Scleritis and development of immune-mediated disease: A retrospective chart review.

OBJECTIVE: Scleritis may be idiopathic or caused by trauma, infections, or an immune-mediated condition. Our study aimed to understand the relationship between scleritis and immune-mediated disease, including presenting characteristics, serologies, and treatment course. Understanding these associations may allow clinicians to risk-stratify patients and predict their clinical and treatment course. METHODS: We conducted a retrospective chart review of 341 scleritis patients seen at a tertiary care center between January 1, 2005, and December 31, 2020. Demographics, scleritis characteristics, treatment response, recurrence, and serologic data were compared among patients with idiopathic and immune-mediated disease-associated scleritis. RESULTS: Among scleritis patients seen, 145 patients (43%) had an associated immune-mediated disease, most commonly rheumatoid arthritis (39%), vasculitis (21%), or inflammatory bowel disease (14%). In most cases, the immune-mediated disease diagnosis predated the scleritis presentation (65%), though vasculitis cases were more likely to develop during or after scleritis episodes. There were no significant differences in demographics or treatment failures among scleritis patients with and without associated immune-mediated conditions. Patients with immune-mediated diseases were more likely to have a recurrence of scleritis (62% vs 49%, p=0.02). CONCLUSION: At our ophthalmology center, 43% of patients with scleritis had an associated immunemediated disease, and most patients with immune-mediated disease were symptomatic from this disease prior to scleritis presentation. Rheumatoid arthritis was the most commonly associated condition and typically predated the scleritis, while vasculitis was more likely diagnosed during or after the scleritis episode. Scleritis among immune-mediated disease patients is more likely to recur compared to scleritis that is idiopathic.

The impact of politics, religion, and rurality on COVID-19 vaccine hesitancy in Oregon: a cross-sectional study.

INTRODUCTION: Vaccine hesitancy has been a major barrier to mitigating the effects of COVID-19, especially in rural Oregon, USA. This study assessed the influence of political affiliation, religious identity, and rurality on vaccine hesitancy in counties across Oregon. METHODS: Cross-sectional association analysis was performed using public data on US President Trump votership in the 2020 election, White Christian identity, population density, and COVID-19 vaccination data for adults as of 29 August 2021. RESULTS: By 29 August 2021, 68.0% of adults had been fully vaccinated in Oregon. Trump votership was the strongest independent association with vaccination status in Oregon (r=0.90, p<0.01), followed by White Christian identity (r= -0.69, p<0.01), and population density (r=0.55, p<0.01). In multivariate analysis, White Christian identity and political affiliation with Trump in the 2020 election explained 84.1% of the variability in COVID-19 vaccination status in Oregon counties. CONCLUSION: White Christian identity, Trump affiliation, and rurality were identified as factors in vaccine hesitancy among counties in Oregon. Without addressing these factors in public health outreach, vaccine hesitancy is likely to continue unabated.

Shared decision making in rheumatology: A scoping review.

INTRODUCTION: Shared decision making is a collaborative process where patients and clinicians work together to understand the patient's situation and to determine how best to address it. While shared decision making offers benefits for patients and clinicians, shared decision making use across the field of rheumatology has not been previously described. OBJECTIVE: To perform a scoping review of research on shared decision making in rheumatology METHODS: We analyzed literature on shared decision making in rheumatology from Ovid MEDLINE, PsycINFO, Sciverse Scopus, EBM Reviews, and PsycARTICLES. RESULTS: Of 3191 articles screened, 63 studies were included for analysis. Shared decision making in rheumatology improves patient satisfaction and adherence to treatment plans. We identified 13 patient decision aids from the studies and discussed the process of evaluating patient decision aids and shared decision making outcomes. The most important factors for decision making were understanding benefits versus side effects, medication logistics, and cost. Decision making conversations are affected by age, race, socioeconomic status, gender, health literacy, and language proficiency. Barriers to shared decision making include time constraints and training. CONCLUSIONS: Our review identified 63 studies of shared decision making in rheumatology, including 13 studies of patient decision aids. Future areas of research include identifying tools for shared decision making, understanding social and cultural factors, and improving equity in shared decision making practices. By improving shared decision making practices in rheumatology, we can strive to improve patient experience, satisfaction, trust, and enhance outcomes for all.

Personal Agency and Community Resilience: Narratives of Women Navigating Health Care With Chronic Lyme Disease.

Chronic Lyme disease can manifest as a debilitating illness with symptoms that change over time. With its varied presentation, timeline variation, diagnostic difficulty, and lack of definitive treatment, clinical recognition of chronic Lyme disease remains controversial. At the same time, patients face challenges in finding a provider who is supportive and knowledgeable about diagnosing and treating Lyme. We examined the ways the medical system may have affected the lived experiences of chronic Lyme patients. In this article, we communicate the personal, health care, and community illness experiences of 14 women navigating the medical system with chronic Lyme disease through a qualitative community-based participatory research study using interviews and narrative reflection in a rural community setting. The women were interviewed by a researcher living with chronic Lyme disease and the transcripts were analyzed for themes. All participants described navigating multiple allopathic and nonallopathic care modalities to find satisfactory care. They struggled with physical and emotional burdens of chronic, nonlinear illness, as well as disbelief and discrimination by medical providers. Their lives followed patterns of illness and wellness, trust and mistrust of medical treatment, and community connection and disengagement. They learned to become their own advocates to seek affirmative care. They are aware of the controversial nature of their illness, and many have channeled their frustrations into caring for one another through their Lyme community. Women living with controversial diagnoses like chronic Lyme disease experience increased challenges navigating the medical system to find satisfactory care and thus create communities with each other for mutual aid and support. In understanding these challenges, the medical community can improve care for people living with contested chronic illnesses.

