Liz Scherer

British Columbia (BC) could eliminate cervical cancer within the next 20 years if the province shifts from cytology to human papillomavirus (HPV)–based screening before the end of the decade, data suggested. To achieve this goal, the province will also need to reach historically underscreened, equity-seeking populations (ie, Black, indigenous, immigrant, LGBTQ, and disabled patients, and those with sexual trauma) through mailed self-screening HPV tests.

The adoption of both these strategies is essential, according to a modeling study that was published on June 3 in CMAJ, especially because the true impact of HPV vaccination has yet to be fully realized.

“In BC, we have a school-based program to increase vaccine coverage in boys and girls starting in grade 6,” study author Reka Pataky, PhD, a senior research health economist at the Canadian Centre for Applied Research in Cancer Control and BC Cancer in Vancouver, British Columbia, Canada, told this news organization. Dr. Pataky noted that this immunization program was launched in 2008 and that some of the initial cohorts haven›t yet reached the average age of diagnosis, which is between 30 and 59 years.

Three’s a Charm

The investigators undertook a modeling study to determine when and how BC might achieve the elimination of cervical cancer following a transition to HPV-based screening. Elimination was defined as an annual age-standardized incidence rate of < 4.0 per 100,000 women.

Modeling scenarios were developed using the Canadian Partnership Against Cancer’s priority targets, which include increasing HPV vaccination through school-based coverage from 70% to 90%, increasing the probability of ever receiving a screening test from 90% to 95%, increasing the rate of on-time screening from 70% to 90%, and improving follow-up to 95% for colposcopy (currently 88%) and HPV testing (currently 80%). Modeling simulated HPV transmission and the natural history of cervical cancer in the Canadian population and relied upon two reference scenarios: One using BC’s cytology-based screening at the time of analysis, and the other an HPV base-case scenario.

The researchers found that with the status quo (ie, cytology-based screening and no change to vaccination or screening participation rates), BC would not eliminate cervical cancer until 2045. Implementation of HPV-based screening at the current 70% participation rate would achieve elimination in 2034 and prevent 942 cases compared with cytology screening. Increasing the proportion of patients who were ever screened or increasing vaccination coverage would result in cervical cancer elimination by 2033. The time line would be shortened even further (to 2031) through a combination of three strategies (ie, improving recruitment, on-time screening, and follow-up compliance).

Low Incidence, Strained System

The incidence of cervical cancer in Canada is relatively low, accounting for 1.3% of all new female cancers and 1.1% of all female cancer deaths.

“The reason that we have such low rates is because we have organized screening programs,” explained Rachel Kupets, MD, associate professor of gynecologic oncology at the University of Toronto and Sunnybrook Hospital, Toronto. She was not involved in the study.

“We’re starting to see what happens when the system gets strained with lower participation rates. I am starting to see a lot more women with invasive cervical cancer. They’re younger, and their cancers are less curable and less treatable,” she said.

Difficulties with access, interest, and education have contributed to low cervical screening rates among equity-seeking populations, according to Dr. Pataky and Dr. Kupets.

“Self-screening is another tool that can incrementally benefit those folks who wouldn’t otherwise undergo screening or don’t want an invasive test,” said Dr. Kupets. It can also play an increasing role, while current access to primary care services in Canada is at an all-time low. Community outreach through centers, mobile coaches, and nursing stations might help ensure participation by at-risk populations. These measures also could boost follow-up for and education about positive results, said Dr. Kupets.

In a related editorial, Shannon Charlebois, MD, medical editor of CMAJ, and Sarah Kean, MD, assistant professor of gynecologic oncology at the University of Manitoba in Winnipeg, Manitoba, Canada, emphasized the need for mailed HPV self-screening kits to be paid for and integrated into provincial cervical cancer screening programs across Canada to support earlier cervical cancer detection and lower invasive cancer rates.

Dr. Pataky concurred. “There have been discussions about making the big transition from traditional cytology to implementing HPV self-screening,” she said. “We have really effective tools for preventing cervical cancer, and it’s important to not lose sight of that goal.”

The study was funded by the National Institutes of Health. Dr. Pataky and Dr. Kupets reported no relevant financial relationships.
 

A version of this article appeared on Medscape.com.

British Columbia (BC) could eliminate cervical cancer within the next 20 years if the province shifts from cytology to human papillomavirus (HPV)–based screening before the end of the decade, data suggested. To achieve this goal, the province will also need to reach historically underscreened, equity-seeking populations (ie, Black, indigenous, immigrant, LGBTQ, and disabled patients, and those with sexual trauma) through mailed self-screening HPV tests.

The adoption of both these strategies is essential, according to a modeling study that was published on June 3 in CMAJ, especially because the true impact of HPV vaccination has yet to be fully realized.

“In BC, we have a school-based program to increase vaccine coverage in boys and girls starting in grade 6,” study author Reka Pataky, PhD, a senior research health economist at the Canadian Centre for Applied Research in Cancer Control and BC Cancer in Vancouver, British Columbia, Canada, told this news organization. Dr. Pataky noted that this immunization program was launched in 2008 and that some of the initial cohorts haven›t yet reached the average age of diagnosis, which is between 30 and 59 years.

Three’s a Charm

The investigators undertook a modeling study to determine when and how BC might achieve the elimination of cervical cancer following a transition to HPV-based screening. Elimination was defined as an annual age-standardized incidence rate of < 4.0 per 100,000 women.

Modeling scenarios were developed using the Canadian Partnership Against Cancer’s priority targets, which include increasing HPV vaccination through school-based coverage from 70% to 90%, increasing the probability of ever receiving a screening test from 90% to 95%, increasing the rate of on-time screening from 70% to 90%, and improving follow-up to 95% for colposcopy (currently 88%) and HPV testing (currently 80%). Modeling simulated HPV transmission and the natural history of cervical cancer in the Canadian population and relied upon two reference scenarios: One using BC’s cytology-based screening at the time of analysis, and the other an HPV base-case scenario.

The researchers found that with the status quo (ie, cytology-based screening and no change to vaccination or screening participation rates), BC would not eliminate cervical cancer until 2045. Implementation of HPV-based screening at the current 70% participation rate would achieve elimination in 2034 and prevent 942 cases compared with cytology screening. Increasing the proportion of patients who were ever screened or increasing vaccination coverage would result in cervical cancer elimination by 2033. The time line would be shortened even further (to 2031) through a combination of three strategies (ie, improving recruitment, on-time screening, and follow-up compliance).

Low Incidence, Strained System

The incidence of cervical cancer in Canada is relatively low, accounting for 1.3% of all new female cancers and 1.1% of all female cancer deaths.

“The reason that we have such low rates is because we have organized screening programs,” explained Rachel Kupets, MD, associate professor of gynecologic oncology at the University of Toronto and Sunnybrook Hospital, Toronto. She was not involved in the study.

“We’re starting to see what happens when the system gets strained with lower participation rates. I am starting to see a lot more women with invasive cervical cancer. They’re younger, and their cancers are less curable and less treatable,” she said.

Difficulties with access, interest, and education have contributed to low cervical screening rates among equity-seeking populations, according to Dr. Pataky and Dr. Kupets.

“Self-screening is another tool that can incrementally benefit those folks who wouldn’t otherwise undergo screening or don’t want an invasive test,” said Dr. Kupets. It can also play an increasing role, while current access to primary care services in Canada is at an all-time low. Community outreach through centers, mobile coaches, and nursing stations might help ensure participation by at-risk populations. These measures also could boost follow-up for and education about positive results, said Dr. Kupets.

In a related editorial, Shannon Charlebois, MD, medical editor of CMAJ, and Sarah Kean, MD, assistant professor of gynecologic oncology at the University of Manitoba in Winnipeg, Manitoba, Canada, emphasized the need for mailed HPV self-screening kits to be paid for and integrated into provincial cervical cancer screening programs across Canada to support earlier cervical cancer detection and lower invasive cancer rates.

Dr. Pataky concurred. “There have been discussions about making the big transition from traditional cytology to implementing HPV self-screening,” she said. “We have really effective tools for preventing cervical cancer, and it’s important to not lose sight of that goal.”

The study was funded by the National Institutes of Health. Dr. Pataky and Dr. Kupets reported no relevant financial relationships.
 

A version of this article appeared on Medscape.com.

British Columbia (BC) could eliminate cervical cancer within the next 20 years if the province shifts from cytology to human papillomavirus (HPV)–based screening before the end of the decade, data suggested. To achieve this goal, the province will also need to reach historically underscreened, equity-seeking populations (ie, Black, indigenous, immigrant, LGBTQ, and disabled patients, and those with sexual trauma) through mailed self-screening HPV tests.

The adoption of both these strategies is essential, according to a modeling study that was published on June 3 in CMAJ, especially because the true impact of HPV vaccination has yet to be fully realized.

“In BC, we have a school-based program to increase vaccine coverage in boys and girls starting in grade 6,” study author Reka Pataky, PhD, a senior research health economist at the Canadian Centre for Applied Research in Cancer Control and BC Cancer in Vancouver, British Columbia, Canada, told this news organization. Dr. Pataky noted that this immunization program was launched in 2008 and that some of the initial cohorts haven›t yet reached the average age of diagnosis, which is between 30 and 59 years.

Three’s a Charm

The investigators undertook a modeling study to determine when and how BC might achieve the elimination of cervical cancer following a transition to HPV-based screening. Elimination was defined as an annual age-standardized incidence rate of < 4.0 per 100,000 women.

Modeling scenarios were developed using the Canadian Partnership Against Cancer’s priority targets, which include increasing HPV vaccination through school-based coverage from 70% to 90%, increasing the probability of ever receiving a screening test from 90% to 95%, increasing the rate of on-time screening from 70% to 90%, and improving follow-up to 95% for colposcopy (currently 88%) and HPV testing (currently 80%). Modeling simulated HPV transmission and the natural history of cervical cancer in the Canadian population and relied upon two reference scenarios: One using BC’s cytology-based screening at the time of analysis, and the other an HPV base-case scenario.

The researchers found that with the status quo (ie, cytology-based screening and no change to vaccination or screening participation rates), BC would not eliminate cervical cancer until 2045. Implementation of HPV-based screening at the current 70% participation rate would achieve elimination in 2034 and prevent 942 cases compared with cytology screening. Increasing the proportion of patients who were ever screened or increasing vaccination coverage would result in cervical cancer elimination by 2033. The time line would be shortened even further (to 2031) through a combination of three strategies (ie, improving recruitment, on-time screening, and follow-up compliance).

Low Incidence, Strained System

The incidence of cervical cancer in Canada is relatively low, accounting for 1.3% of all new female cancers and 1.1% of all female cancer deaths.

“The reason that we have such low rates is because we have organized screening programs,” explained Rachel Kupets, MD, associate professor of gynecologic oncology at the University of Toronto and Sunnybrook Hospital, Toronto. She was not involved in the study.

“We’re starting to see what happens when the system gets strained with lower participation rates. I am starting to see a lot more women with invasive cervical cancer. They’re younger, and their cancers are less curable and less treatable,” she said.

Difficulties with access, interest, and education have contributed to low cervical screening rates among equity-seeking populations, according to Dr. Pataky and Dr. Kupets.

“Self-screening is another tool that can incrementally benefit those folks who wouldn’t otherwise undergo screening or don’t want an invasive test,” said Dr. Kupets. It can also play an increasing role, while current access to primary care services in Canada is at an all-time low. Community outreach through centers, mobile coaches, and nursing stations might help ensure participation by at-risk populations. These measures also could boost follow-up for and education about positive results, said Dr. Kupets.

In a related editorial, Shannon Charlebois, MD, medical editor of CMAJ, and Sarah Kean, MD, assistant professor of gynecologic oncology at the University of Manitoba in Winnipeg, Manitoba, Canada, emphasized the need for mailed HPV self-screening kits to be paid for and integrated into provincial cervical cancer screening programs across Canada to support earlier cervical cancer detection and lower invasive cancer rates.

Dr. Pataky concurred. “There have been discussions about making the big transition from traditional cytology to implementing HPV self-screening,” she said. “We have really effective tools for preventing cervical cancer, and it’s important to not lose sight of that goal.”

The study was funded by the National Institutes of Health. Dr. Pataky and Dr. Kupets reported no relevant financial relationships.
 

A version of this article appeared on Medscape.com.

What if a walk in a green environment could reshape brains, recalibrate sense of time, and stave off mental health conditions? If the research trends are true, you might soon find yourself writing prescriptions of 20 minutes of nature per day.

Evidence for the health benefits of exposure to green spaces, like parks, open spaces, gardens, outdoor gyms, and woodland trails, has been mostly interventional and observational, but that has not stopped global recognition that these exposures are important. 

In the wake of the pandemic, the British government allocated more than £5 million to pandemic recovery efforts that specifically involved green spaces. Since then, it has committed even more funding toward an expansive social prescribing program that connects patients to “link workers” who determine personal care needs and facilitate community and volunteer-based interventions. These can include group walking and volunteering to help out in community gardens or conservation efforts. Similar green programs can be found in Japan, where shinrin-yoku (forest bathing) was recently adopted as a national health strategy, and in the United States and Canada.

“Disconnection from nature is a major part of the health problems that we have on this planet,” said William Bird, a UK-based general practitioner, green prescriber, and CEO of Intelligent Health, which is geared toward building healthy, active, and connected communities. Dr. Bird received the prestigious Member of the Order of the British Empire (MBE) in 2010 for services related to physical activity and health. 

“Our brains are designed to connect to nature ... and we haven’t lost that instinct,” he explained. “Once we are with birdsong and water flowing and greenery, cortisol levels drop, our central vagus nerve improves, our fight and flight [response] disappears, and we start to be more receptive to other people.” 
 

Shifting Time Perception and Health

Ricardo A. Correia, PhD, a biologist and researcher at the University of Helsinki in Finland, said he believed that the mechanism for at least some of these outcomes might be differences in how time is perceived. In a perspective that appeared in March in People and Nature, Dr. Correia explored how the “services” that nature provides shift time perceptions and, in turn, regulate overall well-being. 

“I reached the realization that there was some evidence for the shift in some of the dimensions that we use to make sense of time in urban vs natural environments,” he told this news organization. 

Dr. Correia explained that human time perception facilitates understanding cause and effect, so we can act in a way that allows us to survive. 

“Time perception in humans is really complex and multifaceted,” he said. “The way that we make sense of time is not directly attached to any sensory organ, but rather goes through a range of cognitive, emotional, and bodily processes, all of which vary from person to person.” 

Dr. Correia pointed to evidence showing that time perception is shorter in urban environments and longer in natural ones. This, in turn, influences attention and attention restoration. “When we live in cities, we are exposed to similar sorts of demanding environments, increased time pressures, less time for oneself and for recreational purposes,” he said. “Ever-mounting pressure on daily demands plus processes we use to make sense of time, especially attention, means that we pay a cognitive toll.”

Dr. Correia posits that it might be possible to recalibrate time perception, but only by breaking the cycle of exposure. 

“If we are always exposed to fast-paced lifestyles, we become attuned to them and get caught up in an endless loop.” This cycle can be broken, Dr. Correia explained, by increasing exposure to natural environments. This leads to positive emotions, a sense of being in the present, and a heightened sense of mindfulness, all of which help mitigate the physical and mental health outcomes commonly associated with time scarcity. 
 

Brain-Mental Health Benefits

To date, there is quite a bit of research exploring the impacts of exposure to nature on the brain. For example, data have shown that adolescents raised exclusively in rural environments have a larger hippocampus and better spatial processing than children exclusively raised in cities. Other research demonstrated that spending just an hour in the forest led to a decline in amygdala activity in adults, whereas it remained stable after walking in an urban setting, underscoring the salutogenic effects on brain regions related to stress. There is also evidence from a 10-year longitudinal study of more than 2 million Welsh adults that highlights the value of proximity to green or blue (eg, lakes and rivers) spaces and common mental health conditions, with every additional 360 meters to the nearest green or blue space associated with 10% greater odds of anxiety and depression.

Dr. Bird said there has been a massive sea change in attitudes among general practitioners, who have come around to embracing the concept of nature as medicine. This shift among peers, who teased him in the 1990s about his green walking and conservation prescriptions, portends a bandwagon of epic proportions that could benefit patients. He said that he was especially hopeful that green prescriptions will become mainstream in certain conditions, especially those like depression and anxiety that are resistant to medication.

But Dr. Bird cautions that primary care professionals need to be mindful. “Patients need to know that it’s real science, otherwise they’ll think that they’re being pawned off or dismissed,” he said. “I try to put real evidence behind it and explain that there’s no contraindication. The main thing is to start where patients are, what they’re feeling, and what they need. Some people just don’t like nature,” he said.
 

A version of this article appeared on Medscape.com.

What if a walk in a green environment could reshape brains, recalibrate sense of time, and stave off mental health conditions? If the research trends are true, you might soon find yourself writing prescriptions of 20 minutes of nature per day.

Evidence for the health benefits of exposure to green spaces, like parks, open spaces, gardens, outdoor gyms, and woodland trails, has been mostly interventional and observational, but that has not stopped global recognition that these exposures are important. 

In the wake of the pandemic, the British government allocated more than £5 million to pandemic recovery efforts that specifically involved green spaces. Since then, it has committed even more funding toward an expansive social prescribing program that connects patients to “link workers” who determine personal care needs and facilitate community and volunteer-based interventions. These can include group walking and volunteering to help out in community gardens or conservation efforts. Similar green programs can be found in Japan, where shinrin-yoku (forest bathing) was recently adopted as a national health strategy, and in the United States and Canada.

“Disconnection from nature is a major part of the health problems that we have on this planet,” said William Bird, a UK-based general practitioner, green prescriber, and CEO of Intelligent Health, which is geared toward building healthy, active, and connected communities. Dr. Bird received the prestigious Member of the Order of the British Empire (MBE) in 2010 for services related to physical activity and health. 

“Our brains are designed to connect to nature ... and we haven’t lost that instinct,” he explained. “Once we are with birdsong and water flowing and greenery, cortisol levels drop, our central vagus nerve improves, our fight and flight [response] disappears, and we start to be more receptive to other people.” 
 

