5 Top Papers You May Have Missed in November 2021

AUTHOR:
Scott T. Vergano, MD,
Department of Pediatrics, Children’s Hospital of The King’s Daughters, Norfolk, VA

CITATION:
Vergano ST. 5 top papers you may have missed in November 2021. Consultant360. Published online December 15, 2021.

 

Sometimes, when reading the literature, trends can be as important as individual articles. This month, I share with you several articles that, while important on their own, are made more significant because of the other studies that have been published around the same time. Please feel free to share with your colleagues, discuss in your offices, and write to editors@consultant360.com with your thoughts and opinions.

Human Papillomavirus Vaccination and Trends in Cervical Cancer Incidence and Mortality in the United States1

The Effects of the National HPV Vaccination Programme in England, UK, on Cervical Cancer and Grade 3 Cervical Intraepithelial Neoplasia Incidence: A Register-Based Observational Study2

Two studies published in November, 1 in Lancet and 1 in JAMA Pediatrics, documented the effect of human papillomavirus (HPV) vaccination on the rates of cervical intraepithelial neoplasia (CIN) and cervical cancer in England and the United States, respectively. The authors of the first study extracted data from a population-based cancer registry for women aged 20 to 29 years in England from 2006 to 2019 and estimated the effect of the HPV vaccination campaign that started in England in September 2008. Their model estimated approximately 450 fewer-than-expected cases of cervical cancer and 17,000 fewer cases of CIN across England because of the HPV vaccine. They also estimated a relative reduction in the rate of cervical cancer among vaccinated populations compared with unvaccinated populations of 34% in teenagers aged 16 to 18 years, 75% in teenagers aged 14 to 16 years, and 97% in teenagers aged 12 to 13 years.

The authors of the second study used national cancer database registries in the United States to compare rates of cervical cancer incidence and mortality in periods of time before and after implementation of HPV vaccination, which started among young women in the United States in 2006. During the period from 2001 to 2017, they found decreases in incidence and mortality from cervical cancer among women aged 15 to 39 years and compared the amount of risk reduction in younger cohorts after HPV vaccine recommendations with older cohorts who had not been eligible for the HPV vaccine. The percent reduction in incidence among women aged 15 to 24 years was 37.7%, compared with a reduction in women aged 30 to 39 years of 8.0%. The percent reception in mortality among the same cohorts was 43.4% in the younger women and 38.6% in the older women. The authors suggest that the decreases in incidence and mortality of cervical cancer are associated with the implementation of HPV vaccination.

Documentation of decreased rates of CIN and cervical cancer takes time, as 10 to 15 years or more are required from initial HPV infection to develop high-grade CIN and cervical cancer. It is reassuring to see documentation of the desired effect of HPV immunization campaigns in England and the United States, despite a less-than-aggressive uptake of the vaccine. I hope that it is finally time for the HPV vaccine to take its place alongside the varicella and rotavirus vaccines as immunizations that, despite early resistance, have finally earned widespread acceptance as a safe and effective part of the routine immunization schedule for all children and adolescents.

Maternal Cannabis Use Is Associated With Suppression of Immune Gene Networks In Placenta and Increased Anxiety Phenotypes in Offspring3

The authors of this study examined children whose mothers reported cannabis use during pregnancy and performed a behavioral assessment, assessed hair hormone levels, and when available, conducted RNA sequencing on placental specimens. They reported that the behavioral surveys revealed higher levels of anxiety, aggression, and hyperactivity among the infants exposed to marijuana in utero. The hair specimens revealed increased levels of cortisol, and the placental specimens revealed reductions in the expression of multiple genes involved in immune system function.

As recreational use of marijuana becomes legal and more widespread in the United States, it is important to study its effects on adults and children. This study adds to emerging literature on the effect of prenatal exposure to cannabis. Previous studies have documented links between prenatal marijuana exposure and low birth weight, inattention, autism, and childhood psychosis.4,5,6 As physicians, it is vital that we share this literature with our patients so that they can adequately appreciate the effects that their recreational marijuana use may have during pregnancy.

