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A concise update on legal status, FDA approvals, patient safety, and public perception.  

Cannabis: An "Ins and Outs" Primer for Primary Care 

, and the link between HPV and cancer remains low across the United States, particularly in Midwestern and Southern states where HPV-associated cancers are most prevalent, according to a new cross-sectional study published in 

Researchers analyzed data from the Health Information National Trends Survey (HINTS) collected between 2017 and 2022, including 22 344 adults (mean age, 49 years; 51.1% women). Nationally, 34.3% of adults were unaware of HPV, and 37.6% were unaware of the HPV vaccine. Lack of awareness exceeded 40% in 7 states, primarily in the Midwest (Kansas, Nebraska, Illinois) and South (Mississippi, Arkansas, Alabama). More than 40% of respondents in 13 states were unaware of the HPV vaccine.

Among respondents who had heard of HPV, 70.8% were unaware that HPV causes oral cancers and 28.3% were unaware that HPV causes cervical cancer. In 45 states and Washington, DC, more than 60% of adults did not know about the link between HPV and oral cancer. In contrast, lack of awareness of the 

 was less common, ranging from 6.9% to 57.4% across states.

Authors noted that the results highlight an urgent gap in public knowledge given that HPV is associated with an estimated 48 000 cancer cases annually in the US, with nearly two-thirds occurring in the Midwest and South. Limited awareness in these regions coincides with lower 

 rates and rising incidence of HPV-related cancers, including oropharyngeal cancers.

The study’s limitations include its cross-sectional design, the ecological nature of state-level analyses, and small sample sizes for certain states. "Despite these limitations, this study offers valuable insights into public understanding of HPV and related topics across US states," investigators concluded. 

"Given the importance of timely HPV vaccination and the risk of early-life exposure, there is a critical need to enhance HPV awareness among adolescents, young adults, parents or caregivers, and pediatric and adult health care professionals," they added. 

Source: Garg A, Damgacioglu H, Graboyes EM, et al. State-Level Public Awareness of HPV, HPV Vaccine, and Association With Cancer. 

 Published online August 14, 2025. doi:10.1001/jamaoncol.2025.2638

New data show more than one-third of US adults are unaware of HPV or the HPV vaccine, with gaps greatest in the Midwest and South, where HPV-related cancers are most common.

Clinical Topics

Public Awareness of HPV and HPV Vaccine Remains Low, Especially in Midwest and South, Study Finds

A 64-year-old woman with a history of basal cell carcinoma presents to the dermatologist for skin cancer surveillance. She is incidentally noted to have bruising on her upper eyelids (above). On questioning, she reports experiencing recurrent intermittent eyelid bruising for several years. She denies a history of trauma to her face, pain, or other associated symptoms.

Her medical history is significant for hyperlipidemia, hepatitis C (diagnosed >30 years earlier), osteoporosis, celiac disease, and idiopathic proteinuria for several years. Her surgical history includes appendectomy and carpal tunnel repair.

Pertinent family history includes her mother dying of multiple myeloma and her father of complications of diabetes.

Review of systems is significant for vague symptoms of gastrointestinal discomfort. On more directed questioning, she reports the eyelid purpura is temporally related to the Valsalva maneuver/ strained bowel movements. Her medications include atorvastatin, risedronate sodium, a daily multivitamin, calcium, vitamin D, and aspirin.

Her examination reveals no bruising elsewhere and no findings of interest on skin or mucous membranes.

B. Allergic contact dermatitis, purpuric type

Eyelid bruising was observed on a 64-year-old woman during routine skin cancer follow-up. She denied trauma or pain. What does this look like to you? 

Image IQ

Image IQ: Recurrent Eyelid Purpura 

No labs, no biopsies . . .  you can make this Doorway Diagnosis just by looking.

Pictured is the posterior right knee of a 69-year-old woman showing a rounded protuberance at the popliteal fossa.

No labs, no biopsies, no imaging -- only your seasoned clinical judgement is required to make a diagnosis in this case. 

Bulge Behind the Knee 

The American College of Cardiology (ACC) on August 27 issued a new 

—including influenza, COVID-19, and respiratory syncytial virus (RSV)—as part of standard prevention and treatment strategies. 