Shifting Time Perception and Health

Ricardo A. Correia, PhD, a biologist and researcher at the University of Helsinki in Finland, said he believed that the mechanism for at least some of these outcomes might be differences in how time is perceived. In a perspective that appeared in March in People and Nature, Dr. Correia explored how the “services” that nature provides shift time perceptions and, in turn, regulate overall well-being. 

“I reached the realization that there was some evidence for the shift in some of the dimensions that we use to make sense of time in urban vs natural environments,” he told this news organization. 

Dr. Correia explained that human time perception facilitates understanding cause and effect, so we can act in a way that allows us to survive. 

“Time perception in humans is really complex and multifaceted,” he said. “The way that we make sense of time is not directly attached to any sensory organ, but rather goes through a range of cognitive, emotional, and bodily processes, all of which vary from person to person.” 

Dr. Correia pointed to evidence showing that time perception is shorter in urban environments and longer in natural ones. This, in turn, influences attention and attention restoration. “When we live in cities, we are exposed to similar sorts of demanding environments, increased time pressures, less time for oneself and for recreational purposes,” he said. “Ever-mounting pressure on daily demands plus processes we use to make sense of time, especially attention, means that we pay a cognitive toll.”

Dr. Correia posits that it might be possible to recalibrate time perception, but only by breaking the cycle of exposure. 

“If we are always exposed to fast-paced lifestyles, we become attuned to them and get caught up in an endless loop.” This cycle can be broken, Dr. Correia explained, by increasing exposure to natural environments. This leads to positive emotions, a sense of being in the present, and a heightened sense of mindfulness, all of which help mitigate the physical and mental health outcomes commonly associated with time scarcity. 
 

Brain-Mental Health Benefits

To date, there is quite a bit of research exploring the impacts of exposure to nature on the brain. For example, data have shown that adolescents raised exclusively in rural environments have a larger hippocampus and better spatial processing than children exclusively raised in cities. Other research demonstrated that spending just an hour in the forest led to a decline in amygdala activity in adults, whereas it remained stable after walking in an urban setting, underscoring the salutogenic effects on brain regions related to stress. There is also evidence from a 10-year longitudinal study of more than 2 million Welsh adults that highlights the value of proximity to green or blue (eg, lakes and rivers) spaces and common mental health conditions, with every additional 360 meters to the nearest green or blue space associated with 10% greater odds of anxiety and depression.

Dr. Bird said there has been a massive sea change in attitudes among general practitioners, who have come around to embracing the concept of nature as medicine. This shift among peers, who teased him in the 1990s about his green walking and conservation prescriptions, portends a bandwagon of epic proportions that could benefit patients. He said that he was especially hopeful that green prescriptions will become mainstream in certain conditions, especially those like depression and anxiety that are resistant to medication.

But Dr. Bird cautions that primary care professionals need to be mindful. “Patients need to know that it’s real science, otherwise they’ll think that they’re being pawned off or dismissed,” he said. “I try to put real evidence behind it and explain that there’s no contraindication. The main thing is to start where patients are, what they’re feeling, and what they need. Some people just don’t like nature,” he said.
 

A version of this article appeared on Medscape.com.

What if a walk in a green environment could reshape brains, recalibrate sense of time, and stave off mental health conditions? If the research trends are true, you might soon find yourself writing prescriptions of 20 minutes of nature per day.

Evidence for the health benefits of exposure to green spaces, like parks, open spaces, gardens, outdoor gyms, and woodland trails, has been mostly interventional and observational, but that has not stopped global recognition that these exposures are important. 

In the wake of the pandemic, the British government allocated more than £5 million to pandemic recovery efforts that specifically involved green spaces. Since then, it has committed even more funding toward an expansive social prescribing program that connects patients to “link workers” who determine personal care needs and facilitate community and volunteer-based interventions. These can include group walking and volunteering to help out in community gardens or conservation efforts. Similar green programs can be found in Japan, where shinrin-yoku (forest bathing) was recently adopted as a national health strategy, and in the United States and Canada.

“Disconnection from nature is a major part of the health problems that we have on this planet,” said William Bird, a UK-based general practitioner, green prescriber, and CEO of Intelligent Health, which is geared toward building healthy, active, and connected communities. Dr. Bird received the prestigious Member of the Order of the British Empire (MBE) in 2010 for services related to physical activity and health. 

“Our brains are designed to connect to nature ... and we haven’t lost that instinct,” he explained. “Once we are with birdsong and water flowing and greenery, cortisol levels drop, our central vagus nerve improves, our fight and flight [response] disappears, and we start to be more receptive to other people.” 
 

Shifting Time Perception and Health

Ricardo A. Correia, PhD, a biologist and researcher at the University of Helsinki in Finland, said he believed that the mechanism for at least some of these outcomes might be differences in how time is perceived. In a perspective that appeared in March in People and Nature, Dr. Correia explored how the “services” that nature provides shift time perceptions and, in turn, regulate overall well-being. 

“I reached the realization that there was some evidence for the shift in some of the dimensions that we use to make sense of time in urban vs natural environments,” he told this news organization. 

Dr. Correia explained that human time perception facilitates understanding cause and effect, so we can act in a way that allows us to survive. 

“Time perception in humans is really complex and multifaceted,” he said. “The way that we make sense of time is not directly attached to any sensory organ, but rather goes through a range of cognitive, emotional, and bodily processes, all of which vary from person to person.” 

Dr. Correia pointed to evidence showing that time perception is shorter in urban environments and longer in natural ones. This, in turn, influences attention and attention restoration. “When we live in cities, we are exposed to similar sorts of demanding environments, increased time pressures, less time for oneself and for recreational purposes,” he said. “Ever-mounting pressure on daily demands plus processes we use to make sense of time, especially attention, means that we pay a cognitive toll.”

Dr. Correia posits that it might be possible to recalibrate time perception, but only by breaking the cycle of exposure. 

“If we are always exposed to fast-paced lifestyles, we become attuned to them and get caught up in an endless loop.” This cycle can be broken, Dr. Correia explained, by increasing exposure to natural environments. This leads to positive emotions, a sense of being in the present, and a heightened sense of mindfulness, all of which help mitigate the physical and mental health outcomes commonly associated with time scarcity. 
 

Brain-Mental Health Benefits

To date, there is quite a bit of research exploring the impacts of exposure to nature on the brain. For example, data have shown that adolescents raised exclusively in rural environments have a larger hippocampus and better spatial processing than children exclusively raised in cities. Other research demonstrated that spending just an hour in the forest led to a decline in amygdala activity in adults, whereas it remained stable after walking in an urban setting, underscoring the salutogenic effects on brain regions related to stress. There is also evidence from a 10-year longitudinal study of more than 2 million Welsh adults that highlights the value of proximity to green or blue (eg, lakes and rivers) spaces and common mental health conditions, with every additional 360 meters to the nearest green or blue space associated with 10% greater odds of anxiety and depression.

Dr. Bird said there has been a massive sea change in attitudes among general practitioners, who have come around to embracing the concept of nature as medicine. This shift among peers, who teased him in the 1990s about his green walking and conservation prescriptions, portends a bandwagon of epic proportions that could benefit patients. He said that he was especially hopeful that green prescriptions will become mainstream in certain conditions, especially those like depression and anxiety that are resistant to medication.

But Dr. Bird cautions that primary care professionals need to be mindful. “Patients need to know that it’s real science, otherwise they’ll think that they’re being pawned off or dismissed,” he said. “I try to put real evidence behind it and explain that there’s no contraindication. The main thing is to start where patients are, what they’re feeling, and what they need. Some people just don’t like nature,” he said.
 

A version of this article appeared on Medscape.com.

For women who are obese, daily life is wrought with landmines. Whether it’s the challenges of air travel because plane seats are too small, the need to shield themselves from the world’s discriminating eyes, or the great lengths many will go to achieve better health and the promise of longevity, navigating life as an obese person requires a thick skin.

So, it’s no wonder so many are willing to pay more than $1,000 a month out of pocket to get their hands on drugs like semaglutide (Ozempic and Wegovy) or tirzepatide (Mounjaro). The benefits of these drugs, which are part of a new class called glucagonlike peptide–1 (GLP-1) receptor agonists, include significant and rapid weight loss, blood sugar control, and improved life quality; they are unprecedented in a setting where surgery has long been considered the most effective long-term option.

On the flip side, the desire for rapid weight loss and better blood sugar control also comes with an unexpected cost. Many women living with obesity who take oral contraceptives are unaware that these drugs – especially Mounjaro – can interfere with the absorption of birth control pills and how well they work, making an unintended pregnancy more likely.

Neel Shah, MD, an endocrinologist and associate professor at the University of Texas Health Science Center at Houston, said he has had several patients become pregnant without intending to. 

“It was when Mounjaro came out on the market when we started using it,” he said of the drug the Food and Drug Administration approved for type 2 diabetes in 2022. “It [the warning] was in the product insert, but clinically speaking, I don’t know if it was at the top of providers’ minds when they were prescribing Mounjaro.”

When asked if he believed that we were going to be seeing a significant increase in so-called Mounjaro babies, Dr. Shah was sure in his response. 

“Absolutely. We will because the sheer volume [of patients] will increase,” he said.
 

It’s all in the gut

One of the ways that drugs like Mounjaro work is by delaying the time that it takes for food to move from the stomach to the small intestine. Although data are still evolving, it is believed that this process – delayed gastric emptying – may affect the absorption of birth control pills. 

Dr. Shah said another theory is that vomiting, which is a common side effect of these types of drugs, also affects the pills’ ability to prevent pregnancy. 

And “there’s a prolonged period of ramping up the dose because of the GI side effects,” said Pinar Kodaman, MD, PhD, a reproductive endocrinologist and assistant professor of gynecology at Yale University in New Haven, Conn. 

“Initially, at the lowest dose, there may not be a lot of potential effect on absorption and gastric emptying. But as the dose goes up, it becomes more common, and it can cause diarrhea, which is another condition that can affect the absorption of any medication,” she said.
 

Unanticipated outcomes, extra prevention

Roughly 42% of women in the United States are obese, 40% of whom are between the ages of 20 and 39. Although these new drugs can improve fertility outcomes for women who are obese (especially those with polycystic ovary syndrome, or PCOS), only one – Mounjaro – currently carries a warning about birth control pill effectiveness on its label. Unfortunately, it appears that some doctors are unaware or not counseling patients about this risk, and the data are unclear about whether other drugs in this class, like Ozempic and Wegovy, have the same risks. 

“To date, it hasn’t been a typical thing that we counsel about,” said Dr. Kodaman. “It’s all fairly new, but when we have patients on birth control pills, we do review other medications that they are on because some can affect efficacy, and it’s something to keep in mind.”

It’s also unclear if other forms of birth control – for example, birth control patches that deliver through the skin – might carry similar pregnancy risks. Dr. Shah said some of his patients who became pregnant without intending to were using these patches. This raises even more questions, since they deliver drugs through the skin directly into the bloodstream and not through the GI system. 

What can women do to help ensure that they don’t become pregnant while using these drugs? 

“I really think that if patients want to protect themselves from an unplanned pregnancy, that as soon as they start the GLP receptor agonists, it wouldn’t be a bad idea to use condoms, because the onset of action is pretty quick,” said Dr. Kodaman, noting also that “at the lowest dose there may not be a lot of potential effect on gastric emptying. But as the dose goes up, it becomes much more common or can cause diarrhea.” 

Dr. Shah said that in his practice he’s “been telling patients to add barrier contraception” 4 weeks before they start their first dose “and at any dose adjustment.”

Zoobia Chaudhry, an obesity medicine doctor and assistant professor of medicine at Johns Hopkins University in Baltimore, recommends that “patients just make sure that the injection and medication that they take are at least 1 hour apart.”

“Most of the time, patients do take birth control before bedtime, so if the two are spaced, it should be OK,” she said.

Another option is for women to speak to their doctors about other contraceptive options like IUDs or implantable rods, where gastric absorption is not going to be an issue. 

“There’s very little research on this class of drugs,” said Emily Goodstein, a 40-year-old small-business owner in Washington, who recently switched from Ozempic to Mounjaro. “Being a person who lives in a larger body is such a horrifying experience because of the way that the world discriminates against you.”

She appreciates the feeling of being proactive that these new drugs grant. It has “opened up a bunch of opportunities for me to be seen as a full individual by the medical establishment,” she said. “I was willing to take the risk, knowing that I would be on these drugs for the rest of my life.”

In addition to being what Dr. Goodstein refers to as a guinea pig, she said she made sure that her primary care doctor was aware that she was not trying or planning to become pregnant again. (She has a 3-year-old child.) Still, her doctor mentioned only the most common side effects linked to these drugs, like nausea, vomiting, and diarrhea, and did not mention the risk of pregnancy.

“Folks are really not talking about the reproductive implications,” she said, referring to members of a Facebook group on these drugs that she belongs to. 

Like patients themselves, many doctors are just beginning to get their arms around these agents. “Awareness, education, provider involvement, and having a multidisciplinary team could help patients achieve the goals that they set out for themselves,” said Dr. Shah. 

Clear conversations are key.

A version of this article first appeared on WebMD.com.

For women who are obese, daily life is wrought with landmines. Whether it’s the challenges of air travel because plane seats are too small, the need to shield themselves from the world’s discriminating eyes, or the great lengths many will go to achieve better health and the promise of longevity, navigating life as an obese person requires a thick skin.

So, it’s no wonder so many are willing to pay more than $1,000 a month out of pocket to get their hands on drugs like semaglutide (Ozempic and Wegovy) or tirzepatide (Mounjaro). The benefits of these drugs, which are part of a new class called glucagonlike peptide–1 (GLP-1) receptor agonists, include significant and rapid weight loss, blood sugar control, and improved life quality; they are unprecedented in a setting where surgery has long been considered the most effective long-term option.

On the flip side, the desire for rapid weight loss and better blood sugar control also comes with an unexpected cost. Many women living with obesity who take oral contraceptives are unaware that these drugs – especially Mounjaro – can interfere with the absorption of birth control pills and how well they work, making an unintended pregnancy more likely.

Neel Shah, MD, an endocrinologist and associate professor at the University of Texas Health Science Center at Houston, said he has had several patients become pregnant without intending to. 

“It was when Mounjaro came out on the market when we started using it,” he said of the drug the Food and Drug Administration approved for type 2 diabetes in 2022. “It [the warning] was in the product insert, but clinically speaking, I don’t know if it was at the top of providers’ minds when they were prescribing Mounjaro.”

When asked if he believed that we were going to be seeing a significant increase in so-called Mounjaro babies, Dr. Shah was sure in his response. 

“Absolutely. We will because the sheer volume [of patients] will increase,” he said.
 

It’s all in the gut

One of the ways that drugs like Mounjaro work is by delaying the time that it takes for food to move from the stomach to the small intestine. Although data are still evolving, it is believed that this process – delayed gastric emptying – may affect the absorption of birth control pills. 

Dr. Shah said another theory is that vomiting, which is a common side effect of these types of drugs, also affects the pills’ ability to prevent pregnancy. 

And “there’s a prolonged period of ramping up the dose because of the GI side effects,” said Pinar Kodaman, MD, PhD, a reproductive endocrinologist and assistant professor of gynecology at Yale University in New Haven, Conn. 

“Initially, at the lowest dose, there may not be a lot of potential effect on absorption and gastric emptying. But as the dose goes up, it becomes more common, and it can cause diarrhea, which is another condition that can affect the absorption of any medication,” she said.
 

Unanticipated outcomes, extra prevention

Roughly 42% of women in the United States are obese, 40% of whom are between the ages of 20 and 39. Although these new drugs can improve fertility outcomes for women who are obese (especially those with polycystic ovary syndrome, or PCOS), only one – Mounjaro – currently carries a warning about birth control pill effectiveness on its label. Unfortunately, it appears that some doctors are unaware or not counseling patients about this risk, and the data are unclear about whether other drugs in this class, like Ozempic and Wegovy, have the same risks. 

“To date, it hasn’t been a typical thing that we counsel about,” said Dr. Kodaman. “It’s all fairly new, but when we have patients on birth control pills, we do review other medications that they are on because some can affect efficacy, and it’s something to keep in mind.”

It’s also unclear if other forms of birth control – for example, birth control patches that deliver through the skin – might carry similar pregnancy risks. Dr. Shah said some of his patients who became pregnant without intending to were using these patches. This raises even more questions, since they deliver drugs through the skin directly into the bloodstream and not through the GI system. 

What can women do to help ensure that they don’t become pregnant while using these drugs? 

“I really think that if patients want to protect themselves from an unplanned pregnancy, that as soon as they start the GLP receptor agonists, it wouldn’t be a bad idea to use condoms, because the onset of action is pretty quick,” said Dr. Kodaman, noting also that “at the lowest dose there may not be a lot of potential effect on gastric emptying. But as the dose goes up, it becomes much more common or can cause diarrhea.” 

Dr. Shah said that in his practice he’s “been telling patients to add barrier contraception” 4 weeks before they start their first dose “and at any dose adjustment.”

Zoobia Chaudhry, an obesity medicine doctor and assistant professor of medicine at Johns Hopkins University in Baltimore, recommends that “patients just make sure that the injection and medication that they take are at least 1 hour apart.”

“Most of the time, patients do take birth control before bedtime, so if the two are spaced, it should be OK,” she said.

Another option is for women to speak to their doctors about other contraceptive options like IUDs or implantable rods, where gastric absorption is not going to be an issue. 

“There’s very little research on this class of drugs,” said Emily Goodstein, a 40-year-old small-business owner in Washington, who recently switched from Ozempic to Mounjaro. “Being a person who lives in a larger body is such a horrifying experience because of the way that the world discriminates against you.”

She appreciates the feeling of being proactive that these new drugs grant. It has “opened up a bunch of opportunities for me to be seen as a full individual by the medical establishment,” she said. “I was willing to take the risk, knowing that I would be on these drugs for the rest of my life.”

