Rates of minor diabetes-related lower extremity amputations (LEAs) in hospitalized patients increased between 2009 and 2017 in all racial and ethnic groups, in both rural and urban areas, and in all geographic regions across the United States, a new retrospective, observational study indicates.

In contrast, major lower extremity amputation rates held steady during the study period with a few exceptions.

There was also a decline in major-to-minor amputation ratios, especially among Native Americans – a sign that diabetes was being better managed and foot ulcers were being caught earlier, preventing the need for a major amputation above the foot or below or above the knee.

Minor LEAs include the loss of a toe, toes, or a foot.

“While I know an amputation is devastating either way, having a minor amputation is better than having a major amputation, and trends [at least to 2017] show that comprehensive foot examinations are paying off,” lead author Marvellous Akinlotan, PhD, MPH, a research associate at the Southwest Rural Health Research Center in Bryan, Texas, said in an interview.

Asked to comment, Marcia Ory, PhD, MPH, director of the Center for Population Health & Aging, Texas A&M School of Public Health, College Station, who was not involved in the study, said: “It points to some successes, but it also points to the need for continued education and preventive care to reduce all types of amputations.”

The study was published online in Diabetes Care.
 

Amputations increased during COVID-19

However, the study was conducted prior to the COVID-19 pandemic, and amputation rates appear to have significantly worsened during the past 18 months.

In a summary of recent evidence collated by the Amputee Coalition, the authors point out that not only does COVID-19 itself put patients at higher risk for limb loss because severe infection increases the risk of blood clots, but patients with diabetes appear to have been far more likely to undergo any level of amputation during the pandemic than before it began.

In a study of patients with diabetes attending a foot and ankle surgery service in Ohio, the risk of having any level of amputation was 10.8 times higher during compared with before the pandemic. And of patients undergoing any amputation, the odds for receiving a major amputation was 3.1 times higher than before the pandemic.

Telehealth and web-based options for diabetes care and education could help improve health outcomes, particularly during lockdowns.

“Having a diabetes-related amputation is life-changing – it brings disability and functional limitations to the individual – and within the health care system, it reflects the failure of secondary prevention efforts, which ideally should slow the progression of diabetic complications,” noted Dr. Akinlotan.
 

Race and geography affect risk of amputation

In their study, Dr. Akinlotan and colleagues used data from the National Inpatient Sample to identify trends in LEAs among patients primarily hospitalized for diabetes in the United States between 2009 and 2017.

“The primary outcome variable was documentation of either minor or major LEA during a diabetes-related admission,” they explain.

Minor LEAs increased significantly across all ethnic groups.

A version of this article first appeared on Medscape.com.

Rates of minor diabetes-related lower extremity amputations (LEAs) in hospitalized patients increased between 2009 and 2017 in all racial and ethnic groups, in both rural and urban areas, and in all geographic regions across the United States, a new retrospective, observational study indicates.

In contrast, major lower extremity amputation rates held steady during the study period with a few exceptions.

There was also a decline in major-to-minor amputation ratios, especially among Native Americans – a sign that diabetes was being better managed and foot ulcers were being caught earlier, preventing the need for a major amputation above the foot or below or above the knee.

Minor LEAs include the loss of a toe, toes, or a foot.

“While I know an amputation is devastating either way, having a minor amputation is better than having a major amputation, and trends [at least to 2017] show that comprehensive foot examinations are paying off,” lead author Marvellous Akinlotan, PhD, MPH, a research associate at the Southwest Rural Health Research Center in Bryan, Texas, said in an interview.

Asked to comment, Marcia Ory, PhD, MPH, director of the Center for Population Health & Aging, Texas A&M School of Public Health, College Station, who was not involved in the study, said: “It points to some successes, but it also points to the need for continued education and preventive care to reduce all types of amputations.”

The study was published online in Diabetes Care.
 

Amputations increased during COVID-19

However, the study was conducted prior to the COVID-19 pandemic, and amputation rates appear to have significantly worsened during the past 18 months.

In a summary of recent evidence collated by the Amputee Coalition, the authors point out that not only does COVID-19 itself put patients at higher risk for limb loss because severe infection increases the risk of blood clots, but patients with diabetes appear to have been far more likely to undergo any level of amputation during the pandemic than before it began.

In a study of patients with diabetes attending a foot and ankle surgery service in Ohio, the risk of having any level of amputation was 10.8 times higher during compared with before the pandemic. And of patients undergoing any amputation, the odds for receiving a major amputation was 3.1 times higher than before the pandemic.

Telehealth and web-based options for diabetes care and education could help improve health outcomes, particularly during lockdowns.

“Having a diabetes-related amputation is life-changing – it brings disability and functional limitations to the individual – and within the health care system, it reflects the failure of secondary prevention efforts, which ideally should slow the progression of diabetic complications,” noted Dr. Akinlotan.
 

Race and geography affect risk of amputation

In their study, Dr. Akinlotan and colleagues used data from the National Inpatient Sample to identify trends in LEAs among patients primarily hospitalized for diabetes in the United States between 2009 and 2017.

“The primary outcome variable was documentation of either minor or major LEA during a diabetes-related admission,” they explain.

Minor LEAs increased significantly across all ethnic groups.

A version of this article first appeared on Medscape.com.

Rates of minor diabetes-related lower extremity amputations (LEAs) in hospitalized patients increased between 2009 and 2017 in all racial and ethnic groups, in both rural and urban areas, and in all geographic regions across the United States, a new retrospective, observational study indicates.

In contrast, major lower extremity amputation rates held steady during the study period with a few exceptions.

There was also a decline in major-to-minor amputation ratios, especially among Native Americans – a sign that diabetes was being better managed and foot ulcers were being caught earlier, preventing the need for a major amputation above the foot or below or above the knee.

Minor LEAs include the loss of a toe, toes, or a foot.

“While I know an amputation is devastating either way, having a minor amputation is better than having a major amputation, and trends [at least to 2017] show that comprehensive foot examinations are paying off,” lead author Marvellous Akinlotan, PhD, MPH, a research associate at the Southwest Rural Health Research Center in Bryan, Texas, said in an interview.

Asked to comment, Marcia Ory, PhD, MPH, director of the Center for Population Health & Aging, Texas A&M School of Public Health, College Station, who was not involved in the study, said: “It points to some successes, but it also points to the need for continued education and preventive care to reduce all types of amputations.”

The study was published online in Diabetes Care.
 

Amputations increased during COVID-19

However, the study was conducted prior to the COVID-19 pandemic, and amputation rates appear to have significantly worsened during the past 18 months.

In a summary of recent evidence collated by the Amputee Coalition, the authors point out that not only does COVID-19 itself put patients at higher risk for limb loss because severe infection increases the risk of blood clots, but patients with diabetes appear to have been far more likely to undergo any level of amputation during the pandemic than before it began.

