Cosmetic Skin Lightening: Contextualizing Biomedical and Ethical Issues.

The skin lightening (SL) industry has a global reach and is projected to continue to grow over the coming decade. While SL treatments may be safely prescribed for treatment of some dermatologic conditions, many over-the-counter SL products contain ingredients that can cause harm to the skin and other organ systems. Given a lack of transparent information to patients and the historical colorist foundation that contextualizes a component of the cosmetic SL industry, dermatologists need to navigate biomedical and ethical concerns when explaining SL products to patients. This commentary briefly outlines the medical ethical issues surrounding this topic and describes avenues by which dermatologists may provide informed patient care that best supports beneficence, justice, autonomy, and nonmaleficence.

Conservation Practices for Personal Protective Equipment: A Systematic Review with Focus on Lower-Income Countries.

During the start of the COVID-19 pandemic, shortages of personal protective equipment (PPE) necessitated unprecedented and non-validated approaches to conserve PPE at healthcare facilities, especially in high income countries where single-use disposable PPE was ubiquitous. Our team conducted a systematic literature review to evaluate historic approaches for conserving single-use PPE, expecting that lower-income countries or developing contexts may already be uniquely conserving PPE. However, of the 50 included studies, only 3 originated from middle-income countries and none originated from low-income countries. Data from the included studies suggest PPE remained effective with extended use and with multiple or repeated use in clinical settings, as long as donning and doffing were performed in a standard manner. Multiple decontamination techniques were effective in disinfecting single use PPE for repeated use. These findings can inform healthcare facilities and providers in establishing protocols for safe conservation of PPE supplies and updating existing protocols to improve sustainability and overall resilience. Future studies should evaluate conservation practices in low-resource settings during non-pandemic times to develop strategies for more sustainable and resilient healthcare worldwide.

What Would It Mean for Health Care Organizations to Justly Manage Their Waste?

Waste generated by health care includes harmful emissions and often disproportionately affects already vulnerable communities. Justly restructuring health care waste management involves better understanding key drivers of waste production, using sustainability as an ethical value to guide disposal decisions and practices, and reducing overall disposal quantity. Restructuring can be facilitated by making existing waste audit data transparent, incorporating waste accounting into social responsibility metrics used to evaluate health care organizational performance, and implementing policies that prioritize frontline workers' safety.

Factors associated with use of antibiotic prophylaxis following dental procedures in total joint replacement recipients.

Background: Total joint replacement recipients (TJR) are at risk for prosthetic joint infection (PJI), particularly those with comorbidities such as diabetes mellitus (DM) and rheumatoid arthritis (RA). Methods: We mailed surveys to 1078 subjects undergoing primary TJR between 2011 and 2016 â€‹at an academic center. The survey asked about medical, dental, and orthopedic history and use of antibiotics prior to dental appointments. We generated adjusted relative risks (aRR) for using antibiotic prophylaxis less than always using Poisson regression, adjusting for demographic, clinical, and behavioral factors. Results: We received surveys from 639 subjects; 597 were eligible and formed the analytical sample. 66 â€‹% reported always using antibiotic prophylaxis. DM and RA were not associated with prophylaxis use. Factors associated with less frequent use included: BMI ≥30 (aRR â€‹= â€‹1.27, 95 â€‹% CI [1.01, 1.60]), dental cleanings <2 times/year (aRR â€‹= â€‹1.95, 95 â€‹% CI [1.56, 2.43]), and expressing little concern (compared to neutral) about getting PJI (aRR â€‹= â€‹1.23, 95 â€‹% CI [0.97, 1.55]), though this association was not statistically significant. Greater antibiotic use was reported in subjects who had ≥3 TJRs, (aRR â€‹= â€‹0.48, 95 â€‹% CI [0.29, 0.80]), underwent more invasive dental procedures (aRR â€‹= â€‹0.74, 95 â€‹% CI [0.59, 0.93]), and were concerned (vs. neutral) about PJI (aRR â€‹= â€‹0.53, 95 â€‹%CI [0.33, 0.84]). Conclusions: Two-thirds of TJR recipients in an academic center reported always using antibiotic prophylaxis prior to dental visits. Usage rates varied by demographics, BMI, number of TJRs, type of dental procedure, and behavioral factors -- but not by comorbidities associated with higher PJI risk.