In addition to being what Dr. Goodstein refers to as a guinea pig, she said she made sure that her primary care doctor was aware that she was not trying or planning to become pregnant again. (She has a 3-year-old child.) Still, her doctor mentioned only the most common side effects linked to these drugs, like nausea, vomiting, and diarrhea, and did not mention the risk of pregnancy.

“Folks are really not talking about the reproductive implications,” she said, referring to members of a Facebook group on these drugs that she belongs to. 

Like patients themselves, many doctors are just beginning to get their arms around these agents. “Awareness, education, provider involvement, and having a multidisciplinary team could help patients achieve the goals that they set out for themselves,” said Dr. Shah. 

Clear conversations are key.

A version of this article first appeared on WebMD.com.

For women who are obese, daily life is wrought with landmines. Whether it’s the challenges of air travel because plane seats are too small, the need to shield themselves from the world’s discriminating eyes, or the great lengths many will go to achieve better health and the promise of longevity, navigating life as an obese person requires a thick skin.

So, it’s no wonder so many are willing to pay more than $1,000 a month out of pocket to get their hands on drugs like semaglutide (Ozempic and Wegovy) or tirzepatide (Mounjaro). The benefits of these drugs, which are part of a new class called glucagonlike peptide–1 (GLP-1) receptor agonists, include significant and rapid weight loss, blood sugar control, and improved life quality; they are unprecedented in a setting where surgery has long been considered the most effective long-term option.

On the flip side, the desire for rapid weight loss and better blood sugar control also comes with an unexpected cost. Many women living with obesity who take oral contraceptives are unaware that these drugs – especially Mounjaro – can interfere with the absorption of birth control pills and how well they work, making an unintended pregnancy more likely.

Neel Shah, MD, an endocrinologist and associate professor at the University of Texas Health Science Center at Houston, said he has had several patients become pregnant without intending to. 

“It was when Mounjaro came out on the market when we started using it,” he said of the drug the Food and Drug Administration approved for type 2 diabetes in 2022. “It [the warning] was in the product insert, but clinically speaking, I don’t know if it was at the top of providers’ minds when they were prescribing Mounjaro.”

When asked if he believed that we were going to be seeing a significant increase in so-called Mounjaro babies, Dr. Shah was sure in his response. 

“Absolutely. We will because the sheer volume [of patients] will increase,” he said.
 

It’s all in the gut

One of the ways that drugs like Mounjaro work is by delaying the time that it takes for food to move from the stomach to the small intestine. Although data are still evolving, it is believed that this process – delayed gastric emptying – may affect the absorption of birth control pills. 

Dr. Shah said another theory is that vomiting, which is a common side effect of these types of drugs, also affects the pills’ ability to prevent pregnancy. 

And “there’s a prolonged period of ramping up the dose because of the GI side effects,” said Pinar Kodaman, MD, PhD, a reproductive endocrinologist and assistant professor of gynecology at Yale University in New Haven, Conn. 

“Initially, at the lowest dose, there may not be a lot of potential effect on absorption and gastric emptying. But as the dose goes up, it becomes more common, and it can cause diarrhea, which is another condition that can affect the absorption of any medication,” she said.
 

Unanticipated outcomes, extra prevention

Roughly 42% of women in the United States are obese, 40% of whom are between the ages of 20 and 39. Although these new drugs can improve fertility outcomes for women who are obese (especially those with polycystic ovary syndrome, or PCOS), only one – Mounjaro – currently carries a warning about birth control pill effectiveness on its label. Unfortunately, it appears that some doctors are unaware or not counseling patients about this risk, and the data are unclear about whether other drugs in this class, like Ozempic and Wegovy, have the same risks. 

“To date, it hasn’t been a typical thing that we counsel about,” said Dr. Kodaman. “It’s all fairly new, but when we have patients on birth control pills, we do review other medications that they are on because some can affect efficacy, and it’s something to keep in mind.”

It’s also unclear if other forms of birth control – for example, birth control patches that deliver through the skin – might carry similar pregnancy risks. Dr. Shah said some of his patients who became pregnant without intending to were using these patches. This raises even more questions, since they deliver drugs through the skin directly into the bloodstream and not through the GI system. 

What can women do to help ensure that they don’t become pregnant while using these drugs? 

“I really think that if patients want to protect themselves from an unplanned pregnancy, that as soon as they start the GLP receptor agonists, it wouldn’t be a bad idea to use condoms, because the onset of action is pretty quick,” said Dr. Kodaman, noting also that “at the lowest dose there may not be a lot of potential effect on gastric emptying. But as the dose goes up, it becomes much more common or can cause diarrhea.” 

Dr. Shah said that in his practice he’s “been telling patients to add barrier contraception” 4 weeks before they start their first dose “and at any dose adjustment.”

Zoobia Chaudhry, an obesity medicine doctor and assistant professor of medicine at Johns Hopkins University in Baltimore, recommends that “patients just make sure that the injection and medication that they take are at least 1 hour apart.”

“Most of the time, patients do take birth control before bedtime, so if the two are spaced, it should be OK,” she said.

Another option is for women to speak to their doctors about other contraceptive options like IUDs or implantable rods, where gastric absorption is not going to be an issue. 

“There’s very little research on this class of drugs,” said Emily Goodstein, a 40-year-old small-business owner in Washington, who recently switched from Ozempic to Mounjaro. “Being a person who lives in a larger body is such a horrifying experience because of the way that the world discriminates against you.”

She appreciates the feeling of being proactive that these new drugs grant. It has “opened up a bunch of opportunities for me to be seen as a full individual by the medical establishment,” she said. “I was willing to take the risk, knowing that I would be on these drugs for the rest of my life.”

In addition to being what Dr. Goodstein refers to as a guinea pig, she said she made sure that her primary care doctor was aware that she was not trying or planning to become pregnant again. (She has a 3-year-old child.) Still, her doctor mentioned only the most common side effects linked to these drugs, like nausea, vomiting, and diarrhea, and did not mention the risk of pregnancy.

“Folks are really not talking about the reproductive implications,” she said, referring to members of a Facebook group on these drugs that she belongs to. 

Like patients themselves, many doctors are just beginning to get their arms around these agents. “Awareness, education, provider involvement, and having a multidisciplinary team could help patients achieve the goals that they set out for themselves,” said Dr. Shah. 

Clear conversations are key.

A version of this article first appeared on WebMD.com.

New clinical practice guidelines for cannabis in chronic pain management have been released.

Developed by a group of Canadian researchers, clinicians, and patients, the guidelines note that cannabinoid-based medicines (CBM) may help clinicians offer an effective, less addictive, alternative to opioids in patients with chronic noncancer pain and comorbid conditions.

“We don’t recommend using CBM first line for anything pretty much because there are other alternatives that may be more effective and also offer fewer side effects,” lead guideline author Alan Bell, MD, assistant professor of family and community medicine at the University of Toronto, told this news organization.

Bell_Alan_CANADA_web.jpg

Examining the evidence

A consistent criticism of CBM has been the lack of quality research supporting its therapeutic utility. To develop the current recommendations, the task force reviewed 47 pain management studies enrolling more than 11,000 patients. Almost half of the studies (n = 22) were randomized controlled trials (RCTs) and 12 of the 19 included systematic reviews focused solely on RCTs.

Overall, 38 of the 47 included studies demonstrated that CBM provided at least moderate benefits for chronic pain, resulting in a “strong” recommendation – mostly as an adjunct or replacement treatment in individuals living with chronic pain.

Overall, the guidelines place a high value on improving chronic pain and functionality, and addressing co-occurring conditions such as insomnia, anxiety and depression, mobility, and inflammation. They also provide practical dosing and formulation tips to support the use of CBM in the clinical setting.

When it comes to chronic pain, CBM is not a panacea. However, prior research suggests cannabinoids and opioids share several pharmacologic properties, including independent but possibly related mechanisms for antinociception, making them an intriguing combination.

In the current guidelines, all of the four studies specifically addressing combined opioids and vaporized cannabis flower demonstrated further pain reduction, reinforcing the conclusion that the benefits of CBM for improving pain control in patients taking opioids outweigh the risk of nonserious adverse events (AEs), such as dry mouth, dizziness, increased appetite, sedation, and concentration difficulties.

[embed:render:related:node:246394]

The recommendations also highlighted evidence demonstrating that a majority of participants were able to reduce use of routine pain medications with concomitant CBM/opioid administration, while simultaneously offering secondary benefits such as improved sleep, anxiety, and mood, as well as prevention of opioid tolerance and dose escalation.

Importantly, the guidelines offer an evidence-based algorithm with a clear framework for tapering patients off opioids, especially those who are on > 50 mg MED, which places them with a twofold greater risk for fatal overdose.

An effective alternative

Commenting on the new guidelines, Mark Wallace, MD, who has extensive experience researching and treating pain patients with medical cannabis, said the genesis of his interest in medical cannabis mirrors the guidelines’ focus.

“What got me interested in medical cannabis was trying to get patients off of opioids,” said Dr. Wallace, professor of anesthesiology and chief of the division of pain medicine in the department of anesthesiology at the University of California, San Diego. Dr. Wallace, who was not involved in the guidelines’ development study, said that he’s “titrated hundreds of patients off of opioids using cannabis.”

Dr. Wallace said he found the guidelines’ dosing recommendations helpful.

“If you stay within the 1- to 5-mg dosing range, the risks are so incredibly low, you’re not going to harm the patient.”

While there are patients who abuse cannabis and CBMs, Dr. Wallace noted that he has seen only one patient in the past 20 years who was overusing the medical cannabis. He added that his patient population does not use medical cannabis to get high and, in fact, wants to avoid doses that produce that effect at all costs.

Also commenting on the guidelines, Christopher Gilligan, MD, MBA, associate chief medical officer and a pain medicine physician at Brigham and Women’s Hospital in Boston, who was not involved in the guidelines’ development, points to the risks.

Gilligan_Christopher_MA_web.jpg

A version of this article first appeared on Medscape.com.

New clinical practice guidelines for cannabis in chronic pain management have been released.

Developed by a group of Canadian researchers, clinicians, and patients, the guidelines note that cannabinoid-based medicines (CBM) may help clinicians offer an effective, less addictive, alternative to opioids in patients with chronic noncancer pain and comorbid conditions.

“We don’t recommend using CBM first line for anything pretty much because there are other alternatives that may be more effective and also offer fewer side effects,” lead guideline author Alan Bell, MD, assistant professor of family and community medicine at the University of Toronto, told this news organization.

Bell_Alan_CANADA_web.jpg

Examining the evidence

A consistent criticism of CBM has been the lack of quality research supporting its therapeutic utility. To develop the current recommendations, the task force reviewed 47 pain management studies enrolling more than 11,000 patients. Almost half of the studies (n = 22) were randomized controlled trials (RCTs) and 12 of the 19 included systematic reviews focused solely on RCTs.

Overall, 38 of the 47 included studies demonstrated that CBM provided at least moderate benefits for chronic pain, resulting in a “strong” recommendation – mostly as an adjunct or replacement treatment in individuals living with chronic pain.

Overall, the guidelines place a high value on improving chronic pain and functionality, and addressing co-occurring conditions such as insomnia, anxiety and depression, mobility, and inflammation. They also provide practical dosing and formulation tips to support the use of CBM in the clinical setting.

When it comes to chronic pain, CBM is not a panacea. However, prior research suggests cannabinoids and opioids share several pharmacologic properties, including independent but possibly related mechanisms for antinociception, making them an intriguing combination.

In the current guidelines, all of the four studies specifically addressing combined opioids and vaporized cannabis flower demonstrated further pain reduction, reinforcing the conclusion that the benefits of CBM for improving pain control in patients taking opioids outweigh the risk of nonserious adverse events (AEs), such as dry mouth, dizziness, increased appetite, sedation, and concentration difficulties.

[embed:render:related:node:246394]

The recommendations also highlighted evidence demonstrating that a majority of participants were able to reduce use of routine pain medications with concomitant CBM/opioid administration, while simultaneously offering secondary benefits such as improved sleep, anxiety, and mood, as well as prevention of opioid tolerance and dose escalation.

Importantly, the guidelines offer an evidence-based algorithm with a clear framework for tapering patients off opioids, especially those who are on > 50 mg MED, which places them with a twofold greater risk for fatal overdose.

An effective alternative

Commenting on the new guidelines, Mark Wallace, MD, who has extensive experience researching and treating pain patients with medical cannabis, said the genesis of his interest in medical cannabis mirrors the guidelines’ focus.

“What got me interested in medical cannabis was trying to get patients off of opioids,” said Dr. Wallace, professor of anesthesiology and chief of the division of pain medicine in the department of anesthesiology at the University of California, San Diego. Dr. Wallace, who was not involved in the guidelines’ development study, said that he’s “titrated hundreds of patients off of opioids using cannabis.”

Dr. Wallace said he found the guidelines’ dosing recommendations helpful.

“If you stay within the 1- to 5-mg dosing range, the risks are so incredibly low, you’re not going to harm the patient.”

While there are patients who abuse cannabis and CBMs, Dr. Wallace noted that he has seen only one patient in the past 20 years who was overusing the medical cannabis. He added that his patient population does not use medical cannabis to get high and, in fact, wants to avoid doses that produce that effect at all costs.

Also commenting on the guidelines, Christopher Gilligan, MD, MBA, associate chief medical officer and a pain medicine physician at Brigham and Women’s Hospital in Boston, who was not involved in the guidelines’ development, points to the risks.

Gilligan_Christopher_MA_web.jpg

A version of this article first appeared on Medscape.com.

New clinical practice guidelines for cannabis in chronic pain management have been released.

Developed by a group of Canadian researchers, clinicians, and patients, the guidelines note that cannabinoid-based medicines (CBM) may help clinicians offer an effective, less addictive, alternative to opioids in patients with chronic noncancer pain and comorbid conditions.

“We don’t recommend using CBM first line for anything pretty much because there are other alternatives that may be more effective and also offer fewer side effects,” lead guideline author Alan Bell, MD, assistant professor of family and community medicine at the University of Toronto, told this news organization.

Bell_Alan_CANADA_web.jpg

Examining the evidence

A consistent criticism of CBM has been the lack of quality research supporting its therapeutic utility. To develop the current recommendations, the task force reviewed 47 pain management studies enrolling more than 11,000 patients. Almost half of the studies (n = 22) were randomized controlled trials (RCTs) and 12 of the 19 included systematic reviews focused solely on RCTs.

Overall, 38 of the 47 included studies demonstrated that CBM provided at least moderate benefits for chronic pain, resulting in a “strong” recommendation – mostly as an adjunct or replacement treatment in individuals living with chronic pain.

Overall, the guidelines place a high value on improving chronic pain and functionality, and addressing co-occurring conditions such as insomnia, anxiety and depression, mobility, and inflammation. They also provide practical dosing and formulation tips to support the use of CBM in the clinical setting.

When it comes to chronic pain, CBM is not a panacea. However, prior research suggests cannabinoids and opioids share several pharmacologic properties, including independent but possibly related mechanisms for antinociception, making them an intriguing combination.

In the current guidelines, all of the four studies specifically addressing combined opioids and vaporized cannabis flower demonstrated further pain reduction, reinforcing the conclusion that the benefits of CBM for improving pain control in patients taking opioids outweigh the risk of nonserious adverse events (AEs), such as dry mouth, dizziness, increased appetite, sedation, and concentration difficulties.

[embed:render:related:node:246394]

The recommendations also highlighted evidence demonstrating that a majority of participants were able to reduce use of routine pain medications with concomitant CBM/opioid administration, while simultaneously offering secondary benefits such as improved sleep, anxiety, and mood, as well as prevention of opioid tolerance and dose escalation.

Importantly, the guidelines offer an evidence-based algorithm with a clear framework for tapering patients off opioids, especially those who are on > 50 mg MED, which places them with a twofold greater risk for fatal overdose.

An effective alternative

Commenting on the new guidelines, Mark Wallace, MD, who has extensive experience researching and treating pain patients with medical cannabis, said the genesis of his interest in medical cannabis mirrors the guidelines’ focus.

“What got me interested in medical cannabis was trying to get patients off of opioids,” said Dr. Wallace, professor of anesthesiology and chief of the division of pain medicine in the department of anesthesiology at the University of California, San Diego. Dr. Wallace, who was not involved in the guidelines’ development study, said that he’s “titrated hundreds of patients off of opioids using cannabis.”

Dr. Wallace said he found the guidelines’ dosing recommendations helpful.

“If you stay within the 1- to 5-mg dosing range, the risks are so incredibly low, you’re not going to harm the patient.”

While there are patients who abuse cannabis and CBMs, Dr. Wallace noted that he has seen only one patient in the past 20 years who was overusing the medical cannabis. He added that his patient population does not use medical cannabis to get high and, in fact, wants to avoid doses that produce that effect at all costs.

Also commenting on the guidelines, Christopher Gilligan, MD, MBA, associate chief medical officer and a pain medicine physician at Brigham and Women’s Hospital in Boston, who was not involved in the guidelines’ development, points to the risks.

Gilligan_Christopher_MA_web.jpg

A version of this article first appeared on Medscape.com.

Almost three-quarters of adults living in the United States report having never tested for HIV according to a newly published study from the Centers for Disease Control and Prevention. The reasons are complex and could jeopardize goals of ending the AIDS epidemic by 2030.

Patients and doctors alike face system challenges, including stigma, confidentiality concerns, racism, and inequitable access. Yet doctors, public health authorities, and even some patients agree that testing does work: In 2022, 81% of people diagnosed with HIV were linked to care within 30 days. Moreover, many patients are aware of where and how they wish to be tested. So, what would it take to achieve what ostensibly should be the lowest hanging fruit in the HIV care continuum?

“We didn’t look at the reasons for not testing,” Marc Pitasi, MPH, CDC epidemiologist and coauthor of the CDC study said in an interview. But “we found that the majority of people prefer the test in a clinical setting, so that’s a huge important piece of the puzzle,” he said.