In a study of patients with diabetes attending a foot and ankle surgery service in Ohio, the risk of having any level of amputation was 10.8 times higher during compared with before the pandemic. And of patients undergoing any amputation, the odds for receiving a major amputation was 3.1 times higher than before the pandemic.

Telehealth and web-based options for diabetes care and education could help improve health outcomes, particularly during lockdowns.

“Having a diabetes-related amputation is life-changing – it brings disability and functional limitations to the individual – and within the health care system, it reflects the failure of secondary prevention efforts, which ideally should slow the progression of diabetic complications,” noted Dr. Akinlotan.
 

Race and geography affect risk of amputation

In their study, Dr. Akinlotan and colleagues used data from the National Inpatient Sample to identify trends in LEAs among patients primarily hospitalized for diabetes in the United States between 2009 and 2017.

“The primary outcome variable was documentation of either minor or major LEA during a diabetes-related admission,” they explain.

Minor LEAs increased significantly across all ethnic groups.

A version of this article first appeared on Medscape.com.

It was a typical, busy evening shift in the emergency department (ED) when Steve Carroll, DO, an emergency medicine physician in the Philadelphia area, noticed an odd listing on the tracking board. In the waiting room, there was someone whose chief complaint was that she needed to have surgical drains pulled.

According to the woman’s chart, she’d undergone liposuction in Miami a week before. She came bearing a letter from her surgeon to an ED physician with specific instructions on when and how to remove the drains. The surgeon had effectively relinquished all follow-up care to the woman’s local ED.

Dr. Carroll searched the name of her surgeon and found that his site “specifically advertised medical tourism,” Dr. Carroll said. The site lured patients with the idea of recovering by the beach and that a local nurse would come to their room every day.

But when Dr. Carroll told the patient that her surgeon should be the one who removes the drains, she became concerned. She didn’t know that her surgeon wasn’t providing the standard of care, he said. Somewhat appalled that a board-certified plastic surgeon would place the burden of follow-up care on an ED doctor hundreds of miles away, Dr. Carroll posted the case to Twitter and several Facebook groups.

“Yes I could refuse to take [the drains] out but that’s not patient-centered care,” Dr. Carroll wrote in a Twitter thread. “It’s unfairly shifting routine outpatient surgical followup (and liability) onto me and extra cost to [the patient].” Comments from ED physicians and sympathetic surgeons across the country flowed in. Dr. Carroll quickly realized his situation was part of a much larger problem than he’d thought.

Dr. Carroll’s patient told him that the Miami surgery cost less than undergoing the surgery locally; that’s why she’d made the trip. She’s not alone. Traveling to get the lowest price for a plastic surgery procedure has been a rising phenomenon since the early 2000s, according to the American Society of Plastic Surgeons (ASPS). Many countries are actively fostering their medical tourism industries, as are states such as Florida.

People have long traveled to get the best medical care. But “medical tourism is completely different,” said Alan Matarasso, MD, FACS, a Manhattan-based plastic surgeon and member of the ASPS Executive Committee. “People [are] traveling to get a simultaneous vacation or lower cost,” he said.

Choosing facilities on the basis of these criteria comes with myriad problems, and the quality of medical care may be lower. It’s difficult to verify the credentials of the surgeons, anesthesiologists, and facilities involved. Medical records can be in a different language, and traveling immediately after surgery increases the risk for pulmonary embolism and death, not to mention the added complications of traveling and being a surgical patient during the COVID-19 pandemic, he said.

Typically, surgeons are protective of their patients. But Murtaza Akhter, MD, an emergency medicine physician based in Miami, says it’s the opposite with the medical tourism surgeons whose patients regularly end up in his ED. “There’s almost no ownership,” he said. “Every time, [the patients] say, ‘My doctor isn’t responding,’ or they said go to the ER.” And that’s before they’ve even made it out of Miami.

The most common cosmetic surgery complications Dr. Akhter sees occur in patients who’ve undergone so-called Brazilian butt lifts. They show up in his ED face down, suffering from severe blood loss. He has them undergo a transfusion and maybe some imaging, but if they need a higher degree of care, they have to be transferred. “There’s a reason it’s cheaper,” he said.

Medical tourism mishaps are such a regular occurrence in Miami that no one flinches when the patients show up in the ED, Dr. Akhter said. He had begun to think he was overreacting to the problem until he saw Dr. Carroll’s Twitter thread.

“Since it’s daily, I just thought maybe I had gone crazy and that it’s considered normal for plastic surgeons to do this. Thanks for making me feel sane again,” Dr. Akhter tweeted in a reply to Dr. Carroll.

There are no reliable data as to of how often or where such surgeries are occurring or of patients’ outcomes. But Nicholas Genes, MD, an ED physician in Manhattan, says he sees far more postsurgical patients who traveled for their procedures than ones who underwent surgery locally. He can’t say for certain whether that’s because procedures performed by doctors in New York City have fewer complications or the physicians just handle postprocedure problems themselves.

In a 2021 systematic review of aesthetic breast surgeries performed through medical tourism, researchers found that of 171 patients who traveled for surgery, 88 (51%) had a total of 106 complications that required returning to the operating room and undergoing general anesthesia. They also found that 39% of breast augmentation implant surgeries required either a unilateral or bilateral explantation procedure after patients returned home.

The rate of complications was higher than the study authors had expected. “These are totally elective procedures,” Dr. Matarasso said. “They should be optimized.” And high rates of complications come with hefty price tags.

The cost of managing these complications, which falls to the home healthcare system or the patient themselves, can range from $5,500 (determined on the basis of data from a 2019 study in the United Kingdom) to as much as $123,000, researchers in New York City calculated, if the patient develops a complicated mycobacterium infection.

“In your effort to get a good deal or around the system, you could still end up with a lot of extensive medical bills if something goes wrong,” Dr. Genes said.
 

The liability dilemma

Many of the ED physicians Dr. Carroll heard from said that they wouldn’t have treated the woman who needed to have drains removed. Unlike the Brazilian-butt-lifts-gone-wrong in Miami or the complications Dr. Genes sees in New York City, Dr. Carroll’s patient wasn’t in a state of emergency. Most ED physicians said they would have sent her on her way to find a surgeon.

“In general, we shouldn’t be doing things we aren’t trained to do. It’s sort of a slippery slope,” Dr. Genes said. He’s comfortable with removing stitches, but for surgical drains and plastic apparatuses, “I don’t feel particularly well trained. I’d have to consult a colleague in general surgery,” he said. When he does get one of these patients, he works the phones to find a plastic surgeon who will see the patient, something he says their original plastic surgeon should have done.

“Sitting there with the patient, I felt a little bad for her,” Dr. Carroll said. “I knew if I didn’t do it, it would be weeks while she bounced around to urgent care, primary care, and finally found a surgeon.” But by removing the drains, he did shift some of the liability to himself. “If she developed a wound infection, then I’m on the hook for [that],” he said. “If I send her away, I have less liability but didn’t quite do the right thing for the patient.”

