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Starting indicated heart failure meds in-hospital: Progress, opportunities
Most patients aren’t receiving all the medications they should based on guidelines, nor are they getting them at the most effective time in their disease course, suggests a registry study of patients in the United States hospitalized with heart failure with reduced ejection fraction (HFrEF).
On average, one such medication was initiated per patient for every 6 days in the hospital.
Shortfalls in predischarge GDMT initiation disproportionately landed on women, patients at rural centers, and those with renal failure or other comorbidities. But they didn’t seem related to patient race or ethnicity in the study reported in JACC: Heart Failure.
The analysis covers the 3 years preceding the May 2020 first-time approval of a sodium-glucose cotransporter 2 (SGLT2) inhibitor for nondiabetic patients with HFrEF, and therefore doesn’t cover such drugs for that indication. The SGLT2 inhibitors would later join beta-blockers, renin-angiotensin system (RAS) inhibitors, and mineralocorticoid receptor antagonists (MRAs) in the quartet of core GDMT medications broadly indicated for HFrEF.
In-hospital initiation of GDMT for HFrEF is considered a predictor of being on those medications after discharge and is itself guideline recommended. There’s clear evidence that treatment with the four core medications boosts survival and cuts rehospitalization risk, and that “getting those on board as soon as possible will eventually benefit many patients,” Paul L. Hess, MD, MHS, said in an interview.
Dr. Hess, University of Colorado Anschutz Medical Campus, Aurora, is senior author on the report from the Get With The Guidelines–Heart Failure (GWTG-HF) quality improvement program of the American Heart Association.
Broad uptake of new medical therapies into practice may sometimes take 15 or more years from first publication, Dr. Hess said, so, “I find it encouraging in the study that over a shorter time period, 2017-2020, there was improvement.”
Indeed, the odds of in-hospital initiation of an indicated med during that period on average climbed a significant 8% every 3 months, the report states.
The finding suggests that “heart failure hospitalization is, in and of itself, an important intervention for getting folks on the appropriate medications,” Dr. Hess said. It also means “we’re getting better at it,” at least at the study’s 160 GWTG-HF participating hospitals nationwide.
Those centers, the report acknowledges, varied in size, geography, and teaching status but were not necessarily representative of all U.S. hospitals. In another potential limitation, the study couldn’t account for patients who weren’t prescribed all indicated medications for clinically valid reasons. It excluded patients with “clear contraindications,” Dr. Hess said. But there could have been “legitimate reasons” some indicated medications weren’t always prescribed, including patient frailty, hemodynamic intolerance, renal dysfunction, or polypharmacy concerns.
“Positive takeaways” from the analysis, notes an accompanying editorial, include improved prescription rates for key GDMT categories across more than 3 years of data, and evidence that in-hospital initiation “was feasible and, at least for some medications, reliably undertaken.”
Of note, new GDMT prescriptions from admission to discharge went from 70% to almost 98% for beta-blockers, from 59% to about 91% for RAS inhibitors, from about 26% to 56% for MRAs, and from 15.5% to 27.4% for hydralazine/nitrates, wrote Karen E. Joynt Maddox, MD, MPH, and Daniel K. Fox, MD, PhD, both of Washington University in St. Louis.
“Key areas for improvement,” they noted, include prescriptions for women, who were 12% less likely than men to have appropriate GDMT initiated during hospitalization (P < .001); and practice at rural hospitals, which were 40% less likely than urban centers to have patients on full GDMT by discharge (P = .017).
Although only 2.6% of the GWTG-HF centers were in rural locations, “rural hospitals make up approximately one-third of general acute care hospitals in this country,” the editorial states. They therefore “represent a key source of health disparity” in the United States in need of further study.
The analysis of 50,170 patients hospitalized with HFrEF compared the number of GDMT medications for which they were eligible, on at-hospital admission, and by discharge.
The drug categories included “evidence based beta blockers,” that is, bisoprolol, carvedilol, or sustained-release metoprolol; RAS inhibitors, specifically ACE inhibitors, angiotensin receptor blockers, or sacubitril/valsartan (Entresto); MRAs; SGLT2 inhibitors in patients with diabetes; diuretics for congestion; oral anticoagulants for atrial fibrillation; and hydralazine/nitrates in African Americans.
About 15% of the patients at hospital admission were on all indicated HFrEF medications for which they were eligible. The proportion more than doubled to 32.8% by discharge.
Factors significantly associated with reduced odds for in-hospital GDMT initiation include older age (odds ratio, 0.94 per 5-year increment), being female versus male (OR, 0.88), rural location (OR, 0.60), Medicaid versus Medicare or private insurance (OR, 0.93), stroke history (OR, 0.91), peripheral artery disease (OR, 0.93), chronic obstructive pulmonary disease or asthma (OR, 0.86), and renal insufficiency (OR, 0.77).
The findings suggest that there has been at least some progress in getting hospitalized patients “on the right meds” by discharge, Dr. Hess observed. To help address shortfalls in some patient groups, “there is interest in engaging pharmacists in helping us encourage providers on the front lines to initiate and titrate medications.”
The GWTG-HF program is sponsored, in part, by Novartis, Boehringer Ingelheim, Novo Nordisk, AstraZeneca, Bayer, Tylenol, and Alnylam Pharmaceuticals. Dr. Hess disclosed no relevant financial relationships. Dr. Maddox disclosed serving on the Health Policy Advisory Council for Centene. Dr. Fox reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Most patients aren’t receiving all the medications they should based on guidelines, nor are they getting them at the most effective time in their disease course, suggests a registry study of patients in the United States hospitalized with heart failure with reduced ejection fraction (HFrEF).
On average, one such medication was initiated per patient for every 6 days in the hospital.
Shortfalls in predischarge GDMT initiation disproportionately landed on women, patients at rural centers, and those with renal failure or other comorbidities. But they didn’t seem related to patient race or ethnicity in the study reported in JACC: Heart Failure.
The analysis covers the 3 years preceding the May 2020 first-time approval of a sodium-glucose cotransporter 2 (SGLT2) inhibitor for nondiabetic patients with HFrEF, and therefore doesn’t cover such drugs for that indication. The SGLT2 inhibitors would later join beta-blockers, renin-angiotensin system (RAS) inhibitors, and mineralocorticoid receptor antagonists (MRAs) in the quartet of core GDMT medications broadly indicated for HFrEF.
In-hospital initiation of GDMT for HFrEF is considered a predictor of being on those medications after discharge and is itself guideline recommended. There’s clear evidence that treatment with the four core medications boosts survival and cuts rehospitalization risk, and that “getting those on board as soon as possible will eventually benefit many patients,” Paul L. Hess, MD, MHS, said in an interview.
Dr. Hess, University of Colorado Anschutz Medical Campus, Aurora, is senior author on the report from the Get With The Guidelines–Heart Failure (GWTG-HF) quality improvement program of the American Heart Association.
Broad uptake of new medical therapies into practice may sometimes take 15 or more years from first publication, Dr. Hess said, so, “I find it encouraging in the study that over a shorter time period, 2017-2020, there was improvement.”
Indeed, the odds of in-hospital initiation of an indicated med during that period on average climbed a significant 8% every 3 months, the report states.
The finding suggests that “heart failure hospitalization is, in and of itself, an important intervention for getting folks on the appropriate medications,” Dr. Hess said. It also means “we’re getting better at it,” at least at the study’s 160 GWTG-HF participating hospitals nationwide.
Those centers, the report acknowledges, varied in size, geography, and teaching status but were not necessarily representative of all U.S. hospitals. In another potential limitation, the study couldn’t account for patients who weren’t prescribed all indicated medications for clinically valid reasons. It excluded patients with “clear contraindications,” Dr. Hess said. But there could have been “legitimate reasons” some indicated medications weren’t always prescribed, including patient frailty, hemodynamic intolerance, renal dysfunction, or polypharmacy concerns.
“Positive takeaways” from the analysis, notes an accompanying editorial, include improved prescription rates for key GDMT categories across more than 3 years of data, and evidence that in-hospital initiation “was feasible and, at least for some medications, reliably undertaken.”
Of note, new GDMT prescriptions from admission to discharge went from 70% to almost 98% for beta-blockers, from 59% to about 91% for RAS inhibitors, from about 26% to 56% for MRAs, and from 15.5% to 27.4% for hydralazine/nitrates, wrote Karen E. Joynt Maddox, MD, MPH, and Daniel K. Fox, MD, PhD, both of Washington University in St. Louis.
“Key areas for improvement,” they noted, include prescriptions for women, who were 12% less likely than men to have appropriate GDMT initiated during hospitalization (P < .001); and practice at rural hospitals, which were 40% less likely than urban centers to have patients on full GDMT by discharge (P = .017).
Although only 2.6% of the GWTG-HF centers were in rural locations, “rural hospitals make up approximately one-third of general acute care hospitals in this country,” the editorial states. They therefore “represent a key source of health disparity” in the United States in need of further study.
The analysis of 50,170 patients hospitalized with HFrEF compared the number of GDMT medications for which they were eligible, on at-hospital admission, and by discharge.
The drug categories included “evidence based beta blockers,” that is, bisoprolol, carvedilol, or sustained-release metoprolol; RAS inhibitors, specifically ACE inhibitors, angiotensin receptor blockers, or sacubitril/valsartan (Entresto); MRAs; SGLT2 inhibitors in patients with diabetes; diuretics for congestion; oral anticoagulants for atrial fibrillation; and hydralazine/nitrates in African Americans.
About 15% of the patients at hospital admission were on all indicated HFrEF medications for which they were eligible. The proportion more than doubled to 32.8% by discharge.
Factors significantly associated with reduced odds for in-hospital GDMT initiation include older age (odds ratio, 0.94 per 5-year increment), being female versus male (OR, 0.88), rural location (OR, 0.60), Medicaid versus Medicare or private insurance (OR, 0.93), stroke history (OR, 0.91), peripheral artery disease (OR, 0.93), chronic obstructive pulmonary disease or asthma (OR, 0.86), and renal insufficiency (OR, 0.77).
The findings suggest that there has been at least some progress in getting hospitalized patients “on the right meds” by discharge, Dr. Hess observed. To help address shortfalls in some patient groups, “there is interest in engaging pharmacists in helping us encourage providers on the front lines to initiate and titrate medications.”
The GWTG-HF program is sponsored, in part, by Novartis, Boehringer Ingelheim, Novo Nordisk, AstraZeneca, Bayer, Tylenol, and Alnylam Pharmaceuticals. Dr. Hess disclosed no relevant financial relationships. Dr. Maddox disclosed serving on the Health Policy Advisory Council for Centene. Dr. Fox reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Most patients aren’t receiving all the medications they should based on guidelines, nor are they getting them at the most effective time in their disease course, suggests a registry study of patients in the United States hospitalized with heart failure with reduced ejection fraction (HFrEF).
On average, one such medication was initiated per patient for every 6 days in the hospital.
Shortfalls in predischarge GDMT initiation disproportionately landed on women, patients at rural centers, and those with renal failure or other comorbidities. But they didn’t seem related to patient race or ethnicity in the study reported in JACC: Heart Failure.
The analysis covers the 3 years preceding the May 2020 first-time approval of a sodium-glucose cotransporter 2 (SGLT2) inhibitor for nondiabetic patients with HFrEF, and therefore doesn’t cover such drugs for that indication. The SGLT2 inhibitors would later join beta-blockers, renin-angiotensin system (RAS) inhibitors, and mineralocorticoid receptor antagonists (MRAs) in the quartet of core GDMT medications broadly indicated for HFrEF.
In-hospital initiation of GDMT for HFrEF is considered a predictor of being on those medications after discharge and is itself guideline recommended. There’s clear evidence that treatment with the four core medications boosts survival and cuts rehospitalization risk, and that “getting those on board as soon as possible will eventually benefit many patients,” Paul L. Hess, MD, MHS, said in an interview.
Dr. Hess, University of Colorado Anschutz Medical Campus, Aurora, is senior author on the report from the Get With The Guidelines–Heart Failure (GWTG-HF) quality improvement program of the American Heart Association.
Broad uptake of new medical therapies into practice may sometimes take 15 or more years from first publication, Dr. Hess said, so, “I find it encouraging in the study that over a shorter time period, 2017-2020, there was improvement.”
Indeed, the odds of in-hospital initiation of an indicated med during that period on average climbed a significant 8% every 3 months, the report states.
The finding suggests that “heart failure hospitalization is, in and of itself, an important intervention for getting folks on the appropriate medications,” Dr. Hess said. It also means “we’re getting better at it,” at least at the study’s 160 GWTG-HF participating hospitals nationwide.
Those centers, the report acknowledges, varied in size, geography, and teaching status but were not necessarily representative of all U.S. hospitals. In another potential limitation, the study couldn’t account for patients who weren’t prescribed all indicated medications for clinically valid reasons. It excluded patients with “clear contraindications,” Dr. Hess said. But there could have been “legitimate reasons” some indicated medications weren’t always prescribed, including patient frailty, hemodynamic intolerance, renal dysfunction, or polypharmacy concerns.
“Positive takeaways” from the analysis, notes an accompanying editorial, include improved prescription rates for key GDMT categories across more than 3 years of data, and evidence that in-hospital initiation “was feasible and, at least for some medications, reliably undertaken.”
Of note, new GDMT prescriptions from admission to discharge went from 70% to almost 98% for beta-blockers, from 59% to about 91% for RAS inhibitors, from about 26% to 56% for MRAs, and from 15.5% to 27.4% for hydralazine/nitrates, wrote Karen E. Joynt Maddox, MD, MPH, and Daniel K. Fox, MD, PhD, both of Washington University in St. Louis.
“Key areas for improvement,” they noted, include prescriptions for women, who were 12% less likely than men to have appropriate GDMT initiated during hospitalization (P < .001); and practice at rural hospitals, which were 40% less likely than urban centers to have patients on full GDMT by discharge (P = .017).
Although only 2.6% of the GWTG-HF centers were in rural locations, “rural hospitals make up approximately one-third of general acute care hospitals in this country,” the editorial states. They therefore “represent a key source of health disparity” in the United States in need of further study.
The analysis of 50,170 patients hospitalized with HFrEF compared the number of GDMT medications for which they were eligible, on at-hospital admission, and by discharge.
The drug categories included “evidence based beta blockers,” that is, bisoprolol, carvedilol, or sustained-release metoprolol; RAS inhibitors, specifically ACE inhibitors, angiotensin receptor blockers, or sacubitril/valsartan (Entresto); MRAs; SGLT2 inhibitors in patients with diabetes; diuretics for congestion; oral anticoagulants for atrial fibrillation; and hydralazine/nitrates in African Americans.
About 15% of the patients at hospital admission were on all indicated HFrEF medications for which they were eligible. The proportion more than doubled to 32.8% by discharge.
Factors significantly associated with reduced odds for in-hospital GDMT initiation include older age (odds ratio, 0.94 per 5-year increment), being female versus male (OR, 0.88), rural location (OR, 0.60), Medicaid versus Medicare or private insurance (OR, 0.93), stroke history (OR, 0.91), peripheral artery disease (OR, 0.93), chronic obstructive pulmonary disease or asthma (OR, 0.86), and renal insufficiency (OR, 0.77).
The findings suggest that there has been at least some progress in getting hospitalized patients “on the right meds” by discharge, Dr. Hess observed. To help address shortfalls in some patient groups, “there is interest in engaging pharmacists in helping us encourage providers on the front lines to initiate and titrate medications.”
The GWTG-HF program is sponsored, in part, by Novartis, Boehringer Ingelheim, Novo Nordisk, AstraZeneca, Bayer, Tylenol, and Alnylam Pharmaceuticals. Dr. Hess disclosed no relevant financial relationships. Dr. Maddox disclosed serving on the Health Policy Advisory Council for Centene. Dr. Fox reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM JACC: HEART FAILURE
Should you dismiss a difficult patient?
Some patients continually cancel their appointments, ignore your medical directions, treat your staff rudely, or send you harassing emails.
Do you have to tolerate their behavior?
No, these are all appropriate reasons to terminate patients, attorneys say. Patients also can be dismissed for misleading doctors about their past medical history, chronic drug-seeking, displaying threatening or seductive behavior toward staff members or physicians, or any criminal behavior in the office, experts say.
But even if a reason seems legitimate, that doesn’t make it legal. Doctors should consider whether the reason is legal, said Chicago-area attorney Ericka Adler, JD, a partner at Roetzel & Andress, who advises doctors about terminating patients.
Ms. Adler said.
Terminating patients for an “illegal” reason such as discrimination based on race or gender or sexual orientation – even if couched as a legitimate patient issue – could open the practice to a lawsuit, Ms. Adler said.
Doctors also want to avoid patient abandonment claims by talking to the patient about problems and documenting them as they arise. If they can’t be resolved, doctors should ensure that there’s continuity of care when patients change physicians, said Ms. Adler.
About 90% of physicians have dismissed at least one patient during their career, according to a study of nearly 800 primary care practices. The most common reasons were legitimate: a patient was “extremely disruptive and/or behaved inappropriately toward clinicians or staff”; a patient had “violated chronic pain and controlled substance policies”; and a patient had “repeatedly missed appointments.”
Jacqui O’Kane, DO, a family physician at South Georgia Medical Center in rural Nashville, said she has dismissed about 15 of 3,000 patients she has seen in the past 3 years at the clinic. Before she dismisses a patient, she looks at whether there has been a pattern of behavior and tries to talk to them about the problem first to find out if there are other reasons for it.
She also gives patients a warning: If the unacceptable behavior continues, it will lead to their dismissal.
When patients cross a line
Dr. O’Kane warned an elderly man who used the N-word with her that she wouldn’t tolerate that language in her office. Then, when he later called her front office employee the N-word, she decided to dismiss him.