The “never-tested” populations (4,334 of 6,072) in the study were predominantly aged 18-29 years (79.7%) and 50 years plus (78.1%). A total of 48% of never-tested adults also indicated that they had engaged in past-year risky behaviors (that is, injection drug use, treated for a sexually transmitted disease, exchanged sex/drugs for money, engaged in condomless anal sex, or had more than four sex partners). However, the difference between never-tested adults who live in EHE (Ending the HIV Epidemic in the U.S.)–designated jurisdictions (comprising 50 areas and 7 U.S. states responsible for more than 50% of new HIV infections) and those residing in non-EHE areas was only about 5 percentage points (69.1% vs. 74.5%, respectively), underscoring the need for broader engagement.

“There’s definitely a lack of testing across the board,” explained Lina Rosengren-Hovee, MD, MPH, MS, an infectious disease epidemiologist at the University of North Carolina at Chapel Hill. “There are all sorts of biases on how we make decisions and how we stratify … and these heuristics that we have in our minds to identify who is at risk and who needs testing,” she said.

“If we just look at the need for HIV testing based on who is at risk, I think that we are always going to fall short.”
 

Conflicting priorities

Seventeen years have passed since the CDC recommended that HIV testing and screening be offered at least once to all people aged 13-64 years in a routine clinical setting, with an opt-out option and without a separate written consent. People at higher risk (sexually active gay, bisexual, and other men who have sex with men) should be rescreened at least annually.

These recommendations were subsequently reinforced by numerous organizations, including the U.S. Preventive Services Task Force in 2013 and again in 2019, and the American Academy of Pediatrics in 2021.

But Dr. Rosengren-Hovee said that some clinicians remain unaware of the guidelines; for others, they’re usually not top-of-mind because of conflicting priorities.

This is especially true of pediatricians, who, despite data demonstrating that adolescents account for roughly 21% of new HIV diagnoses, rarely recognize or take advantage of HIV-testing opportunities during routine clinical visits.

“Pediatricians want to do the right thing for their patients but at the same time, they want to do the right thing on so many different fronts,” said Sarah Wood, MD, of the University of Pennsylvania, Philadelphia, and attending physician of adolescent medicine at Children’s Hospital of Philadelphia.

Dr. Wood is coauthor of a study published in Implementation Science Communicationsexamining pediatrician perspectives on implementing HIV testing and prevention. Participants identified confidentiality and time constraints as the most important challenges across every step of their workflow, which in turn, influenced perceptions about patients’ perceived risks for acquiring HIV – perceptions that Dr. Wood believes can be overcome.

“We need to really push pediatricians (through guideline-making societies like AAP and USPSTF) that screening should be universal and not linked to sexual activity or pinned to behavior, so the offer of testing is a universal opt-out,” she said. Additionally, “we need to make it easier for pediatricians to order the test,” for example, “through an office rapid test … and a redesigned workflow that moves the conversation away from physicians and nurse practitioners to medical assistants.”

Dr. Wood also pointed out that any effort would require pediatricians and other types of providers to overcome discomfort around sexual health conversations, noting that, while pediatricians are ideally positioned to work with parents to do education around sexual health, training and impetus are needed.
 

A fractured system

A fractured, often ill-funded U.S. health care system might also be at play according to Scott Harris, MD, MPH, state health officer of the Alabama Department of Public Health in Montgomery, and Association of State and Territorial Health Officials’ Infectious Disease Policy Committee chair.

“There’s a general consensus among everyone in public health that [HIV testing] is an important issue that we’re not addressing as well as we’d like to,” he said.

Dr. Harris acknowledged that, while COVID diverted attention away from HIV, some states have prioritized HIV more than others.

“We don’t have a national public health program; we have a nationwide public health program,” he said. “Everyone’s different and has different responsibilities and authorities ... depending on where their funding streams come from.”

The White House recently announced that it proposed a measure in its Fiscal Year 2023 budget to increase funding for HIV a further $313 million to accelerate efforts to end HIV by 2030, also adding a mandatory program to increase preexposure prophylaxis (PrEP) access. Without congressional approval, the measures are doomed to fail, leaving many states without the proper tools to enhance existing programs, and further painting overworked clinicians into a corner.

For patients, the ramifications are even greater.

“The majority of folks [in the CDC study] that were not tested said that if they were to get tested, they’d prefer to do that within the context of their primary care setting,” said Justin C. Smith, MS, MPH, director of the Campaign to End AIDS, Positive Impact Health Centers; a behavioral scientist at Emory University’s Rollins School of Public Health in Atlanta; and a member of the Presidential Advisory Council on HIV/AIDS.

“When you create a more responsive system that really speaks to the needs that people are expressing, that can provide better outcomes,” Dr. Smith said.

“It’s vital that we create health care and public health interventions that change the dynamics ... and make sure that we’re designing systems with the people that we’re trying to serve at the center.”

Mr. Pitasi, Dr. Rosengren-Hovee, Dr. Wood, Dr. Harris, and Dr. Smith have disclosed no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

Almost three-quarters of adults living in the United States report having never tested for HIV according to a newly published study from the Centers for Disease Control and Prevention. The reasons are complex and could jeopardize goals of ending the AIDS epidemic by 2030.

Patients and doctors alike face system challenges, including stigma, confidentiality concerns, racism, and inequitable access. Yet doctors, public health authorities, and even some patients agree that testing does work: In 2022, 81% of people diagnosed with HIV were linked to care within 30 days. Moreover, many patients are aware of where and how they wish to be tested. So, what would it take to achieve what ostensibly should be the lowest hanging fruit in the HIV care continuum?

“We didn’t look at the reasons for not testing,” Marc Pitasi, MPH, CDC epidemiologist and coauthor of the CDC study said in an interview. But “we found that the majority of people prefer the test in a clinical setting, so that’s a huge important piece of the puzzle,” he said.

The “never-tested” populations (4,334 of 6,072) in the study were predominantly aged 18-29 years (79.7%) and 50 years plus (78.1%). A total of 48% of never-tested adults also indicated that they had engaged in past-year risky behaviors (that is, injection drug use, treated for a sexually transmitted disease, exchanged sex/drugs for money, engaged in condomless anal sex, or had more than four sex partners). However, the difference between never-tested adults who live in EHE (Ending the HIV Epidemic in the U.S.)–designated jurisdictions (comprising 50 areas and 7 U.S. states responsible for more than 50% of new HIV infections) and those residing in non-EHE areas was only about 5 percentage points (69.1% vs. 74.5%, respectively), underscoring the need for broader engagement.

“There’s definitely a lack of testing across the board,” explained Lina Rosengren-Hovee, MD, MPH, MS, an infectious disease epidemiologist at the University of North Carolina at Chapel Hill. “There are all sorts of biases on how we make decisions and how we stratify … and these heuristics that we have in our minds to identify who is at risk and who needs testing,” she said.

“If we just look at the need for HIV testing based on who is at risk, I think that we are always going to fall short.”
 

Conflicting priorities

Seventeen years have passed since the CDC recommended that HIV testing and screening be offered at least once to all people aged 13-64 years in a routine clinical setting, with an opt-out option and without a separate written consent. People at higher risk (sexually active gay, bisexual, and other men who have sex with men) should be rescreened at least annually.

These recommendations were subsequently reinforced by numerous organizations, including the U.S. Preventive Services Task Force in 2013 and again in 2019, and the American Academy of Pediatrics in 2021.

But Dr. Rosengren-Hovee said that some clinicians remain unaware of the guidelines; for others, they’re usually not top-of-mind because of conflicting priorities.

This is especially true of pediatricians, who, despite data demonstrating that adolescents account for roughly 21% of new HIV diagnoses, rarely recognize or take advantage of HIV-testing opportunities during routine clinical visits.

“Pediatricians want to do the right thing for their patients but at the same time, they want to do the right thing on so many different fronts,” said Sarah Wood, MD, of the University of Pennsylvania, Philadelphia, and attending physician of adolescent medicine at Children’s Hospital of Philadelphia.

Dr. Wood is coauthor of a study published in Implementation Science Communicationsexamining pediatrician perspectives on implementing HIV testing and prevention. Participants identified confidentiality and time constraints as the most important challenges across every step of their workflow, which in turn, influenced perceptions about patients’ perceived risks for acquiring HIV – perceptions that Dr. Wood believes can be overcome.

“We need to really push pediatricians (through guideline-making societies like AAP and USPSTF) that screening should be universal and not linked to sexual activity or pinned to behavior, so the offer of testing is a universal opt-out,” she said. Additionally, “we need to make it easier for pediatricians to order the test,” for example, “through an office rapid test … and a redesigned workflow that moves the conversation away from physicians and nurse practitioners to medical assistants.”

Dr. Wood also pointed out that any effort would require pediatricians and other types of providers to overcome discomfort around sexual health conversations, noting that, while pediatricians are ideally positioned to work with parents to do education around sexual health, training and impetus are needed.
 

A fractured system

A fractured, often ill-funded U.S. health care system might also be at play according to Scott Harris, MD, MPH, state health officer of the Alabama Department of Public Health in Montgomery, and Association of State and Territorial Health Officials’ Infectious Disease Policy Committee chair.

“There’s a general consensus among everyone in public health that [HIV testing] is an important issue that we’re not addressing as well as we’d like to,” he said.

Dr. Harris acknowledged that, while COVID diverted attention away from HIV, some states have prioritized HIV more than others.

“We don’t have a national public health program; we have a nationwide public health program,” he said. “Everyone’s different and has different responsibilities and authorities ... depending on where their funding streams come from.”

The White House recently announced that it proposed a measure in its Fiscal Year 2023 budget to increase funding for HIV a further $313 million to accelerate efforts to end HIV by 2030, also adding a mandatory program to increase preexposure prophylaxis (PrEP) access. Without congressional approval, the measures are doomed to fail, leaving many states without the proper tools to enhance existing programs, and further painting overworked clinicians into a corner.

For patients, the ramifications are even greater.

“The majority of folks [in the CDC study] that were not tested said that if they were to get tested, they’d prefer to do that within the context of their primary care setting,” said Justin C. Smith, MS, MPH, director of the Campaign to End AIDS, Positive Impact Health Centers; a behavioral scientist at Emory University’s Rollins School of Public Health in Atlanta; and a member of the Presidential Advisory Council on HIV/AIDS.

“When you create a more responsive system that really speaks to the needs that people are expressing, that can provide better outcomes,” Dr. Smith said.

“It’s vital that we create health care and public health interventions that change the dynamics ... and make sure that we’re designing systems with the people that we’re trying to serve at the center.”

Mr. Pitasi, Dr. Rosengren-Hovee, Dr. Wood, Dr. Harris, and Dr. Smith have disclosed no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

Almost three-quarters of adults living in the United States report having never tested for HIV according to a newly published study from the Centers for Disease Control and Prevention. The reasons are complex and could jeopardize goals of ending the AIDS epidemic by 2030.

Patients and doctors alike face system challenges, including stigma, confidentiality concerns, racism, and inequitable access. Yet doctors, public health authorities, and even some patients agree that testing does work: In 2022, 81% of people diagnosed with HIV were linked to care within 30 days. Moreover, many patients are aware of where and how they wish to be tested. So, what would it take to achieve what ostensibly should be the lowest hanging fruit in the HIV care continuum?

“We didn’t look at the reasons for not testing,” Marc Pitasi, MPH, CDC epidemiologist and coauthor of the CDC study said in an interview. But “we found that the majority of people prefer the test in a clinical setting, so that’s a huge important piece of the puzzle,” he said.

The “never-tested” populations (4,334 of 6,072) in the study were predominantly aged 18-29 years (79.7%) and 50 years plus (78.1%). A total of 48% of never-tested adults also indicated that they had engaged in past-year risky behaviors (that is, injection drug use, treated for a sexually transmitted disease, exchanged sex/drugs for money, engaged in condomless anal sex, or had more than four sex partners). However, the difference between never-tested adults who live in EHE (Ending the HIV Epidemic in the U.S.)–designated jurisdictions (comprising 50 areas and 7 U.S. states responsible for more than 50% of new HIV infections) and those residing in non-EHE areas was only about 5 percentage points (69.1% vs. 74.5%, respectively), underscoring the need for broader engagement.

“There’s definitely a lack of testing across the board,” explained Lina Rosengren-Hovee, MD, MPH, MS, an infectious disease epidemiologist at the University of North Carolina at Chapel Hill. “There are all sorts of biases on how we make decisions and how we stratify … and these heuristics that we have in our minds to identify who is at risk and who needs testing,” she said.

“If we just look at the need for HIV testing based on who is at risk, I think that we are always going to fall short.”
 

Conflicting priorities

Seventeen years have passed since the CDC recommended that HIV testing and screening be offered at least once to all people aged 13-64 years in a routine clinical setting, with an opt-out option and without a separate written consent. People at higher risk (sexually active gay, bisexual, and other men who have sex with men) should be rescreened at least annually.

These recommendations were subsequently reinforced by numerous organizations, including the U.S. Preventive Services Task Force in 2013 and again in 2019, and the American Academy of Pediatrics in 2021.

But Dr. Rosengren-Hovee said that some clinicians remain unaware of the guidelines; for others, they’re usually not top-of-mind because of conflicting priorities.

This is especially true of pediatricians, who, despite data demonstrating that adolescents account for roughly 21% of new HIV diagnoses, rarely recognize or take advantage of HIV-testing opportunities during routine clinical visits.

“Pediatricians want to do the right thing for their patients but at the same time, they want to do the right thing on so many different fronts,” said Sarah Wood, MD, of the University of Pennsylvania, Philadelphia, and attending physician of adolescent medicine at Children’s Hospital of Philadelphia.

Dr. Wood is coauthor of a study published in Implementation Science Communicationsexamining pediatrician perspectives on implementing HIV testing and prevention. Participants identified confidentiality and time constraints as the most important challenges across every step of their workflow, which in turn, influenced perceptions about patients’ perceived risks for acquiring HIV – perceptions that Dr. Wood believes can be overcome.

“We need to really push pediatricians (through guideline-making societies like AAP and USPSTF) that screening should be universal and not linked to sexual activity or pinned to behavior, so the offer of testing is a universal opt-out,” she said. Additionally, “we need to make it easier for pediatricians to order the test,” for example, “through an office rapid test … and a redesigned workflow that moves the conversation away from physicians and nurse practitioners to medical assistants.”

Dr. Wood also pointed out that any effort would require pediatricians and other types of providers to overcome discomfort around sexual health conversations, noting that, while pediatricians are ideally positioned to work with parents to do education around sexual health, training and impetus are needed.
 

A fractured system

A fractured, often ill-funded U.S. health care system might also be at play according to Scott Harris, MD, MPH, state health officer of the Alabama Department of Public Health in Montgomery, and Association of State and Territorial Health Officials’ Infectious Disease Policy Committee chair.

“There’s a general consensus among everyone in public health that [HIV testing] is an important issue that we’re not addressing as well as we’d like to,” he said.

Dr. Harris acknowledged that, while COVID diverted attention away from HIV, some states have prioritized HIV more than others.

“We don’t have a national public health program; we have a nationwide public health program,” he said. “Everyone’s different and has different responsibilities and authorities ... depending on where their funding streams come from.”

The White House recently announced that it proposed a measure in its Fiscal Year 2023 budget to increase funding for HIV a further $313 million to accelerate efforts to end HIV by 2030, also adding a mandatory program to increase preexposure prophylaxis (PrEP) access. Without congressional approval, the measures are doomed to fail, leaving many states without the proper tools to enhance existing programs, and further painting overworked clinicians into a corner.

For patients, the ramifications are even greater.

“The majority of folks [in the CDC study] that were not tested said that if they were to get tested, they’d prefer to do that within the context of their primary care setting,” said Justin C. Smith, MS, MPH, director of the Campaign to End AIDS, Positive Impact Health Centers; a behavioral scientist at Emory University’s Rollins School of Public Health in Atlanta; and a member of the Presidential Advisory Council on HIV/AIDS.

“When you create a more responsive system that really speaks to the needs that people are expressing, that can provide better outcomes,” Dr. Smith said.

“It’s vital that we create health care and public health interventions that change the dynamics ... and make sure that we’re designing systems with the people that we’re trying to serve at the center.”

Mr. Pitasi, Dr. Rosengren-Hovee, Dr. Wood, Dr. Harris, and Dr. Smith have disclosed no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

The Centers for Disease Control and Prevention has issued a Health Alert Network (HAN) health advisory notifying clinicians and public health officials of a confirmed measles case in an individual who for 2 days (February 17-18) attended a large religious gathering that was attended by an estimated 20,000 people at Asbury University in Wilmore, Ky.

Given that large numbers of people might have been exposed to the attendee (who was not vaccinated) and that the individual had a history of recent international travel, the CDC has encouraged clinicians to be vigilant for patients presenting with symptoms that meet the measles case definition. A steady increase in measles cases from 49 in 2021 to 121 in 2022 in children who were not fully vaccinated – coupled with outbreaks in Ohio and Minnesota – underscores the potential gravity of the CDC advisory as well as the need to mitigate the risk of ongoing or secondary transmission.

Currently, little is known about the individual who contracted measles other than the fact that he is a resident of Jessamine County, Ky., according to a news release issued by the Kentucky Department of Public Health. It is the third confirmed case in Kentucky over the past 3 months. State and national health officials are concerned that the individual might have transmitted measles to attendees visiting from other states.

David Sugerman, MD, MPH, a medical officer in CDC’s division of viral diseases and lead for the measles, rubella, and cytomegalovirus team, noted that the timing of the alert coincides with the period in which persons who had had contact with the initial case patient might be expected to develop symptoms.

For clinicians, “It’s really about considering measles in any un- or undervaccinated patient that arrives at a clinic and recently traveled internationally,” Dr. Sugerman told this news organization. He explained that “when doctors are seeing patients, they’re not going to necessarily share that information off the bat when they present with fever or rash, or if their child has fever and rash, or that they traveled internationally. So, eliciting that history from the patient or their parents is really critical.”