In replies to Dr. Carroll’s thread, some doctors debated whether these types of cases, particularly those in which surgeons forgo follow-up care, could be considered medical abandonment. Legal experts say that’s not exactly the case, at least it would not be the case with Dr. Carroll’s patient.

“I don’t think they’ve abandoned the patient; I think they’ve abandoned care,” said Michael Flynn, JD, professor of personal injury law at Nova Southeastern University, in Fort Lauderdale–Davie, Fla. “And that abandonment of follow-up care, if it falls below the standard of what medical professionals should do, then it’s malpractice.”

“The doctor didn’t just walk away and become unreachable,” said Bernard Black, JD, a medical malpractice attorney and law professor at Northwestern University, in Evanston, Ill. Technically, the surgeon referred the patient to the ED. Mr. Black agreed that it sounds more like a question of malpractice, “but without real damages, there’s no claim.”

Even if not illegal, sending these patients to the ED is still highly unethical, Dr. Carroll said. The authors of a 2014 article in Aesthetic Plastic Surgery concur: “It is the duty and ethical responsibility of plastic surgeons to prevent unnecessary complications following tourism medicine by adequately counseling patients, defining perioperative treatment protocols, and reporting complications to regional and specialty-specific governing bodies,” they write.

Sometimes patients need to travel, Dr. Matarasso said. Recently, three out-of-state patients came to him for procedures. Two stayed in Manhattan until their follow-up care was finished; he arranged care elsewhere for the third. It’s the operating surgeon’s job to connect patients with someone who can provide follow-up care when they go home, Dr. Matarasso said. If a surgeon doesn’t have a connection in a patient’s home city, the ASPS has a referral service to help, he said.

“My frustration was never with the patient,” Dr. Carroll said. “No one should feel bad about coming to an ED for literally anything, and I mean that. My frustration is with the surgeon who didn’t go the one extra step to arrange her follow-up.”

A version of this article first appeared on Medscape.com.

It was a typical, busy evening shift in the emergency department (ED) when Steve Carroll, DO, an emergency medicine physician in the Philadelphia area, noticed an odd listing on the tracking board. In the waiting room, there was someone whose chief complaint was that she needed to have surgical drains pulled.

According to the woman’s chart, she’d undergone liposuction in Miami a week before. She came bearing a letter from her surgeon to an ED physician with specific instructions on when and how to remove the drains. The surgeon had effectively relinquished all follow-up care to the woman’s local ED.

Dr. Carroll searched the name of her surgeon and found that his site “specifically advertised medical tourism,” Dr. Carroll said. The site lured patients with the idea of recovering by the beach and that a local nurse would come to their room every day.

But when Dr. Carroll told the patient that her surgeon should be the one who removes the drains, she became concerned. She didn’t know that her surgeon wasn’t providing the standard of care, he said. Somewhat appalled that a board-certified plastic surgeon would place the burden of follow-up care on an ED doctor hundreds of miles away, Dr. Carroll posted the case to Twitter and several Facebook groups.

“Yes I could refuse to take [the drains] out but that’s not patient-centered care,” Dr. Carroll wrote in a Twitter thread. “It’s unfairly shifting routine outpatient surgical followup (and liability) onto me and extra cost to [the patient].” Comments from ED physicians and sympathetic surgeons across the country flowed in. Dr. Carroll quickly realized his situation was part of a much larger problem than he’d thought.

Dr. Carroll’s patient told him that the Miami surgery cost less than undergoing the surgery locally; that’s why she’d made the trip. She’s not alone. Traveling to get the lowest price for a plastic surgery procedure has been a rising phenomenon since the early 2000s, according to the American Society of Plastic Surgeons (ASPS). Many countries are actively fostering their medical tourism industries, as are states such as Florida.

People have long traveled to get the best medical care. But “medical tourism is completely different,” said Alan Matarasso, MD, FACS, a Manhattan-based plastic surgeon and member of the ASPS Executive Committee. “People [are] traveling to get a simultaneous vacation or lower cost,” he said.

Choosing facilities on the basis of these criteria comes with myriad problems, and the quality of medical care may be lower. It’s difficult to verify the credentials of the surgeons, anesthesiologists, and facilities involved. Medical records can be in a different language, and traveling immediately after surgery increases the risk for pulmonary embolism and death, not to mention the added complications of traveling and being a surgical patient during the COVID-19 pandemic, he said.

Typically, surgeons are protective of their patients. But Murtaza Akhter, MD, an emergency medicine physician based in Miami, says it’s the opposite with the medical tourism surgeons whose patients regularly end up in his ED. “There’s almost no ownership,” he said. “Every time, [the patients] say, ‘My doctor isn’t responding,’ or they said go to the ER.” And that’s before they’ve even made it out of Miami.

The most common cosmetic surgery complications Dr. Akhter sees occur in patients who’ve undergone so-called Brazilian butt lifts. They show up in his ED face down, suffering from severe blood loss. He has them undergo a transfusion and maybe some imaging, but if they need a higher degree of care, they have to be transferred. “There’s a reason it’s cheaper,” he said.

Medical tourism mishaps are such a regular occurrence in Miami that no one flinches when the patients show up in the ED, Dr. Akhter said. He had begun to think he was overreacting to the problem until he saw Dr. Carroll’s Twitter thread.

“Since it’s daily, I just thought maybe I had gone crazy and that it’s considered normal for plastic surgeons to do this. Thanks for making me feel sane again,” Dr. Akhter tweeted in a reply to Dr. Carroll.

There are no reliable data as to of how often or where such surgeries are occurring or of patients’ outcomes. But Nicholas Genes, MD, an ED physician in Manhattan, says he sees far more postsurgical patients who traveled for their procedures than ones who underwent surgery locally. He can’t say for certain whether that’s because procedures performed by doctors in New York City have fewer complications or the physicians just handle postprocedure problems themselves.

In a 2021 systematic review of aesthetic breast surgeries performed through medical tourism, researchers found that of 171 patients who traveled for surgery, 88 (51%) had a total of 106 complications that required returning to the operating room and undergoing general anesthesia. They also found that 39% of breast augmentation implant surgeries required either a unilateral or bilateral explantation procedure after patients returned home.

The rate of complications was higher than the study authors had expected. “These are totally elective procedures,” Dr. Matarasso said. “They should be optimized.” And high rates of complications come with hefty price tags.

The cost of managing these complications, which falls to the home healthcare system or the patient themselves, can range from $5,500 (determined on the basis of data from a 2019 study in the United Kingdom) to as much as $123,000, researchers in New York City calculated, if the patient develops a complicated mycobacterium infection.

“In your effort to get a good deal or around the system, you could still end up with a lot of extensive medical bills if something goes wrong,” Dr. Genes said.
 