“I said, ‘That’s it, you can’t say that to someone in this office. I already told you once, and you did it again. I’m sorry, you have to find another doctor,’ ” said Dr. O’Kane.
Another patient crossed a line when she missed four appointments, refused to come in, and kept sending Dr. O’Kane long messages on MyChart demanding medications and advice. One message was fairly obtrusive: “If you don’t give me something stronger for my nerves TODAY, I am going to LOSE MY MIND!!!” Dr. O’Kane said the patient wrote.
“I then told her that’s not how I run my practice and that she needed to find someone else.”
Another common reason doctors dismiss patients is for nonpayment, says Ms. Adler.
Recently, however, some patients have also begun demanding their money back from doctors for services already received and billed because they were unhappy about something that occurred at the doctor’s office, said Ms. Adler.
“I advise doctors to respond: ‘We disagree that you didn’t get the service, but we will give you your money back, and we’re also terminating you from our practice.’ At that point, the doctor-patient relationship has become impossible,” said Ms. Adler.
How to dismiss difficult patients ethically and legally
According to the AMA’s Council on Ethical and Judicial Affairs, a physician may not discontinue treatment of a patient if further treatment is medically indicated without giving the patient reasonable notice and sufficient opportunity to make alternative arrangements for care.
Terminating a patient abruptly without transferring their care could lead to a claim of patient abandonment and the physician being called before a licensing board for potentially violating the state’s Medical Practice Act, said Ms. Adler.
Doctors can take these six steps to set the stage for dismissal and avoid a claim of patient abandonment.
1. Create written policies. Medical practices can describe the rules and behavior they expect from patients in these policies, which can cover, for example, payment, treating staff with courtesy, and medications. “When the rules are in writing and patients sign off on them, that gives doctors a certain comfort level in being able to refer to them and say that the patient hasn’t been compliant,” said Ms. Adler.
She also recommends that your practice create a policy that doctors should let the patient know about their concerns and meet with them to discuss the problem before receiving a termination letter.
2. Document any consistent problems you’re having with a patient. When you start having problems with a patient, you should document when the problem occurred, how often it occurred, any discussions with the patient about the problem, warnings you gave the patient, and if and when you decided to terminate the patient.
3. Meet with the patient to discuss the problem. “Talking and meeting with a patient also allows the physician to assess whether there’s another issue. For example, is there a mental health concern? Is there a financial reason for nonpayment or no-shows? There are multiple benefits to finding out what the problem is,” said Ms. Adler.
Once you’ve decided to terminate a patient, here’s what you should do:
4. Allow enough time for the patient to find alternative care. Ms. Adler recommends giving patients 30 days’ notice and that physicians offer to provide emergency care during that time. However, if the patient is undergoing treatment or has other challenges, more time may be needed to transfer care.
“It’s important to consider the patient’s context – if the patient is receiving cancer treatment, or is in a late stage of pregnancy, or lives in a rural area where few specialists are available, you may want to treat them longer – at least until they finish their treatment,” said Ms. Adler. Also, states may have their own requirements about minimum notice periods, she said.
5. Provide patients with written notice that you intend to terminate their care. Ms. Adler recommends that each letter be tailored to the patient’s specific circumstances. “You could spell out a patient’s history of noncompliance or nonpayment or inappropriate conduct because it’s been documented and the patient is already aware of it from a previous discussion,” she said.
Ms. Adler also recommends that doctors consult with legal counsel when in doubt or if contacted by the patient’s lawyer. Some lawyers will draft the termination letters, she said.
6. Include the following information in the written letter: The date that they will no longer receive care, how they can obtain copies of their medical records, and how they can find a new physician by providing contact information for a state medical association or similar organization, which often maintains a database of clinicians by specialty and location.
The letter should also state that the doctor will provide emergency care during the 30 days. Ms. Adler also recommends sending the notice by certified mail.
Dr. O’Kane said she may be more likely to give patients a second chance because she practices in a rural underserved area, and she understands that her patients don’t have many other options for health care. She also has developed a reputation for being willing to take on difficult patients that other physicians didn’t want to deal with, she said.
She encourages physicians to talk to patients to find out why, for example, they may not be compliant with medications.
“The patient may say, ‘I had to choose between paying for medications and putting food on the table,’ ” said Dr. O’Kane.
A version of this article first appeared on Medscape.com.
Some patients continually cancel their appointments, ignore your medical directions, treat your staff rudely, or send you harassing emails.
Do you have to tolerate their behavior?
No, these are all appropriate reasons to terminate patients, attorneys say. Patients also can be dismissed for misleading doctors about their past medical history, chronic drug-seeking, displaying threatening or seductive behavior toward staff members or physicians, or any criminal behavior in the office, experts say.
But even if a reason seems legitimate, that doesn’t make it legal. Doctors should consider whether the reason is legal, said Chicago-area attorney Ericka Adler, JD, a partner at Roetzel & Andress, who advises doctors about terminating patients.
Ms. Adler said.
Terminating patients for an “illegal” reason such as discrimination based on race or gender or sexual orientation – even if couched as a legitimate patient issue – could open the practice to a lawsuit, Ms. Adler said.
Doctors also want to avoid patient abandonment claims by talking to the patient about problems and documenting them as they arise. If they can’t be resolved, doctors should ensure that there’s continuity of care when patients change physicians, said Ms. Adler.
About 90% of physicians have dismissed at least one patient during their career, according to a study of nearly 800 primary care practices. The most common reasons were legitimate: a patient was “extremely disruptive and/or behaved inappropriately toward clinicians or staff”; a patient had “violated chronic pain and controlled substance policies”; and a patient had “repeatedly missed appointments.”
Jacqui O’Kane, DO, a family physician at South Georgia Medical Center in rural Nashville, said she has dismissed about 15 of 3,000 patients she has seen in the past 3 years at the clinic. Before she dismisses a patient, she looks at whether there has been a pattern of behavior and tries to talk to them about the problem first to find out if there are other reasons for it.
She also gives patients a warning: If the unacceptable behavior continues, it will lead to their dismissal.
When patients cross a line
Dr. O’Kane warned an elderly man who used the N-word with her that she wouldn’t tolerate that language in her office. Then, when he later called her front office employee the N-word, she decided to dismiss him.
“I said, ‘That’s it, you can’t say that to someone in this office. I already told you once, and you did it again. I’m sorry, you have to find another doctor,’ ” said Dr. O’Kane.
Another patient crossed a line when she missed four appointments, refused to come in, and kept sending Dr. O’Kane long messages on MyChart demanding medications and advice. One message was fairly obtrusive: “If you don’t give me something stronger for my nerves TODAY, I am going to LOSE MY MIND!!!” Dr. O’Kane said the patient wrote.
“I then told her that’s not how I run my practice and that she needed to find someone else.”
Another common reason doctors dismiss patients is for nonpayment, says Ms. Adler.
Recently, however, some patients have also begun demanding their money back from doctors for services already received and billed because they were unhappy about something that occurred at the doctor’s office, said Ms. Adler.
“I advise doctors to respond: ‘We disagree that you didn’t get the service, but we will give you your money back, and we’re also terminating you from our practice.’ At that point, the doctor-patient relationship has become impossible,” said Ms. Adler.
How to dismiss difficult patients ethically and legally
According to the AMA’s Council on Ethical and Judicial Affairs, a physician may not discontinue treatment of a patient if further treatment is medically indicated without giving the patient reasonable notice and sufficient opportunity to make alternative arrangements for care.
Terminating a patient abruptly without transferring their care could lead to a claim of patient abandonment and the physician being called before a licensing board for potentially violating the state’s Medical Practice Act, said Ms. Adler.
Doctors can take these six steps to set the stage for dismissal and avoid a claim of patient abandonment.
1. Create written policies. Medical practices can describe the rules and behavior they expect from patients in these policies, which can cover, for example, payment, treating staff with courtesy, and medications. “When the rules are in writing and patients sign off on them, that gives doctors a certain comfort level in being able to refer to them and say that the patient hasn’t been compliant,” said Ms. Adler.
She also recommends that your practice create a policy that doctors should let the patient know about their concerns and meet with them to discuss the problem before receiving a termination letter.
2. Document any consistent problems you’re having with a patient. When you start having problems with a patient, you should document when the problem occurred, how often it occurred, any discussions with the patient about the problem, warnings you gave the patient, and if and when you decided to terminate the patient.
3. Meet with the patient to discuss the problem. “Talking and meeting with a patient also allows the physician to assess whether there’s another issue. For example, is there a mental health concern? Is there a financial reason for nonpayment or no-shows? There are multiple benefits to finding out what the problem is,” said Ms. Adler.
Once you’ve decided to terminate a patient, here’s what you should do:
4. Allow enough time for the patient to find alternative care. Ms. Adler recommends giving patients 30 days’ notice and that physicians offer to provide emergency care during that time. However, if the patient is undergoing treatment or has other challenges, more time may be needed to transfer care.
“It’s important to consider the patient’s context – if the patient is receiving cancer treatment, or is in a late stage of pregnancy, or lives in a rural area where few specialists are available, you may want to treat them longer – at least until they finish their treatment,” said Ms. Adler. Also, states may have their own requirements about minimum notice periods, she said.
5. Provide patients with written notice that you intend to terminate their care. Ms. Adler recommends that each letter be tailored to the patient’s specific circumstances. “You could spell out a patient’s history of noncompliance or nonpayment or inappropriate conduct because it’s been documented and the patient is already aware of it from a previous discussion,” she said.
Ms. Adler also recommends that doctors consult with legal counsel when in doubt or if contacted by the patient’s lawyer. Some lawyers will draft the termination letters, she said.
6. Include the following information in the written letter: The date that they will no longer receive care, how they can obtain copies of their medical records, and how they can find a new physician by providing contact information for a state medical association or similar organization, which often maintains a database of clinicians by specialty and location.
The letter should also state that the doctor will provide emergency care during the 30 days. Ms. Adler also recommends sending the notice by certified mail.
Dr. O’Kane said she may be more likely to give patients a second chance because she practices in a rural underserved area, and she understands that her patients don’t have many other options for health care. She also has developed a reputation for being willing to take on difficult patients that other physicians didn’t want to deal with, she said.
She encourages physicians to talk to patients to find out why, for example, they may not be compliant with medications.
“The patient may say, ‘I had to choose between paying for medications and putting food on the table,’ ” said Dr. O’Kane.
A version of this article first appeared on Medscape.com.
Some patients continually cancel their appointments, ignore your medical directions, treat your staff rudely, or send you harassing emails.
Do you have to tolerate their behavior?
No, these are all appropriate reasons to terminate patients, attorneys say. Patients also can be dismissed for misleading doctors about their past medical history, chronic drug-seeking, displaying threatening or seductive behavior toward staff members or physicians, or any criminal behavior in the office, experts say.
But even if a reason seems legitimate, that doesn’t make it legal. Doctors should consider whether the reason is legal, said Chicago-area attorney Ericka Adler, JD, a partner at Roetzel & Andress, who advises doctors about terminating patients.
Ms. Adler said.
Terminating patients for an “illegal” reason such as discrimination based on race or gender or sexual orientation – even if couched as a legitimate patient issue – could open the practice to a lawsuit, Ms. Adler said.
Doctors also want to avoid patient abandonment claims by talking to the patient about problems and documenting them as they arise. If they can’t be resolved, doctors should ensure that there’s continuity of care when patients change physicians, said Ms. Adler.
About 90% of physicians have dismissed at least one patient during their career, according to a study of nearly 800 primary care practices. The most common reasons were legitimate: a patient was “extremely disruptive and/or behaved inappropriately toward clinicians or staff”; a patient had “violated chronic pain and controlled substance policies”; and a patient had “repeatedly missed appointments.”
Jacqui O’Kane, DO, a family physician at South Georgia Medical Center in rural Nashville, said she has dismissed about 15 of 3,000 patients she has seen in the past 3 years at the clinic. Before she dismisses a patient, she looks at whether there has been a pattern of behavior and tries to talk to them about the problem first to find out if there are other reasons for it.
She also gives patients a warning: If the unacceptable behavior continues, it will lead to their dismissal.
When patients cross a line
Dr. O’Kane warned an elderly man who used the N-word with her that she wouldn’t tolerate that language in her office. Then, when he later called her front office employee the N-word, she decided to dismiss him.
“I said, ‘That’s it, you can’t say that to someone in this office. I already told you once, and you did it again. I’m sorry, you have to find another doctor,’ ” said Dr. O’Kane.
Another patient crossed a line when she missed four appointments, refused to come in, and kept sending Dr. O’Kane long messages on MyChart demanding medications and advice. One message was fairly obtrusive: “If you don’t give me something stronger for my nerves TODAY, I am going to LOSE MY MIND!!!” Dr. O’Kane said the patient wrote.
“I then told her that’s not how I run my practice and that she needed to find someone else.”
Another common reason doctors dismiss patients is for nonpayment, says Ms. Adler.
Recently, however, some patients have also begun demanding their money back from doctors for services already received and billed because they were unhappy about something that occurred at the doctor’s office, said Ms. Adler.
“I advise doctors to respond: ‘We disagree that you didn’t get the service, but we will give you your money back, and we’re also terminating you from our practice.’ At that point, the doctor-patient relationship has become impossible,” said Ms. Adler.
How to dismiss difficult patients ethically and legally
According to the AMA’s Council on Ethical and Judicial Affairs, a physician may not discontinue treatment of a patient if further treatment is medically indicated without giving the patient reasonable notice and sufficient opportunity to make alternative arrangements for care.
Terminating a patient abruptly without transferring their care could lead to a claim of patient abandonment and the physician being called before a licensing board for potentially violating the state’s Medical Practice Act, said Ms. Adler.
Doctors can take these six steps to set the stage for dismissal and avoid a claim of patient abandonment.
1. Create written policies. Medical practices can describe the rules and behavior they expect from patients in these policies, which can cover, for example, payment, treating staff with courtesy, and medications. “When the rules are in writing and patients sign off on them, that gives doctors a certain comfort level in being able to refer to them and say that the patient hasn’t been compliant,” said Ms. Adler.
She also recommends that your practice create a policy that doctors should let the patient know about their concerns and meet with them to discuss the problem before receiving a termination letter.
2. Document any consistent problems you’re having with a patient. When you start having problems with a patient, you should document when the problem occurred, how often it occurred, any discussions with the patient about the problem, warnings you gave the patient, and if and when you decided to terminate the patient.
3. Meet with the patient to discuss the problem. “Talking and meeting with a patient also allows the physician to assess whether there’s another issue. For example, is there a mental health concern? Is there a financial reason for nonpayment or no-shows? There are multiple benefits to finding out what the problem is,” said Ms. Adler.
Once you’ve decided to terminate a patient, here’s what you should do:
4. Allow enough time for the patient to find alternative care. Ms. Adler recommends giving patients 30 days’ notice and that physicians offer to provide emergency care during that time. However, if the patient is undergoing treatment or has other challenges, more time may be needed to transfer care.
“It’s important to consider the patient’s context – if the patient is receiving cancer treatment, or is in a late stage of pregnancy, or lives in a rural area where few specialists are available, you may want to treat them longer – at least until they finish their treatment,” said Ms. Adler. Also, states may have their own requirements about minimum notice periods, she said.
5. Provide patients with written notice that you intend to terminate their care. Ms. Adler recommends that each letter be tailored to the patient’s specific circumstances. “You could spell out a patient’s history of noncompliance or nonpayment or inappropriate conduct because it’s been documented and the patient is already aware of it from a previous discussion,” she said.
Ms. Adler also recommends that doctors consult with legal counsel when in doubt or if contacted by the patient’s lawyer. Some lawyers will draft the termination letters, she said.
6. Include the following information in the written letter: The date that they will no longer receive care, how they can obtain copies of their medical records, and how they can find a new physician by providing contact information for a state medical association or similar organization, which often maintains a database of clinicians by specialty and location.
The letter should also state that the doctor will provide emergency care during the 30 days. Ms. Adler also recommends sending the notice by certified mail.
Dr. O’Kane said she may be more likely to give patients a second chance because she practices in a rural underserved area, and she understands that her patients don’t have many other options for health care. She also has developed a reputation for being willing to take on difficult patients that other physicians didn’t want to deal with, she said.
She encourages physicians to talk to patients to find out why, for example, they may not be compliant with medications.
“The patient may say, ‘I had to choose between paying for medications and putting food on the table,’ ” said Dr. O’Kane.
A version of this article first appeared on Medscape.com.
Low-calorie tastes sweeter with a little salt
Low-calorie tastes sweeter with a little salt
Diet and sugar-free foods and drinks seem like a good idea, but it’s hard to get past that strange aftertaste, right? It’s the calling card for the noncaloric aspartame- and stevia-containing sweeteners that we consume to make us feel like we can have the best of both worlds.
That weird lingering taste can be a total turn-off for some (raises hand), but researchers have found an almost facepalm solution to the not-so-sweet problem, and it’s salt.
Now, the concept of sweet and salty is not a far-fetched partnership when it comes to snack consumption (try M&Ms in your popcorn). The researchers at Almendra, a manufacturer of stevia sweeteners, put that iconic flavor pair to the test by adding mineral salts that have some nutritional value to lessen the effect of a stevia compound, rebaudioside A, found in noncaloric sweeteners.
The researchers added in magnesium chloride, calcium chloride, and potassium chloride separately to lessen rebaudioside A’s intensity, but they needed so much salt that it killed the sweet taste completely. A blend of the three mineral salts, however, reduced the lingering taste by 79% and improved the real sugar-like taste. The researchers tried this blend in reduced-calorie orange juice and a citrus-flavored soft drink, improving the taste in both.