While the evidence strongly supports vaccination, CCG authors emphasize that  translating these recommendations into clinical practice requires addressing  implementation challenges and, importantly overcoming patient barriers to vaccination uptake. The writers note that while the benefits are documented and clear, vaccination rates among adults, particularly those with cardiovascular disease, remain suboptimal. The reasons reflect a complex interplay of patient hesitancy, access limitations, and healthcare system barriers. 

A dedicated section of the CCG highlights evidence-based strategies for cardiovascular care teams to improve vaccination rates, to confidently address patient concerns and vaccine hesitancy, and improve access to vaccination services within cardiology practice settings. Following is a summary of the recommendations. 

Community and School-Based Interventions:

 These approaches, along with financial incentives, show limited effectiveness in improving adult vaccination rates compared to targeted behavioral approaches.

 Studies of Medicare beneficiaries show that mailed letters—especially 

—modestly improve vaccination uptake regardless of behavioral content, and text messages stating a “vaccine is reserved for you” deliver the greatest impact on improving vaccine rates.

 The NUDGE-FLU trial in Denmark demonstrated that electronic communications emphasizing cardiovascular benefits and repeat letters reliably increase influenza vaccination rates across age groups and populations with chronic diseases, as well as among individuals with both recent and stable CVD.

 Vaccine hesitancy is “a state of indecision and uncertainty that precedes a decision to become (or not become) vaccinated.” It differs from vaccine resistance, which is characterized by outright opposition rather than uncertainty.

 Hesitancy is exacerbated by socioeconomic challenges, misinformation, social and familial networks, and prior negative experiences with vaccines.

 Education from trusted healthcare providers—especially primary care physicians—proves most effective in overcoming hesitancy. Comprehensive education should address misconceptions (such as the belief that vaccines cause the disease), explain benefits, and discuss common side effects. Group-based interventions may be aided by community leaders, media, and social platforms to combat misinformation.

 The guidance includes a FAQ table specifically addressing concerns about side effects, risk of myocarditis, vaccine costs, safety, and the concurrent administration of multiple vaccines, assisting clinicians in patient discussions.

 Although CDC-recommended vaccines are covered by insurance, actual access depends on whether clinicians routinely recommend and administer vaccines and whether vaccine workflows are integrated into clinical practice. Only about 30% of primary care physicians assess adult vaccination status at clinics, illustrating missed opportunities for intervention; similar gaps likely exist in specialty practices.

 Cardiology clinics serve as pivotal access points for vaccine assessment and intervention, especially since patients may have greater comfort discussing immunization in the context of cardiovascular secondary prevention, including post-MI and follow-up visits. Clinicians should actively consider vaccination “in the suite of secondary therapies for patients with recent MI or CVD”.

 Cardiologists must familiarize themselves with vaccine availability in their health systems and proactively direct patients to alternative options, such as local pharmacies, when administration at the point of care is not feasible. Health system resources and insurance status have a profound impact on uptake, as seen during rapid COVID-19 vaccine rollout in well-resourced systems.

 Special focus is required for under/uninsured populations and those with poor healthcare access to ensure broad and equitable vaccine uptake. Targeted communication, clinician and staff education, and systematic “vaccine champion” roles help drive success in implementation across different care environments.

8 FAQs About Vaccination from People with Cardiovascular Disease, from the ACC Concise Clinical Guideline

2025 Concise Clinical Guidance: An ACC Expert Consensus Statement on Adult Immunizations as Part of Cardiovascular Care 

The ACC provides evidence-based guidance on improving vaccine uptake in vulnerable patients, addressing vaccine hesitancy, and improving overall vaccine  access. 

American College of Cardiology: How to Address Barriers to Immunization for Adults With CVD

A 67-year-old woman noted the appearance of several non-tender, rock-hard, purple-colored nodules on her legs. Her medical history was significant for distant non-Hodgkin lymphoma.

A 67-year-old woman noted the appearance of several non-tender, rock-hard, purple-colored nodules on her legs. Her medical history was significant for distant non-Hodgkin lymphoma. The violaceous color and configuration of the skin lesions suggests which of the following? 

Merle Myerson, MD, EdD

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