The CDC recommends that measles be considered in anyone presenting with a febrile illness and symptoms that are clinically compatible with measles (that is, rash, cough, coryza, or conjunctivitis), as well as in patients who have recently traveled abroad, especially to countries with ongoing outbreaks, including India, Somalia, and Yemen.

“In general, if they’ve traveled internationally and they are undervaccinated, measles should be part of the differential diagnosis,” Sugerman said. He also emphasized the need to follow airborne isolation precautions in addition to general infection control measures.

Immediate triage is critical, especially since overcrowded waiting rooms might be filled with patients who are not yet eligible for vaccination or are not up to date or fully vaccinated.

“Measles is under airborne isolation criteria and precautions, and therefore, [patients] need to be placed as soon as possible into a negative pressure or airborne infection isolation room – and that should be a single room,” he explained. He noted, “In some settings, there may not be a negative pressure room, e.g., an outpatient pediatrics or family medicine office.”

Dr. Sugerman said that in these circumstances, patients should be placed in a room with masked health care providers who have received two doses of measles, mumps, and rubella (MMR) vaccine and that they should wear an N95 mask when entering the room and interviewing the patient.

Clinicians should follow CDC’s testing recommendations and collect a nasopharyngeal or throat swab or a urine specimen for PCR testing and a blood specimen for serology. In addition, they should immediately report cases to local and state public health authorities.

For all patients, it’s critical to be up to date on MMR vaccines, especially persons who are going to be traveling internationally. “We recommend that when they’ve got infants traveling with them who are 6-11 months of age, that they get a first dose (which we consider a zero dose), because they need a routine dose at 12-15 months, and then 4-6 years,” said Dr. Sugerman. He said that it’s safe for adults who are unsure of their status to receive an MMR dose as well.

Dr. Sugerman stressed that despite major strides, “we just don’t have enough coverage in all individuals in this country. Because people are traveling as often as they are, it can be imported. Until measles is eliminated globally, there’s going to be an ongoing risk of importation and potential spread amongst others in their household or community, especially amongst individuals who are not fully vaccinated and, in particular, amongst those who are unvaccinated,” he said.

Dr. Sugerman reports no relevant financial relationships.

A version of this article first appeared on Medscape.com.

The Centers for Disease Control and Prevention has issued a Health Alert Network (HAN) health advisory notifying clinicians and public health officials of a confirmed measles case in an individual who for 2 days (February 17-18) attended a large religious gathering that was attended by an estimated 20,000 people at Asbury University in Wilmore, Ky.

Given that large numbers of people might have been exposed to the attendee (who was not vaccinated) and that the individual had a history of recent international travel, the CDC has encouraged clinicians to be vigilant for patients presenting with symptoms that meet the measles case definition. A steady increase in measles cases from 49 in 2021 to 121 in 2022 in children who were not fully vaccinated – coupled with outbreaks in Ohio and Minnesota – underscores the potential gravity of the CDC advisory as well as the need to mitigate the risk of ongoing or secondary transmission.

Currently, little is known about the individual who contracted measles other than the fact that he is a resident of Jessamine County, Ky., according to a news release issued by the Kentucky Department of Public Health. It is the third confirmed case in Kentucky over the past 3 months. State and national health officials are concerned that the individual might have transmitted measles to attendees visiting from other states.

David Sugerman, MD, MPH, a medical officer in CDC’s division of viral diseases and lead for the measles, rubella, and cytomegalovirus team, noted that the timing of the alert coincides with the period in which persons who had had contact with the initial case patient might be expected to develop symptoms.

For clinicians, “It’s really about considering measles in any un- or undervaccinated patient that arrives at a clinic and recently traveled internationally,” Dr. Sugerman told this news organization. He explained that “when doctors are seeing patients, they’re not going to necessarily share that information off the bat when they present with fever or rash, or if their child has fever and rash, or that they traveled internationally. So, eliciting that history from the patient or their parents is really critical.”

The CDC recommends that measles be considered in anyone presenting with a febrile illness and symptoms that are clinically compatible with measles (that is, rash, cough, coryza, or conjunctivitis), as well as in patients who have recently traveled abroad, especially to countries with ongoing outbreaks, including India, Somalia, and Yemen.

“In general, if they’ve traveled internationally and they are undervaccinated, measles should be part of the differential diagnosis,” Sugerman said. He also emphasized the need to follow airborne isolation precautions in addition to general infection control measures.

Immediate triage is critical, especially since overcrowded waiting rooms might be filled with patients who are not yet eligible for vaccination or are not up to date or fully vaccinated.

“Measles is under airborne isolation criteria and precautions, and therefore, [patients] need to be placed as soon as possible into a negative pressure or airborne infection isolation room – and that should be a single room,” he explained. He noted, “In some settings, there may not be a negative pressure room, e.g., an outpatient pediatrics or family medicine office.”

Dr. Sugerman said that in these circumstances, patients should be placed in a room with masked health care providers who have received two doses of measles, mumps, and rubella (MMR) vaccine and that they should wear an N95 mask when entering the room and interviewing the patient.

Clinicians should follow CDC’s testing recommendations and collect a nasopharyngeal or throat swab or a urine specimen for PCR testing and a blood specimen for serology. In addition, they should immediately report cases to local and state public health authorities.

For all patients, it’s critical to be up to date on MMR vaccines, especially persons who are going to be traveling internationally. “We recommend that when they’ve got infants traveling with them who are 6-11 months of age, that they get a first dose (which we consider a zero dose), because they need a routine dose at 12-15 months, and then 4-6 years,” said Dr. Sugerman. He said that it’s safe for adults who are unsure of their status to receive an MMR dose as well.

Dr. Sugerman stressed that despite major strides, “we just don’t have enough coverage in all individuals in this country. Because people are traveling as often as they are, it can be imported. Until measles is eliminated globally, there’s going to be an ongoing risk of importation and potential spread amongst others in their household or community, especially amongst individuals who are not fully vaccinated and, in particular, amongst those who are unvaccinated,” he said.

Dr. Sugerman reports no relevant financial relationships.

A version of this article first appeared on Medscape.com.

The Centers for Disease Control and Prevention has issued a Health Alert Network (HAN) health advisory notifying clinicians and public health officials of a confirmed measles case in an individual who for 2 days (February 17-18) attended a large religious gathering that was attended by an estimated 20,000 people at Asbury University in Wilmore, Ky.

Given that large numbers of people might have been exposed to the attendee (who was not vaccinated) and that the individual had a history of recent international travel, the CDC has encouraged clinicians to be vigilant for patients presenting with symptoms that meet the measles case definition. A steady increase in measles cases from 49 in 2021 to 121 in 2022 in children who were not fully vaccinated – coupled with outbreaks in Ohio and Minnesota – underscores the potential gravity of the CDC advisory as well as the need to mitigate the risk of ongoing or secondary transmission.

Currently, little is known about the individual who contracted measles other than the fact that he is a resident of Jessamine County, Ky., according to a news release issued by the Kentucky Department of Public Health. It is the third confirmed case in Kentucky over the past 3 months. State and national health officials are concerned that the individual might have transmitted measles to attendees visiting from other states.

David Sugerman, MD, MPH, a medical officer in CDC’s division of viral diseases and lead for the measles, rubella, and cytomegalovirus team, noted that the timing of the alert coincides with the period in which persons who had had contact with the initial case patient might be expected to develop symptoms.

For clinicians, “It’s really about considering measles in any un- or undervaccinated patient that arrives at a clinic and recently traveled internationally,” Dr. Sugerman told this news organization. He explained that “when doctors are seeing patients, they’re not going to necessarily share that information off the bat when they present with fever or rash, or if their child has fever and rash, or that they traveled internationally. So, eliciting that history from the patient or their parents is really critical.”

The CDC recommends that measles be considered in anyone presenting with a febrile illness and symptoms that are clinically compatible with measles (that is, rash, cough, coryza, or conjunctivitis), as well as in patients who have recently traveled abroad, especially to countries with ongoing outbreaks, including India, Somalia, and Yemen.

“In general, if they’ve traveled internationally and they are undervaccinated, measles should be part of the differential diagnosis,” Sugerman said. He also emphasized the need to follow airborne isolation precautions in addition to general infection control measures.

Immediate triage is critical, especially since overcrowded waiting rooms might be filled with patients who are not yet eligible for vaccination or are not up to date or fully vaccinated.

“Measles is under airborne isolation criteria and precautions, and therefore, [patients] need to be placed as soon as possible into a negative pressure or airborne infection isolation room – and that should be a single room,” he explained. He noted, “In some settings, there may not be a negative pressure room, e.g., an outpatient pediatrics or family medicine office.”

Dr. Sugerman said that in these circumstances, patients should be placed in a room with masked health care providers who have received two doses of measles, mumps, and rubella (MMR) vaccine and that they should wear an N95 mask when entering the room and interviewing the patient.

Clinicians should follow CDC’s testing recommendations and collect a nasopharyngeal or throat swab or a urine specimen for PCR testing and a blood specimen for serology. In addition, they should immediately report cases to local and state public health authorities.

For all patients, it’s critical to be up to date on MMR vaccines, especially persons who are going to be traveling internationally. “We recommend that when they’ve got infants traveling with them who are 6-11 months of age, that they get a first dose (which we consider a zero dose), because they need a routine dose at 12-15 months, and then 4-6 years,” said Dr. Sugerman. He said that it’s safe for adults who are unsure of their status to receive an MMR dose as well.

Dr. Sugerman stressed that despite major strides, “we just don’t have enough coverage in all individuals in this country. Because people are traveling as often as they are, it can be imported. Until measles is eliminated globally, there’s going to be an ongoing risk of importation and potential spread amongst others in their household or community, especially amongst individuals who are not fully vaccinated and, in particular, amongst those who are unvaccinated,” he said.

Dr. Sugerman reports no relevant financial relationships.

A version of this article first appeared on Medscape.com.

When it comes to sexual health education in the United States, one thing is abundantly clear: It’s a messy patchwork of programs, topics, and criteria. Only 29 states and the District of Columbia currently mandate sexual health education. Sixteen states have an abstinence-only curriculum, whereas 13 do not require that instruction be age-appropriate, inclusive, medically accurate, or evidence-based/informed. And this is just the tip of the iceberg, according to a 2022 report issued by the Sex Ed for Social Change organization.

Parents should take an inclusive approach to sex communication and create a safe space for discussing sex and sexual orientation, said almost all (96.7%) of male young adults who participated in a qualitative study. This would help reinforce acceptance and parents could possibly serve as a proxy for children who’ve not yet disclosed their sexual orientation. Yet, few parents are equipped or prepared to have these meaningful conversations with gay, bisexual, queer, or gender-diverse children, despite the fact that they are especially vulnerable to poor sexual health outcomes, bullying, abuse, and mental health challenges, as well as high-risk sexual behaviors.

“Parents are sexual socialization agents,” Dalmacio Dennis Flores, PhD, ACRN, assistant professor of nursing at the University of Pennsylvania, Philadelphia, told this news organization. “It’s through the information that they convey, the way that they normalize rituals and expectations, that they inform young people of all of societal expectations or roles they’ll be fulfilling in the future.”

Dr. Flores is lead author of a study published in the Journal of Adolescent Health. He and his colleagues collected perspectives on comprehensive, inclusive, and age-appropriate parent-child sex communications from 30 GBQ adolescent males aged 15-20 years who were already “out” to their parents. Participants were asked to sort through 28 preprinted note cards containing broad sexual health topics (for instance, human anatomy, dating, sexually transmitted infections) as well as topics theoretically specific to GBQ individuals (for example, anal sex), and were asked to add additional topics that they felt were missing. They were then directed to recommend topics along with ideal timing (that is, elementary, middle, or high school) for these conversations.

Study findings also underscored the importance of initiating comprehensive sexuality talks as early as elementary school age – namely to start preparing GBQ children for inevitable adversities that they were likely to encounter later in life, as well as to form building blocks for more mature, in-depth discussions during high school.

Importantly, these recommendations generally align with those aimed at heterosexual youth.

“When we refer to topics for elementary school, they are general parameters of what kids might be interested in or want to hear more about; it’s not planting a seed,” explained Dr. Flores.

Eva Goldfarb, PhD, LHD, MA, professor of public health at Montclair (N.J.) State University, agreed. “We always talk about (in sex education) to follow young people’s lead. If your child is asking you a question, they deserve a response,” said Dr. Goldfarb, who wasn’t involved in the study. “It doesn’t mean you have to give a detailed- level explanation but if they’re asking about it, it means that they are thinking about it. But it’s really important for all young people to know all of this information.”

Along those lines, participants deemed that fundamental issues about bodies (for example, human anatomy, reproduction), different sexual orientations, and an introduction to foundational issues (like privacy, peer or social pressure, sexual abuse) would help elementary-aged children to normalize discussions about sex, anatomy, and sexual orientation.

Middle school conversations were ideally more in-depth to reflect the time when young people are beginning to explore and accept their social and sexual identities. Topics of discussion might include types of sexual intercourse (anal, oral, and vaginal), health promotion strategies (abstinence, condoms, and contraception), possible adverse outcomes of condomless intercourse (HIV, STIs), considerations about engaging in sexual intercourse (including readiness, negotiating boundaries, virginity), and interpersonal safety (for instance, sexting, alcohol/drugs/chemsex, sexual coercion, and partner abuse/violence).

Finally, high school age recommendations focused on socio-relational topics (such as hook-up culture, technology/online dating, and multiple or concurrent sex partners), which are most relevant during a time when adolescents are most prone to experimentation and risk-taking.

Acknowledging that the study approach was novel, Dr. Flores noted that hearing about these topics from the youth perspective allowed parents to prepare. “Communication is better when it’s anticipated vs. reactive,” he said.

Last but not least, clinicians also have an important role in supporting these conversations.

“We’ve always looked at sex communication as a dyadic process, as a parent bestowing wisdom on a child who doesn’t have that knowledge yet. But it can be a triadic model,” said Dr. Flores. “Providers can encourage parents to ask if a child is dating or is familiar with ways to protect themselves or provide consent, and act as a resource exclusively to troubleshoot emergent issues.”

This study was funded by the National Institutes of Health. The study also received supplementary funding from the Surgeon General C. Everett Koop HIV/AIDS Research Award. Dr. Flores and Dr. Goldfarb report no relevant financial relationships.
 

A version of this article originally appeared on Medscape.com.

When it comes to sexual health education in the United States, one thing is abundantly clear: It’s a messy patchwork of programs, topics, and criteria. Only 29 states and the District of Columbia currently mandate sexual health education. Sixteen states have an abstinence-only curriculum, whereas 13 do not require that instruction be age-appropriate, inclusive, medically accurate, or evidence-based/informed. And this is just the tip of the iceberg, according to a 2022 report issued by the Sex Ed for Social Change organization.

Parents should take an inclusive approach to sex communication and create a safe space for discussing sex and sexual orientation, said almost all (96.7%) of male young adults who participated in a qualitative study. This would help reinforce acceptance and parents could possibly serve as a proxy for children who’ve not yet disclosed their sexual orientation. Yet, few parents are equipped or prepared to have these meaningful conversations with gay, bisexual, queer, or gender-diverse children, despite the fact that they are especially vulnerable to poor sexual health outcomes, bullying, abuse, and mental health challenges, as well as high-risk sexual behaviors.

“Parents are sexual socialization agents,” Dalmacio Dennis Flores, PhD, ACRN, assistant professor of nursing at the University of Pennsylvania, Philadelphia, told this news organization. “It’s through the information that they convey, the way that they normalize rituals and expectations, that they inform young people of all of societal expectations or roles they’ll be fulfilling in the future.”

Dr. Flores is lead author of a study published in the Journal of Adolescent Health. He and his colleagues collected perspectives on comprehensive, inclusive, and age-appropriate parent-child sex communications from 30 GBQ adolescent males aged 15-20 years who were already “out” to their parents. Participants were asked to sort through 28 preprinted note cards containing broad sexual health topics (for instance, human anatomy, dating, sexually transmitted infections) as well as topics theoretically specific to GBQ individuals (for example, anal sex), and were asked to add additional topics that they felt were missing. They were then directed to recommend topics along with ideal timing (that is, elementary, middle, or high school) for these conversations.

Study findings also underscored the importance of initiating comprehensive sexuality talks as early as elementary school age – namely to start preparing GBQ children for inevitable adversities that they were likely to encounter later in life, as well as to form building blocks for more mature, in-depth discussions during high school.

Importantly, these recommendations generally align with those aimed at heterosexual youth.

“When we refer to topics for elementary school, they are general parameters of what kids might be interested in or want to hear more about; it’s not planting a seed,” explained Dr. Flores.

Eva Goldfarb, PhD, LHD, MA, professor of public health at Montclair (N.J.) State University, agreed. “We always talk about (in sex education) to follow young people’s lead. If your child is asking you a question, they deserve a response,” said Dr. Goldfarb, who wasn’t involved in the study. “It doesn’t mean you have to give a detailed- level explanation but if they’re asking about it, it means that they are thinking about it. But it’s really important for all young people to know all of this information.”

Along those lines, participants deemed that fundamental issues about bodies (for example, human anatomy, reproduction), different sexual orientations, and an introduction to foundational issues (like privacy, peer or social pressure, sexual abuse) would help elementary-aged children to normalize discussions about sex, anatomy, and sexual orientation.

Middle school conversations were ideally more in-depth to reflect the time when young people are beginning to explore and accept their social and sexual identities. Topics of discussion might include types of sexual intercourse (anal, oral, and vaginal), health promotion strategies (abstinence, condoms, and contraception), possible adverse outcomes of condomless intercourse (HIV, STIs), considerations about engaging in sexual intercourse (including readiness, negotiating boundaries, virginity), and interpersonal safety (for instance, sexting, alcohol/drugs/chemsex, sexual coercion, and partner abuse/violence).

Finally, high school age recommendations focused on socio-relational topics (such as hook-up culture, technology/online dating, and multiple or concurrent sex partners), which are most relevant during a time when adolescents are most prone to experimentation and risk-taking.

Acknowledging that the study approach was novel, Dr. Flores noted that hearing about these topics from the youth perspective allowed parents to prepare. “Communication is better when it’s anticipated vs. reactive,” he said.