The salty and sweet match comes in for the win once again. This time helping against the fight of obesity instead of making it worse.
Pseudomonas’ Achilles’ heel is more of an Achilles’ genetic switch
Today, on the long-awaited return of “Bacteria vs. the World,” we meet one of the rock stars of infectious disease.
LOTME: Through the use of imaginary technology, we’re talking to Pseudomonas aeruginosa. Thanks for joining us on such short notice, after Neisseria gonorrhoeae canceled at the last minute.
P. aeruginosa: No problem. I think we can all guess what that little devil is up to.
LOTME: Bacterial resistance to antibiotics is a huge problem for our species. What makes you so hard to fight?
P. aeruginosa: We’ve been trying to keep that a secret, actually, but now that researchers in Switzerland and Denmark seem to have figured it out, I guess it’s okay for me to spill the beans.
LOTME: Beans? What do beans have to do with it?
P. aeruginosa: Nothing, it’s just a colloquial expression that means I’m sharing previously private information.
LOTME: Sure, we knew that. Please, continue your spilling.
P. aeruginosa: The secret is … Well, let’s just say we were a little worried when the Clash released “Should I Stay or Should I Go” back in the 1980s.
LOTME: The Clash? Now we’re really confused.
P. aeruginosa: The answer to their question, “Should I stay or should I go? is yes. Successful invasion of a human is all about division of labor. “While one fraction of the bacterial population adheres to the mucosal surface and forms a biofilm, the other subpopulation spreads to distant tissue sites,” is how the investigators described it. We can increase surface colonization by using a “job-sharing” process, they said, and even resist antibiotics because most of us remain in the protective biofilm.
LOTME: And they say you guys don’t have brains.
P. aeruginosa: But wait, there’s more. We don’t just divide the labor randomly. After the initial colonization we form two functionally distinct subpopulations. One has high levels of the bacterial signaling molecule c-di-GMP and stays put to work on the biofilm. The other group, with low levels of c-di-GMP, heads out to the surrounding tissue to continue the colonization. As project leader Urs Jenal put it, “By identifying the genetic switch, we have tracked down the Achilles heel of the pathogen.”
LOTME: Pretty clever stuff, for humans, anyway.
P. aeruginosa: We agree, but now that you know our secret, we can’t let you share it.
LOTME: Wait! The journal article’s already been published. Your secret is out. You can’t stop that by infecting me.
P. aeruginosa: True enough, but are you familiar with the fable of the scorpion and the frog? It’s our nature.
LOTME: Nooooo! N. gonorrhoeae wouldn’t have done this!
What a pain in the Butt
Businesses rise and businesses fall. We all know that one cursed location, that spot in town where we see businesses move in and close up in a matter of months. At the same time, though, there are also businesses that have been around as long as anyone can remember, pillars of the community.
Corydon, IN., likely has a few such long-lived shops, but it is officially down one 70-year-old family business as of late April, with the unfortunate passing of beloved local pharmacy Butt Drugs. Prescription pick-up in rear.
The business dates back to 1952, when it was founded as William H. Butt Drugs. We’re sure William Butt was never teased about his last name. Nope. No one would ever do that. After he passed the store to his children, it underwent a stint as Butt Rexall Drugs. When the shop was passed down to its third-generation and ultimately final owner, Katie Butt Beckort, she decided to simplify the name. Get right down to the bottom of things, as it were.
Butt Drugs was a popular spot, featuring an old-school soda fountain and themed souvenirs. According to Ms. Butt Beckort, people would come from miles away to buy “I love Butt Drugs” T-shirts, magnets, and so on. Yes, they knew perfectly well what they were sitting on.
So, if was such a hit, why did it close? Butt Drugs may have a hilarious name and merchandise to match, but the pharmacy portion of the pharmacy had been losing money for years. You know, the actual point of the business. As with so many things, we can blame it on the insurance companies. More than half the drugs that passed through Butt Drugs’ doors were sold at a loss, because the insurance companies refused to reimburse the store more than the wholesale price of the drug. Not even a good butt drug could clear up that financial diarrhea.
And so, we’ve lost Butt Drugs forever. Spicy food enthusiasts, coffee drinkers, and all patrons of Taco Bell, take a moment to reflect and mourn on what you’ve lost. No more Butt Drugs to relieve your suffering. A true kick in the butt indeed.
Low-calorie tastes sweeter with a little salt
Diet and sugar-free foods and drinks seem like a good idea, but it’s hard to get past that strange aftertaste, right? It’s the calling card for the noncaloric aspartame- and stevia-containing sweeteners that we consume to make us feel like we can have the best of both worlds.
That weird lingering taste can be a total turn-off for some (raises hand), but researchers have found an almost facepalm solution to the not-so-sweet problem, and it’s salt.
Now, the concept of sweet and salty is not a far-fetched partnership when it comes to snack consumption (try M&Ms in your popcorn). The researchers at Almendra, a manufacturer of stevia sweeteners, put that iconic flavor pair to the test by adding mineral salts that have some nutritional value to lessen the effect of a stevia compound, rebaudioside A, found in noncaloric sweeteners.
The researchers added in magnesium chloride, calcium chloride, and potassium chloride separately to lessen rebaudioside A’s intensity, but they needed so much salt that it killed the sweet taste completely. A blend of the three mineral salts, however, reduced the lingering taste by 79% and improved the real sugar-like taste. The researchers tried this blend in reduced-calorie orange juice and a citrus-flavored soft drink, improving the taste in both.
The salty and sweet match comes in for the win once again. This time helping against the fight of obesity instead of making it worse.
Pseudomonas’ Achilles’ heel is more of an Achilles’ genetic switch
Today, on the long-awaited return of “Bacteria vs. the World,” we meet one of the rock stars of infectious disease.
LOTME: Through the use of imaginary technology, we’re talking to Pseudomonas aeruginosa. Thanks for joining us on such short notice, after Neisseria gonorrhoeae canceled at the last minute.
P. aeruginosa: No problem. I think we can all guess what that little devil is up to.
LOTME: Bacterial resistance to antibiotics is a huge problem for our species. What makes you so hard to fight?
P. aeruginosa: We’ve been trying to keep that a secret, actually, but now that researchers in Switzerland and Denmark seem to have figured it out, I guess it’s okay for me to spill the beans.
LOTME: Beans? What do beans have to do with it?
P. aeruginosa: Nothing, it’s just a colloquial expression that means I’m sharing previously private information.
LOTME: Sure, we knew that. Please, continue your spilling.
P. aeruginosa: The secret is … Well, let’s just say we were a little worried when the Clash released “Should I Stay or Should I Go” back in the 1980s.
LOTME: The Clash? Now we’re really confused.
P. aeruginosa: The answer to their question, “Should I stay or should I go? is yes. Successful invasion of a human is all about division of labor. “While one fraction of the bacterial population adheres to the mucosal surface and forms a biofilm, the other subpopulation spreads to distant tissue sites,” is how the investigators described it. We can increase surface colonization by using a “job-sharing” process, they said, and even resist antibiotics because most of us remain in the protective biofilm.
LOTME: And they say you guys don’t have brains.
P. aeruginosa: But wait, there’s more. We don’t just divide the labor randomly. After the initial colonization we form two functionally distinct subpopulations. One has high levels of the bacterial signaling molecule c-di-GMP and stays put to work on the biofilm. The other group, with low levels of c-di-GMP, heads out to the surrounding tissue to continue the colonization. As project leader Urs Jenal put it, “By identifying the genetic switch, we have tracked down the Achilles heel of the pathogen.”
LOTME: Pretty clever stuff, for humans, anyway.
P. aeruginosa: We agree, but now that you know our secret, we can’t let you share it.
LOTME: Wait! The journal article’s already been published. Your secret is out. You can’t stop that by infecting me.
P. aeruginosa: True enough, but are you familiar with the fable of the scorpion and the frog? It’s our nature.
LOTME: Nooooo! N. gonorrhoeae wouldn’t have done this!
What a pain in the Butt
Businesses rise and businesses fall. We all know that one cursed location, that spot in town where we see businesses move in and close up in a matter of months. At the same time, though, there are also businesses that have been around as long as anyone can remember, pillars of the community.
Corydon, IN., likely has a few such long-lived shops, but it is officially down one 70-year-old family business as of late April, with the unfortunate passing of beloved local pharmacy Butt Drugs. Prescription pick-up in rear.
The business dates back to 1952, when it was founded as William H. Butt Drugs. We’re sure William Butt was never teased about his last name. Nope. No one would ever do that. After he passed the store to his children, it underwent a stint as Butt Rexall Drugs. When the shop was passed down to its third-generation and ultimately final owner, Katie Butt Beckort, she decided to simplify the name. Get right down to the bottom of things, as it were.
Butt Drugs was a popular spot, featuring an old-school soda fountain and themed souvenirs. According to Ms. Butt Beckort, people would come from miles away to buy “I love Butt Drugs” T-shirts, magnets, and so on. Yes, they knew perfectly well what they were sitting on.
So, if was such a hit, why did it close? Butt Drugs may have a hilarious name and merchandise to match, but the pharmacy portion of the pharmacy had been losing money for years. You know, the actual point of the business. As with so many things, we can blame it on the insurance companies. More than half the drugs that passed through Butt Drugs’ doors were sold at a loss, because the insurance companies refused to reimburse the store more than the wholesale price of the drug. Not even a good butt drug could clear up that financial diarrhea.
And so, we’ve lost Butt Drugs forever. Spicy food enthusiasts, coffee drinkers, and all patrons of Taco Bell, take a moment to reflect and mourn on what you’ve lost. No more Butt Drugs to relieve your suffering. A true kick in the butt indeed.
Low-calorie tastes sweeter with a little salt
Diet and sugar-free foods and drinks seem like a good idea, but it’s hard to get past that strange aftertaste, right? It’s the calling card for the noncaloric aspartame- and stevia-containing sweeteners that we consume to make us feel like we can have the best of both worlds.
That weird lingering taste can be a total turn-off for some (raises hand), but researchers have found an almost facepalm solution to the not-so-sweet problem, and it’s salt.
Now, the concept of sweet and salty is not a far-fetched partnership when it comes to snack consumption (try M&Ms in your popcorn). The researchers at Almendra, a manufacturer of stevia sweeteners, put that iconic flavor pair to the test by adding mineral salts that have some nutritional value to lessen the effect of a stevia compound, rebaudioside A, found in noncaloric sweeteners.
The researchers added in magnesium chloride, calcium chloride, and potassium chloride separately to lessen rebaudioside A’s intensity, but they needed so much salt that it killed the sweet taste completely. A blend of the three mineral salts, however, reduced the lingering taste by 79% and improved the real sugar-like taste. The researchers tried this blend in reduced-calorie orange juice and a citrus-flavored soft drink, improving the taste in both.
The salty and sweet match comes in for the win once again. This time helping against the fight of obesity instead of making it worse.
Pseudomonas’ Achilles’ heel is more of an Achilles’ genetic switch
Today, on the long-awaited return of “Bacteria vs. the World,” we meet one of the rock stars of infectious disease.
LOTME: Through the use of imaginary technology, we’re talking to Pseudomonas aeruginosa. Thanks for joining us on such short notice, after Neisseria gonorrhoeae canceled at the last minute.
P. aeruginosa: No problem. I think we can all guess what that little devil is up to.
LOTME: Bacterial resistance to antibiotics is a huge problem for our species. What makes you so hard to fight?
P. aeruginosa: We’ve been trying to keep that a secret, actually, but now that researchers in Switzerland and Denmark seem to have figured it out, I guess it’s okay for me to spill the beans.
LOTME: Beans? What do beans have to do with it?
P. aeruginosa: Nothing, it’s just a colloquial expression that means I’m sharing previously private information.
LOTME: Sure, we knew that. Please, continue your spilling.
P. aeruginosa: The secret is … Well, let’s just say we were a little worried when the Clash released “Should I Stay or Should I Go” back in the 1980s.
LOTME: The Clash? Now we’re really confused.
P. aeruginosa: The answer to their question, “Should I stay or should I go? is yes. Successful invasion of a human is all about division of labor. “While one fraction of the bacterial population adheres to the mucosal surface and forms a biofilm, the other subpopulation spreads to distant tissue sites,” is how the investigators described it. We can increase surface colonization by using a “job-sharing” process, they said, and even resist antibiotics because most of us remain in the protective biofilm.
LOTME: And they say you guys don’t have brains.
P. aeruginosa: But wait, there’s more. We don’t just divide the labor randomly. After the initial colonization we form two functionally distinct subpopulations. One has high levels of the bacterial signaling molecule c-di-GMP and stays put to work on the biofilm. The other group, with low levels of c-di-GMP, heads out to the surrounding tissue to continue the colonization. As project leader Urs Jenal put it, “By identifying the genetic switch, we have tracked down the Achilles heel of the pathogen.”
LOTME: Pretty clever stuff, for humans, anyway.
P. aeruginosa: We agree, but now that you know our secret, we can’t let you share it.
LOTME: Wait! The journal article’s already been published. Your secret is out. You can’t stop that by infecting me.
P. aeruginosa: True enough, but are you familiar with the fable of the scorpion and the frog? It’s our nature.
LOTME: Nooooo! N. gonorrhoeae wouldn’t have done this!
What a pain in the Butt
Businesses rise and businesses fall. We all know that one cursed location, that spot in town where we see businesses move in and close up in a matter of months. At the same time, though, there are also businesses that have been around as long as anyone can remember, pillars of the community.
Corydon, IN., likely has a few such long-lived shops, but it is officially down one 70-year-old family business as of late April, with the unfortunate passing of beloved local pharmacy Butt Drugs. Prescription pick-up in rear.
The business dates back to 1952, when it was founded as William H. Butt Drugs. We’re sure William Butt was never teased about his last name. Nope. No one would ever do that. After he passed the store to his children, it underwent a stint as Butt Rexall Drugs. When the shop was passed down to its third-generation and ultimately final owner, Katie Butt Beckort, she decided to simplify the name. Get right down to the bottom of things, as it were.
Butt Drugs was a popular spot, featuring an old-school soda fountain and themed souvenirs. According to Ms. Butt Beckort, people would come from miles away to buy “I love Butt Drugs” T-shirts, magnets, and so on. Yes, they knew perfectly well what they were sitting on.
So, if was such a hit, why did it close? Butt Drugs may have a hilarious name and merchandise to match, but the pharmacy portion of the pharmacy had been losing money for years. You know, the actual point of the business. As with so many things, we can blame it on the insurance companies. More than half the drugs that passed through Butt Drugs’ doors were sold at a loss, because the insurance companies refused to reimburse the store more than the wholesale price of the drug. Not even a good butt drug could clear up that financial diarrhea.
And so, we’ve lost Butt Drugs forever. Spicy food enthusiasts, coffee drinkers, and all patrons of Taco Bell, take a moment to reflect and mourn on what you’ve lost. No more Butt Drugs to relieve your suffering. A true kick in the butt indeed.
How not to establish rapport with your patient
1. Stride confidently into the room to greet your 84-year-old female patient.
2. Introduce yourself saying, “Hi, I’m Dr. Jeff Benabio.”
3. Extend your clenched fist toward her chest and wait for her to reciprocate.
4. Smile awkwardly behind your mask while you wait.
5. Advise that you are doing a fist bump instead of a handshake to prevent the spread of viruses.
6. Wait.
7. Explain that she can bump, also known as “dap,” you back by extending her clenched fist and bumping into yours.
8. Wait a bit more.
9. Lower your fist and pat her on the shoulder with your left hand. Do so gently so it doesn’t seem like you just did a quick right jab followed by a left hook.
10. Sit down diffidently and pray that you can help her so this office visit is not an utter disaster.
It seemed a good idea for 2020: Let’s stop shaking hands while we wait out this viral apocalypse. Sensible, but entering a patient room and just sitting down didn’t work. It felt cold, impolite – this isn’t the DMV. In medicine, a complete stranger has to trust us to get naked, tell intimate secrets, even be stuck by needles all within minutes of meeting. We needed a trust-building substitute greeting.
There was the Muslim hand-on-my-heart greeting. Or the Hindu “namaste” or Buddhist “amituofo” folded hands. Or perhaps the paternalistic shoulder pat? I went with the fist bump. With some of my partner docs, my old MBA squad, my neighbor, the fist bump felt natural, reciprocated without hesitation. But it fails with many patients. To understand why, it’s helpful to know the history of the fist bump, also known as the dap.
Dap is an acronym for Dignity And Pride. It’s a variation of a handshake that originated among Black soldiers in the Vietnam war as a means of showing fraternity and establishing connectedness. In Vietnam, 30% of the combat battalions were Black. Marginalized in the military and at home, they created a greeting that was meaningful and unique. The dap was a series of shakes, bumps, slaps, and hugs that was symbolic. It was a means of showing respect and humility, that no one is above others, that I’ve got your back and you’ve got mine. It was a powerful recognition of humanity and effective means of personal connection. It spread from the Black community to the general population and it exists still today. The choreographed pregame handshake you see so many NBA players engage in is a descendant of the dap. Like many rituals, it reinforces bonds with those who are your people, your team, those you trust.
The more generalized version is the simple fist bump. It is widely used, notably by President Obama, and in the appropriate circumstance, will almost always be reciprocated. But it doesn’t work well to create trust with a stranger. With a patient for example, you are not showing them respect for some accomplishment. Nor are we connecting with them as a member of your team. Unless this is a patient whom you’ve seen many times before, a fist bump attempt might be met with “are you serious?” In fact, a survey done in 2016 asking infectious disease professionals what they thought of fist bumps as a greeting, very few replied it was a good idea. Most felt it was unprofessional. Not to mention that a fist bump does not symbolize an agreement in the way that a handshake does (and has done since at least the 9th century BC).