The liability dilemma

Many of the ED physicians Dr. Carroll heard from said that they wouldn’t have treated the woman who needed to have drains removed. Unlike the Brazilian-butt-lifts-gone-wrong in Miami or the complications Dr. Genes sees in New York City, Dr. Carroll’s patient wasn’t in a state of emergency. Most ED physicians said they would have sent her on her way to find a surgeon.

“In general, we shouldn’t be doing things we aren’t trained to do. It’s sort of a slippery slope,” Dr. Genes said. He’s comfortable with removing stitches, but for surgical drains and plastic apparatuses, “I don’t feel particularly well trained. I’d have to consult a colleague in general surgery,” he said. When he does get one of these patients, he works the phones to find a plastic surgeon who will see the patient, something he says their original plastic surgeon should have done.

“Sitting there with the patient, I felt a little bad for her,” Dr. Carroll said. “I knew if I didn’t do it, it would be weeks while she bounced around to urgent care, primary care, and finally found a surgeon.” But by removing the drains, he did shift some of the liability to himself. “If she developed a wound infection, then I’m on the hook for [that],” he said. “If I send her away, I have less liability but didn’t quite do the right thing for the patient.”

In replies to Dr. Carroll’s thread, some doctors debated whether these types of cases, particularly those in which surgeons forgo follow-up care, could be considered medical abandonment. Legal experts say that’s not exactly the case, at least it would not be the case with Dr. Carroll’s patient.

“I don’t think they’ve abandoned the patient; I think they’ve abandoned care,” said Michael Flynn, JD, professor of personal injury law at Nova Southeastern University, in Fort Lauderdale–Davie, Fla. “And that abandonment of follow-up care, if it falls below the standard of what medical professionals should do, then it’s malpractice.”

“The doctor didn’t just walk away and become unreachable,” said Bernard Black, JD, a medical malpractice attorney and law professor at Northwestern University, in Evanston, Ill. Technically, the surgeon referred the patient to the ED. Mr. Black agreed that it sounds more like a question of malpractice, “but without real damages, there’s no claim.”

Even if not illegal, sending these patients to the ED is still highly unethical, Dr. Carroll said. The authors of a 2014 article in Aesthetic Plastic Surgery concur: “It is the duty and ethical responsibility of plastic surgeons to prevent unnecessary complications following tourism medicine by adequately counseling patients, defining perioperative treatment protocols, and reporting complications to regional and specialty-specific governing bodies,” they write.

Sometimes patients need to travel, Dr. Matarasso said. Recently, three out-of-state patients came to him for procedures. Two stayed in Manhattan until their follow-up care was finished; he arranged care elsewhere for the third. It’s the operating surgeon’s job to connect patients with someone who can provide follow-up care when they go home, Dr. Matarasso said. If a surgeon doesn’t have a connection in a patient’s home city, the ASPS has a referral service to help, he said.

“My frustration was never with the patient,” Dr. Carroll said. “No one should feel bad about coming to an ED for literally anything, and I mean that. My frustration is with the surgeon who didn’t go the one extra step to arrange her follow-up.”

A version of this article first appeared on Medscape.com.

It was a typical, busy evening shift in the emergency department (ED) when Steve Carroll, DO, an emergency medicine physician in the Philadelphia area, noticed an odd listing on the tracking board. In the waiting room, there was someone whose chief complaint was that she needed to have surgical drains pulled.

According to the woman’s chart, she’d undergone liposuction in Miami a week before. She came bearing a letter from her surgeon to an ED physician with specific instructions on when and how to remove the drains. The surgeon had effectively relinquished all follow-up care to the woman’s local ED.

Dr. Carroll searched the name of her surgeon and found that his site “specifically advertised medical tourism,” Dr. Carroll said. The site lured patients with the idea of recovering by the beach and that a local nurse would come to their room every day.

But when Dr. Carroll told the patient that her surgeon should be the one who removes the drains, she became concerned. She didn’t know that her surgeon wasn’t providing the standard of care, he said. Somewhat appalled that a board-certified plastic surgeon would place the burden of follow-up care on an ED doctor hundreds of miles away, Dr. Carroll posted the case to Twitter and several Facebook groups.

“Yes I could refuse to take [the drains] out but that’s not patient-centered care,” Dr. Carroll wrote in a Twitter thread. “It’s unfairly shifting routine outpatient surgical followup (and liability) onto me and extra cost to [the patient].” Comments from ED physicians and sympathetic surgeons across the country flowed in. Dr. Carroll quickly realized his situation was part of a much larger problem than he’d thought.

Dr. Carroll’s patient told him that the Miami surgery cost less than undergoing the surgery locally; that’s why she’d made the trip. She’s not alone. Traveling to get the lowest price for a plastic surgery procedure has been a rising phenomenon since the early 2000s, according to the American Society of Plastic Surgeons (ASPS). Many countries are actively fostering their medical tourism industries, as are states such as Florida.

People have long traveled to get the best medical care. But “medical tourism is completely different,” said Alan Matarasso, MD, FACS, a Manhattan-based plastic surgeon and member of the ASPS Executive Committee. “People [are] traveling to get a simultaneous vacation or lower cost,” he said.

Choosing facilities on the basis of these criteria comes with myriad problems, and the quality of medical care may be lower. It’s difficult to verify the credentials of the surgeons, anesthesiologists, and facilities involved. Medical records can be in a different language, and traveling immediately after surgery increases the risk for pulmonary embolism and death, not to mention the added complications of traveling and being a surgical patient during the COVID-19 pandemic, he said.

Typically, surgeons are protective of their patients. But Murtaza Akhter, MD, an emergency medicine physician based in Miami, says it’s the opposite with the medical tourism surgeons whose patients regularly end up in his ED. “There’s almost no ownership,” he said. “Every time, [the patients] say, ‘My doctor isn’t responding,’ or they said go to the ER.” And that’s before they’ve even made it out of Miami.

The most common cosmetic surgery complications Dr. Akhter sees occur in patients who’ve undergone so-called Brazilian butt lifts. They show up in his ED face down, suffering from severe blood loss. He has them undergo a transfusion and maybe some imaging, but if they need a higher degree of care, they have to be transferred. “There’s a reason it’s cheaper,” he said.

Medical tourism mishaps are such a regular occurrence in Miami that no one flinches when the patients show up in the ED, Dr. Akhter said. He had begun to think he was overreacting to the problem until he saw Dr. Carroll’s Twitter thread.

“Since it’s daily, I just thought maybe I had gone crazy and that it’s considered normal for plastic surgeons to do this. Thanks for making me feel sane again,” Dr. Akhter tweeted in a reply to Dr. Carroll.

There are no reliable data as to of how often or where such surgeries are occurring or of patients’ outcomes. But Nicholas Genes, MD, an ED physician in Manhattan, says he sees far more postsurgical patients who traveled for their procedures than ones who underwent surgery locally. He can’t say for certain whether that’s because procedures performed by doctors in New York City have fewer complications or the physicians just handle postprocedure problems themselves.