Last but not least, clinicians also have an important role in supporting these conversations.

“We’ve always looked at sex communication as a dyadic process, as a parent bestowing wisdom on a child who doesn’t have that knowledge yet. But it can be a triadic model,” said Dr. Flores. “Providers can encourage parents to ask if a child is dating or is familiar with ways to protect themselves or provide consent, and act as a resource exclusively to troubleshoot emergent issues.”

This study was funded by the National Institutes of Health. The study also received supplementary funding from the Surgeon General C. Everett Koop HIV/AIDS Research Award. Dr. Flores and Dr. Goldfarb report no relevant financial relationships.
 

A version of this article originally appeared on Medscape.com.

When it comes to sexual health education in the United States, one thing is abundantly clear: It’s a messy patchwork of programs, topics, and criteria. Only 29 states and the District of Columbia currently mandate sexual health education. Sixteen states have an abstinence-only curriculum, whereas 13 do not require that instruction be age-appropriate, inclusive, medically accurate, or evidence-based/informed. And this is just the tip of the iceberg, according to a 2022 report issued by the Sex Ed for Social Change organization.

Parents should take an inclusive approach to sex communication and create a safe space for discussing sex and sexual orientation, said almost all (96.7%) of male young adults who participated in a qualitative study. This would help reinforce acceptance and parents could possibly serve as a proxy for children who’ve not yet disclosed their sexual orientation. Yet, few parents are equipped or prepared to have these meaningful conversations with gay, bisexual, queer, or gender-diverse children, despite the fact that they are especially vulnerable to poor sexual health outcomes, bullying, abuse, and mental health challenges, as well as high-risk sexual behaviors.

“Parents are sexual socialization agents,” Dalmacio Dennis Flores, PhD, ACRN, assistant professor of nursing at the University of Pennsylvania, Philadelphia, told this news organization. “It’s through the information that they convey, the way that they normalize rituals and expectations, that they inform young people of all of societal expectations or roles they’ll be fulfilling in the future.”

Dr. Flores is lead author of a study published in the Journal of Adolescent Health. He and his colleagues collected perspectives on comprehensive, inclusive, and age-appropriate parent-child sex communications from 30 GBQ adolescent males aged 15-20 years who were already “out” to their parents. Participants were asked to sort through 28 preprinted note cards containing broad sexual health topics (for instance, human anatomy, dating, sexually transmitted infections) as well as topics theoretically specific to GBQ individuals (for example, anal sex), and were asked to add additional topics that they felt were missing. They were then directed to recommend topics along with ideal timing (that is, elementary, middle, or high school) for these conversations.

Study findings also underscored the importance of initiating comprehensive sexuality talks as early as elementary school age – namely to start preparing GBQ children for inevitable adversities that they were likely to encounter later in life, as well as to form building blocks for more mature, in-depth discussions during high school.

Importantly, these recommendations generally align with those aimed at heterosexual youth.

“When we refer to topics for elementary school, they are general parameters of what kids might be interested in or want to hear more about; it’s not planting a seed,” explained Dr. Flores.

Eva Goldfarb, PhD, LHD, MA, professor of public health at Montclair (N.J.) State University, agreed. “We always talk about (in sex education) to follow young people’s lead. If your child is asking you a question, they deserve a response,” said Dr. Goldfarb, who wasn’t involved in the study. “It doesn’t mean you have to give a detailed- level explanation but if they’re asking about it, it means that they are thinking about it. But it’s really important for all young people to know all of this information.”

Along those lines, participants deemed that fundamental issues about bodies (for example, human anatomy, reproduction), different sexual orientations, and an introduction to foundational issues (like privacy, peer or social pressure, sexual abuse) would help elementary-aged children to normalize discussions about sex, anatomy, and sexual orientation.

Middle school conversations were ideally more in-depth to reflect the time when young people are beginning to explore and accept their social and sexual identities. Topics of discussion might include types of sexual intercourse (anal, oral, and vaginal), health promotion strategies (abstinence, condoms, and contraception), possible adverse outcomes of condomless intercourse (HIV, STIs), considerations about engaging in sexual intercourse (including readiness, negotiating boundaries, virginity), and interpersonal safety (for instance, sexting, alcohol/drugs/chemsex, sexual coercion, and partner abuse/violence).

Finally, high school age recommendations focused on socio-relational topics (such as hook-up culture, technology/online dating, and multiple or concurrent sex partners), which are most relevant during a time when adolescents are most prone to experimentation and risk-taking.

Acknowledging that the study approach was novel, Dr. Flores noted that hearing about these topics from the youth perspective allowed parents to prepare. “Communication is better when it’s anticipated vs. reactive,” he said.

Last but not least, clinicians also have an important role in supporting these conversations.

“We’ve always looked at sex communication as a dyadic process, as a parent bestowing wisdom on a child who doesn’t have that knowledge yet. But it can be a triadic model,” said Dr. Flores. “Providers can encourage parents to ask if a child is dating or is familiar with ways to protect themselves or provide consent, and act as a resource exclusively to troubleshoot emergent issues.”

This study was funded by the National Institutes of Health. The study also received supplementary funding from the Surgeon General C. Everett Koop HIV/AIDS Research Award. Dr. Flores and Dr. Goldfarb report no relevant financial relationships.
 

A version of this article originally appeared on Medscape.com.

“Take it from me, parents just don’t understand.”

Fresh Prince and D.J. Jazzy Jeff penned this lyric roughly 35 years ago, and coincidentally the HIV/AIDS epidemic has also been with us just as long. But the connection between the two may be highly relevant – that is, if you consider how infrequently parents appear (or have the proper tools) to engage with their gay or bisexual sons to prevent and curb HIV infections.

The glaring disparities in new and undiagnosed cases in young men who have sex with men (YMSM) help highlight why novel strategies (such as greater parental involvement) are needed.

Currently, YMSM between the ages of 13 and 24 are among the most affected by the ongoing HIV epidemic, with CDC estimates suggesting that, in 2020, this group alone represented about 35% of new diagnoses. At the same time, about half of these HIV infections go undiagnosed. Recent data also suggest that care linkage in this group is similar to adults, but only a third of YMSM start antiretroviral therapy and are retained in care, leading to viral suppression rates as low as 12%.

With a goal to change these discouraging numbers, researchers from George Washington University, Washington, and other institutions conducted a randomized controlled pilot study targeting parents of YMSM to improve both the frequency and quality of communication around sexual health and HIV risk, prevention, and testing.

The findings, which were published online in the journal AIDS and Behavior, highlight the observation that parents could be an essential resource for combating the HIV epidemic, but they’re a resource that’s often underutilized. In fact, after participating in an online offering – PATHS (Parents and Adolescents Talking about Healthy Sexuality) – parents reported significantly greater engagement with their sons, especially around discussions focusing on HIV information and condom use.

“From what we know from the research, parents are uncomfortable talking about sex; they’re not great at talking about it. But when they do and do it effectively, those kids seem to have better health outcomes,” lead author David Huebner, PhD, MPH, associate professor of prevention and community health at George Washington University, said in an interview.

“The goal was to get parents to deliver more messages and engage in more behaviors with their sons that we think are likely to help their sons stay healthy,” he said.

For the pilot study, Huebner and his team recruited 61 parents (95% of whom were mothers) with predominantly high school-aged cisgender sons (median, 16.7-17 years) who had come out as gay or bisexual at least a month prior, whose HIV status was negative or unknown, and who were living at home.

The interventions were strictly parent focused, Dr. Huebner said, noting that the only interaction with the kids involved independent surveys at the start and end of the study that explored parental behavior and engagement.

For the study, parental participants were stratified by son’s age (13-17 or 18-22 years) and then randomly assigned to participate in a web-accessible PATHS intervention (intervention group) or view a 35-minute, documentary-style film that encouraged acceptance of lesbian, gay, or bisexual children (control group),

Parents assigned to the intervention group were asked to engage in their own time with six modules that explored the importance of communication, HIV information, using and acquiring condoms, HIV testing, and as follow-up, a “to-do” list encouraging selection of how they would follow up with their sons about the content. They were also offered the option to participate in supplemental modules on pre-exposure prophylaxis (PrEP), anal intercourse, and what to do if a child tested positive for HIV.

“The intervention ... showed strong evidence of being effective at changing the parent behaviors that we hoped to change,” Dr. Huebner explained.

“We got independent reports from parents and kids that showed the same thing: parents were more likely to communicate with their sons about HIV in the 3 months after the intervention and were more likely to help their sons get access to condoms,” he said.

Both of these findings were significant, with parents in the experimental group being almost 10 times more likely to share HIV information with their sons (odds ratio, 9.50; 95% confidence interval, 1.02-39.99; P < .05) and five times more likely to teach proper condom use (OR, 5.04; 95% CI 1.56-12.46; P < .05), compared with parents receiving the placebo.

“It’s very promising that the initial signals from their intervention do show that parents facilitating the acquisition of information for young men who have sex with men really works,” said Dalmacio Dennis Flores, PhD, ACRN, an assistant professor of nursing in family and community health at the University of Pennsylvania, Philadelphia. He was not directly involved in the study.

“On the outcomes that matter for us, such as HIV prevention or getting tested, they were able to document that parents receiving guidance on how to have these conversations does result in youth outcomes – something that has been lacking in the literature specifically for this population up until today,” Dr. Flores told this news organization.

Overall, parents engaging in the PATHS intervention showed improvements in skills, attitudes, and behavioral intention toward engagement with their sons, including assisting with HIV testing. However, what about parental involvement in these types of dialogues with children who have not yet come out to their parents?

Dr. Flores said that, although Dr. Huebner’s work is pivotal for families where the child’s sexual orientation is known to parents, there is value in inclusive sex communication for all youth, regardless of how they identify (that is, out of the closet, closeted, straight, or those who are questioning their identity), especially since younger generations of LGBTQ youth are coming out at earlier ages, compared with previous generations.

It’s not just parents. Clinicians also have critical roles to play in helping bridge the sex-talk communication gaps between parents and adolescents and young adult children.

“In my work, I’ve found that more clinicians are willing to broach this within the discussion with dyads, with parents and adolescents in the room,” said Dr. Flores.

And he added: “If clinicians signal that there’s no such thing as too early to have these conversations or that issues such as consent, safety, and sexting are all okay to talk about because these are the current realities of young people, then parents can feel that they’re empowered to broach or sustain these conversations.”

Importantly, Dr. Huebner and associates are currently recruiting larger numbers of families for a new, yearlong trial that will not only examine parental behavior changes but also whether these changes translate into improvements in their child’s sexual health and/or competency. Interested families can learn more about the study and sign up to receive updates at www.parentwithlove.org.

Dr. Huebner and Dr. Flores reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

“Take it from me, parents just don’t understand.”

Fresh Prince and D.J. Jazzy Jeff penned this lyric roughly 35 years ago, and coincidentally the HIV/AIDS epidemic has also been with us just as long. But the connection between the two may be highly relevant – that is, if you consider how infrequently parents appear (or have the proper tools) to engage with their gay or bisexual sons to prevent and curb HIV infections.

The glaring disparities in new and undiagnosed cases in young men who have sex with men (YMSM) help highlight why novel strategies (such as greater parental involvement) are needed.

Currently, YMSM between the ages of 13 and 24 are among the most affected by the ongoing HIV epidemic, with CDC estimates suggesting that, in 2020, this group alone represented about 35% of new diagnoses. At the same time, about half of these HIV infections go undiagnosed. Recent data also suggest that care linkage in this group is similar to adults, but only a third of YMSM start antiretroviral therapy and are retained in care, leading to viral suppression rates as low as 12%.

With a goal to change these discouraging numbers, researchers from George Washington University, Washington, and other institutions conducted a randomized controlled pilot study targeting parents of YMSM to improve both the frequency and quality of communication around sexual health and HIV risk, prevention, and testing.

The findings, which were published online in the journal AIDS and Behavior, highlight the observation that parents could be an essential resource for combating the HIV epidemic, but they’re a resource that’s often underutilized. In fact, after participating in an online offering – PATHS (Parents and Adolescents Talking about Healthy Sexuality) – parents reported significantly greater engagement with their sons, especially around discussions focusing on HIV information and condom use.

“From what we know from the research, parents are uncomfortable talking about sex; they’re not great at talking about it. But when they do and do it effectively, those kids seem to have better health outcomes,” lead author David Huebner, PhD, MPH, associate professor of prevention and community health at George Washington University, said in an interview.

“The goal was to get parents to deliver more messages and engage in more behaviors with their sons that we think are likely to help their sons stay healthy,” he said.

For the pilot study, Huebner and his team recruited 61 parents (95% of whom were mothers) with predominantly high school-aged cisgender sons (median, 16.7-17 years) who had come out as gay or bisexual at least a month prior, whose HIV status was negative or unknown, and who were living at home.

The interventions were strictly parent focused, Dr. Huebner said, noting that the only interaction with the kids involved independent surveys at the start and end of the study that explored parental behavior and engagement.

For the study, parental participants were stratified by son’s age (13-17 or 18-22 years) and then randomly assigned to participate in a web-accessible PATHS intervention (intervention group) or view a 35-minute, documentary-style film that encouraged acceptance of lesbian, gay, or bisexual children (control group),

Parents assigned to the intervention group were asked to engage in their own time with six modules that explored the importance of communication, HIV information, using and acquiring condoms, HIV testing, and as follow-up, a “to-do” list encouraging selection of how they would follow up with their sons about the content. They were also offered the option to participate in supplemental modules on pre-exposure prophylaxis (PrEP), anal intercourse, and what to do if a child tested positive for HIV.

“The intervention ... showed strong evidence of being effective at changing the parent behaviors that we hoped to change,” Dr. Huebner explained.

“We got independent reports from parents and kids that showed the same thing: parents were more likely to communicate with their sons about HIV in the 3 months after the intervention and were more likely to help their sons get access to condoms,” he said.

Both of these findings were significant, with parents in the experimental group being almost 10 times more likely to share HIV information with their sons (odds ratio, 9.50; 95% confidence interval, 1.02-39.99; P < .05) and five times more likely to teach proper condom use (OR, 5.04; 95% CI 1.56-12.46; P < .05), compared with parents receiving the placebo.

“It’s very promising that the initial signals from their intervention do show that parents facilitating the acquisition of information for young men who have sex with men really works,” said Dalmacio Dennis Flores, PhD, ACRN, an assistant professor of nursing in family and community health at the University of Pennsylvania, Philadelphia. He was not directly involved in the study.

“On the outcomes that matter for us, such as HIV prevention or getting tested, they were able to document that parents receiving guidance on how to have these conversations does result in youth outcomes – something that has been lacking in the literature specifically for this population up until today,” Dr. Flores told this news organization.

Overall, parents engaging in the PATHS intervention showed improvements in skills, attitudes, and behavioral intention toward engagement with their sons, including assisting with HIV testing. However, what about parental involvement in these types of dialogues with children who have not yet come out to their parents?

Dr. Flores said that, although Dr. Huebner’s work is pivotal for families where the child’s sexual orientation is known to parents, there is value in inclusive sex communication for all youth, regardless of how they identify (that is, out of the closet, closeted, straight, or those who are questioning their identity), especially since younger generations of LGBTQ youth are coming out at earlier ages, compared with previous generations.

It’s not just parents. Clinicians also have critical roles to play in helping bridge the sex-talk communication gaps between parents and adolescents and young adult children.

“In my work, I’ve found that more clinicians are willing to broach this within the discussion with dyads, with parents and adolescents in the room,” said Dr. Flores.

And he added: “If clinicians signal that there’s no such thing as too early to have these conversations or that issues such as consent, safety, and sexting are all okay to talk about because these are the current realities of young people, then parents can feel that they’re empowered to broach or sustain these conversations.”

Importantly, Dr. Huebner and associates are currently recruiting larger numbers of families for a new, yearlong trial that will not only examine parental behavior changes but also whether these changes translate into improvements in their child’s sexual health and/or competency. Interested families can learn more about the study and sign up to receive updates at www.parentwithlove.org.

Dr. Huebner and Dr. Flores reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

“Take it from me, parents just don’t understand.”

Fresh Prince and D.J. Jazzy Jeff penned this lyric roughly 35 years ago, and coincidentally the HIV/AIDS epidemic has also been with us just as long. But the connection between the two may be highly relevant – that is, if you consider how infrequently parents appear (or have the proper tools) to engage with their gay or bisexual sons to prevent and curb HIV infections.

The glaring disparities in new and undiagnosed cases in young men who have sex with men (YMSM) help highlight why novel strategies (such as greater parental involvement) are needed.

Currently, YMSM between the ages of 13 and 24 are among the most affected by the ongoing HIV epidemic, with CDC estimates suggesting that, in 2020, this group alone represented about 35% of new diagnoses. At the same time, about half of these HIV infections go undiagnosed. Recent data also suggest that care linkage in this group is similar to adults, but only a third of YMSM start antiretroviral therapy and are retained in care, leading to viral suppression rates as low as 12%.

With a goal to change these discouraging numbers, researchers from George Washington University, Washington, and other institutions conducted a randomized controlled pilot study targeting parents of YMSM to improve both the frequency and quality of communication around sexual health and HIV risk, prevention, and testing.

The findings, which were published online in the journal AIDS and Behavior, highlight the observation that parents could be an essential resource for combating the HIV epidemic, but they’re a resource that’s often underutilized. In fact, after participating in an online offering – PATHS (Parents and Adolescents Talking about Healthy Sexuality) – parents reported significantly greater engagement with their sons, especially around discussions focusing on HIV information and condom use.

“From what we know from the research, parents are uncomfortable talking about sex; they’re not great at talking about it. But when they do and do it effectively, those kids seem to have better health outcomes,” lead author David Huebner, PhD, MPH, associate professor of prevention and community health at George Washington University, said in an interview.

“The goal was to get parents to deliver more messages and engage in more behaviors with their sons that we think are likely to help their sons stay healthy,” he said.