With COVID waning and masks doffed, I’ve found myself back to handshaking. Yes, I sanitize before and after, another ritual that has symbolic as well as practical significance. I get fewer sideways glances from my geriatric patients for sure. But I do still offer a little dap for my liquid nitrogen–survivor kids and for the occasional fellow Gen Xer. “Wonder Twin powers, activate!”
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com
1. Stride confidently into the room to greet your 84-year-old female patient.
2. Introduce yourself saying, “Hi, I’m Dr. Jeff Benabio.”
3. Extend your clenched fist toward her chest and wait for her to reciprocate.
4. Smile awkwardly behind your mask while you wait.
5. Advise that you are doing a fist bump instead of a handshake to prevent the spread of viruses.
6. Wait.
7. Explain that she can bump, also known as “dap,” you back by extending her clenched fist and bumping into yours.
8. Wait a bit more.
9. Lower your fist and pat her on the shoulder with your left hand. Do so gently so it doesn’t seem like you just did a quick right jab followed by a left hook.
10. Sit down diffidently and pray that you can help her so this office visit is not an utter disaster.
It seemed a good idea for 2020: Let’s stop shaking hands while we wait out this viral apocalypse. Sensible, but entering a patient room and just sitting down didn’t work. It felt cold, impolite – this isn’t the DMV. In medicine, a complete stranger has to trust us to get naked, tell intimate secrets, even be stuck by needles all within minutes of meeting. We needed a trust-building substitute greeting.
There was the Muslim hand-on-my-heart greeting. Or the Hindu “namaste” or Buddhist “amituofo” folded hands. Or perhaps the paternalistic shoulder pat? I went with the fist bump. With some of my partner docs, my old MBA squad, my neighbor, the fist bump felt natural, reciprocated without hesitation. But it fails with many patients. To understand why, it’s helpful to know the history of the fist bump, also known as the dap.
Dap is an acronym for Dignity And Pride. It’s a variation of a handshake that originated among Black soldiers in the Vietnam war as a means of showing fraternity and establishing connectedness. In Vietnam, 30% of the combat battalions were Black. Marginalized in the military and at home, they created a greeting that was meaningful and unique. The dap was a series of shakes, bumps, slaps, and hugs that was symbolic. It was a means of showing respect and humility, that no one is above others, that I’ve got your back and you’ve got mine. It was a powerful recognition of humanity and effective means of personal connection. It spread from the Black community to the general population and it exists still today. The choreographed pregame handshake you see so many NBA players engage in is a descendant of the dap. Like many rituals, it reinforces bonds with those who are your people, your team, those you trust.
The more generalized version is the simple fist bump. It is widely used, notably by President Obama, and in the appropriate circumstance, will almost always be reciprocated. But it doesn’t work well to create trust with a stranger. With a patient for example, you are not showing them respect for some accomplishment. Nor are we connecting with them as a member of your team. Unless this is a patient whom you’ve seen many times before, a fist bump attempt might be met with “are you serious?” In fact, a survey done in 2016 asking infectious disease professionals what they thought of fist bumps as a greeting, very few replied it was a good idea. Most felt it was unprofessional. Not to mention that a fist bump does not symbolize an agreement in the way that a handshake does (and has done since at least the 9th century BC).
With COVID waning and masks doffed, I’ve found myself back to handshaking. Yes, I sanitize before and after, another ritual that has symbolic as well as practical significance. I get fewer sideways glances from my geriatric patients for sure. But I do still offer a little dap for my liquid nitrogen–survivor kids and for the occasional fellow Gen Xer. “Wonder Twin powers, activate!”
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com
1. Stride confidently into the room to greet your 84-year-old female patient.
2. Introduce yourself saying, “Hi, I’m Dr. Jeff Benabio.”
3. Extend your clenched fist toward her chest and wait for her to reciprocate.
4. Smile awkwardly behind your mask while you wait.
5. Advise that you are doing a fist bump instead of a handshake to prevent the spread of viruses.
6. Wait.
7. Explain that she can bump, also known as “dap,” you back by extending her clenched fist and bumping into yours.
8. Wait a bit more.
9. Lower your fist and pat her on the shoulder with your left hand. Do so gently so it doesn’t seem like you just did a quick right jab followed by a left hook.
10. Sit down diffidently and pray that you can help her so this office visit is not an utter disaster.
It seemed a good idea for 2020: Let’s stop shaking hands while we wait out this viral apocalypse. Sensible, but entering a patient room and just sitting down didn’t work. It felt cold, impolite – this isn’t the DMV. In medicine, a complete stranger has to trust us to get naked, tell intimate secrets, even be stuck by needles all within minutes of meeting. We needed a trust-building substitute greeting.
There was the Muslim hand-on-my-heart greeting. Or the Hindu “namaste” or Buddhist “amituofo” folded hands. Or perhaps the paternalistic shoulder pat? I went with the fist bump. With some of my partner docs, my old MBA squad, my neighbor, the fist bump felt natural, reciprocated without hesitation. But it fails with many patients. To understand why, it’s helpful to know the history of the fist bump, also known as the dap.
Dap is an acronym for Dignity And Pride. It’s a variation of a handshake that originated among Black soldiers in the Vietnam war as a means of showing fraternity and establishing connectedness. In Vietnam, 30% of the combat battalions were Black. Marginalized in the military and at home, they created a greeting that was meaningful and unique. The dap was a series of shakes, bumps, slaps, and hugs that was symbolic. It was a means of showing respect and humility, that no one is above others, that I’ve got your back and you’ve got mine. It was a powerful recognition of humanity and effective means of personal connection. It spread from the Black community to the general population and it exists still today. The choreographed pregame handshake you see so many NBA players engage in is a descendant of the dap. Like many rituals, it reinforces bonds with those who are your people, your team, those you trust.
The more generalized version is the simple fist bump. It is widely used, notably by President Obama, and in the appropriate circumstance, will almost always be reciprocated. But it doesn’t work well to create trust with a stranger. With a patient for example, you are not showing them respect for some accomplishment. Nor are we connecting with them as a member of your team. Unless this is a patient whom you’ve seen many times before, a fist bump attempt might be met with “are you serious?” In fact, a survey done in 2016 asking infectious disease professionals what they thought of fist bumps as a greeting, very few replied it was a good idea. Most felt it was unprofessional. Not to mention that a fist bump does not symbolize an agreement in the way that a handshake does (and has done since at least the 9th century BC).
With COVID waning and masks doffed, I’ve found myself back to handshaking. Yes, I sanitize before and after, another ritual that has symbolic as well as practical significance. I get fewer sideways glances from my geriatric patients for sure. But I do still offer a little dap for my liquid nitrogen–survivor kids and for the occasional fellow Gen Xer. “Wonder Twin powers, activate!”
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com
Time to prescribe sauna bathing for cardiovascular health?
Is it time to start recommending regular sauna bathing to improve heart health?
While a post-workout sauna can compound the benefits of exercise, the hormetic effects of heat therapy alone can produce significant gains for microvascular and endothelial function, no workout required.
“There’s enough evidence to say that regular sauna use improves cardiovascular health,” Matthew S. Ganio, PhD, a professor of exercise science at the University of Arkansas in Fayetteville, who studies thermoregulatory responses and cardiovascular health, said.
“The more they used it, the greater the reduction in cardiovascular events like heart attack. But you don’t need to be in there more than 20-30 minutes. That’s where it seemed to have the best effect,” Dr. Ganio said, adding that studies have shown a dose-response.
A prospective cohort study published in 2015 in JAMA Internal Medicine included 20 years of data on more than 2,300 Finnish men who regularly sauna bathed. The researchers found that among participants who sat in saunas more frequently, rates of death from heart disease and stroke were lower than among those who did so less often.
Cutaneous vasodilation
The body experiences several physiologic changes when exposed to heat therapy of any kind, including sauna, hot water submerging, shortwave diathermy, and heat wrapping. Many of these changes involve elements of the cardiovascular system, said Earric Lee, PhD, an exercise physiologist and postdoctoral researcher at the University of Jyväskylä in Finland, who has studied the effects of sauna on cardiovascular health.
The mechanisms by which heat therapy improves cardiovascular fitness have not been determined, as few studies of sauna bathing have been conducted to this degree. One driver appears to be cutaneous vasodilation. To cool the body when exposed to extreme external heat, cutaneous vessels dilate and push blood to the skin, which lowers body temperature, increases heart rate, and delivers oxygen to muscles in the limbs in a way similar to aerobic exercise.
Sauna bathing has similar effects on heart rate and cardiac output. Studies have shown it can improve the circulation of blood through the body, as well as vascular endothelial function, which is closely tied to vascular tone.
“Increased cardiac output is one of the physiologic reasons sauna is good for heart health,” Dr. Ganio said.
During a sauna session, cardiac output can increase by as much as 70% in relation to elevated heart rate. And while heart rate and cardiac output rise, stroke volume remains stable. As stroke volume increases, the effort that muscle must exert increases. When heart rate rises, stroke volume often falls, which subjects the heart to less of a workout and reduces the amount of oxygen and blood circulating throughout the body.
Heat therapy also temporarily increases blood pressure, but in a way similar to exercise, which supports better long-term heart health, said Christopher Minson, PhD, the Kenneth M. and Kenda H. Singer Endowed Professor of Human Physiology at the University of Oregon in Eugene.
A small study of 19 healthy adults that was published in Complementary Therapies in Medicine in 2019 found that blood pressure and heart rate rose during a 25-minute sauna session as they might during moderate exercise, equivalent to an exercise load of about 60-100 watts. These parameters then steadily decreased for 30 minutes after the sauna. An earlier study found that in the long term, blood pressure was lower after a sauna than before a sauna.
Upregulated heat shock proteins
Both aerobic exercise and heat stress from sauna bathing increase the activity of heat shock proteins. A 2021 review published in Experimental Gerontology found that heat shock proteins become elevated in cells within 30 minutes of exposure to heat and remain elevated over time – an effect similar to exercise.
“Saunas increase heat shock proteins that break down old, dysfunctional proteins and then protect new proteins from becoming dysfunctional,” Hunter S. Waldman, PhD, an assistant professor of exercise science at the University of North Alabama in Florence, said. This effect is one way sauna bathing may quell systemic inflammation, Dr. Waldman said.
According to a 2018 review published in BioMed Research International, an abundance of heat shock proteins may increase exercise tolerance. The researchers concluded that the positive stress associated with elevated body temperature could help people be physically active for longer periods.
Added stress, especially heat-related strain, is not good for everyone, however. Dr. Waldman cautioned that heat exposure, be it through a sauna, hot tub, or other source, can be harmful for pregnant women and children and can be dangerous for people who have low blood pressure, since blood pressure often drops to rates that are lower than before taking a sauna. It also can impair semen quality for months after exposure, so people who are trying to conceive should avoid sauna bathing.
Anyone who has been diagnosed with a heart condition, including cardiac arrhythmia, coronary artery disease, and congestive heart failure, should always consult their physician prior to using sauna for the first time or before using it habitually, Dr. Lee said.
Effects compounded by exercise
Dr. Minson stressed that any type of heat therapy should be part of a lifestyle that includes mostly healthy habits overall, especially a regular exercise regime when possible.
“You have to have everything else working as well: finding time to relax, not being overly stressed, staying hydrated – all those things are critical with any exercise training and heat therapy program,” he said.
Dr. Lee said it’s easy to overhype the benefits of sauna bathing and agreed the practice should be used in tandem with other therapies, not as a replacement. So far, stacking research has shown it to be an effective extension of aerobic exercise.
A June 2023 review published in Mayo Clinic Proceedings found that while sauna bathing can produce benefits on its own, a post-workout sauna can extend the benefits of exercise. As a result, the researchers concluded, saunas likely provide the most benefit when combined with aerobic and strength training.
While some of the benefits of exercise overlap those associated with sauna bathing, “you’re going to get some benefits with exercise that you’re never going to get with sauna,” Dr. Ganio said.
For instance, strength training or aerobic exercise usually results in muscle contractions, which sauna bathing does not produce.
If a person is impaired in a way that makes exercise difficult, taking a sauna after aerobic activity can extend the cardiovascular benefits of the workout, even if muscle-building does not occur, Dr. Lee said.
“All other things considered, especially with aerobic exercise, it is very comparable, so we can look at adding sauna bathing post exercise as a way to lengthen the aerobic exercise workout,” he said. “It’s not to the same degree, but you can get many of the ranging benefits of exercising simply by going into the sauna.”
The authors have disclosed no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
Is it time to start recommending regular sauna bathing to improve heart health?
While a post-workout sauna can compound the benefits of exercise, the hormetic effects of heat therapy alone can produce significant gains for microvascular and endothelial function, no workout required.
“There’s enough evidence to say that regular sauna use improves cardiovascular health,” Matthew S. Ganio, PhD, a professor of exercise science at the University of Arkansas in Fayetteville, who studies thermoregulatory responses and cardiovascular health, said.
“The more they used it, the greater the reduction in cardiovascular events like heart attack. But you don’t need to be in there more than 20-30 minutes. That’s where it seemed to have the best effect,” Dr. Ganio said, adding that studies have shown a dose-response.
A prospective cohort study published in 2015 in JAMA Internal Medicine included 20 years of data on more than 2,300 Finnish men who regularly sauna bathed. The researchers found that among participants who sat in saunas more frequently, rates of death from heart disease and stroke were lower than among those who did so less often.
Cutaneous vasodilation
The body experiences several physiologic changes when exposed to heat therapy of any kind, including sauna, hot water submerging, shortwave diathermy, and heat wrapping. Many of these changes involve elements of the cardiovascular system, said Earric Lee, PhD, an exercise physiologist and postdoctoral researcher at the University of Jyväskylä in Finland, who has studied the effects of sauna on cardiovascular health.
The mechanisms by which heat therapy improves cardiovascular fitness have not been determined, as few studies of sauna bathing have been conducted to this degree. One driver appears to be cutaneous vasodilation. To cool the body when exposed to extreme external heat, cutaneous vessels dilate and push blood to the skin, which lowers body temperature, increases heart rate, and delivers oxygen to muscles in the limbs in a way similar to aerobic exercise.
Sauna bathing has similar effects on heart rate and cardiac output. Studies have shown it can improve the circulation of blood through the body, as well as vascular endothelial function, which is closely tied to vascular tone.
“Increased cardiac output is one of the physiologic reasons sauna is good for heart health,” Dr. Ganio said.
During a sauna session, cardiac output can increase by as much as 70% in relation to elevated heart rate. And while heart rate and cardiac output rise, stroke volume remains stable. As stroke volume increases, the effort that muscle must exert increases. When heart rate rises, stroke volume often falls, which subjects the heart to less of a workout and reduces the amount of oxygen and blood circulating throughout the body.
Heat therapy also temporarily increases blood pressure, but in a way similar to exercise, which supports better long-term heart health, said Christopher Minson, PhD, the Kenneth M. and Kenda H. Singer Endowed Professor of Human Physiology at the University of Oregon in Eugene.
A small study of 19 healthy adults that was published in Complementary Therapies in Medicine in 2019 found that blood pressure and heart rate rose during a 25-minute sauna session as they might during moderate exercise, equivalent to an exercise load of about 60-100 watts. These parameters then steadily decreased for 30 minutes after the sauna. An earlier study found that in the long term, blood pressure was lower after a sauna than before a sauna.
Upregulated heat shock proteins
Both aerobic exercise and heat stress from sauna bathing increase the activity of heat shock proteins. A 2021 review published in Experimental Gerontology found that heat shock proteins become elevated in cells within 30 minutes of exposure to heat and remain elevated over time – an effect similar to exercise.
“Saunas increase heat shock proteins that break down old, dysfunctional proteins and then protect new proteins from becoming dysfunctional,” Hunter S. Waldman, PhD, an assistant professor of exercise science at the University of North Alabama in Florence, said. This effect is one way sauna bathing may quell systemic inflammation, Dr. Waldman said.
According to a 2018 review published in BioMed Research International, an abundance of heat shock proteins may increase exercise tolerance. The researchers concluded that the positive stress associated with elevated body temperature could help people be physically active for longer periods.
Added stress, especially heat-related strain, is not good for everyone, however. Dr. Waldman cautioned that heat exposure, be it through a sauna, hot tub, or other source, can be harmful for pregnant women and children and can be dangerous for people who have low blood pressure, since blood pressure often drops to rates that are lower than before taking a sauna. It also can impair semen quality for months after exposure, so people who are trying to conceive should avoid sauna bathing.
Anyone who has been diagnosed with a heart condition, including cardiac arrhythmia, coronary artery disease, and congestive heart failure, should always consult their physician prior to using sauna for the first time or before using it habitually, Dr. Lee said.
Effects compounded by exercise
Dr. Minson stressed that any type of heat therapy should be part of a lifestyle that includes mostly healthy habits overall, especially a regular exercise regime when possible.
“You have to have everything else working as well: finding time to relax, not being overly stressed, staying hydrated – all those things are critical with any exercise training and heat therapy program,” he said.
Dr. Lee said it’s easy to overhype the benefits of sauna bathing and agreed the practice should be used in tandem with other therapies, not as a replacement. So far, stacking research has shown it to be an effective extension of aerobic exercise.
A June 2023 review published in Mayo Clinic Proceedings found that while sauna bathing can produce benefits on its own, a post-workout sauna can extend the benefits of exercise. As a result, the researchers concluded, saunas likely provide the most benefit when combined with aerobic and strength training.
While some of the benefits of exercise overlap those associated with sauna bathing, “you’re going to get some benefits with exercise that you’re never going to get with sauna,” Dr. Ganio said.
For instance, strength training or aerobic exercise usually results in muscle contractions, which sauna bathing does not produce.