In a 2021 systematic review of aesthetic breast surgeries performed through medical tourism, researchers found that of 171 patients who traveled for surgery, 88 (51%) had a total of 106 complications that required returning to the operating room and undergoing general anesthesia. They also found that 39% of breast augmentation implant surgeries required either a unilateral or bilateral explantation procedure after patients returned home.

The rate of complications was higher than the study authors had expected. “These are totally elective procedures,” Dr. Matarasso said. “They should be optimized.” And high rates of complications come with hefty price tags.

The cost of managing these complications, which falls to the home healthcare system or the patient themselves, can range from $5,500 (determined on the basis of data from a 2019 study in the United Kingdom) to as much as $123,000, researchers in New York City calculated, if the patient develops a complicated mycobacterium infection.

“In your effort to get a good deal or around the system, you could still end up with a lot of extensive medical bills if something goes wrong,” Dr. Genes said.
 

The liability dilemma

Many of the ED physicians Dr. Carroll heard from said that they wouldn’t have treated the woman who needed to have drains removed. Unlike the Brazilian-butt-lifts-gone-wrong in Miami or the complications Dr. Genes sees in New York City, Dr. Carroll’s patient wasn’t in a state of emergency. Most ED physicians said they would have sent her on her way to find a surgeon.

“In general, we shouldn’t be doing things we aren’t trained to do. It’s sort of a slippery slope,” Dr. Genes said. He’s comfortable with removing stitches, but for surgical drains and plastic apparatuses, “I don’t feel particularly well trained. I’d have to consult a colleague in general surgery,” he said. When he does get one of these patients, he works the phones to find a plastic surgeon who will see the patient, something he says their original plastic surgeon should have done.

“Sitting there with the patient, I felt a little bad for her,” Dr. Carroll said. “I knew if I didn’t do it, it would be weeks while she bounced around to urgent care, primary care, and finally found a surgeon.” But by removing the drains, he did shift some of the liability to himself. “If she developed a wound infection, then I’m on the hook for [that],” he said. “If I send her away, I have less liability but didn’t quite do the right thing for the patient.”

In replies to Dr. Carroll’s thread, some doctors debated whether these types of cases, particularly those in which surgeons forgo follow-up care, could be considered medical abandonment. Legal experts say that’s not exactly the case, at least it would not be the case with Dr. Carroll’s patient.

“I don’t think they’ve abandoned the patient; I think they’ve abandoned care,” said Michael Flynn, JD, professor of personal injury law at Nova Southeastern University, in Fort Lauderdale–Davie, Fla. “And that abandonment of follow-up care, if it falls below the standard of what medical professionals should do, then it’s malpractice.”

“The doctor didn’t just walk away and become unreachable,” said Bernard Black, JD, a medical malpractice attorney and law professor at Northwestern University, in Evanston, Ill. Technically, the surgeon referred the patient to the ED. Mr. Black agreed that it sounds more like a question of malpractice, “but without real damages, there’s no claim.”

Even if not illegal, sending these patients to the ED is still highly unethical, Dr. Carroll said. The authors of a 2014 article in Aesthetic Plastic Surgery concur: “It is the duty and ethical responsibility of plastic surgeons to prevent unnecessary complications following tourism medicine by adequately counseling patients, defining perioperative treatment protocols, and reporting complications to regional and specialty-specific governing bodies,” they write.

Sometimes patients need to travel, Dr. Matarasso said. Recently, three out-of-state patients came to him for procedures. Two stayed in Manhattan until their follow-up care was finished; he arranged care elsewhere for the third. It’s the operating surgeon’s job to connect patients with someone who can provide follow-up care when they go home, Dr. Matarasso said. If a surgeon doesn’t have a connection in a patient’s home city, the ASPS has a referral service to help, he said.

“My frustration was never with the patient,” Dr. Carroll said. “No one should feel bad about coming to an ED for literally anything, and I mean that. My frustration is with the surgeon who didn’t go the one extra step to arrange her follow-up.”

A version of this article first appeared on Medscape.com.

From mid-December 2020 through early May 2021, there were 139,393 fewer deaths from COVID-19 and about 3.1 million fewer confirmed cases in the United States than would have been expected without the COVID-19 vaccination campaign, finds a new report published online in Health Affairs.

New York had 11.7 fewer COVID-19 deaths per 10,000 adults, and Hawaii had 1.1 fewer deaths per 10,000 than would have occurred without vaccinations, the study shows. The rest of the states fell somewhere in between, with the average state experiencing five fewer COVID-19 deaths per 10,000 adults.

At a national level, this means that instead of the 550,000 COVID-19 deaths that occurred by early May, there would have been 709,000 deaths in the absence of a vaccination campaign, according to the study.

Researchers from RAND and Indiana University created models to estimate the number of COVID-19 deaths that would have happened without vaccinations. The difference between the actual number of deaths and those estimates provides a measure of the number of COVID-19 deaths averted by the vaccination campaign.

Information about vaccine doses administered in each state came from the Bloomberg COVID-19 Vaccine Tracker, and data on COVID-19 deaths for each state came from The New York Times’ Coronavirus (COVID-19) Data in the United States database.

The study spanned the period from Dec. 21, 2020 to May 9, 2021. The U.S. Food and Drug Administration issued its first emergency use authorization (EUA) for a COVID-19 vaccine to Pfizer/BioNTech on December 11, followed by an EUA for the Moderna vaccine on December 18 and one for Johnson & Johnson’s vaccine on Feb. 27, 2021.
 

Varied by state

There were wide variations in the speed and extent of the vaccination campaigns in various states, the researchers found. For example, West Virginia was the first state to reach 10 doses per 100 adults, reaching that goal on Jan. 16, 2021, and Idaho was the last state to hit that mark, on Feb. 4, 2021. Alaska was the first to reach 20 doses per 100 adults, on January 29, and Alabama was the last to do it, on February 21.

On May 6, California was the first state to administer 120 doses per 100 adults, but many states have still not reached that milestone.

The median number of days between the milestones of 10 and 20 doses per 100 adults was 19 days, and the median number of days between 20 and 40 doses per 100 adults was 24 days.
 

Hard to establish causality

The researchers emphasized that “establishment of causality is challenging” in comparing individual states’ vaccination levels with their COVID-19 mortality rates.

Aside from the study being observational, they pointed out, the analysis “relied on variation in the administration of COVID-19 vaccines across states … Vaccine administration patterns may be associated with declining mortality because of vaccine prevention of deaths and severe complications as state-level vaccine campaigns allocated initial doses to the highest-risk populations with the aim of immediately reducing COVID-19 deaths.”

Nevertheless, the authors note, “clinical trial evidence has shown that COVID-19 vaccines have high efficacy. Our study provides support for policies that further expand vaccine administration, which will enable larger populations to benefit.”
 

Study confirms vaccine benefit

Aaron Glatt, MD, chair of medicine at Mount Sinai South Nassau in Oceanside, New York, and a spokesman for the Infectious Disease Society of America, said in an interview that the study is important because it confirms the benefit of COVID-19 vaccination.