The Erasure of Intersex, Transgender, Nonbinary, and Agender Experiences Through Misuse of Sex and Gender in Health Research.

Conflation of the terms and concepts of "sex" and "gender" continues to perpetuate the invisibility of sex and gender minorities and obscure information about the ways in which biological sex and gender affect health. The misuse of sex and gender terms and the sex and gender binaries can yield inaccurate results but also, more importantly, contributes to the erasure of intersex, transgender, nonbinary, and agender health experiences. In this article, we discuss ways in which public health researchers can use sex and gender terms correctly and center the health experiences of intersex, transgender, nonbinary, and agender individuals. This includes promoting sensitivity in approaching sex and gender minority communities, improving survey questions, and collaborating with GSM communities to improve research quality and participant experiences. Improving our standards for the quality of sex and gender term usage and centering sex and gender minorities in public health research are imperative to addressing the health inequalities faced by sex and gender minorities.

Shared Decision-making in Dermatology: A Scoping Review.

Importance: Shared decision-making (SDM) can improve the quality of care for patients. The extent to which this tool has been used and the evidence supporting its use in dermatology have not been systematically examined. Objective: To perform a scoping review of the literature regarding SDM in dermatology. Evidence Review: Searches of Ovid MEDLINE, PsycINFO, PsycARTICLES, Sciverse Scopus, and EBM Reviews were conduced on July 11, 2019, and March 6, 2020. There were no limits on date, type of article, language, or subject for the initial search. A total of 1673 titles and abstracts were screened by 2 independent reviewers in the Covidence mixed-methods platform. Forty-one full-text studies were assessed for eligibility. For inclusion, articles needed to include a dermatologic diagnosis as well as discussion of SDM or patient decision aids. Two independent reviewers screened 29 full-text articles for inclusion and extracted qualitative data using a set of 26 predefined codes. Qualitative coding was applied to excerpts to categorize the article, define and describe advantages and disadvantages of SDM, understand patient and physician requests for SDM, and discuss methods of implementation. Findings: Despite a small number of articles on SDM (n = 29) in dermatology, the selected literature provided consistent messages regarding the importance of SDM for dermatology and a number of strategies and tools for implementation. Medical dermatology was the most common subspecialty studied, with melanoma, psoriasis, and connective tissue diseases most examined. Only 5 publications introduced SDM tools specifically for dermatologic conditions; of these, only 2 tools were validated. Barriers to implementation that were cited included time and a lack of training for clinicians, although the literature also provided potential solutions to these issues. All articles emphasized the value of SDM for both patients and physicians. Conclusions and Relevance: The literature regarding SDM in dermatology consistently suggests that it is a useful tool for providing patient-centered care. Established tools have been proposed since 2012. More research is needed to implement better practices, especially in dermatologic subspecialties. However, there are substantial suggestions from the literature for strategies and tools with which to begin a shared decision-making practice.

Providing Gender Confirmation Surgery at an Academic Medical Center: Analysis of Use, Insurance Payer, and Fiscal Impact.

BACKGROUND: Expansion of insurance coverage for gender confirmation surgery (GCS) has led to a large demand for GCS in the US. We sought to determine the financial impact of providing comprehensive GCS services at an academic medical center. METHODS: This was a cross-sectional study of patients older than 18 years who presented for GCS between January 1, 2015 and July 31, 2018 at a single academic medical center. The use of GCS services and associated work relative value units is reported. Departmental and hospital-level operating (profit) margins are reported relative to other hospital services, as well as the payer mix. RESULTS: A total of 818 patients underwent 970 GCS procedures between January 2015 and July 2018. Mean (SD) age was 35.32 (12.84) years. Four hundred and ninety-three (60.3%) patients underwent a masculinizing procedure, and 325 (39.7%) had a feminizing procedure. The most commonly performed procedure was chest masculinization (n = 403). The GCS case volume grew to generate 23.8% (plastic surgery) and 17.8% (urology) of total annual departmental work relative value units, and was associated with positive operating margins after recouping new faculty hiring costs. There were positive operating margins for GCS procedures for the hospital system that compare favorably with other common procedures and admissions. Medicare and Medicaid remained the most common payer throughout the study period, but dropped from 70% in 2015 to 48% in 2018. CONCLUSIONS: We found that providing GCS at our academic medical center is profitable for both the surgical department and the hospital system. This suggests such a program can be a favorable addition to academic medical centers in the US.

Gender Confirmation Surgery for the Endocrinologist.

Endocrinologists are at the front line for providing gender-affirming care for transgender patients by managing hormone regiments before and after surgery. This article provides the endocrinologist with an overview of the surgical options for transgender and nonbinary patients considering gender confirmation surgery, including feminizing and masculinizing facial, chest, and genital reconstruction. Discussions of the impact of hormones on surgery, and vice versa, as well as information on surgical decision making are provided to help inform patient education via the endocrinologist.