Climate change and dermatology: An introduction to a special topic, for this special issue.

Anthropogenic global climate change is a well-documented phenomenon that has led to average global temperatures climbing to approximately 1 °C above preindustrial (1850-1900) levels, with even higher regional deviations in some areas and significantly increased average warming in densely populated urban centers. In 2018, the United Nations Intergovernmental Panel on Climate Change set a threshold of 1.5 °C of average warming (above the preindustrial baseline), beyond which our planet will become significantly less hospitable to human life. However, adverse human health impacts are already occurring due to current levels of global climate change, as summarized by publications such as The Lancet's annual "Countdown on Health and Climate Change," initiated in 2016. The human health impacts of climate change are truly cross-disciplinary, with nearly every medical specialty either already facing or set to face effects. The field of dermatology is not immune to these risks. This special issue of the International Journal of Women's Dermatology is dedicated to the cross section of dermatology and climate change. This initial article will serve as an overview to introduce readers to the topic and to lay the groundwork for the rest of the issue. We are delighted to work with the Women's Dermatological Society and welcome their support for this dedicated issue. Herein, you will read from up-and-coming stars in the field and established experts, including articles on the following key areas: infectious diseases, environmentally friendly office practices, sunscreens and the environment, refugee health, heat-related illness, the effect of air pollution on the skin, the impact of climate change on pediatric dermatology, implications for skin cancer, and skin issues related to flooding and extreme weather events.

Patient experiences of decision-making in the treatment of spinal metastases: a qualitative study.

BACKGROUND: In the treatment of spinal metastases the risks of surgery must be balanced against potential benefits, particularly in light of limited life-expectancy. Patient experiences and preferences regarding decision-making in this context are not well explored. PURPOSE: We performed a qualitative study involving patients receiving treatment for spinal metastatic disease. We sought to understand factors that influenced decision-making around care for spinal metastases. STUDY SETTING: Three tertiary academic medical centers. PATIENT SAMPLE: We recruited patients presenting for treatment of spinal metastatic disease at one of three tertiary centers in Boston, MA. OUTCOME MEASURES: We conducted semistructured interviews using a guide that probed participants' experiences with making treatment decisions. METHODS: We performed a thematic analysis that produced a list of themes, subthemes, and statement explaining how the themes related to the study's guiding questions. Patients were recruited until thematic saturation was reached. RESULTS: We interviewed 23 participants before reaching thematic saturation. The enormity of treatment decisions, and of the diagnosis of spinal metastases itself, shaped participant preferences for who should take responsibility for the decision and whether to accept treatments bearing greater risk of complications. Pre-existing participant beliefs about decision-making and about surgery interacted with the clinical context in a way that tended to promote accepting physician recommendations and delaying or avoiding surgery. CONCLUSIONS: The diagnosis of spinal metastatic disease played an outsized role in shaping participant preferences for agency in treatment decision-making. Further research should address strategies to support patient understanding of treatment options in clinical contexts-such as spinal metastases-characterized by ominous underlying disease and high-risk, often urgent interventions.

Quality-Adjusted Life-Years Lost Due to Physical Inactivity in a US Population With Osteoarthritis.