If a person is impaired in a way that makes exercise difficult, taking a sauna after aerobic activity can extend the cardiovascular benefits of the workout, even if muscle-building does not occur, Dr. Lee said.
“All other things considered, especially with aerobic exercise, it is very comparable, so we can look at adding sauna bathing post exercise as a way to lengthen the aerobic exercise workout,” he said. “It’s not to the same degree, but you can get many of the ranging benefits of exercising simply by going into the sauna.”
The authors have disclosed no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
Is it time to start recommending regular sauna bathing to improve heart health?
While a post-workout sauna can compound the benefits of exercise, the hormetic effects of heat therapy alone can produce significant gains for microvascular and endothelial function, no workout required.
“There’s enough evidence to say that regular sauna use improves cardiovascular health,” Matthew S. Ganio, PhD, a professor of exercise science at the University of Arkansas in Fayetteville, who studies thermoregulatory responses and cardiovascular health, said.
“The more they used it, the greater the reduction in cardiovascular events like heart attack. But you don’t need to be in there more than 20-30 minutes. That’s where it seemed to have the best effect,” Dr. Ganio said, adding that studies have shown a dose-response.
A prospective cohort study published in 2015 in JAMA Internal Medicine included 20 years of data on more than 2,300 Finnish men who regularly sauna bathed. The researchers found that among participants who sat in saunas more frequently, rates of death from heart disease and stroke were lower than among those who did so less often.
Cutaneous vasodilation
The body experiences several physiologic changes when exposed to heat therapy of any kind, including sauna, hot water submerging, shortwave diathermy, and heat wrapping. Many of these changes involve elements of the cardiovascular system, said Earric Lee, PhD, an exercise physiologist and postdoctoral researcher at the University of Jyväskylä in Finland, who has studied the effects of sauna on cardiovascular health.
The mechanisms by which heat therapy improves cardiovascular fitness have not been determined, as few studies of sauna bathing have been conducted to this degree. One driver appears to be cutaneous vasodilation. To cool the body when exposed to extreme external heat, cutaneous vessels dilate and push blood to the skin, which lowers body temperature, increases heart rate, and delivers oxygen to muscles in the limbs in a way similar to aerobic exercise.
Sauna bathing has similar effects on heart rate and cardiac output. Studies have shown it can improve the circulation of blood through the body, as well as vascular endothelial function, which is closely tied to vascular tone.
“Increased cardiac output is one of the physiologic reasons sauna is good for heart health,” Dr. Ganio said.
During a sauna session, cardiac output can increase by as much as 70% in relation to elevated heart rate. And while heart rate and cardiac output rise, stroke volume remains stable. As stroke volume increases, the effort that muscle must exert increases. When heart rate rises, stroke volume often falls, which subjects the heart to less of a workout and reduces the amount of oxygen and blood circulating throughout the body.
Heat therapy also temporarily increases blood pressure, but in a way similar to exercise, which supports better long-term heart health, said Christopher Minson, PhD, the Kenneth M. and Kenda H. Singer Endowed Professor of Human Physiology at the University of Oregon in Eugene.
A small study of 19 healthy adults that was published in Complementary Therapies in Medicine in 2019 found that blood pressure and heart rate rose during a 25-minute sauna session as they might during moderate exercise, equivalent to an exercise load of about 60-100 watts. These parameters then steadily decreased for 30 minutes after the sauna. An earlier study found that in the long term, blood pressure was lower after a sauna than before a sauna.
Upregulated heat shock proteins
Both aerobic exercise and heat stress from sauna bathing increase the activity of heat shock proteins. A 2021 review published in Experimental Gerontology found that heat shock proteins become elevated in cells within 30 minutes of exposure to heat and remain elevated over time – an effect similar to exercise.
“Saunas increase heat shock proteins that break down old, dysfunctional proteins and then protect new proteins from becoming dysfunctional,” Hunter S. Waldman, PhD, an assistant professor of exercise science at the University of North Alabama in Florence, said. This effect is one way sauna bathing may quell systemic inflammation, Dr. Waldman said.
According to a 2018 review published in BioMed Research International, an abundance of heat shock proteins may increase exercise tolerance. The researchers concluded that the positive stress associated with elevated body temperature could help people be physically active for longer periods.
Added stress, especially heat-related strain, is not good for everyone, however. Dr. Waldman cautioned that heat exposure, be it through a sauna, hot tub, or other source, can be harmful for pregnant women and children and can be dangerous for people who have low blood pressure, since blood pressure often drops to rates that are lower than before taking a sauna. It also can impair semen quality for months after exposure, so people who are trying to conceive should avoid sauna bathing.
Anyone who has been diagnosed with a heart condition, including cardiac arrhythmia, coronary artery disease, and congestive heart failure, should always consult their physician prior to using sauna for the first time or before using it habitually, Dr. Lee said.
Effects compounded by exercise
Dr. Minson stressed that any type of heat therapy should be part of a lifestyle that includes mostly healthy habits overall, especially a regular exercise regime when possible.
“You have to have everything else working as well: finding time to relax, not being overly stressed, staying hydrated – all those things are critical with any exercise training and heat therapy program,” he said.
Dr. Lee said it’s easy to overhype the benefits of sauna bathing and agreed the practice should be used in tandem with other therapies, not as a replacement. So far, stacking research has shown it to be an effective extension of aerobic exercise.
A June 2023 review published in Mayo Clinic Proceedings found that while sauna bathing can produce benefits on its own, a post-workout sauna can extend the benefits of exercise. As a result, the researchers concluded, saunas likely provide the most benefit when combined with aerobic and strength training.
While some of the benefits of exercise overlap those associated with sauna bathing, “you’re going to get some benefits with exercise that you’re never going to get with sauna,” Dr. Ganio said.
For instance, strength training or aerobic exercise usually results in muscle contractions, which sauna bathing does not produce.
If a person is impaired in a way that makes exercise difficult, taking a sauna after aerobic activity can extend the cardiovascular benefits of the workout, even if muscle-building does not occur, Dr. Lee said.
“All other things considered, especially with aerobic exercise, it is very comparable, so we can look at adding sauna bathing post exercise as a way to lengthen the aerobic exercise workout,” he said. “It’s not to the same degree, but you can get many of the ranging benefits of exercising simply by going into the sauna.”
The authors have disclosed no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
Prognostic factors of SCCs in organ transplant recipients worse compared with general population
, results from a dual cohort study demonstrated.
The findings build on previous research and underscore the need for early diagnosis and aggressive surveillance in this patient population, corresponding author Adele C. Green, MBBS, PhD, professor and senior scientist at the QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia, and colleagues wrote in the study, which was published online in JAMA Dermatology. “Squamous cell carcinomas (SCCs) of the skin develop up to 77 times more frequently in immunosuppressed organ transplant recipients (OTRs) than the general population,” they wrote. “Because SCCs cause substantially more morbidity and death in the former, they are postulated to be innately more aggressive than in immunocompetent patients, but OTRs’ higher SCC mortality may simply reflect greater SCC tumor burdens per patient.”
In what is believed to be the first study of its kind, Dr. Green and colleagues drew data from two cohort studies to evaluate five key clinicopathologic indicators of poor SCC outcomes in organ transplant recipients, and in those from the general population in Queensland, Australia: cephalic location, perineural invasion, invasion to/beyond subcutaneous fat, poor differentiation, and tumor size greater than 20 mm. The study population included organ transplant recipients at high risk of skin cancer, who were enrolled in the Skin Tumours in Allograft Recipients (STAR) study, and those from a population-based cohort, the QSkin Sun and Health Study. STAR consisted of lung transplant recipients and kidney and liver transplant recipients at high risk of skin cancer who were recruited from tertiary centers and diagnosed with histopathologically confirmed SCC from 2012 to 2015. QSkin consisted of individuals from Queensland’s general adult population diagnosed with SCCs from 2012 to 2015.
SCC cases in QSkin were ascertained through Australia’s universal health insurance agency and linked with histopathology records. Next, the researchers performed data analysis from both cohort studies to determine the prevalence ratio (PR) of head/neck location, perineural invasion, tumor invasion to/beyond subcutaneous fat, poor cellular differentiation, and tumor diameter greater than 20 mm among SCCs among organ transplant recipients compared with the general population.
After combining the two studies, the researchers compared 741 SCCs excised from 191 organ transplant recipients and 2,558 SCCs excised from 1,507 individuals in the general population. Their median ages were similar (62.7 and 63.7 years, respectively) and most were male (78% and 63.4%, respectively).
As for site of involvement, SCCs developed most often on the head and neck in the transplant recipients (38.6%) and on the arms and hands in the general population (35.2%). After adjustment for age and sex, perineural invasion of SCCs was more than twice as common in transplant recipients than among cases in the general population, as was invasion to/beyond subcutaneous fat (PR of 2.37 for both associations).
In other findings, compared with SCCs in the general population, poorly vs. well-differentiated SCCs were more than threefold more common in transplant recipients (PR, 3.45), while the prevalence of tumors greater than 20 mm vs. 20 mm or smaller was moderately higher in transplant recipients (PR, 1.52).
“These findings are considered generalizable, confirming that OTRs’ poorer SCC outcomes are associated with not only their sheer numbers of SCC tumors, but also with a strong shift toward more invasive, less differentiated, and larger SCC tumors, in agreement with previous findings,” the researchers wrote. “This shift is likely associated with decreased immunosurveillance resulting from immunosuppressive therapy (since carcinogenesis decelerates with therapy cessation) interacting with effects of high UV radiation exposure.”
They acknowledged certain limitations of their analysis, chiefly the lack of central review of SCCs to ensure standard assessment of histopathologic features “including caliber of nerves with perineural invasion and cell differentiation; such a review would not have been feasible logistically.”
The study was supported by grants from the National Health and Medical Research Council of Australia. The researchers reported having no disclosures related to the submitted work.
, results from a dual cohort study demonstrated.
The findings build on previous research and underscore the need for early diagnosis and aggressive surveillance in this patient population, corresponding author Adele C. Green, MBBS, PhD, professor and senior scientist at the QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia, and colleagues wrote in the study, which was published online in JAMA Dermatology. “Squamous cell carcinomas (SCCs) of the skin develop up to 77 times more frequently in immunosuppressed organ transplant recipients (OTRs) than the general population,” they wrote. “Because SCCs cause substantially more morbidity and death in the former, they are postulated to be innately more aggressive than in immunocompetent patients, but OTRs’ higher SCC mortality may simply reflect greater SCC tumor burdens per patient.”
In what is believed to be the first study of its kind, Dr. Green and colleagues drew data from two cohort studies to evaluate five key clinicopathologic indicators of poor SCC outcomes in organ transplant recipients, and in those from the general population in Queensland, Australia: cephalic location, perineural invasion, invasion to/beyond subcutaneous fat, poor differentiation, and tumor size greater than 20 mm. The study population included organ transplant recipients at high risk of skin cancer, who were enrolled in the Skin Tumours in Allograft Recipients (STAR) study, and those from a population-based cohort, the QSkin Sun and Health Study. STAR consisted of lung transplant recipients and kidney and liver transplant recipients at high risk of skin cancer who were recruited from tertiary centers and diagnosed with histopathologically confirmed SCC from 2012 to 2015. QSkin consisted of individuals from Queensland’s general adult population diagnosed with SCCs from 2012 to 2015.
SCC cases in QSkin were ascertained through Australia’s universal health insurance agency and linked with histopathology records. Next, the researchers performed data analysis from both cohort studies to determine the prevalence ratio (PR) of head/neck location, perineural invasion, tumor invasion to/beyond subcutaneous fat, poor cellular differentiation, and tumor diameter greater than 20 mm among SCCs among organ transplant recipients compared with the general population.
After combining the two studies, the researchers compared 741 SCCs excised from 191 organ transplant recipients and 2,558 SCCs excised from 1,507 individuals in the general population. Their median ages were similar (62.7 and 63.7 years, respectively) and most were male (78% and 63.4%, respectively).
As for site of involvement, SCCs developed most often on the head and neck in the transplant recipients (38.6%) and on the arms and hands in the general population (35.2%). After adjustment for age and sex, perineural invasion of SCCs was more than twice as common in transplant recipients than among cases in the general population, as was invasion to/beyond subcutaneous fat (PR of 2.37 for both associations).
In other findings, compared with SCCs in the general population, poorly vs. well-differentiated SCCs were more than threefold more common in transplant recipients (PR, 3.45), while the prevalence of tumors greater than 20 mm vs. 20 mm or smaller was moderately higher in transplant recipients (PR, 1.52).
“These findings are considered generalizable, confirming that OTRs’ poorer SCC outcomes are associated with not only their sheer numbers of SCC tumors, but also with a strong shift toward more invasive, less differentiated, and larger SCC tumors, in agreement with previous findings,” the researchers wrote. “This shift is likely associated with decreased immunosurveillance resulting from immunosuppressive therapy (since carcinogenesis decelerates with therapy cessation) interacting with effects of high UV radiation exposure.”
They acknowledged certain limitations of their analysis, chiefly the lack of central review of SCCs to ensure standard assessment of histopathologic features “including caliber of nerves with perineural invasion and cell differentiation; such a review would not have been feasible logistically.”
The study was supported by grants from the National Health and Medical Research Council of Australia. The researchers reported having no disclosures related to the submitted work.
, results from a dual cohort study demonstrated.
The findings build on previous research and underscore the need for early diagnosis and aggressive surveillance in this patient population, corresponding author Adele C. Green, MBBS, PhD, professor and senior scientist at the QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia, and colleagues wrote in the study, which was published online in JAMA Dermatology. “Squamous cell carcinomas (SCCs) of the skin develop up to 77 times more frequently in immunosuppressed organ transplant recipients (OTRs) than the general population,” they wrote. “Because SCCs cause substantially more morbidity and death in the former, they are postulated to be innately more aggressive than in immunocompetent patients, but OTRs’ higher SCC mortality may simply reflect greater SCC tumor burdens per patient.”
In what is believed to be the first study of its kind, Dr. Green and colleagues drew data from two cohort studies to evaluate five key clinicopathologic indicators of poor SCC outcomes in organ transplant recipients, and in those from the general population in Queensland, Australia: cephalic location, perineural invasion, invasion to/beyond subcutaneous fat, poor differentiation, and tumor size greater than 20 mm. The study population included organ transplant recipients at high risk of skin cancer, who were enrolled in the Skin Tumours in Allograft Recipients (STAR) study, and those from a population-based cohort, the QSkin Sun and Health Study. STAR consisted of lung transplant recipients and kidney and liver transplant recipients at high risk of skin cancer who were recruited from tertiary centers and diagnosed with histopathologically confirmed SCC from 2012 to 2015. QSkin consisted of individuals from Queensland’s general adult population diagnosed with SCCs from 2012 to 2015.
SCC cases in QSkin were ascertained through Australia’s universal health insurance agency and linked with histopathology records. Next, the researchers performed data analysis from both cohort studies to determine the prevalence ratio (PR) of head/neck location, perineural invasion, tumor invasion to/beyond subcutaneous fat, poor cellular differentiation, and tumor diameter greater than 20 mm among SCCs among organ transplant recipients compared with the general population.
After combining the two studies, the researchers compared 741 SCCs excised from 191 organ transplant recipients and 2,558 SCCs excised from 1,507 individuals in the general population. Their median ages were similar (62.7 and 63.7 years, respectively) and most were male (78% and 63.4%, respectively).
As for site of involvement, SCCs developed most often on the head and neck in the transplant recipients (38.6%) and on the arms and hands in the general population (35.2%). After adjustment for age and sex, perineural invasion of SCCs was more than twice as common in transplant recipients than among cases in the general population, as was invasion to/beyond subcutaneous fat (PR of 2.37 for both associations).
In other findings, compared with SCCs in the general population, poorly vs. well-differentiated SCCs were more than threefold more common in transplant recipients (PR, 3.45), while the prevalence of tumors greater than 20 mm vs. 20 mm or smaller was moderately higher in transplant recipients (PR, 1.52).
“These findings are considered generalizable, confirming that OTRs’ poorer SCC outcomes are associated with not only their sheer numbers of SCC tumors, but also with a strong shift toward more invasive, less differentiated, and larger SCC tumors, in agreement with previous findings,” the researchers wrote. “This shift is likely associated with decreased immunosurveillance resulting from immunosuppressive therapy (since carcinogenesis decelerates with therapy cessation) interacting with effects of high UV radiation exposure.”
They acknowledged certain limitations of their analysis, chiefly the lack of central review of SCCs to ensure standard assessment of histopathologic features “including caliber of nerves with perineural invasion and cell differentiation; such a review would not have been feasible logistically.”
The study was supported by grants from the National Health and Medical Research Council of Australia. The researchers reported having no disclosures related to the submitted work.
FROM JAMA DERMATOLOGY
FDA OKs low-dose colchicine for broad CV indication
The Food and Drug Administration has approved the anti-inflammatory drug colchicine 0.5 mg tablets (Lodoco) as the first specific anti-inflammatory drug demonstrated to reduce the risk for myocardial infarction, stroke, coronary revascularization, and cardiovascular death in adult patients with established atherosclerotic disease or with multiple risk factors for cardiovascular disease.
The drug, which targets residual inflammation as an underlying cause of atherosclerotic cardiovascular disease, has a dosage of 0.5 mg once daily, and can be used alone or in combination with cholesterol-lowering medications. 
The drug’s manufacturer, Agepha Pharma, said it anticipates that Lodoco will be available for prescription in the second half of 2023.
Colchicine has been available for many years and used at higher doses for the acute treatment of gout and pericarditis, but the current formulation is a much lower dose for long-term use in patients with atherosclerotic heart disease.
Data supporting the approval has come from two major randomized trials, LoDoCo-2 and COLCOT.