Regardless of whether the study’s results are statistically valid, he said, “I don’t think anyone can argue the benefit isn’t there. It’s a question of how important the benefit is.”

Dr. Glatt is not surprised that there are variations across states in the number of COVID-19 deaths averted through vaccination. “Clearly, in states where there was a lot of disease, a significant amount of vaccination is going to impact that tremendously.”

The authors note that their paper has some limitations. For one thing, they couldn’t determine what share of the estimated reduction in COVID-19 deaths was a result of the proportion of the population that was vaccinated or had antibodies and what share was a result of lower population-level risk for COVID-19 transmission.
 

Vaccination versus natural immunity

In addition, the researchers weren’t able to identify the roles of vaccination, natural immunity, and changes in mobility in the numbers of COVID-19 deaths.

Dr. Glatt says that’s understandable, since this was a retrospective study, and the researchers didn’t know how many people had been infected with COVID-19 at some point. Moreover, he adds, scientists don’t know how strong natural immunity from prior infection is, how long it endures, or how robust it is against new variants.

“It’s clear to me that there’s a benefit in preventing the second episode of COVID in people who had a first episode of COVID,” he said. “What we don’t know is how much that benefit is and how long it will last.”

The researchers also didn’t know how many people had gotten both doses of the Pfizer or the Moderna vaccine and how many of them had received only one. This is an important piece of information, Dr. Glatt said, but the lack of it doesn’t impair the study’s overall finding.

“Every vaccine potentially prevents death,” he stressed. “The more we vaccinate, the more deaths we’ll prevent. We’re starting to see increased vaccinations again. There were a million of them yesterday. So people are recognizing that COVID hasn’t gone away, and we need to vaccinate more people. The benefit from the vaccination hasn’t decreased. The more we vaccinate, the more the benefit will be.”

A version of this article first appeared on Medscape.com.

From mid-December 2020 through early May 2021, there were 139,393 fewer deaths from COVID-19 and about 3.1 million fewer confirmed cases in the United States than would have been expected without the COVID-19 vaccination campaign, finds a new report published online in Health Affairs.

New York had 11.7 fewer COVID-19 deaths per 10,000 adults, and Hawaii had 1.1 fewer deaths per 10,000 than would have occurred without vaccinations, the study shows. The rest of the states fell somewhere in between, with the average state experiencing five fewer COVID-19 deaths per 10,000 adults.

At a national level, this means that instead of the 550,000 COVID-19 deaths that occurred by early May, there would have been 709,000 deaths in the absence of a vaccination campaign, according to the study.

Researchers from RAND and Indiana University created models to estimate the number of COVID-19 deaths that would have happened without vaccinations. The difference between the actual number of deaths and those estimates provides a measure of the number of COVID-19 deaths averted by the vaccination campaign.

Information about vaccine doses administered in each state came from the Bloomberg COVID-19 Vaccine Tracker, and data on COVID-19 deaths for each state came from The New York Times’ Coronavirus (COVID-19) Data in the United States database.

The study spanned the period from Dec. 21, 2020 to May 9, 2021. The U.S. Food and Drug Administration issued its first emergency use authorization (EUA) for a COVID-19 vaccine to Pfizer/BioNTech on December 11, followed by an EUA for the Moderna vaccine on December 18 and one for Johnson & Johnson’s vaccine on Feb. 27, 2021.
 

Varied by state

There were wide variations in the speed and extent of the vaccination campaigns in various states, the researchers found. For example, West Virginia was the first state to reach 10 doses per 100 adults, reaching that goal on Jan. 16, 2021, and Idaho was the last state to hit that mark, on Feb. 4, 2021. Alaska was the first to reach 20 doses per 100 adults, on January 29, and Alabama was the last to do it, on February 21.

On May 6, California was the first state to administer 120 doses per 100 adults, but many states have still not reached that milestone.

The median number of days between the milestones of 10 and 20 doses per 100 adults was 19 days, and the median number of days between 20 and 40 doses per 100 adults was 24 days.
 

Hard to establish causality

The researchers emphasized that “establishment of causality is challenging” in comparing individual states’ vaccination levels with their COVID-19 mortality rates.

Aside from the study being observational, they pointed out, the analysis “relied on variation in the administration of COVID-19 vaccines across states … Vaccine administration patterns may be associated with declining mortality because of vaccine prevention of deaths and severe complications as state-level vaccine campaigns allocated initial doses to the highest-risk populations with the aim of immediately reducing COVID-19 deaths.”

Nevertheless, the authors note, “clinical trial evidence has shown that COVID-19 vaccines have high efficacy. Our study provides support for policies that further expand vaccine administration, which will enable larger populations to benefit.”
 

Study confirms vaccine benefit

Aaron Glatt, MD, chair of medicine at Mount Sinai South Nassau in Oceanside, New York, and a spokesman for the Infectious Disease Society of America, said in an interview that the study is important because it confirms the benefit of COVID-19 vaccination.

Regardless of whether the study’s results are statistically valid, he said, “I don’t think anyone can argue the benefit isn’t there. It’s a question of how important the benefit is.”

Dr. Glatt is not surprised that there are variations across states in the number of COVID-19 deaths averted through vaccination. “Clearly, in states where there was a lot of disease, a significant amount of vaccination is going to impact that tremendously.”

The authors note that their paper has some limitations. For one thing, they couldn’t determine what share of the estimated reduction in COVID-19 deaths was a result of the proportion of the population that was vaccinated or had antibodies and what share was a result of lower population-level risk for COVID-19 transmission.
 

Vaccination versus natural immunity

In addition, the researchers weren’t able to identify the roles of vaccination, natural immunity, and changes in mobility in the numbers of COVID-19 deaths.

Dr. Glatt says that’s understandable, since this was a retrospective study, and the researchers didn’t know how many people had been infected with COVID-19 at some point. Moreover, he adds, scientists don’t know how strong natural immunity from prior infection is, how long it endures, or how robust it is against new variants.

“It’s clear to me that there’s a benefit in preventing the second episode of COVID in people who had a first episode of COVID,” he said. “What we don’t know is how much that benefit is and how long it will last.”

The researchers also didn’t know how many people had gotten both doses of the Pfizer or the Moderna vaccine and how many of them had received only one. This is an important piece of information, Dr. Glatt said, but the lack of it doesn’t impair the study’s overall finding.

“Every vaccine potentially prevents death,” he stressed. “The more we vaccinate, the more deaths we’ll prevent. We’re starting to see increased vaccinations again. There were a million of them yesterday. So people are recognizing that COVID hasn’t gone away, and we need to vaccinate more people. The benefit from the vaccination hasn’t decreased. The more we vaccinate, the more the benefit will be.”

A version of this article first appeared on Medscape.com.