OBJECTIVE: One-half of the 14 million persons in the US with knee osteoarthritis (OA) are not physically active, despite evidence that physical activity (PA) is associated with improved health. We undertook this study to estimate both the quality-adjusted life-year (QALY) losses in a US population with knee OA due to physical inactivity and the health benefits associated with higher PA levels. METHODS: We used data from the Osteoarthritis Initiative and the Centers for Disease Control and Prevention to estimate the proportions of a US population with knee OA ages ≥45 years that are inactive, insufficiently active, and active, and the likelihood of a shift in their PA level. We used the OA Policy Model, a computer simulation of knee OA, to determine QALYs lost due to inactivity and to measure potential benefits of increased PA (comorbidities averted and QALYs saved). RESULTS: Among 13.7 million persons with knee OA, a total of 7.5 million QALYs, or 0.55 QALYs per person, were lost due to inactivity or insufficient PA relative to activity over their remaining lifetimes. Black Hispanic women experienced the highest losses, at 0.76 QALYs per person. Women of all races/ethnicities had ~20% higher loss burdens than men. According to our model, if 20% of the inactive population were instead active, 95,920 cases of cancer, 222,413 of cardiovascular disease, and 214,725 of diabetes mellitus would potentially be averted, and 871,541 potential QALYs would be saved. CONCLUSION: Physical inactivity leads to substantial QALY losses in a US population with knee OA. Increases in the activity levels in even a fraction of this population may have considerable collateral health benefits, potentially averting cases of cancer, cardiovascular disease, and diabetes mellitus.

Five-Year Outcome of Operative and Nonoperative Management of Meniscal Tear in Persons Older Than Forty-Five Years.

OBJECTIVE: To determine the 5-year outcome of treatment for meniscal tear in osteoarthritis. METHODS: We examined 5-year follow-up data from the Meniscal Tear in Osteoarthritis Research trial (METEOR) of physical therapy versus arthroscopic partial meniscectomy. We performed primary intent-to-treat (ITT) and secondary as-treated analyses. The primary outcome measure was the Knee Injury and Osteoarthritis Outcome Score (KOOS) pain scale; total knee replacement (TKR) was a secondary outcome measure. We used piecewise linear mixed models to describe change in KOOS pain. We calculated 5-year cumulative TKR incidence and used a Cox model to estimate hazard ratios (HRs) for TKR, with 95% confidence intervals (95% CIs). RESULTS: Three hundred fifty-one participants were randomized. In the ITT analysis, the KOOS pain scores were ~46 (scale of 0 [no pain] to 100 [most pain]) at baseline in both groups. Pain scores improved substantially in both groups over the first 3 months, continued to improve through the next 24 months (to ~18 in each group), and were stable at 24-60 months. Results of the as-treated analyses of the KOOS pain score were similar. Twenty-five participants (7.1% [95% CI 4.4-9.8%]) underwent TKR over 5 years. In the ITT model, the HR for TKR was 2.0 (95% CI 0.8-4.9) for subjects randomized to the arthroscopic partial meniscectomy group, compared to those randomized to the physical therapy group. In the as-treated analysis, the HR for TKR was 4.9 (95% CI 1.1-20.9) for subjects ultimately treated with arthroscopic partial meniscectomy, compared to those treated nonoperatively. CONCLUSION: Pain improved considerably in both groups over 60 months. While ITT analysis revealed no statistically significant differences following TKR, greater frequency of TKR in those undergoing arthroscopic partial meniscectomy merits further study.

Surgical Implant Generation Network Implant Follow-up: Assessment of Squat and Smile and Fracture Healing.

OBJECTIVES: To evaluate the reliability, sensitivity, and specificity of the Squat and Smile (S&S) test, a clinical photographic follow-up, in determination of fracture healing and to assess the extent of continued fracture healing beyond 1-year postoperation. DESIGN: Retrospective review of the Surgical Implant Generation Network (SIGN) database. SETTING: The S&S test is utilized in low-resource settings where the SIGN intramedullary nail is used due to unavailability of intraoperative fluoroscopy. PATIENTS/PARTICIPANTS: One hundred fifty patients undergoing fracture fixation utilizing SIGN intramedullary nails with data available at least 1 year (9-16 months) after surgery. INTERVENTION: None. MAIN OUTCOME MEASURES: We extracted clinical data and calculated scores for the S&S photographs and radiographs at the 1-year (9-16 month postoperative) follow-up and last follow-up available beyond that. We analyzed the sensitivity of S&S scoring, using Radiographic Union Scale for Tibia fracture scores as the gold standard for fracture union. RESULTS: Of the 126 patients analyzed, 21% were found to have incomplete healing at 1 year, whereas 17% of the 64 patients with further follow-up past 1 year had incomplete healing. We found that both S&S and radiographic fracture healing scores had good interrater reliability (k = 0.73-0.78 for S&S and 0.94 for radiographs). The S&S test had poor sensitivity (0.11) and specificity (0.85) in determining fracture healing at the 1-year follow-up. CONCLUSIONS: The S&S scoring method was reliable but neither sensitive nor specific for determining fracture healing at 1 year. Fractures deemed incompletely healed by radiographic evaluation at 1 year after SIGN implant may still have the potential to heal over time. LEVEL OF EVIDENCE: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Validating Fitbit for Evaluation of Physical Activity in Patients with Knee Osteoarthritis: Do Thresholds Matter?