In the LoDoCo-2 trial, the anti-inflammatory drug cut the risk of cardiovascular events by one third when added to standard prevention therapies in patients with chronic coronary disease. And in the COLCOT study, use of colchicine reduced cardiovascular events by 23% compared with placebo in patients with a recent MI.
Paul Ridker, MD, director of the Center for Cardiovascular Disease Prevention at Brigham and Women’s Hospital in Boston, who has been a pioneer in establishing inflammation as an underlying cause of atherosclerotic cardiovascular disease, welcomed the Lodoco approval.
‘A very big day for cardiology’
“This is a very big day for cardiology,” Dr. Ridker said in an interview.
“The FDA approval of colchicine for patients with atherosclerotic disease is a huge signal that physicians need to be aware of inflammation as a key player in cardiovascular disease,” he said.
Dr. Ridker was the lead author of a recent study showing that among patients receiving contemporary statins, inflammation assessed by high-sensitivity C-reactive protein (hsCRP) was a stronger predictor for risk of future cardiovascular events and death than LDL cholesterol.
He pointed out that
“That is virtually identical to the indication approved for statin therapy. That shows just how important the FDA thinks this is,” he commented.
But Dr. Ridker added that, while the label does not specify that Lodoco has to be used in addition to statin therapy, he believes that it will be used as additional therapy to statins in the vast majority of patients.
“This is not an alternative to statin therapy. In the randomized trials, the benefits were seen on top of statins,” he stressed.
Dr. Ridker believes that physicians will need time to feel comfortable with this new approach.
“Initially, I think, it will be used mainly by cardiologists who know about inflammation, but I believe over time it will be widely prescribed by internists, in much the same way as statins are used today,” he commented.
Dr. Ridker said he already uses low dose colchicine in his high-risk patients who have high levels of inflammation as seen on hsCRP testing. He believes this is where the drug will mostly be used initially, as this is where it is likely to be most effective.
The prescribing information states that Lodoco is contraindicated in patients who are taking strong CYP3A4 inhibitors or P-glycoprotein inhibitors, such as ketoconazole, fluconazole, and clarithromycin, and in patients with preexisting blood dyscrasias, renal failure, and severe hepatic impairment.
Common side effects reported in published clinical studies and literature with the use of colchicine are gastrointestinal symptoms (diarrhea, vomiting, abdominal cramping) and myalgia.
More serious adverse effects are listed as blood dyscrasias such as myelosuppression, leukopenia, granulocytopenia, thrombocytopenia, pancytopenia, and aplastic anemia; and neuromuscular toxicity in the form of myotoxicity including rhabdomyolysis, which may occur, especially in combination with other drugs known to cause this effect. If these adverse effects occur, it is recommended that the drug be stopped.
The prescribing information also notes that Lodoco may rarely and transiently impair fertility in males; and that patients with renal or hepatic impairment should be monitored closely for adverse effects of colchicine.
A version of this article first appeared on Medscape.com.
The Food and Drug Administration has approved the anti-inflammatory drug colchicine 0.5 mg tablets (Lodoco) as the first specific anti-inflammatory drug demonstrated to reduce the risk for myocardial infarction, stroke, coronary revascularization, and cardiovascular death in adult patients with established atherosclerotic disease or with multiple risk factors for cardiovascular disease.
The drug, which targets residual inflammation as an underlying cause of atherosclerotic cardiovascular disease, has a dosage of 0.5 mg once daily, and can be used alone or in combination with cholesterol-lowering medications.
The drug’s manufacturer, Agepha Pharma, said it anticipates that Lodoco will be available for prescription in the second half of 2023.
Colchicine has been available for many years and used at higher doses for the acute treatment of gout and pericarditis, but the current formulation is a much lower dose for long-term use in patients with atherosclerotic heart disease.
Data supporting the approval has come from two major randomized trials, LoDoCo-2 and COLCOT.
In the LoDoCo-2 trial, the anti-inflammatory drug cut the risk of cardiovascular events by one third when added to standard prevention therapies in patients with chronic coronary disease. And in the COLCOT study, use of colchicine reduced cardiovascular events by 23% compared with placebo in patients with a recent MI.
Paul Ridker, MD, director of the Center for Cardiovascular Disease Prevention at Brigham and Women’s Hospital in Boston, who has been a pioneer in establishing inflammation as an underlying cause of atherosclerotic cardiovascular disease, welcomed the Lodoco approval.
‘A very big day for cardiology’
“This is a very big day for cardiology,” Dr. Ridker said in an interview.
“The FDA approval of colchicine for patients with atherosclerotic disease is a huge signal that physicians need to be aware of inflammation as a key player in cardiovascular disease,” he said.
Dr. Ridker was the lead author of a recent study showing that among patients receiving contemporary statins, inflammation assessed by high-sensitivity C-reactive protein (hsCRP) was a stronger predictor for risk of future cardiovascular events and death than LDL cholesterol.
He pointed out that
“That is virtually identical to the indication approved for statin therapy. That shows just how important the FDA thinks this is,” he commented.
But Dr. Ridker added that, while the label does not specify that Lodoco has to be used in addition to statin therapy, he believes that it will be used as additional therapy to statins in the vast majority of patients.
“This is not an alternative to statin therapy. In the randomized trials, the benefits were seen on top of statins,” he stressed.
Dr. Ridker believes that physicians will need time to feel comfortable with this new approach.
“Initially, I think, it will be used mainly by cardiologists who know about inflammation, but I believe over time it will be widely prescribed by internists, in much the same way as statins are used today,” he commented.
Dr. Ridker said he already uses low dose colchicine in his high-risk patients who have high levels of inflammation as seen on hsCRP testing. He believes this is where the drug will mostly be used initially, as this is where it is likely to be most effective.
The prescribing information states that Lodoco is contraindicated in patients who are taking strong CYP3A4 inhibitors or P-glycoprotein inhibitors, such as ketoconazole, fluconazole, and clarithromycin, and in patients with preexisting blood dyscrasias, renal failure, and severe hepatic impairment.
Common side effects reported in published clinical studies and literature with the use of colchicine are gastrointestinal symptoms (diarrhea, vomiting, abdominal cramping) and myalgia.
More serious adverse effects are listed as blood dyscrasias such as myelosuppression, leukopenia, granulocytopenia, thrombocytopenia, pancytopenia, and aplastic anemia; and neuromuscular toxicity in the form of myotoxicity including rhabdomyolysis, which may occur, especially in combination with other drugs known to cause this effect. If these adverse effects occur, it is recommended that the drug be stopped.
The prescribing information also notes that Lodoco may rarely and transiently impair fertility in males; and that patients with renal or hepatic impairment should be monitored closely for adverse effects of colchicine.
A version of this article first appeared on Medscape.com.
The Food and Drug Administration has approved the anti-inflammatory drug colchicine 0.5 mg tablets (Lodoco) as the first specific anti-inflammatory drug demonstrated to reduce the risk for myocardial infarction, stroke, coronary revascularization, and cardiovascular death in adult patients with established atherosclerotic disease or with multiple risk factors for cardiovascular disease.
The drug, which targets residual inflammation as an underlying cause of atherosclerotic cardiovascular disease, has a dosage of 0.5 mg once daily, and can be used alone or in combination with cholesterol-lowering medications.
The drug’s manufacturer, Agepha Pharma, said it anticipates that Lodoco will be available for prescription in the second half of 2023.
Colchicine has been available for many years and used at higher doses for the acute treatment of gout and pericarditis, but the current formulation is a much lower dose for long-term use in patients with atherosclerotic heart disease.
Data supporting the approval has come from two major randomized trials, LoDoCo-2 and COLCOT.
In the LoDoCo-2 trial, the anti-inflammatory drug cut the risk of cardiovascular events by one third when added to standard prevention therapies in patients with chronic coronary disease. And in the COLCOT study, use of colchicine reduced cardiovascular events by 23% compared with placebo in patients with a recent MI.
Paul Ridker, MD, director of the Center for Cardiovascular Disease Prevention at Brigham and Women’s Hospital in Boston, who has been a pioneer in establishing inflammation as an underlying cause of atherosclerotic cardiovascular disease, welcomed the Lodoco approval.
‘A very big day for cardiology’
“This is a very big day for cardiology,” Dr. Ridker said in an interview.
“The FDA approval of colchicine for patients with atherosclerotic disease is a huge signal that physicians need to be aware of inflammation as a key player in cardiovascular disease,” he said.
Dr. Ridker was the lead author of a recent study showing that among patients receiving contemporary statins, inflammation assessed by high-sensitivity C-reactive protein (hsCRP) was a stronger predictor for risk of future cardiovascular events and death than LDL cholesterol.
He pointed out that
“That is virtually identical to the indication approved for statin therapy. That shows just how important the FDA thinks this is,” he commented.
But Dr. Ridker added that, while the label does not specify that Lodoco has to be used in addition to statin therapy, he believes that it will be used as additional therapy to statins in the vast majority of patients.
“This is not an alternative to statin therapy. In the randomized trials, the benefits were seen on top of statins,” he stressed.
Dr. Ridker believes that physicians will need time to feel comfortable with this new approach.
“Initially, I think, it will be used mainly by cardiologists who know about inflammation, but I believe over time it will be widely prescribed by internists, in much the same way as statins are used today,” he commented.
Dr. Ridker said he already uses low dose colchicine in his high-risk patients who have high levels of inflammation as seen on hsCRP testing. He believes this is where the drug will mostly be used initially, as this is where it is likely to be most effective.
The prescribing information states that Lodoco is contraindicated in patients who are taking strong CYP3A4 inhibitors or P-glycoprotein inhibitors, such as ketoconazole, fluconazole, and clarithromycin, and in patients with preexisting blood dyscrasias, renal failure, and severe hepatic impairment.
Common side effects reported in published clinical studies and literature with the use of colchicine are gastrointestinal symptoms (diarrhea, vomiting, abdominal cramping) and myalgia.
More serious adverse effects are listed as blood dyscrasias such as myelosuppression, leukopenia, granulocytopenia, thrombocytopenia, pancytopenia, and aplastic anemia; and neuromuscular toxicity in the form of myotoxicity including rhabdomyolysis, which may occur, especially in combination with other drugs known to cause this effect. If these adverse effects occur, it is recommended that the drug be stopped.
The prescribing information also notes that Lodoco may rarely and transiently impair fertility in males; and that patients with renal or hepatic impairment should be monitored closely for adverse effects of colchicine.
A version of this article first appeared on Medscape.com.
Aspirin warning: Anemia may increase with daily use
, according to results from a new randomized controlled trial.
In the study, which was published in Annals of Internal Medicine, investigators analyzed data from the Aspirin in Reducing Events in the Elderly (ASPREE) trial and examined hemoglobin concentrations among 19,114 healthy, community-dwelling older patients.
“We knew from large clinical trials, including our ASPREE trial, that daily low-dose aspirin increased the risk of clinically significant bleeding,” said Zoe McQuilten, MBBS, PhD, a hematologist at Monash University in Australia and the study’s lead author. “From our study, we found that low-dose aspirin also increased the risk of anemia during the trial, and this was most likely due to bleeding that was not clinically apparent.”
Anemia is common among elderly patients. It can cause fatigue, fast or irregular heartbeat, headache, chest pain, and pounding or whooshing sounds in the ear, according to the Cleveland Clinic. It can also worsen conditions such as heart failure, cognitive impairment, and depression in people aged 65 and older.
The U.S. Preventive Services Task Force changed its recommendation on aspirin for the primary prevention of cardiovascular disease in 2022, recommending against initiating low-dose aspirin for adults aged 60 years or older. For adults aged 40-59 who have a 10% or greater 10-year risk for cardiovascular disease, the agency recommends that patients and clinicians make the decision to initiate low-dose aspirin use on a case-by-case basis, as the net benefit is small.
Dr. McQuilten said she spent the last 5 years designing substages of anemia and conditions such as blood cancer. In many cases of anemia, doctors are unable to determine the underlying cause, she said. One study published in the Journal of American Geriatrics Society in 2021 found that in about one-third of anemia cases, the etiology was not clear.
About 50% of people older than 60 who were involved in the latest study took aspirin for prevention from 2011 to 2018. That number likely dropped after changes were made to the guidelines in 2022, according to Dr. McQuilten, but long-term use may have continued among older patients. The researchers also examined ferritin levels, which serve as a proxy for iron levels, at baseline and after 3 years.
The incidence of anemia was 51 events per 1,000 person-years in the aspirin group compared with 43 events per 1,000 person-years in the placebo group, according to the researchers. The estimated probability of experiencing anemia within 5 years was 23.5% (95% confidence interval [CI], 22.4%-24.6%) in the aspirin group and 20.3% (95% CI: 19.3% to 21.4%) in the placebo group. Aspirin therapy resulted in a 20% increase in the risk for anemia (95% CI, 1.12-1.29).
People who took aspirin were more likely to have lower serum levels of ferritin at the 3-year mark than were those who received placebo. The average decrease in ferritin among participants who took aspirin was 11.5% greater (95% CI, 9.3%-13.7%) than among those who took placebo.
Basil Eldadah, MD, PhD, supervisory medical officer at the National Institute on Aging, part of the National Institutes of Health, said the findings should encourage clinicians to pay closer attention to hemoglobin levels and have conversations with patients to discuss their need for taking aspirin.
“If somebody is already taking aspirin for any reason, keep an eye on hemoglobin,” said Dr. Eldadah, who was not involved in the study. “For somebody who’s taking aspirin and who’s older, and it’s not for an indication like cardiovascular disease, consider seriously whether that’s the best treatment option.”
The study did not examine the functional consequences of anemia on participants, which Dr. Eldadah said could be fodder for future research. The researchers said one limitation was that it was not clear whether anemia was sufficient to cause symptoms that affected participants’ quality of life or whether occult bleeding caused the anemia. The researchers also did not document whether patients saw their regular physicians and received treatment for anemia over the course of the trial.
The study was funded through grants from the National Health and Medical Research Council and the Bill and Melinda Gates Foundation. The authors reported receiving consulting fees, honoraria, and stock options, and have participated on data monitoring boards not related to the study for Vifor Pharma, ITL Biomedical, Pfizer, Boehringer Ingelheim, Bayer Healthcare, AbbVie, and Abbott Diagnostics.
A version of this article originally appeared on Medscape.com.
, according to results from a new randomized controlled trial.
In the study, which was published in Annals of Internal Medicine, investigators analyzed data from the Aspirin in Reducing Events in the Elderly (ASPREE) trial and examined hemoglobin concentrations among 19,114 healthy, community-dwelling older patients.
“We knew from large clinical trials, including our ASPREE trial, that daily low-dose aspirin increased the risk of clinically significant bleeding,” said Zoe McQuilten, MBBS, PhD, a hematologist at Monash University in Australia and the study’s lead author. “From our study, we found that low-dose aspirin also increased the risk of anemia during the trial, and this was most likely due to bleeding that was not clinically apparent.”
Anemia is common among elderly patients. It can cause fatigue, fast or irregular heartbeat, headache, chest pain, and pounding or whooshing sounds in the ear, according to the Cleveland Clinic. It can also worsen conditions such as heart failure, cognitive impairment, and depression in people aged 65 and older.
The U.S. Preventive Services Task Force changed its recommendation on aspirin for the primary prevention of cardiovascular disease in 2022, recommending against initiating low-dose aspirin for adults aged 60 years or older. For adults aged 40-59 who have a 10% or greater 10-year risk for cardiovascular disease, the agency recommends that patients and clinicians make the decision to initiate low-dose aspirin use on a case-by-case basis, as the net benefit is small.
Dr. McQuilten said she spent the last 5 years designing substages of anemia and conditions such as blood cancer. In many cases of anemia, doctors are unable to determine the underlying cause, she said. One study published in the Journal of American Geriatrics Society in 2021 found that in about one-third of anemia cases, the etiology was not clear.
About 50% of people older than 60 who were involved in the latest study took aspirin for prevention from 2011 to 2018. That number likely dropped after changes were made to the guidelines in 2022, according to Dr. McQuilten, but long-term use may have continued among older patients. The researchers also examined ferritin levels, which serve as a proxy for iron levels, at baseline and after 3 years.
The incidence of anemia was 51 events per 1,000 person-years in the aspirin group compared with 43 events per 1,000 person-years in the placebo group, according to the researchers. The estimated probability of experiencing anemia within 5 years was 23.5% (95% confidence interval [CI], 22.4%-24.6%) in the aspirin group and 20.3% (95% CI: 19.3% to 21.4%) in the placebo group. Aspirin therapy resulted in a 20% increase in the risk for anemia (95% CI, 1.12-1.29).
People who took aspirin were more likely to have lower serum levels of ferritin at the 3-year mark than were those who received placebo. The average decrease in ferritin among participants who took aspirin was 11.5% greater (95% CI, 9.3%-13.7%) than among those who took placebo.
Basil Eldadah, MD, PhD, supervisory medical officer at the National Institute on Aging, part of the National Institutes of Health, said the findings should encourage clinicians to pay closer attention to hemoglobin levels and have conversations with patients to discuss their need for taking aspirin.
“If somebody is already taking aspirin for any reason, keep an eye on hemoglobin,” said Dr. Eldadah, who was not involved in the study. “For somebody who’s taking aspirin and who’s older, and it’s not for an indication like cardiovascular disease, consider seriously whether that’s the best treatment option.”
The study did not examine the functional consequences of anemia on participants, which Dr. Eldadah said could be fodder for future research. The researchers said one limitation was that it was not clear whether anemia was sufficient to cause symptoms that affected participants’ quality of life or whether occult bleeding caused the anemia. The researchers also did not document whether patients saw their regular physicians and received treatment for anemia over the course of the trial.
