
A systematic review analyzed elements of rape myths related to victim characteristics and their impact on credibility and blame attribution in the investigative process. Victims who knew the (male) perpetrator and were deemed provocative based on attire were assigned greater blame. In addition, detail and consistency in victims› statements and the presence of physical evidence and injuries increased credibility. However, in certain situations, rape myths may lead to blaming victims who do not fit the “real victim” stereotype, thus resulting in secondary victimization or revictimization.
Anogenital Injuries
Anogenital injuries can occur in relation to consensual sexual activity (CSA), and SV may not be associated with injuries. Therefore, the presence of anogenital injuries does not “prove” SV nor does their absence exclude rape.
This statement is supported by a systematic review and meta-analysis investigating the prevalence of anogenital injuries in women following SV and CSA, using consistent examination techniques for better forensic evidence evaluation in criminal proceedings.
The following two groups were defined for comparison: SV, indicating any nonconsensual sexual contact with the survivor’s anogenital area, and CSA, representing the same type of sexual contact with participants’ consent.
The outcome measure was the presence of anogenital injury (defined as any genital, anal, or perineal injury detected using described techniques in each study). With no universal definition of genital trauma, the result assessment was dichotomous: The presence or absence of injury.
The systematic search yielded 1401 results, and 10 cohort studies published from 1997 to 2022 met the inclusion criteria. The study participants were 3165 women, with 59% (1874/3165) surviving SV.
Anogenital injuries were found in 48% of women who experienced SV (901/1874) and in 31% of those with CSA (394/1291). Anogenital injuries were significantly more likely in women who had experienced SV, compared with those with CSA (risk ratio, 1.59; P < .001). However, both groups had cases where anogenital injuries were either detected or not.
Some SV survivors had no identified anogenital injuries, and women examined after CSA had detectable anogenital injuries. Subgroup analysis for high-quality studies showed no significant differences between groups. These data support the hypothesis that the presence of anogenital injuries does not prove SV, and the absence of injuries does not disprove it.
Point for Practice
Numerous myths reinforce cultural attitudes toward reporting SV. One myth suggests that physical violence, and thus injuries, are inevitable accompaniments to rape. If the victim does not react physically, it might be argued that it was not really rape, or without physical trauma, one might be less inclined to believe that a rape occurred.
Physicians and healthcare professionals involved in the care and support of SV survivors must explicitly reassure them that the lack of anogenital injury evidence does not diminish the credibility of their account.
This article was translated from Univadis Italy, which is part of the Medscape Professional Network. A version of this article appeared on Medscape.com.