OBJECTIVE: We sought to evaluate the performance of Fitbit in estimating ActiGraph-derived moderate-to-vigorous physical activity (MVPA) and sedentary time in the knee osteoarthritis (OA) population. METHODS: We used data from two weeks of Fitbit and ActiGraph wear among knee OA subjects. In primary analyses, we used literature-based ActiGraph thresholds of 200 and 1924 counts/min (triaxial vector magnitude) for sedentary and MVPA time as the gold standard to which we compared three sets of Fitbit thresholds informed by literature and data (Youden index). We also considered personalized, stride length-based Fitbit thresholds. In sensitivity analyses, we used uniaxial, vertical axis-based as well as personalized, BMI-based ActiGraph thresholds. We calculated agreement, sensitivity, and specificity of Fitbit in classifying sedentary and MVPA time. RESULTS: In the primary analysis (vector magnitude thresholds), maximum agreement for sedentary and MVPA time was 67.0% from the Youden index-based and 91.1% from the stride length-based Fitbit thresholds. For sedentary time, the 20 strides/min threshold had the highest sensitivity (97.6%), and Youden-derived 1 stride/min had the highest specificity (51.6%). For MVPA, Youden-derived 14 strides/min yielded 72.8% sensitivity, and using stride length yielded 98.6% specificity. MVPA time ranged from 49-323 min/d, depending on threshold used, with literature-based and personalized thresholds leading to more conservative estimates of MVPA than Youden-derived thresholds. CONCLUSION: Using Fitbit for MVPA and sedentary time assessment may lead to inaccurate estimates of both. Fitbit MVPA estimates were generally more conservative than ActiGraph estimates. Incorporating individuals' characteristics did not meaningfully improve Fitbit performance. Caution should be exercised when measuring activity using Fitbit.

Ambulatory status after surgical and nonsurgical treatment for spinal metastasis.

BACKGROUND: Decisions for operative or nonoperative management remain challenging for patients with spinal metastases, especially when life expectancy and quality of life are not easily predicted. This study evaluated the effects of operative and nonoperative management on maintenance of ambulatory function and survival for patients treated for spinal metastases. METHODS: Propensity matching was used to yield an analytic sample in which operatively and nonoperatively treated patients were similar with respect to key baseline covariates. The study included patients treated for spinal metastases between 2005 and 2017 who were 40 to 80 years old, were independent ambulators at presentation, and had fewer than 5 medical comorbidities. It evaluated the influence of operative care and nonoperative care on ambulatory function 6 months after presentation as the primary outcome. Survival at 6 months and survival at 1 year were secondary outcomes. RESULTS: Nine hundred twenty-nine individuals eligible for inclusion were identified, with 402 (201 operative patients and 201 nonoperative patients) retained after propensity score matching. Patients treated operatively had a lower likelihood than those treated nonoperatively of being nonambulatory 6 months after presentation (3% vs 16%; relative risk [RR], 0.16; 95% confidence interval [CI], 0.06-0.46) as well as a reduced risk of 6-month mortality (20% vs 29%; RR, 0.69; 95% CI, 0.49-0.98). CONCLUSIONS: These results indicate that in a group of patients with similar demographic and clinical characteristics, those treated operatively were less likely to lose ambulatory function 6 months after presentation than those managed nonoperatively. For patients with spinal metastases, our data can be incorporated into discussions about the treatments that align best with patients' preferences regarding surgical risk, mortality, and ambulatory status.