The study was funded through grants from the National Health and Medical Research Council and the Bill and Melinda Gates Foundation. The authors reported receiving consulting fees, honoraria, and stock options, and have participated on data monitoring boards not related to the study for Vifor Pharma, ITL Biomedical, Pfizer, Boehringer Ingelheim, Bayer Healthcare, AbbVie, and Abbott Diagnostics.
A version of this article originally appeared on Medscape.com.
, according to results from a new randomized controlled trial.
In the study, which was published in Annals of Internal Medicine, investigators analyzed data from the Aspirin in Reducing Events in the Elderly (ASPREE) trial and examined hemoglobin concentrations among 19,114 healthy, community-dwelling older patients.
“We knew from large clinical trials, including our ASPREE trial, that daily low-dose aspirin increased the risk of clinically significant bleeding,” said Zoe McQuilten, MBBS, PhD, a hematologist at Monash University in Australia and the study’s lead author. “From our study, we found that low-dose aspirin also increased the risk of anemia during the trial, and this was most likely due to bleeding that was not clinically apparent.”
Anemia is common among elderly patients. It can cause fatigue, fast or irregular heartbeat, headache, chest pain, and pounding or whooshing sounds in the ear, according to the Cleveland Clinic. It can also worsen conditions such as heart failure, cognitive impairment, and depression in people aged 65 and older.
The U.S. Preventive Services Task Force changed its recommendation on aspirin for the primary prevention of cardiovascular disease in 2022, recommending against initiating low-dose aspirin for adults aged 60 years or older. For adults aged 40-59 who have a 10% or greater 10-year risk for cardiovascular disease, the agency recommends that patients and clinicians make the decision to initiate low-dose aspirin use on a case-by-case basis, as the net benefit is small.
Dr. McQuilten said she spent the last 5 years designing substages of anemia and conditions such as blood cancer. In many cases of anemia, doctors are unable to determine the underlying cause, she said. One study published in the Journal of American Geriatrics Society in 2021 found that in about one-third of anemia cases, the etiology was not clear.
About 50% of people older than 60 who were involved in the latest study took aspirin for prevention from 2011 to 2018. That number likely dropped after changes were made to the guidelines in 2022, according to Dr. McQuilten, but long-term use may have continued among older patients. The researchers also examined ferritin levels, which serve as a proxy for iron levels, at baseline and after 3 years.
The incidence of anemia was 51 events per 1,000 person-years in the aspirin group compared with 43 events per 1,000 person-years in the placebo group, according to the researchers. The estimated probability of experiencing anemia within 5 years was 23.5% (95% confidence interval [CI], 22.4%-24.6%) in the aspirin group and 20.3% (95% CI: 19.3% to 21.4%) in the placebo group. Aspirin therapy resulted in a 20% increase in the risk for anemia (95% CI, 1.12-1.29).
People who took aspirin were more likely to have lower serum levels of ferritin at the 3-year mark than were those who received placebo. The average decrease in ferritin among participants who took aspirin was 11.5% greater (95% CI, 9.3%-13.7%) than among those who took placebo.
Basil Eldadah, MD, PhD, supervisory medical officer at the National Institute on Aging, part of the National Institutes of Health, said the findings should encourage clinicians to pay closer attention to hemoglobin levels and have conversations with patients to discuss their need for taking aspirin.
“If somebody is already taking aspirin for any reason, keep an eye on hemoglobin,” said Dr. Eldadah, who was not involved in the study. “For somebody who’s taking aspirin and who’s older, and it’s not for an indication like cardiovascular disease, consider seriously whether that’s the best treatment option.”
The study did not examine the functional consequences of anemia on participants, which Dr. Eldadah said could be fodder for future research. The researchers said one limitation was that it was not clear whether anemia was sufficient to cause symptoms that affected participants’ quality of life or whether occult bleeding caused the anemia. The researchers also did not document whether patients saw their regular physicians and received treatment for anemia over the course of the trial.
The study was funded through grants from the National Health and Medical Research Council and the Bill and Melinda Gates Foundation. The authors reported receiving consulting fees, honoraria, and stock options, and have participated on data monitoring boards not related to the study for Vifor Pharma, ITL Biomedical, Pfizer, Boehringer Ingelheim, Bayer Healthcare, AbbVie, and Abbott Diagnostics.
A version of this article originally appeared on Medscape.com.
FROM ANNALS OF INTERNAL MEDICINE
Docs misdiagnose aneurysm and patient dies; must pay $29M; more
and untreated, according to a story posted on Boston.com, among other news sites.
On the morning of Jan. 13, 2018, Joseph Brown awoke with shortness of breath and upper abdominal pain, which eventually spread to his chest and back. Taken to Salem Hospital’s emergency department, Mr. Brown was seen by Steven D. Browell, MD, an emergency medicine specialist.
Dr. Browell ordered tests that ruled out both a heart attack and a pulmonary embolism. He called for a blood test, which indicated that the patient’s white blood count was elevated. Suspecting an infection, Dr. Browell ordered that Mr. Brown be admitted to the hospital.
Accepting Mr. Brown’s admission was William D. Kenyon, MD, a hospitalist, who also examined the patient and concurred with Dr. Browell’s probable diagnosis. The patient was then sent to the medical floor.
There he underwent additional testing, including a chest x-ray, which proved negative except for one finding: a “mild hazy interstitial opacity that could represent a small airway inflammation or developing/early pneumonia.” Because Mr. Brown had reported that he had punctured his foot several days earlier, he also underwent a foot x-ray, which showed a possible foreign body. It was thought that might be the source of his infection.
Neither Dr. Browell nor Dr. Kenyon had completely ruled out a possible aortic aneurysm and dissection. Mr. Brown’s symptoms, after all, were in some ways suggestive of those conditions. Then again, he was very young – only 43 at the time – and his pain, while severe, didn’t correspond to the “searing” pain that, at trial, Dr. Kenyon described as typical of an aneurysm and dissection. As the hospitalist testified at trial, Mr. Brown had “a constellation of nonspecific symptoms” and an “unusual presentation of a rare condition,” typically seen in patients aged 65 and older.
Given these factors – and the results of Mr. Brown’s tests, lab studies, and physical exam – Dr. Kenyon didn’t think that the case warranted a CT scan to rule out an aortic aneurysm or aortic dissection.
By early the next morning, though, Mr. Brown’s shortness of breath and pain had intensified significantly. The on-duty doctor ordered a CT scan, which showed “a massive aneurysm at the beginning of [the patient’s] aorta and a dissection extending through most of his aorta.”
Mr. Brown was flown to Boston to undergo emergency surgery. En route to the helicopter, his aorta ruptured, stopping his heart and causing his death.
During the 8-day trial, each side introduced expert witnesses. Speaking for the plaintiffs, experts in cardiothoracic surgery and emergency medicine testified that the treating physicians were negligent in failing to order a CT scan on Jan. 13. Had they done so, the patient would have almost certainly undergone surgery earlier, which would have prevented his death.
Experts for the defense saw things differently. They testified that, given the evidence, it was reasonable and appropriate for Dr. Browell and Dr. Kenyon to have treated their patient for an infection rather than an aneurysm or dissection.
The jury found the defense’s arguments unconvincing, however. After deliberating 3 hours, it awarded the plaintiffs $20,000,000, to be paid out over time largely to Mr. Brown’s two daughters, who were aged 12 and 18 when he died. Including interest, the total award is close to $29 million.
In a statement following the verdict, lead plaintiff’s attorney Robert M. Higgins, of Lubin & Meyer, Boston, said the takeaway from the case was: “If you just treat people based on what the likelihood is, statistically, you’re going to miss a lot of life-threatening conditions. And that’s what happened in this case.”
Urologists typically prevail in BPH suits
Malpractice claims following surgery for benign prostatic hyperplasia (BPH) tend to be limited in scope and are typically resolved in favor of the surgeon-defendant, as a study in The Cureus Journal of Medical Science makes clear.
The study – conducted by a team of researchers that included Joao G. Porto, MD, of the Desai Sethi Urology Institute, University of Miami – investigated whether such surgeries pose a significant malpractice risk for urologists.
With information gleaned from two well-known legal databases, the team used a variety of key terms to identify BPH-related claims from January 2000 to December 2021.
Within this universe of claims, researchers identified several significant trends:
- Among BPH-related procedures, transurethral resection of the prostate was the most frequently identified (37%);
- Among the most-often cited reasons cited for a claim, allegations of inadequate postoperative care were the most common (33%);
- Of possible postsurgical complications, those that led to the greatest number of suits were urinary incontinence (23%), erectile dysfunction (13%), and urinary retention (13%); and,
- Not unexpectedly, the specialist most frequently named in a suit was a urologist (57%).
Interestingly, in all but two of the claims, the verdict favored the doctor-defendant. In the two cases in which the plaintiff prevailed, each involved unexpected and serious postsurgical complications.
A version of this article originally appeared on Medscape.com.
and untreated, according to a story posted on Boston.com, among other news sites.
On the morning of Jan. 13, 2018, Joseph Brown awoke with shortness of breath and upper abdominal pain, which eventually spread to his chest and back. Taken to Salem Hospital’s emergency department, Mr. Brown was seen by Steven D. Browell, MD, an emergency medicine specialist.
Dr. Browell ordered tests that ruled out both a heart attack and a pulmonary embolism. He called for a blood test, which indicated that the patient’s white blood count was elevated. Suspecting an infection, Dr. Browell ordered that Mr. Brown be admitted to the hospital.
Accepting Mr. Brown’s admission was William D. Kenyon, MD, a hospitalist, who also examined the patient and concurred with Dr. Browell’s probable diagnosis. The patient was then sent to the medical floor.
There he underwent additional testing, including a chest x-ray, which proved negative except for one finding: a “mild hazy interstitial opacity that could represent a small airway inflammation or developing/early pneumonia.” Because Mr. Brown had reported that he had punctured his foot several days earlier, he also underwent a foot x-ray, which showed a possible foreign body. It was thought that might be the source of his infection.
Neither Dr. Browell nor Dr. Kenyon had completely ruled out a possible aortic aneurysm and dissection. Mr. Brown’s symptoms, after all, were in some ways suggestive of those conditions. Then again, he was very young – only 43 at the time – and his pain, while severe, didn’t correspond to the “searing” pain that, at trial, Dr. Kenyon described as typical of an aneurysm and dissection. As the hospitalist testified at trial, Mr. Brown had “a constellation of nonspecific symptoms” and an “unusual presentation of a rare condition,” typically seen in patients aged 65 and older.
Given these factors – and the results of Mr. Brown’s tests, lab studies, and physical exam – Dr. Kenyon didn’t think that the case warranted a CT scan to rule out an aortic aneurysm or aortic dissection.
By early the next morning, though, Mr. Brown’s shortness of breath and pain had intensified significantly. The on-duty doctor ordered a CT scan, which showed “a massive aneurysm at the beginning of [the patient’s] aorta and a dissection extending through most of his aorta.”
Mr. Brown was flown to Boston to undergo emergency surgery. En route to the helicopter, his aorta ruptured, stopping his heart and causing his death.
During the 8-day trial, each side introduced expert witnesses. Speaking for the plaintiffs, experts in cardiothoracic surgery and emergency medicine testified that the treating physicians were negligent in failing to order a CT scan on Jan. 13. Had they done so, the patient would have almost certainly undergone surgery earlier, which would have prevented his death.
Experts for the defense saw things differently. They testified that, given the evidence, it was reasonable and appropriate for Dr. Browell and Dr. Kenyon to have treated their patient for an infection rather than an aneurysm or dissection.
The jury found the defense’s arguments unconvincing, however. After deliberating 3 hours, it awarded the plaintiffs $20,000,000, to be paid out over time largely to Mr. Brown’s two daughters, who were aged 12 and 18 when he died. Including interest, the total award is close to $29 million.
In a statement following the verdict, lead plaintiff’s attorney Robert M. Higgins, of Lubin & Meyer, Boston, said the takeaway from the case was: “If you just treat people based on what the likelihood is, statistically, you’re going to miss a lot of life-threatening conditions. And that’s what happened in this case.”
Urologists typically prevail in BPH suits
Malpractice claims following surgery for benign prostatic hyperplasia (BPH) tend to be limited in scope and are typically resolved in favor of the surgeon-defendant, as a study in The Cureus Journal of Medical Science makes clear.
The study – conducted by a team of researchers that included Joao G. Porto, MD, of the Desai Sethi Urology Institute, University of Miami – investigated whether such surgeries pose a significant malpractice risk for urologists.
With information gleaned from two well-known legal databases, the team used a variety of key terms to identify BPH-related claims from January 2000 to December 2021.
Within this universe of claims, researchers identified several significant trends:
- Among BPH-related procedures, transurethral resection of the prostate was the most frequently identified (37%);
- Among the most-often cited reasons cited for a claim, allegations of inadequate postoperative care were the most common (33%);
- Of possible postsurgical complications, those that led to the greatest number of suits were urinary incontinence (23%), erectile dysfunction (13%), and urinary retention (13%); and,
- Not unexpectedly, the specialist most frequently named in a suit was a urologist (57%).
Interestingly, in all but two of the claims, the verdict favored the doctor-defendant. In the two cases in which the plaintiff prevailed, each involved unexpected and serious postsurgical complications.
A version of this article originally appeared on Medscape.com.
and untreated, according to a story posted on Boston.com, among other news sites.
On the morning of Jan. 13, 2018, Joseph Brown awoke with shortness of breath and upper abdominal pain, which eventually spread to his chest and back. Taken to Salem Hospital’s emergency department, Mr. Brown was seen by Steven D. Browell, MD, an emergency medicine specialist.
Dr. Browell ordered tests that ruled out both a heart attack and a pulmonary embolism. He called for a blood test, which indicated that the patient’s white blood count was elevated. Suspecting an infection, Dr. Browell ordered that Mr. Brown be admitted to the hospital.
Accepting Mr. Brown’s admission was William D. Kenyon, MD, a hospitalist, who also examined the patient and concurred with Dr. Browell’s probable diagnosis. The patient was then sent to the medical floor.
There he underwent additional testing, including a chest x-ray, which proved negative except for one finding: a “mild hazy interstitial opacity that could represent a small airway inflammation or developing/early pneumonia.” Because Mr. Brown had reported that he had punctured his foot several days earlier, he also underwent a foot x-ray, which showed a possible foreign body. It was thought that might be the source of his infection.
Neither Dr. Browell nor Dr. Kenyon had completely ruled out a possible aortic aneurysm and dissection. Mr. Brown’s symptoms, after all, were in some ways suggestive of those conditions. Then again, he was very young – only 43 at the time – and his pain, while severe, didn’t correspond to the “searing” pain that, at trial, Dr. Kenyon described as typical of an aneurysm and dissection. As the hospitalist testified at trial, Mr. Brown had “a constellation of nonspecific symptoms” and an “unusual presentation of a rare condition,” typically seen in patients aged 65 and older.
Given these factors – and the results of Mr. Brown’s tests, lab studies, and physical exam – Dr. Kenyon didn’t think that the case warranted a CT scan to rule out an aortic aneurysm or aortic dissection.
By early the next morning, though, Mr. Brown’s shortness of breath and pain had intensified significantly. The on-duty doctor ordered a CT scan, which showed “a massive aneurysm at the beginning of [the patient’s] aorta and a dissection extending through most of his aorta.”
Mr. Brown was flown to Boston to undergo emergency surgery. En route to the helicopter, his aorta ruptured, stopping his heart and causing his death.
During the 8-day trial, each side introduced expert witnesses. Speaking for the plaintiffs, experts in cardiothoracic surgery and emergency medicine testified that the treating physicians were negligent in failing to order a CT scan on Jan. 13. Had they done so, the patient would have almost certainly undergone surgery earlier, which would have prevented his death.
Experts for the defense saw things differently. They testified that, given the evidence, it was reasonable and appropriate for Dr. Browell and Dr. Kenyon to have treated their patient for an infection rather than an aneurysm or dissection.
The jury found the defense’s arguments unconvincing, however. After deliberating 3 hours, it awarded the plaintiffs $20,000,000, to be paid out over time largely to Mr. Brown’s two daughters, who were aged 12 and 18 when he died. Including interest, the total award is close to $29 million.
In a statement following the verdict, lead plaintiff’s attorney Robert M. Higgins, of Lubin & Meyer, Boston, said the takeaway from the case was: “If you just treat people based on what the likelihood is, statistically, you’re going to miss a lot of life-threatening conditions. And that’s what happened in this case.”
Urologists typically prevail in BPH suits
Malpractice claims following surgery for benign prostatic hyperplasia (BPH) tend to be limited in scope and are typically resolved in favor of the surgeon-defendant, as a study in The Cureus Journal of Medical Science makes clear.
The study – conducted by a team of researchers that included Joao G. Porto, MD, of the Desai Sethi Urology Institute, University of Miami – investigated whether such surgeries pose a significant malpractice risk for urologists.
With information gleaned from two well-known legal databases, the team used a variety of key terms to identify BPH-related claims from January 2000 to December 2021.
Within this universe of claims, researchers identified several significant trends:
- Among BPH-related procedures, transurethral resection of the prostate was the most frequently identified (37%);
- Among the most-often cited reasons cited for a claim, allegations of inadequate postoperative care were the most common (33%);
- Of possible postsurgical complications, those that led to the greatest number of suits were urinary incontinence (23%), erectile dysfunction (13%), and urinary retention (13%); and,
- Not unexpectedly, the specialist most frequently named in a suit was a urologist (57%).
Interestingly, in all but two of the claims, the verdict favored the doctor-defendant. In the two cases in which the plaintiff prevailed, each involved unexpected and serious postsurgical complications.