​This topic frequently generates passion among advocates for and against legalization of marijuana. What are your thoughts? Is there sufficient health ​justification for restriction of access to cannabis, or does legalization remove legal and financial barriers to what is a largely benign habit acceptable for personal recreational use?

Analysis of Electronic Health Record Use and Clinical Productivity and Their Association With Physician Turnover7

Characterizing Styles of Clinical Note Production and Relationship to Clinical Work Hours Among First-Year Residents8

Published over the past 2 months, these 2 ​studies examined the patterns of documentation in the electronic health record (EHR) and made inferences about practitioners based on their patterns of EHR use. In the first study, the authors suggest the ability to predict which clinicians might be at high risk for leaving their jobs based on the time they spent on certain tasks in the EHR. In the second study, the authors suggest the ability to predict which first-year residents might be at high risk for duty hour violations based on the timing and pattern of completing their EHR notes.

I find this genre of investigation fascinating. It is shocking to me exactly how my EHR documentation is being scrutinized. I am constantly graded for the number of clicks I enter, for problem list or medication reconciliation, scoring attention-deficit hyperactivity disorder or asthma scales, or departing summary additions for identified safety, depression, or social determinant of health needs. None of this has anything to do with what was actually accomplished or discussed in the room. Now I learn that my EHR entries can be monitored for when I do them and how long it takes me (generally too long and too late at night, after my family has gone to bed). There have been only 1 or 2 times that anyone has mentioned to me the content of my EHR notes. Not "I love how well you document the social history or family history, how clear your medical plans are, or how thorough the review of systems you wrote for this child with medical complexity." The focus is on the clicks, the timing, and the length of the documentation, rather than on the content. Amazing!

What are your thoughts and experiences?

The fall colors have been brilliant here in coastal Virginia, and the leaves are still dotting the trees (sorry for all of you in northern climates who are squarely into winter already). Hope you have a joyous holiday season and a chance to spend some quality time with your family away from practice and EHRs.​

References:

  1. Falcaro M, Castañon A, Ndlela B, et al. The effects of the national HPV vaccination programme in England, UK, on cervical cancer and grade 3 cervical intraepithelial neoplasia incidence: a register-based observational study. Lancet. 2021;398(10316):2084-2092. https://doi.org/10.1016/s0140-6736(21)02178-4
  2. Tabibi T, Barnes JM, Shah A, Osazuwa-Peters N, Johnson KJ, Brown DS. Human papillomavirus vaccination and trends in cervical cancer incidence and mortality in the US. JAMA Pediatr. Published online November 29, 2021. https://doi.org/10.1001/jamapediatrics.2021.4807
  3. Rompala G, Nomura Y, Hurd YL. Maternal cannabis use is associated with suppression of immune gene networks in placenta and increased anxiety phenotypes in offspring. Proc Natl Acad Sci U S A. 2021;118(47):e2106115118. https://doi.org/10.1073/pnas.2106115118
  4. Corsi DJ, Donelle J, Sucha E, et al. Maternal cannabis use in pregnancy and child neurodevelopmental outcomes. Nat Med. 2020;26(10):1536-1540. https://doi.org/10.1038/s41591-020-1002-5
  5. Paul SE, Hatoum AS, Fine JD, et al. Associations between prenatal cannabis exposure and childhood outcomes: results from the ABCD study. JAMA Psychiatry. 2021;78(1):64-76. https://doi.org/10.1001/jamapsychiatry.2020.2902
  6. What you need to know about marijuana use and pregnancy. Centers for Disease Control and Prevention. March 16, 2018. Accessed December 15, 2021. https://www.cdc.gov/marijuana/factsheets/pregnancy.htm
  7. Melnick ER, Fong A, Nath B, et al. Analysis of electronic health record use and clinical productivity and their association with physician turnover. JAMA Netw Open. 2021;4(10):e2128790. https://doi.org/10.1001/jamanetworkopen.2021.28790
  8. Gong JJ, Soleimani H, Murray SG, Adler-Milstein J. Characterizing styles of clinical note production and relationship to clinical work hours among first-year residents. J Am Med Inform Assoc. Published online November 22, 2021. https://doi.org/10.1093/jamia/ocab253