A community-based evaluation of proximity to unconventional oil and gas wells, drinking water contaminants, and health symptoms in Ohio.

Over 4 million Americans live within 1.6 km of an unconventional oil and gas (UO&G) well, potentially placing them in the path of toxic releases. We evaluated relationships between residential proximity to UO&G wells and (1) water contamination and (2) health symptoms in an exploratory study. We analyzed drinking water samples from 66 Ohio households for 13 UO&G-related volatile organic compounds (VOCs) (e.g., benzene, disinfection byproducts [DBPs]), gasoline-range organics (GRO), and diesel-range organics. We interviewed participants about health symptoms and calculated metrics capturing proximity to UO&G wells. Based on multivariable logistic regression, odds of detection of bromoform and dibromochloromethane in surface water decreased significantly as distance to nearest UO&G well increased (odds ratios [OR]: 0.28-0.29 per km). Similarly, distance to nearest well was significantly negatively correlated with concentrations of GRO and toluene in ground water (rSpearman: -0.40 to -0.44) and with concentrations of bromoform and dibromochloromethane in surface water (rSpearman: -0.48 to -0.50). In our study population, those with higher inverse-distance-squared-weighted UO&G well counts within 5 km around the home were more likely to report experiencing general health symptoms (e.g. stress, fatigue) (OR: 1.52, 95%CI: 1.02-2.26). This exploratory study, though limited by small sample size and self-reported health symptoms, suggests that those in closer proximity to multiple UO&G wells may be more likely to experience environmental health impacts. Further, presence of brominated DBPs (linked to UO&G wastewater) raises the question of whether UO&G activities are impacting drinking water sources in the region. The findings from this study support expanded studies to advance knowledge of the potential for water quality and human health impacts; such studies could include a greater number of sampling sites, more detailed chemical analyses to examine source attribution, and objective health assessments.

Spatial Modeling to Identify Sociodemographic Predictors of Hydraulic Fracturing Wastewater Injection Wells in Ohio Census Block Groups.

BACKGROUND: Hydraulically fractured wells produce 2-14 million liters of wastewater, which may contain toxic and radioactive compounds. The wastewater is predominantly disposed of using Class II injection wells. OBJECTIVE: Our objective was to evaluate the relationship between sociodemographic characteristics and injection well locations in Ohio. METHODS: Using state and federal data sources, we classified Ohio census block groups by presence of injection wells, number of hydraulically fractured wells, sociodemographic factors (median household income, % white, population density, % ≥high school education, median age, voter turnout), and geographic information (land area, water area, situated over shale). We modeled the odds of having at least one injection well within a block group with respect to all covariates using three multivariable models incorporating different spatial components to account for similarities in neighboring block groups. RESULTS: In bivariate analyses, block groups with injection wells (n=156) compared with those without (n=9,049) had lower population density (71 vs. 2,210 people/mi2 or 27 vs. 854 people/km2), larger median area (43.5 vs. 1.35 km2), higher median age (42.8 vs. 40.2 y), and higher % white (98.1% vs. 92.1%). After adjustment using a spatial logistic regression model, the odds of a block group containing an injection well were 16% lower per $10,000 increase in median income [odds ratio(OR)=0.837; 95% credible interval (CI): 0.719, 0.961] and 97% lower per 1,000 people/mi2 (or per 386 people/km2) increase (OR=0.030; 95% CI=0.008, 0.072). Block groups on shale and those containing fewer hydraulically fractured wells were more likely to include an injection well. Percentage white, median age, % ≥high school education, and % voter turnout were not significant predictors of injection well presence. CONCLUSION: In Ohio, injection wells were inversely associated with block groups' median incomes after adjusting for other sociodemographic and geographic variables. Research is needed to determine whether residents in census blocks with injection wells face increased risk of chemical exposures or adverse health outcomes. https://doi.org/10.1289/EHP2663.