A version of this article originally appeared on Medscape.com.
Interventional cardiologists worldwide burned out: Survey
“What surprised me was the magnitude of the findings,” Emmanouil S. Brilakis, MD, PhD of the Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, said in an interview.
“I was expecting that some interventionalists would feel burned out, but not that 78% would feel they are working too hard, 64% are emotionally exhausted, and 41% considered quitting their job during the past year.
The survey, conducted in January, also showed that while 69% of respondents were affected by burnout, many were either not seeking mental health support or not willing to share whether they were under treatment.
Overall, 28% of interventional cardiologists were not happy with their lives, similar to the 29% reported in the Medscape Cardiologist Lifestyle, Happiness & Burnout Report 2022.
“Many institutions have formed task forces to better understand burnout and recommend solutions, but progress has been slow,” Dr. Brilakis said. “Barriers include financial constraints, understaffing, lack of understanding of the root causes of burnout in each practice, and perhaps underappreciation of the consequences of burnout.”
The study was published online in JACC: Cardiovascular Interventions.
Too much paperwork
The investigators conducted an international, online survey of IC attending physicians and fellows to assess their psychological well-being. The 78 survey questions prepared by the coauthors were shown to perform similarly to the validated Maslach Burnout Inventory.
A total of 1,159 attendings and 192 fellows completed the survey, representing 12% of U.S. IC attendings and 19% of U.S. IC fellows.
Half of attending physicians were from the United States, followed by the European Union (16%). Overall, 37% were from academic institutions; the median age was 41-45 years; 91% were men; and mean clinical work hours per week were 63.
Most (86%) had a partner with whom they lived. Yet most (84%) also felt lonely; 41% considered leaving their jobs during the past year; and 32% said they were currently considering leaving.
Compared with the previous year, 12% had increased enthusiasm and 44% had decreased enthusiasm toward work. One-third (33%) felt overwhelmed and 20% doubted the significance of their work three or more times a week.
As noted, most (78%) felt they were “working too hard,” were emotionally exhausted (64%), and frustrated by work (58%). Almost one-third (30%) considered themselves physically unhealthy.
Unhappiness was highest (33%) among 51- to 60-year-olds, followed by 31- to 40-year-olds (31%); it was lowest (21%) among those over age 60.
Unhappiness was similar between men and women (27% vs. 30%) and was highest in North America (30%) and lower in Asia (26%).
Most (69%) respondents said that burnout impacted their life, with very little difference between men and women (68% vs. 73%).
Two-thirds (67%) said they had somebody they could share their mental health concerns with, yet only 37% reported having access to mental health support if needed through their hospital/practice.
For fellows, the median age was 31-35 years; 88% were men; 42% were from the United States and 22% from the European Union. Two-thirds were from academic institutions (67%) and the mean clinical work hours were 67 per week.
Two-thirds (67%) lived with a partner; half (48%) felt lonely, 29% considered leaving their jobs in the past year, and 15% were currently considering leaving.
Compared with the previous year, 27% had increased enthusiasm, and 32% had decreased enthusiasm toward work. More than one-quarter (29%) felt overwhelmed and 26% doubted the significance of their work three or more times per week.
Attendings rated excessive paperwork requirements, bureaucratic tasks, challenges in equipment acquisition, and excessive government regulations higher (in contributing to burnout) compared with fellows.
Non-U.S. attendings reported insufficient income and challenges with equipment acquisition as significant contributors to their burnout more than did their United States counterparts.
Fellows rated insufficient income as the most significant contributor to burnout.
Their main coping mechanisms were talking with family/friends (at 6.8 rated on a scale of 0-10), watching movies (6.4), and listening/playing music (6.0).
Attendings were more likely to use exercise as a coping skill, and fellows were more likely to cope by watching movies/series, sleeping, and eating junk food.
Asked what hospitals and practices can do to reduce burnout and improve well-being, attendings suggested removing rules/regulations that do not contribute to patient care, such as reforming prior authorization (mean rating, 8.1), better administrative support (8.0), and professional growth opportunities (7.9).
Non-U.S. attendings more often requested growth opportunities, increased compensation, availability of better hospital food, better hospital infrastructure, streamlined access to equipment, better on-call rooms, and access to mental health professionals to improve their well-being.
Overall, fellows were more likely than were attendings to request professional growth opportunities and were more likely to ask for availability of better food in the hospital, and better on-call rooms.
Reforms needed
Laxmi Mehta, MD, chief well-being leader, faculty director of the Gabbe Health and Well-Being Program, professor of medicine at The Ohio State University Wexner Medical Center in Columbus, and spokesperson for the American Heart Association, noted, “The burnout rates are much higher than our previously reported American College of Cardiology data, which found burnout rates at about 27%; however, that survey was conducted prepandemic,” she said. Dr. Mehta was the lead author of that 2019 report.
She said in an interview that she would have liked to see more breakdowns by gender, and whether there was an association between burnout and the number of procedures performed.
“Nevertheless,” she said, “the rates are very high for burnout, stress, and dissatisfaction, as well as mental health issues. Almost one half of the IC attendings considered leaving their job, which is also seen in other surveys, and is concerning given the projected shortages in the workforce.”
Changes need to be made in the profession of medicine as a whole, she said, though that is unlikely to happen any time soon. “Optimizing workflows and improving the work culture requires not only time, but also collaboration between administration and clinicians, along with an intent and strategic plan focused on well-being of the organization.”
With regard to prior authorization, she said, “medical organizations are advocating for reform at the state and national level. If meaningful reforms can occur, that can reduce some of the bureaucracy. However, there is much more [bureaucracy] in medicine.”
With respect to mental health, she added, “there is a lot that needs to be done to reduce the stigma of seeking help. Many physicians don’t seek help due to the shame, lack of time, and potential impact it can have on hospital credentialing and state medical licensing. Medical organizations and individuals are advocating for reforms in this space, as well, to normalize mental health.”
The Minneapolis Heart Institute Foundation’s Science Center for Coronary Artery Disease helped support this research project. Dr. Brilakis, study coauthors, and Dr. Mehta report no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
“What surprised me was the magnitude of the findings,” Emmanouil S. Brilakis, MD, PhD of the Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, said in an interview.
“I was expecting that some interventionalists would feel burned out, but not that 78% would feel they are working too hard, 64% are emotionally exhausted, and 41% considered quitting their job during the past year.
The survey, conducted in January, also showed that while 69% of respondents were affected by burnout, many were either not seeking mental health support or not willing to share whether they were under treatment.
Overall, 28% of interventional cardiologists were not happy with their lives, similar to the 29% reported in the Medscape Cardiologist Lifestyle, Happiness & Burnout Report 2022.
“Many institutions have formed task forces to better understand burnout and recommend solutions, but progress has been slow,” Dr. Brilakis said. “Barriers include financial constraints, understaffing, lack of understanding of the root causes of burnout in each practice, and perhaps underappreciation of the consequences of burnout.”
The study was published online in JACC: Cardiovascular Interventions.
Too much paperwork
The investigators conducted an international, online survey of IC attending physicians and fellows to assess their psychological well-being. The 78 survey questions prepared by the coauthors were shown to perform similarly to the validated Maslach Burnout Inventory.
A total of 1,159 attendings and 192 fellows completed the survey, representing 12% of U.S. IC attendings and 19% of U.S. IC fellows.
Half of attending physicians were from the United States, followed by the European Union (16%). Overall, 37% were from academic institutions; the median age was 41-45 years; 91% were men; and mean clinical work hours per week were 63.
Most (86%) had a partner with whom they lived. Yet most (84%) also felt lonely; 41% considered leaving their jobs during the past year; and 32% said they were currently considering leaving.
Compared with the previous year, 12% had increased enthusiasm and 44% had decreased enthusiasm toward work. One-third (33%) felt overwhelmed and 20% doubted the significance of their work three or more times a week.
As noted, most (78%) felt they were “working too hard,” were emotionally exhausted (64%), and frustrated by work (58%). Almost one-third (30%) considered themselves physically unhealthy.
Unhappiness was highest (33%) among 51- to 60-year-olds, followed by 31- to 40-year-olds (31%); it was lowest (21%) among those over age 60.
Unhappiness was similar between men and women (27% vs. 30%) and was highest in North America (30%) and lower in Asia (26%).
Most (69%) respondents said that burnout impacted their life, with very little difference between men and women (68% vs. 73%).
Two-thirds (67%) said they had somebody they could share their mental health concerns with, yet only 37% reported having access to mental health support if needed through their hospital/practice.
For fellows, the median age was 31-35 years; 88% were men; 42% were from the United States and 22% from the European Union. Two-thirds were from academic institutions (67%) and the mean clinical work hours were 67 per week.
Two-thirds (67%) lived with a partner; half (48%) felt lonely, 29% considered leaving their jobs in the past year, and 15% were currently considering leaving.
Compared with the previous year, 27% had increased enthusiasm, and 32% had decreased enthusiasm toward work. More than one-quarter (29%) felt overwhelmed and 26% doubted the significance of their work three or more times per week.
Attendings rated excessive paperwork requirements, bureaucratic tasks, challenges in equipment acquisition, and excessive government regulations higher (in contributing to burnout) compared with fellows.
Non-U.S. attendings reported insufficient income and challenges with equipment acquisition as significant contributors to their burnout more than did their United States counterparts.
Fellows rated insufficient income as the most significant contributor to burnout.
Their main coping mechanisms were talking with family/friends (at 6.8 rated on a scale of 0-10), watching movies (6.4), and listening/playing music (6.0).
Attendings were more likely to use exercise as a coping skill, and fellows were more likely to cope by watching movies/series, sleeping, and eating junk food.
Asked what hospitals and practices can do to reduce burnout and improve well-being, attendings suggested removing rules/regulations that do not contribute to patient care, such as reforming prior authorization (mean rating, 8.1), better administrative support (8.0), and professional growth opportunities (7.9).
Non-U.S. attendings more often requested growth opportunities, increased compensation, availability of better hospital food, better hospital infrastructure, streamlined access to equipment, better on-call rooms, and access to mental health professionals to improve their well-being.
Overall, fellows were more likely than were attendings to request professional growth opportunities and were more likely to ask for availability of better food in the hospital, and better on-call rooms.
Reforms needed
Laxmi Mehta, MD, chief well-being leader, faculty director of the Gabbe Health and Well-Being Program, professor of medicine at The Ohio State University Wexner Medical Center in Columbus, and spokesperson for the American Heart Association, noted, “The burnout rates are much higher than our previously reported American College of Cardiology data, which found burnout rates at about 27%; however, that survey was conducted prepandemic,” she said. Dr. Mehta was the lead author of that 2019 report.
She said in an interview that she would have liked to see more breakdowns by gender, and whether there was an association between burnout and the number of procedures performed.
“Nevertheless,” she said, “the rates are very high for burnout, stress, and dissatisfaction, as well as mental health issues. Almost one half of the IC attendings considered leaving their job, which is also seen in other surveys, and is concerning given the projected shortages in the workforce.”
Changes need to be made in the profession of medicine as a whole, she said, though that is unlikely to happen any time soon. “Optimizing workflows and improving the work culture requires not only time, but also collaboration between administration and clinicians, along with an intent and strategic plan focused on well-being of the organization.”
With regard to prior authorization, she said, “medical organizations are advocating for reform at the state and national level. If meaningful reforms can occur, that can reduce some of the bureaucracy. However, there is much more [bureaucracy] in medicine.”
With respect to mental health, she added, “there is a lot that needs to be done to reduce the stigma of seeking help. Many physicians don’t seek help due to the shame, lack of time, and potential impact it can have on hospital credentialing and state medical licensing. Medical organizations and individuals are advocating for reforms in this space, as well, to normalize mental health.”
The Minneapolis Heart Institute Foundation’s Science Center for Coronary Artery Disease helped support this research project. Dr. Brilakis, study coauthors, and Dr. Mehta report no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
“What surprised me was the magnitude of the findings,” Emmanouil S. Brilakis, MD, PhD of the Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, said in an interview.
“I was expecting that some interventionalists would feel burned out, but not that 78% would feel they are working too hard, 64% are emotionally exhausted, and 41% considered quitting their job during the past year.
The survey, conducted in January, also showed that while 69% of respondents were affected by burnout, many were either not seeking mental health support or not willing to share whether they were under treatment.
Overall, 28% of interventional cardiologists were not happy with their lives, similar to the 29% reported in the Medscape Cardiologist Lifestyle, Happiness & Burnout Report 2022.
“Many institutions have formed task forces to better understand burnout and recommend solutions, but progress has been slow,” Dr. Brilakis said. “Barriers include financial constraints, understaffing, lack of understanding of the root causes of burnout in each practice, and perhaps underappreciation of the consequences of burnout.”
The study was published online in JACC: Cardiovascular Interventions.
Too much paperwork
The investigators conducted an international, online survey of IC attending physicians and fellows to assess their psychological well-being. The 78 survey questions prepared by the coauthors were shown to perform similarly to the validated Maslach Burnout Inventory.
A total of 1,159 attendings and 192 fellows completed the survey, representing 12% of U.S. IC attendings and 19% of U.S. IC fellows.
Half of attending physicians were from the United States, followed by the European Union (16%). Overall, 37% were from academic institutions; the median age was 41-45 years; 91% were men; and mean clinical work hours per week were 63.
Most (86%) had a partner with whom they lived. Yet most (84%) also felt lonely; 41% considered leaving their jobs during the past year; and 32% said they were currently considering leaving.
Compared with the previous year, 12% had increased enthusiasm and 44% had decreased enthusiasm toward work. One-third (33%) felt overwhelmed and 20% doubted the significance of their work three or more times a week.
As noted, most (78%) felt they were “working too hard,” were emotionally exhausted (64%), and frustrated by work (58%). Almost one-third (30%) considered themselves physically unhealthy.
Unhappiness was highest (33%) among 51- to 60-year-olds, followed by 31- to 40-year-olds (31%); it was lowest (21%) among those over age 60.
Unhappiness was similar between men and women (27% vs. 30%) and was highest in North America (30%) and lower in Asia (26%).
Most (69%) respondents said that burnout impacted their life, with very little difference between men and women (68% vs. 73%).
Two-thirds (67%) said they had somebody they could share their mental health concerns with, yet only 37% reported having access to mental health support if needed through their hospital/practice.
For fellows, the median age was 31-35 years; 88% were men; 42% were from the United States and 22% from the European Union. Two-thirds were from academic institutions (67%) and the mean clinical work hours were 67 per week.
Two-thirds (67%) lived with a partner; half (48%) felt lonely, 29% considered leaving their jobs in the past year, and 15% were currently considering leaving.
Compared with the previous year, 27% had increased enthusiasm, and 32% had decreased enthusiasm toward work. More than one-quarter (29%) felt overwhelmed and 26% doubted the significance of their work three or more times per week.
Attendings rated excessive paperwork requirements, bureaucratic tasks, challenges in equipment acquisition, and excessive government regulations higher (in contributing to burnout) compared with fellows.
Non-U.S. attendings reported insufficient income and challenges with equipment acquisition as significant contributors to their burnout more than did their United States counterparts.
Fellows rated insufficient income as the most significant contributor to burnout.
Their main coping mechanisms were talking with family/friends (at 6.8 rated on a scale of 0-10), watching movies (6.4), and listening/playing music (6.0).
Attendings were more likely to use exercise as a coping skill, and fellows were more likely to cope by watching movies/series, sleeping, and eating junk food.
Asked what hospitals and practices can do to reduce burnout and improve well-being, attendings suggested removing rules/regulations that do not contribute to patient care, such as reforming prior authorization (mean rating, 8.1), better administrative support (8.0), and professional growth opportunities (7.9).
Non-U.S. attendings more often requested growth opportunities, increased compensation, availability of better hospital food, better hospital infrastructure, streamlined access to equipment, better on-call rooms, and access to mental health professionals to improve their well-being.
Overall, fellows were more likely than were attendings to request professional growth opportunities and were more likely to ask for availability of better food in the hospital, and better on-call rooms.
Reforms needed
Laxmi Mehta, MD, chief well-being leader, faculty director of the Gabbe Health and Well-Being Program, professor of medicine at The Ohio State University Wexner Medical Center in Columbus, and spokesperson for the American Heart Association, noted, “The burnout rates are much higher than our previously reported American College of Cardiology data, which found burnout rates at about 27%; however, that survey was conducted prepandemic,” she said. Dr. Mehta was the lead author of that 2019 report.
She said in an interview that she would have liked to see more breakdowns by gender, and whether there was an association between burnout and the number of procedures performed.
“Nevertheless,” she said, “the rates are very high for burnout, stress, and dissatisfaction, as well as mental health issues. Almost one half of the IC attendings considered leaving their job, which is also seen in other surveys, and is concerning given the projected shortages in the workforce.”
Changes need to be made in the profession of medicine as a whole, she said, though that is unlikely to happen any time soon. “Optimizing workflows and improving the work culture requires not only time, but also collaboration between administration and clinicians, along with an intent and strategic plan focused on well-being of the organization.”
With regard to prior authorization, she said, “medical organizations are advocating for reform at the state and national level. If meaningful reforms can occur, that can reduce some of the bureaucracy. However, there is much more [bureaucracy] in medicine.”
With respect to mental health, she added, “there is a lot that needs to be done to reduce the stigma of seeking help. Many physicians don’t seek help due to the shame, lack of time, and potential impact it can have on hospital credentialing and state medical licensing. Medical organizations and individuals are advocating for reforms in this space, as well, to normalize mental health.”
The Minneapolis Heart Institute Foundation’s Science Center for Coronary Artery Disease helped support this research project. Dr. Brilakis, study coauthors, and Dr. Mehta report no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
FROM JACC: CARDIOVASCULAR INTERVENTIONS