For the pilot study, Huebner and his team recruited 61 parents (95% of whom were mothers) with predominantly high school-aged cisgender sons (median, 16.7-17 years) who had come out as gay or bisexual at least a month prior, whose HIV status was negative or unknown, and who were living at home.

The interventions were strictly parent focused, Dr. Huebner said, noting that the only interaction with the kids involved independent surveys at the start and end of the study that explored parental behavior and engagement.

For the study, parental participants were stratified by son’s age (13-17 or 18-22 years) and then randomly assigned to participate in a web-accessible PATHS intervention (intervention group) or view a 35-minute, documentary-style film that encouraged acceptance of lesbian, gay, or bisexual children (control group),

Parents assigned to the intervention group were asked to engage in their own time with six modules that explored the importance of communication, HIV information, using and acquiring condoms, HIV testing, and as follow-up, a “to-do” list encouraging selection of how they would follow up with their sons about the content. They were also offered the option to participate in supplemental modules on pre-exposure prophylaxis (PrEP), anal intercourse, and what to do if a child tested positive for HIV.

“The intervention ... showed strong evidence of being effective at changing the parent behaviors that we hoped to change,” Dr. Huebner explained.

“We got independent reports from parents and kids that showed the same thing: parents were more likely to communicate with their sons about HIV in the 3 months after the intervention and were more likely to help their sons get access to condoms,” he said.

Both of these findings were significant, with parents in the experimental group being almost 10 times more likely to share HIV information with their sons (odds ratio, 9.50; 95% confidence interval, 1.02-39.99; P < .05) and five times more likely to teach proper condom use (OR, 5.04; 95% CI 1.56-12.46; P < .05), compared with parents receiving the placebo.

“It’s very promising that the initial signals from their intervention do show that parents facilitating the acquisition of information for young men who have sex with men really works,” said Dalmacio Dennis Flores, PhD, ACRN, an assistant professor of nursing in family and community health at the University of Pennsylvania, Philadelphia. He was not directly involved in the study.

“On the outcomes that matter for us, such as HIV prevention or getting tested, they were able to document that parents receiving guidance on how to have these conversations does result in youth outcomes – something that has been lacking in the literature specifically for this population up until today,” Dr. Flores told this news organization.

Overall, parents engaging in the PATHS intervention showed improvements in skills, attitudes, and behavioral intention toward engagement with their sons, including assisting with HIV testing. However, what about parental involvement in these types of dialogues with children who have not yet come out to their parents?

Dr. Flores said that, although Dr. Huebner’s work is pivotal for families where the child’s sexual orientation is known to parents, there is value in inclusive sex communication for all youth, regardless of how they identify (that is, out of the closet, closeted, straight, or those who are questioning their identity), especially since younger generations of LGBTQ youth are coming out at earlier ages, compared with previous generations.

It’s not just parents. Clinicians also have critical roles to play in helping bridge the sex-talk communication gaps between parents and adolescents and young adult children.

“In my work, I’ve found that more clinicians are willing to broach this within the discussion with dyads, with parents and adolescents in the room,” said Dr. Flores.

And he added: “If clinicians signal that there’s no such thing as too early to have these conversations or that issues such as consent, safety, and sexting are all okay to talk about because these are the current realities of young people, then parents can feel that they’re empowered to broach or sustain these conversations.”

Importantly, Dr. Huebner and associates are currently recruiting larger numbers of families for a new, yearlong trial that will not only examine parental behavior changes but also whether these changes translate into improvements in their child’s sexual health and/or competency. Interested families can learn more about the study and sign up to receive updates at www.parentwithlove.org.

Dr. Huebner and Dr. Flores reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

In the era of Ebola, COVID-19, and even Legionnaires, technicians and other staff working behind the scenes to ensure provider and patient safety continue to face a long-recognized but under addressed challenge: splashes and airborne droplets.

Granted, National Institute for Occupational Safety and Health (NIOSH) standards, industry standards, and professional guidelines are all in place to prevent unintentional exposure to pathogens. However, findings from a newly published study in the American Journal of Infection Control suggest they fall short.

In the study, researchers found that simulated manual cleaning of medical devices generated a drenching splash throughout the process with droplet dispersal exceeding 7 feet (2.1 meters).

“The guidelines say that droplets stop at 3 or 4 feet, and they don’t,” Cori L. Ofstead, MSPH, lead author and president/CEO of Ofstead & Associates, Bloomington, Minn., told this news organization. “That’s the problem with having standards and guidelines that are not based on relevant evidence, [which] in this case, is a single study that was done in an intensive care area where they had an infection outbreak.”

Ms. Ofstead was referring to a report in the journal Infection Control and Hospital Epidemiology, detailing a Canadian investigation involving a multidrug-resistant Pseudomonas aeruginosa outbreak in an ICU. The report implicated the faucets over the hand hygiene sinks, with fluorescent dye showing droplet dispersal roughly 3 feet away from the sinks.

“Somehow it [the 3-feet rule] got implemented in guidelines in sterile processing decontamination areas, which are not the same as hand hygiene,’’ Ms. Ofstead explained.

With a goal of providing more current evidence on droplet generation and dispersal, as well as personal protection equipment (PPE) exposure/effectiveness, she and her colleagues simulated manual cleaning of a decommissioned colonoscope and transvaginal ultrasound probe, using for the study location a new academic sterile processing unit.

To detect droplet generation and dispersal as well as splash following common technician activities (for example, colonoscope brushing, scrubbing, rinsing and transport to an automated endoscope reprocessor [AER] for sterilization), the researchers affixed blue moisture-detection paper to environmental surfaces, on carts positioned 4 feet (1.2 meters) from the sink (to simulate observers), and along a 15-foot pathway between the sink and AER.

They observed droplets everywhere.

Technician activities such as running the faucet and rinsing the probe under running water generated substantial splashing overall. Instrument rinsing in particular produced small and large droplets and confluent puddles of water around the sink and in the broad area surrounding the workspace. Droplets were also dispersed on the floor 7.25 feet (2.2 meters) away and along the entire 15-foot path from the sink to the AER.

At the sink, the technician risked drenching exposure from head to toe during most activities, and even observers positioned 3-4 feet away were found to have droplets on their gowns. In addition, saturated shoe covers reportedly tracked moisture away from the sink to the unit door – a distance of 13 feet (4 meters) – and 2 feet (0.6 meters) farther out into the PPE foyer for donning and doffing.

Although PPE gowns effectively repelled moisture during cleaning of a single device, Ms. Ofstead emphasized that technicians typically handle up to 10 instruments during a normal, 2-hour shift, further increasing exposure risk with each subsequent cleaning.

However, perhaps one of the most surprising findings was that despite an optimal unit design, including physical separation of clean and dirty activities and pressurized air flow to protect workers, droplets were still broadly dispersed.

Current efforts, however well-intentioned, might not be offering the degree of protection (and consideration) that sterile processing technicians need.

“The study was conducted in a new sterile processing area that had an extra excellent kind of distancing and three separate rooms, something that I think most of our hospitals are working toward,” Stella Hines, MD, associate professor at the University of Maryland School of Medicine, Baltimore, explained. Dr. Hines was not directly involved in the study.

“But it also really kind of highlighted what’s happening to workers potentially,” she added. “For example, we want to know if that spray or splatter has a live microbe it in that could cause a problem or ... in a highly wet environment, if that water has some kind of chemical in it that could pose an occupational hazard to the worker based on skin or mucous membrane exposure.”

Ms. Ofstead agreed. “We need to be thinking about the exposure of critically important workers and the environment in an era where we are worried about aerosol-generating procedures and superbugs,” she explained.

Dr. Hines and Ms. Ofstead also noted that the majority of staff involved in front-line patient care have never actually ventured into the sterile processing units nor do they recognize the risks that technicians working in these units face on a daily, or even hourly, basis.

“The people who run these operations are very well trained and knowledgeable. I think that it would be helpful for them to know that they’re appreciated and for the people upstairs on the front lines using the equipment to see what goes on downstairs and all of the painstaking steps that need to be in place for the equipment to come out of sterile processing and be ready to go,” said Dr. Hines.

In the meantime, hospital leaders need to address the challenges and danger posed by migrating infectious droplets, especially for workers involved in processes that stir them up in the first place – workers who by the end of their shifts are unavoidably drenched with infectious blood and tissue secretions.

“I think that it’s going to take a much bigger kind of worldview from hospital leadership,” Dr. Hines said.

The study was supported in part by a grant from Healthmark Industries. Ms. Ofstead reports research grants or consulting fees through her organization with 3M Company, Ambu, Boston Scientific, Cleanis, Fortive/Advanced Sterilization Products, Healthmark Industries, Pentax, and Steris/Cantel/Medviators. Dr. Hines reports no relevant financial relationships.

A version of this article first appeared on Medscape.com.

In the era of Ebola, COVID-19, and even Legionnaires, technicians and other staff working behind the scenes to ensure provider and patient safety continue to face a long-recognized but under addressed challenge: splashes and airborne droplets.

Granted, National Institute for Occupational Safety and Health (NIOSH) standards, industry standards, and professional guidelines are all in place to prevent unintentional exposure to pathogens. However, findings from a newly published study in the American Journal of Infection Control suggest they fall short.

In the study, researchers found that simulated manual cleaning of medical devices generated a drenching splash throughout the process with droplet dispersal exceeding 7 feet (2.1 meters).

“The guidelines say that droplets stop at 3 or 4 feet, and they don’t,” Cori L. Ofstead, MSPH, lead author and president/CEO of Ofstead & Associates, Bloomington, Minn., told this news organization. “That’s the problem with having standards and guidelines that are not based on relevant evidence, [which] in this case, is a single study that was done in an intensive care area where they had an infection outbreak.”

Ms. Ofstead was referring to a report in the journal Infection Control and Hospital Epidemiology, detailing a Canadian investigation involving a multidrug-resistant Pseudomonas aeruginosa outbreak in an ICU. The report implicated the faucets over the hand hygiene sinks, with fluorescent dye showing droplet dispersal roughly 3 feet away from the sinks.

“Somehow it [the 3-feet rule] got implemented in guidelines in sterile processing decontamination areas, which are not the same as hand hygiene,’’ Ms. Ofstead explained.

With a goal of providing more current evidence on droplet generation and dispersal, as well as personal protection equipment (PPE) exposure/effectiveness, she and her colleagues simulated manual cleaning of a decommissioned colonoscope and transvaginal ultrasound probe, using for the study location a new academic sterile processing unit.

To detect droplet generation and dispersal as well as splash following common technician activities (for example, colonoscope brushing, scrubbing, rinsing and transport to an automated endoscope reprocessor [AER] for sterilization), the researchers affixed blue moisture-detection paper to environmental surfaces, on carts positioned 4 feet (1.2 meters) from the sink (to simulate observers), and along a 15-foot pathway between the sink and AER.

They observed droplets everywhere.

Technician activities such as running the faucet and rinsing the probe under running water generated substantial splashing overall. Instrument rinsing in particular produced small and large droplets and confluent puddles of water around the sink and in the broad area surrounding the workspace. Droplets were also dispersed on the floor 7.25 feet (2.2 meters) away and along the entire 15-foot path from the sink to the AER.

At the sink, the technician risked drenching exposure from head to toe during most activities, and even observers positioned 3-4 feet away were found to have droplets on their gowns. In addition, saturated shoe covers reportedly tracked moisture away from the sink to the unit door – a distance of 13 feet (4 meters) – and 2 feet (0.6 meters) farther out into the PPE foyer for donning and doffing.

Although PPE gowns effectively repelled moisture during cleaning of a single device, Ms. Ofstead emphasized that technicians typically handle up to 10 instruments during a normal, 2-hour shift, further increasing exposure risk with each subsequent cleaning.

However, perhaps one of the most surprising findings was that despite an optimal unit design, including physical separation of clean and dirty activities and pressurized air flow to protect workers, droplets were still broadly dispersed.

Current efforts, however well-intentioned, might not be offering the degree of protection (and consideration) that sterile processing technicians need.

“The study was conducted in a new sterile processing area that had an extra excellent kind of distancing and three separate rooms, something that I think most of our hospitals are working toward,” Stella Hines, MD, associate professor at the University of Maryland School of Medicine, Baltimore, explained. Dr. Hines was not directly involved in the study.

“But it also really kind of highlighted what’s happening to workers potentially,” she added. “For example, we want to know if that spray or splatter has a live microbe it in that could cause a problem or ... in a highly wet environment, if that water has some kind of chemical in it that could pose an occupational hazard to the worker based on skin or mucous membrane exposure.”

Ms. Ofstead agreed. “We need to be thinking about the exposure of critically important workers and the environment in an era where we are worried about aerosol-generating procedures and superbugs,” she explained.

Dr. Hines and Ms. Ofstead also noted that the majority of staff involved in front-line patient care have never actually ventured into the sterile processing units nor do they recognize the risks that technicians working in these units face on a daily, or even hourly, basis.

“The people who run these operations are very well trained and knowledgeable. I think that it would be helpful for them to know that they’re appreciated and for the people upstairs on the front lines using the equipment to see what goes on downstairs and all of the painstaking steps that need to be in place for the equipment to come out of sterile processing and be ready to go,” said Dr. Hines.

In the meantime, hospital leaders need to address the challenges and danger posed by migrating infectious droplets, especially for workers involved in processes that stir them up in the first place – workers who by the end of their shifts are unavoidably drenched with infectious blood and tissue secretions.

“I think that it’s going to take a much bigger kind of worldview from hospital leadership,” Dr. Hines said.

The study was supported in part by a grant from Healthmark Industries. Ms. Ofstead reports research grants or consulting fees through her organization with 3M Company, Ambu, Boston Scientific, Cleanis, Fortive/Advanced Sterilization Products, Healthmark Industries, Pentax, and Steris/Cantel/Medviators. Dr. Hines reports no relevant financial relationships.

A version of this article first appeared on Medscape.com.

In the era of Ebola, COVID-19, and even Legionnaires, technicians and other staff working behind the scenes to ensure provider and patient safety continue to face a long-recognized but under addressed challenge: splashes and airborne droplets.

Granted, National Institute for Occupational Safety and Health (NIOSH) standards, industry standards, and professional guidelines are all in place to prevent unintentional exposure to pathogens. However, findings from a newly published study in the American Journal of Infection Control suggest they fall short.

In the study, researchers found that simulated manual cleaning of medical devices generated a drenching splash throughout the process with droplet dispersal exceeding 7 feet (2.1 meters).

“The guidelines say that droplets stop at 3 or 4 feet, and they don’t,” Cori L. Ofstead, MSPH, lead author and president/CEO of Ofstead & Associates, Bloomington, Minn., told this news organization. “That’s the problem with having standards and guidelines that are not based on relevant evidence, [which] in this case, is a single study that was done in an intensive care area where they had an infection outbreak.”

Ms. Ofstead was referring to a report in the journal Infection Control and Hospital Epidemiology, detailing a Canadian investigation involving a multidrug-resistant Pseudomonas aeruginosa outbreak in an ICU. The report implicated the faucets over the hand hygiene sinks, with fluorescent dye showing droplet dispersal roughly 3 feet away from the sinks.

“Somehow it [the 3-feet rule] got implemented in guidelines in sterile processing decontamination areas, which are not the same as hand hygiene,’’ Ms. Ofstead explained.

With a goal of providing more current evidence on droplet generation and dispersal, as well as personal protection equipment (PPE) exposure/effectiveness, she and her colleagues simulated manual cleaning of a decommissioned colonoscope and transvaginal ultrasound probe, using for the study location a new academic sterile processing unit.

To detect droplet generation and dispersal as well as splash following common technician activities (for example, colonoscope brushing, scrubbing, rinsing and transport to an automated endoscope reprocessor [AER] for sterilization), the researchers affixed blue moisture-detection paper to environmental surfaces, on carts positioned 4 feet (1.2 meters) from the sink (to simulate observers), and along a 15-foot pathway between the sink and AER.

They observed droplets everywhere.

Technician activities such as running the faucet and rinsing the probe under running water generated substantial splashing overall. Instrument rinsing in particular produced small and large droplets and confluent puddles of water around the sink and in the broad area surrounding the workspace. Droplets were also dispersed on the floor 7.25 feet (2.2 meters) away and along the entire 15-foot path from the sink to the AER.

At the sink, the technician risked drenching exposure from head to toe during most activities, and even observers positioned 3-4 feet away were found to have droplets on their gowns. In addition, saturated shoe covers reportedly tracked moisture away from the sink to the unit door – a distance of 13 feet (4 meters) – and 2 feet (0.6 meters) farther out into the PPE foyer for donning and doffing.

Although PPE gowns effectively repelled moisture during cleaning of a single device, Ms. Ofstead emphasized that technicians typically handle up to 10 instruments during a normal, 2-hour shift, further increasing exposure risk with each subsequent cleaning.

However, perhaps one of the most surprising findings was that despite an optimal unit design, including physical separation of clean and dirty activities and pressurized air flow to protect workers, droplets were still broadly dispersed.

Current efforts, however well-intentioned, might not be offering the degree of protection (and consideration) that sterile processing technicians need.

“The study was conducted in a new sterile processing area that had an extra excellent kind of distancing and three separate rooms, something that I think most of our hospitals are working toward,” Stella Hines, MD, associate professor at the University of Maryland School of Medicine, Baltimore, explained. Dr. Hines was not directly involved in the study.

“But it also really kind of highlighted what’s happening to workers potentially,” she added. “For example, we want to know if that spray or splatter has a live microbe it in that could cause a problem or ... in a highly wet environment, if that water has some kind of chemical in it that could pose an occupational hazard to the worker based on skin or mucous membrane exposure.”

Ms. Ofstead agreed. “We need to be thinking about the exposure of critically important workers and the environment in an era where we are worried about aerosol-generating procedures and superbugs,” she explained.

Dr. Hines and Ms. Ofstead also noted that the majority of staff involved in front-line patient care have never actually ventured into the sterile processing units nor do they recognize the risks that technicians working in these units face on a daily, or even hourly, basis.