From mid-December 2020 through early May 2021, there were 139,393 fewer deaths from COVID-19 and about 3.1 million fewer confirmed cases in the United States than would have been expected without the COVID-19 vaccination campaign, finds a new report published online in Health Affairs.

New York had 11.7 fewer COVID-19 deaths per 10,000 adults, and Hawaii had 1.1 fewer deaths per 10,000 than would have occurred without vaccinations, the study shows. The rest of the states fell somewhere in between, with the average state experiencing five fewer COVID-19 deaths per 10,000 adults.

At a national level, this means that instead of the 550,000 COVID-19 deaths that occurred by early May, there would have been 709,000 deaths in the absence of a vaccination campaign, according to the study.

Researchers from RAND and Indiana University created models to estimate the number of COVID-19 deaths that would have happened without vaccinations. The difference between the actual number of deaths and those estimates provides a measure of the number of COVID-19 deaths averted by the vaccination campaign.

Information about vaccine doses administered in each state came from the Bloomberg COVID-19 Vaccine Tracker, and data on COVID-19 deaths for each state came from The New York Times’ Coronavirus (COVID-19) Data in the United States database.

The study spanned the period from Dec. 21, 2020 to May 9, 2021. The U.S. Food and Drug Administration issued its first emergency use authorization (EUA) for a COVID-19 vaccine to Pfizer/BioNTech on December 11, followed by an EUA for the Moderna vaccine on December 18 and one for Johnson & Johnson’s vaccine on Feb. 27, 2021.
 

Varied by state

There were wide variations in the speed and extent of the vaccination campaigns in various states, the researchers found. For example, West Virginia was the first state to reach 10 doses per 100 adults, reaching that goal on Jan. 16, 2021, and Idaho was the last state to hit that mark, on Feb. 4, 2021. Alaska was the first to reach 20 doses per 100 adults, on January 29, and Alabama was the last to do it, on February 21.

On May 6, California was the first state to administer 120 doses per 100 adults, but many states have still not reached that milestone.

The median number of days between the milestones of 10 and 20 doses per 100 adults was 19 days, and the median number of days between 20 and 40 doses per 100 adults was 24 days.
 

Hard to establish causality

The researchers emphasized that “establishment of causality is challenging” in comparing individual states’ vaccination levels with their COVID-19 mortality rates.

Aside from the study being observational, they pointed out, the analysis “relied on variation in the administration of COVID-19 vaccines across states … Vaccine administration patterns may be associated with declining mortality because of vaccine prevention of deaths and severe complications as state-level vaccine campaigns allocated initial doses to the highest-risk populations with the aim of immediately reducing COVID-19 deaths.”

Nevertheless, the authors note, “clinical trial evidence has shown that COVID-19 vaccines have high efficacy. Our study provides support for policies that further expand vaccine administration, which will enable larger populations to benefit.”
 

Study confirms vaccine benefit

Aaron Glatt, MD, chair of medicine at Mount Sinai South Nassau in Oceanside, New York, and a spokesman for the Infectious Disease Society of America, said in an interview that the study is important because it confirms the benefit of COVID-19 vaccination.

Regardless of whether the study’s results are statistically valid, he said, “I don’t think anyone can argue the benefit isn’t there. It’s a question of how important the benefit is.”

Dr. Glatt is not surprised that there are variations across states in the number of COVID-19 deaths averted through vaccination. “Clearly, in states where there was a lot of disease, a significant amount of vaccination is going to impact that tremendously.”

The authors note that their paper has some limitations. For one thing, they couldn’t determine what share of the estimated reduction in COVID-19 deaths was a result of the proportion of the population that was vaccinated or had antibodies and what share was a result of lower population-level risk for COVID-19 transmission.
 

Vaccination versus natural immunity

In addition, the researchers weren’t able to identify the roles of vaccination, natural immunity, and changes in mobility in the numbers of COVID-19 deaths.

Dr. Glatt says that’s understandable, since this was a retrospective study, and the researchers didn’t know how many people had been infected with COVID-19 at some point. Moreover, he adds, scientists don’t know how strong natural immunity from prior infection is, how long it endures, or how robust it is against new variants.

“It’s clear to me that there’s a benefit in preventing the second episode of COVID in people who had a first episode of COVID,” he said. “What we don’t know is how much that benefit is and how long it will last.”

The researchers also didn’t know how many people had gotten both doses of the Pfizer or the Moderna vaccine and how many of them had received only one. This is an important piece of information, Dr. Glatt said, but the lack of it doesn’t impair the study’s overall finding.

“Every vaccine potentially prevents death,” he stressed. “The more we vaccinate, the more deaths we’ll prevent. We’re starting to see increased vaccinations again. There were a million of them yesterday. So people are recognizing that COVID hasn’t gone away, and we need to vaccinate more people. The benefit from the vaccination hasn’t decreased. The more we vaccinate, the more the benefit will be.”

A version of this article first appeared on Medscape.com.

Among adults at high risk of type 2 diabetes – the leading cause of kidney disease – those who received vitamin D supplements as opposed to placebo for close to 3 years did not have significant differences in kidney function, in a secondary analysis of the Vitamin D and Type 2 Diabetes (D2d) study.

However, most of these adults with prediabetes plus obesity or overweight also had sufficient serum levels of 25-hydroxyvitamin D (25[OH]D) and a low risk for adverse kidney outcomes at study entry.

“The benefits of vitamin D might be greater in people with low blood vitamin D levels and/or reduced kidney function,” lead author Sun H. Kim, MD, Stanford (Calif.) University, speculated in a statement from the American Society of Nephrology.

The study was published online August 6 in the Clinical Journal of the American Society of Nephrology.

“The D2d study is unique because we recruited individuals with high-risk prediabetes, having two out of three abnormal glucose values, and we recruited more than 2,000 participants, representing the largest vitamin D diabetes prevention trial to date,” Dr. Kim pointed out.

Although the study did not show a benefit of vitamin D supplements on kidney function outcomes, 43% of participants were already taking up to 1,000 IU of vitamin D daily when they entered the study, she noted.

A subgroup analysis of individuals who were not taking vitamin D at study entry found that vitamin D supplements were associated with lowered proteinuria, “which means that it could have a beneficial effect on kidney health,” said Dr. Kim, cautioning that “additional studies are needed to look into this further.”
 

Effect of vitamin D on three kidney function outcomes

Although low levels of serum 25(OH)D are associated with kidney disease, few trials have evaluated how vitamin D supplements might affect kidney function, Dr. Kim and colleagues write.

The D2d trial, they note, found that vitamin D supplements did not lower the risk of incident diabetes in people with prediabetes recruited from medical centers across the United States, as previously reported in 2019.

However, since then, meta-analyses that included the D2d trial have reported a significant 11%-12% reduction in diabetes risk in people with prediabetes who took vitamin D supplements.

The current secondary analysis of D2d aimed to investigate whether vitamin D supplements affect kidney function in people with prediabetes.