“The people who run these operations are very well trained and knowledgeable. I think that it would be helpful for them to know that they’re appreciated and for the people upstairs on the front lines using the equipment to see what goes on downstairs and all of the painstaking steps that need to be in place for the equipment to come out of sterile processing and be ready to go,” said Dr. Hines.

In the meantime, hospital leaders need to address the challenges and danger posed by migrating infectious droplets, especially for workers involved in processes that stir them up in the first place – workers who by the end of their shifts are unavoidably drenched with infectious blood and tissue secretions.

“I think that it’s going to take a much bigger kind of worldview from hospital leadership,” Dr. Hines said.

The study was supported in part by a grant from Healthmark Industries. Ms. Ofstead reports research grants or consulting fees through her organization with 3M Company, Ambu, Boston Scientific, Cleanis, Fortive/Advanced Sterilization Products, Healthmark Industries, Pentax, and Steris/Cantel/Medviators. Dr. Hines reports no relevant financial relationships.

A version of this article first appeared on Medscape.com.

In recent years, increased use of integrase strand transferase inhibitor (INSTI) antiviral treatment (ART) has raised concerns about weight gain and adverse outcomes in patients with HIV. This is especially true regarding possible excessive gestational weight gain, which in women without HIV has been associated with maternal gestational diabetes, hypertensive and liver conditions, as well as related risks for preterm birth, fetal macrosomia, and higher weight after birth. 

Unfortunately, few studies in pregnant women with HIV have moved out of the controlled environment into real-world settings, potentially limiting current knowledge about the impact of gestational weight gain – as well as strategies to both prevent it and the associated adverse outcomes.

That is what a team of infectious disease specialists at the Hospital Federal dos Servidores do Estado in Rio de Janeiro recently sought to answer among a cohort of INSTI-experienced and INSTI-naive women with BMIs less than 25 kg/m² (underweight/normal weight) and higher than 25 kg/m².
 

Surprising findings

The investigators determined that rates of excessive weight gain were significantly higher in INSTI-naive women with BMI less than 25 who experienced rates as high as 31.6%, compared with approximately 12% of women who conceived while on INSTIs, regardless of BMI values at baseline (P = .004). 

However, rates of unfavorable pregnancy outcomes (for example, small for gestational age, preterm birth, stillbirth, death) appeared to be low overall and similar among all the study groups.

“We had some discussions when we were working on this and thought that the weight gain might have adverse effects,” Trevon Fuller, PhD, lead author and a postdoctoral student at the Hospital Federal dos Servidores do Estado, told this news organization.

“But it looked like the weight gain might actually be good, to the extent that we didn’t see any harm to the mom or the baby of those underweight or normal weight women who were naive to INSTIs,” he explained.

Dr. Fuller and his team enrolled 198 pregnant women living with HIV who sought care at the Hospital Federal dos Servidores do Estado – a national reference center for USAID’s Prevention of Mother to Child Transmission strategic program – between October 2014 and October 2021.

Participants were divided into two primary cohorts: BMI less than 25 at enrollment (n = 74) or BMI of 25 or higher (n = 124), then further divided by timing of INSTI-based combined ART: 

• INSTI-naive: women using INSTI-based ART (raltegravir [Isentress] 400 mg twice per day or dolutegravir [Tivicay] 50 mg/day plus 2 non-nucleoside reverse transcriptase inhibitors – lamivudine plus tenofovir disoproxil fumarate or lamivudine plus zidovudine) for 4 weeks between baseline and near delivery.
• INSTI-experienced: women who became pregnant while using INSTIs for at least 6 months before conception. 

Among underweight/normal weight participants, 77% (n = 57) were INSTI-naive and 23% (n = 17) INSTI-experienced, and among overweight/obese participants, 81.5% (n = 101) were INSTI-naive, and 18.5% (n = 23) were experienced.

Maternal age, which did not differ significantly by BMI or treatment experience, was a median of 28 years, and most participants were non-White. All participants were virally suppressed near delivery.

Study findings, which were published online  in HIV Medicine, highlighted that median weight near delivery in participants who were overweight/obese at baseline was similar regardless of whether they were treatment-experienced (90 kg [198 lb]) or treatment-naive (82.3 kg [181 lb]), P = .026.

However, participants who were underweight/normal weight who were INSTI-naive had significantly higher rates of gestational weight gain (31.5%, 18/57), compared with those of underweight/normal weight who were INSTI-experienced (11.8%, 2/17), P = .004. Notably, this gain was significant in all categories of change (that is, low < 0.18 kg/week, normal 0.18-0.59 kg/week), and high > 0.59 kg/week).

“One of the things that we took away was that this weight gain is primarily happening with women who are starting INSTIs,” said Dr. Fuller. 

“The data suggest that [it] might be temporary in the sense that there’s not going to be continuous weight gain but that it will probably approach some type of horizontal asymptote,” he added.

Although obstetric and neonatal outcomes were secondary measures, the investigators did not observe any significantly different outcomes when comparing the groups, and there were no stillbirths, neonatal deaths, or macrosomia.

Preterm delivery rates in underweight/normal weight participants who were INSTI-experienced (11.8%, 2/17) and INSTI-naive (5.3%, 3/57) were similar to overweight/obese participants who were INSTI-experienced (13%, 3/23) and INSTI-naive (6.9%, 7/101).

The same was true for low birthweight.

Still, the study appears to raise more questions than it answers, Sigal Yawetz, MD, an infectious disease specialist at Brigham and Women’s Hospital, Boston, said in an interview – a factor that she said is common also in some of the more recent randomized controlled studies, such as IMPAACT PROMISE.

Dr. Yawetz, who was not involved in the study, also noted, “The groups were small, so comparisons within the groups are difficult, and so many people were excluded that it’s hard to know if there were adverse outcomes related to this ... It’s very confounded.”

The World Health Organization estimates that there are roughly 1.3 million pregnant women with HIV, 81% of whom are on antiretroviral therapy. Although the literature continues to evolve, data suggest that in general, Black women are at greater risk for gestational weight gain.

“We have to remember that women who gain excess weight in pregnancy are still going to be with this weight following pregnancy as well,” Dr. Yawetz said. “So, it might impact their pregnancy but also their health after delivery and for subsequent pregnancies, which we don’t have data for yet.”

Dr. Fuller agrees that more data are needed and mentioned that the team plans to study this further, ideally with larger sample sizes.

Yet, despite the lingering questions, there is a silver lining, one that Dr. Yawetz was emphatic about.

“I really welcome people doing studies on this because we really need the data. By far, integrase inhibitors are the first-line regimen all over the world for pregnant women, and if you look at the gestalt or full picture, this is the best regimen to give pregnant women,” she said.

Dr. Fuller and Dr. Yawetz report no relevant financial relationships. The study was independently supported.

A version of this article first appeared on Medscape.com.

In recent years, increased use of integrase strand transferase inhibitor (INSTI) antiviral treatment (ART) has raised concerns about weight gain and adverse outcomes in patients with HIV. This is especially true regarding possible excessive gestational weight gain, which in women without HIV has been associated with maternal gestational diabetes, hypertensive and liver conditions, as well as related risks for preterm birth, fetal macrosomia, and higher weight after birth. 

Unfortunately, few studies in pregnant women with HIV have moved out of the controlled environment into real-world settings, potentially limiting current knowledge about the impact of gestational weight gain – as well as strategies to both prevent it and the associated adverse outcomes.

That is what a team of infectious disease specialists at the Hospital Federal dos Servidores do Estado in Rio de Janeiro recently sought to answer among a cohort of INSTI-experienced and INSTI-naive women with BMIs less than 25 kg/m² (underweight/normal weight) and higher than 25 kg/m².
 

Surprising findings

The investigators determined that rates of excessive weight gain were significantly higher in INSTI-naive women with BMI less than 25 who experienced rates as high as 31.6%, compared with approximately 12% of women who conceived while on INSTIs, regardless of BMI values at baseline (P = .004). 

However, rates of unfavorable pregnancy outcomes (for example, small for gestational age, preterm birth, stillbirth, death) appeared to be low overall and similar among all the study groups.

“We had some discussions when we were working on this and thought that the weight gain might have adverse effects,” Trevon Fuller, PhD, lead author and a postdoctoral student at the Hospital Federal dos Servidores do Estado, told this news organization.

“But it looked like the weight gain might actually be good, to the extent that we didn’t see any harm to the mom or the baby of those underweight or normal weight women who were naive to INSTIs,” he explained.

Dr. Fuller and his team enrolled 198 pregnant women living with HIV who sought care at the Hospital Federal dos Servidores do Estado – a national reference center for USAID’s Prevention of Mother to Child Transmission strategic program – between October 2014 and October 2021.

Participants were divided into two primary cohorts: BMI less than 25 at enrollment (n = 74) or BMI of 25 or higher (n = 124), then further divided by timing of INSTI-based combined ART: 

• INSTI-naive: women using INSTI-based ART (raltegravir [Isentress] 400 mg twice per day or dolutegravir [Tivicay] 50 mg/day plus 2 non-nucleoside reverse transcriptase inhibitors – lamivudine plus tenofovir disoproxil fumarate or lamivudine plus zidovudine) for 4 weeks between baseline and near delivery.
• INSTI-experienced: women who became pregnant while using INSTIs for at least 6 months before conception. 

Among underweight/normal weight participants, 77% (n = 57) were INSTI-naive and 23% (n = 17) INSTI-experienced, and among overweight/obese participants, 81.5% (n = 101) were INSTI-naive, and 18.5% (n = 23) were experienced.

Maternal age, which did not differ significantly by BMI or treatment experience, was a median of 28 years, and most participants were non-White. All participants were virally suppressed near delivery.

Study findings, which were published online  in HIV Medicine, highlighted that median weight near delivery in participants who were overweight/obese at baseline was similar regardless of whether they were treatment-experienced (90 kg [198 lb]) or treatment-naive (82.3 kg [181 lb]), P = .026.

However, participants who were underweight/normal weight who were INSTI-naive had significantly higher rates of gestational weight gain (31.5%, 18/57), compared with those of underweight/normal weight who were INSTI-experienced (11.8%, 2/17), P = .004. Notably, this gain was significant in all categories of change (that is, low < 0.18 kg/week, normal 0.18-0.59 kg/week), and high > 0.59 kg/week).

“One of the things that we took away was that this weight gain is primarily happening with women who are starting INSTIs,” said Dr. Fuller. 

“The data suggest that [it] might be temporary in the sense that there’s not going to be continuous weight gain but that it will probably approach some type of horizontal asymptote,” he added.

Although obstetric and neonatal outcomes were secondary measures, the investigators did not observe any significantly different outcomes when comparing the groups, and there were no stillbirths, neonatal deaths, or macrosomia.

Preterm delivery rates in underweight/normal weight participants who were INSTI-experienced (11.8%, 2/17) and INSTI-naive (5.3%, 3/57) were similar to overweight/obese participants who were INSTI-experienced (13%, 3/23) and INSTI-naive (6.9%, 7/101).

The same was true for low birthweight.

Still, the study appears to raise more questions than it answers, Sigal Yawetz, MD, an infectious disease specialist at Brigham and Women’s Hospital, Boston, said in an interview – a factor that she said is common also in some of the more recent randomized controlled studies, such as IMPAACT PROMISE.

Dr. Yawetz, who was not involved in the study, also noted, “The groups were small, so comparisons within the groups are difficult, and so many people were excluded that it’s hard to know if there were adverse outcomes related to this ... It’s very confounded.”

The World Health Organization estimates that there are roughly 1.3 million pregnant women with HIV, 81% of whom are on antiretroviral therapy. Although the literature continues to evolve, data suggest that in general, Black women are at greater risk for gestational weight gain.

“We have to remember that women who gain excess weight in pregnancy are still going to be with this weight following pregnancy as well,” Dr. Yawetz said. “So, it might impact their pregnancy but also their health after delivery and for subsequent pregnancies, which we don’t have data for yet.”

Dr. Fuller agrees that more data are needed and mentioned that the team plans to study this further, ideally with larger sample sizes.

Yet, despite the lingering questions, there is a silver lining, one that Dr. Yawetz was emphatic about.

“I really welcome people doing studies on this because we really need the data. By far, integrase inhibitors are the first-line regimen all over the world for pregnant women, and if you look at the gestalt or full picture, this is the best regimen to give pregnant women,” she said.

Dr. Fuller and Dr. Yawetz report no relevant financial relationships. The study was independently supported.

A version of this article first appeared on Medscape.com.

In recent years, increased use of integrase strand transferase inhibitor (INSTI) antiviral treatment (ART) has raised concerns about weight gain and adverse outcomes in patients with HIV. This is especially true regarding possible excessive gestational weight gain, which in women without HIV has been associated with maternal gestational diabetes, hypertensive and liver conditions, as well as related risks for preterm birth, fetal macrosomia, and higher weight after birth. 

Unfortunately, few studies in pregnant women with HIV have moved out of the controlled environment into real-world settings, potentially limiting current knowledge about the impact of gestational weight gain – as well as strategies to both prevent it and the associated adverse outcomes.

That is what a team of infectious disease specialists at the Hospital Federal dos Servidores do Estado in Rio de Janeiro recently sought to answer among a cohort of INSTI-experienced and INSTI-naive women with BMIs less than 25 kg/m² (underweight/normal weight) and higher than 25 kg/m².
 

Surprising findings

The investigators determined that rates of excessive weight gain were significantly higher in INSTI-naive women with BMI less than 25 who experienced rates as high as 31.6%, compared with approximately 12% of women who conceived while on INSTIs, regardless of BMI values at baseline (P = .004). 

However, rates of unfavorable pregnancy outcomes (for example, small for gestational age, preterm birth, stillbirth, death) appeared to be low overall and similar among all the study groups.

“We had some discussions when we were working on this and thought that the weight gain might have adverse effects,” Trevon Fuller, PhD, lead author and a postdoctoral student at the Hospital Federal dos Servidores do Estado, told this news organization.

“But it looked like the weight gain might actually be good, to the extent that we didn’t see any harm to the mom or the baby of those underweight or normal weight women who were naive to INSTIs,” he explained.

Dr. Fuller and his team enrolled 198 pregnant women living with HIV who sought care at the Hospital Federal dos Servidores do Estado – a national reference center for USAID’s Prevention of Mother to Child Transmission strategic program – between October 2014 and October 2021.

Participants were divided into two primary cohorts: BMI less than 25 at enrollment (n = 74) or BMI of 25 or higher (n = 124), then further divided by timing of INSTI-based combined ART: 

• INSTI-naive: women using INSTI-based ART (raltegravir [Isentress] 400 mg twice per day or dolutegravir [Tivicay] 50 mg/day plus 2 non-nucleoside reverse transcriptase inhibitors – lamivudine plus tenofovir disoproxil fumarate or lamivudine plus zidovudine) for 4 weeks between baseline and near delivery.
• INSTI-experienced: women who became pregnant while using INSTIs for at least 6 months before conception. 

Among underweight/normal weight participants, 77% (n = 57) were INSTI-naive and 23% (n = 17) INSTI-experienced, and among overweight/obese participants, 81.5% (n = 101) were INSTI-naive, and 18.5% (n = 23) were experienced.

Maternal age, which did not differ significantly by BMI or treatment experience, was a median of 28 years, and most participants were non-White. All participants were virally suppressed near delivery.

Study findings, which were published online  in HIV Medicine, highlighted that median weight near delivery in participants who were overweight/obese at baseline was similar regardless of whether they were treatment-experienced (90 kg [198 lb]) or treatment-naive (82.3 kg [181 lb]), P = .026.

However, participants who were underweight/normal weight who were INSTI-naive had significantly higher rates of gestational weight gain (31.5%, 18/57), compared with those of underweight/normal weight who were INSTI-experienced (11.8%, 2/17), P = .004. Notably, this gain was significant in all categories of change (that is, low < 0.18 kg/week, normal 0.18-0.59 kg/week), and high > 0.59 kg/week).

“One of the things that we took away was that this weight gain is primarily happening with women who are starting INSTIs,” said Dr. Fuller. 

“The data suggest that [it] might be temporary in the sense that there’s not going to be continuous weight gain but that it will probably approach some type of horizontal asymptote,” he added.

Although obstetric and neonatal outcomes were secondary measures, the investigators did not observe any significantly different outcomes when comparing the groups, and there were no stillbirths, neonatal deaths, or macrosomia.

Preterm delivery rates in underweight/normal weight participants who were INSTI-experienced (11.8%, 2/17) and INSTI-naive (5.3%, 3/57) were similar to overweight/obese participants who were INSTI-experienced (13%, 3/23) and INSTI-naive (6.9%, 7/101).

The same was true for low birthweight.

Still, the study appears to raise more questions than it answers, Sigal Yawetz, MD, an infectious disease specialist at Brigham and Women’s Hospital, Boston, said in an interview – a factor that she said is common also in some of the more recent randomized controlled studies, such as IMPAACT PROMISE.

Dr. Yawetz, who was not involved in the study, also noted, “The groups were small, so comparisons within the groups are difficult, and so many people were excluded that it’s hard to know if there were adverse outcomes related to this ... It’s very confounded.”

The World Health Organization estimates that there are roughly 1.3 million pregnant women with HIV, 81% of whom are on antiretroviral therapy. Although the literature continues to evolve, data suggest that in general, Black women are at greater risk for gestational weight gain.

“We have to remember that women who gain excess weight in pregnancy are still going to be with this weight following pregnancy as well,” Dr. Yawetz said. “So, it might impact their pregnancy but also their health after delivery and for subsequent pregnancies, which we don’t have data for yet.”

Dr. Fuller agrees that more data are needed and mentioned that the team plans to study this further, ideally with larger sample sizes.

Yet, despite the lingering questions, there is a silver lining, one that Dr. Yawetz was emphatic about.

“I really welcome people doing studies on this because we really need the data. By far, integrase inhibitors are the first-line regimen all over the world for pregnant women, and if you look at the gestalt or full picture, this is the best regimen to give pregnant women,” she said.

Dr. Fuller and Dr. Yawetz report no relevant financial relationships. The study was independently supported.

A version of this article first appeared on Medscape.com.