A total of 2,166 participants in D2d with complete kidney function data were included in the analysis.

The three study outcomes were change in estimated glomerular filtration rate (eGFR) from baseline, change in urine albumin-to-creatinine ratio (UACR) from baseline, and worsening Kidney Disease: Improving Global Outcomes (KDIGO) risk score (which takes eGFR and UACR into account).

At baseline, patients were a mean age of 60, had a mean body mass index (BMI) of 32 kg/m², and 44% were women.

Most (79%) had hypertension, 52% were receiving antihypertensives, and 33% were receiving an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB).

Participants had a mean serum 25(OH) level of 28 ng/mL.

They had a mean eGFR of 87 mL/min/1.73 m² and a mean UACR of 11 mg/g. Only 10% had a moderate, high, or very high KDIGO risk score.

Participants were randomized to receive a daily gel pill containing 4,000 IU vitamin D3 (cholecalciferol) or placebo.

Medication adherence was high (83%) in both groups during a median follow-up of 2.9 years.

There was no significant between-group difference in the following kidney function outcomes:

• 28 patients in the vitamin D group and 30 patients in the placebo group had a worsening KDIGO risk score.
• The mean difference in eGFR from baseline was -1.0 mL/min/1.73 m² in the vitamin D group and -0.1 mL/min/1.73 m² in the placebo group.
• The mean difference in UACR from baseline was 2.7 mg/g in the vitamin D group and 2.0 mg/g in the placebo group.  

The authors have reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Among adults at high risk of type 2 diabetes – the leading cause of kidney disease – those who received vitamin D supplements as opposed to placebo for close to 3 years did not have significant differences in kidney function, in a secondary analysis of the Vitamin D and Type 2 Diabetes (D2d) study.

However, most of these adults with prediabetes plus obesity or overweight also had sufficient serum levels of 25-hydroxyvitamin D (25[OH]D) and a low risk for adverse kidney outcomes at study entry.

“The benefits of vitamin D might be greater in people with low blood vitamin D levels and/or reduced kidney function,” lead author Sun H. Kim, MD, Stanford (Calif.) University, speculated in a statement from the American Society of Nephrology.

The study was published online August 6 in the Clinical Journal of the American Society of Nephrology.

“The D2d study is unique because we recruited individuals with high-risk prediabetes, having two out of three abnormal glucose values, and we recruited more than 2,000 participants, representing the largest vitamin D diabetes prevention trial to date,” Dr. Kim pointed out.

Although the study did not show a benefit of vitamin D supplements on kidney function outcomes, 43% of participants were already taking up to 1,000 IU of vitamin D daily when they entered the study, she noted.

A subgroup analysis of individuals who were not taking vitamin D at study entry found that vitamin D supplements were associated with lowered proteinuria, “which means that it could have a beneficial effect on kidney health,” said Dr. Kim, cautioning that “additional studies are needed to look into this further.”
 

Effect of vitamin D on three kidney function outcomes

Although low levels of serum 25(OH)D are associated with kidney disease, few trials have evaluated how vitamin D supplements might affect kidney function, Dr. Kim and colleagues write.

The D2d trial, they note, found that vitamin D supplements did not lower the risk of incident diabetes in people with prediabetes recruited from medical centers across the United States, as previously reported in 2019.

However, since then, meta-analyses that included the D2d trial have reported a significant 11%-12% reduction in diabetes risk in people with prediabetes who took vitamin D supplements.

The current secondary analysis of D2d aimed to investigate whether vitamin D supplements affect kidney function in people with prediabetes.

A total of 2,166 participants in D2d with complete kidney function data were included in the analysis.

The three study outcomes were change in estimated glomerular filtration rate (eGFR) from baseline, change in urine albumin-to-creatinine ratio (UACR) from baseline, and worsening Kidney Disease: Improving Global Outcomes (KDIGO) risk score (which takes eGFR and UACR into account).

At baseline, patients were a mean age of 60, had a mean body mass index (BMI) of 32 kg/m², and 44% were women.

Most (79%) had hypertension, 52% were receiving antihypertensives, and 33% were receiving an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB).

Participants had a mean serum 25(OH) level of 28 ng/mL.

They had a mean eGFR of 87 mL/min/1.73 m² and a mean UACR of 11 mg/g. Only 10% had a moderate, high, or very high KDIGO risk score.

Participants were randomized to receive a daily gel pill containing 4,000 IU vitamin D3 (cholecalciferol) or placebo.

Medication adherence was high (83%) in both groups during a median follow-up of 2.9 years.

There was no significant between-group difference in the following kidney function outcomes:

• 28 patients in the vitamin D group and 30 patients in the placebo group had a worsening KDIGO risk score.
• The mean difference in eGFR from baseline was -1.0 mL/min/1.73 m² in the vitamin D group and -0.1 mL/min/1.73 m² in the placebo group.
• The mean difference in UACR from baseline was 2.7 mg/g in the vitamin D group and 2.0 mg/g in the placebo group.  

The authors have reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Among adults at high risk of type 2 diabetes – the leading cause of kidney disease – those who received vitamin D supplements as opposed to placebo for close to 3 years did not have significant differences in kidney function, in a secondary analysis of the Vitamin D and Type 2 Diabetes (D2d) study.

However, most of these adults with prediabetes plus obesity or overweight also had sufficient serum levels of 25-hydroxyvitamin D (25[OH]D) and a low risk for adverse kidney outcomes at study entry.

“The benefits of vitamin D might be greater in people with low blood vitamin D levels and/or reduced kidney function,” lead author Sun H. Kim, MD, Stanford (Calif.) University, speculated in a statement from the American Society of Nephrology.

The study was published online August 6 in the Clinical Journal of the American Society of Nephrology.

“The D2d study is unique because we recruited individuals with high-risk prediabetes, having two out of three abnormal glucose values, and we recruited more than 2,000 participants, representing the largest vitamin D diabetes prevention trial to date,” Dr. Kim pointed out.

Although the study did not show a benefit of vitamin D supplements on kidney function outcomes, 43% of participants were already taking up to 1,000 IU of vitamin D daily when they entered the study, she noted.

A subgroup analysis of individuals who were not taking vitamin D at study entry found that vitamin D supplements were associated with lowered proteinuria, “which means that it could have a beneficial effect on kidney health,” said Dr. Kim, cautioning that “additional studies are needed to look into this further.”
 

Effect of vitamin D on three kidney function outcomes

Although low levels of serum 25(OH)D are associated with kidney disease, few trials have evaluated how vitamin D supplements might affect kidney function, Dr. Kim and colleagues write.

The D2d trial, they note, found that vitamin D supplements did not lower the risk of incident diabetes in people with prediabetes recruited from medical centers across the United States, as previously reported in 2019.

However, since then, meta-analyses that included the D2d trial have reported a significant 11%-12% reduction in diabetes risk in people with prediabetes who took vitamin D supplements.

The current secondary analysis of D2d aimed to investigate whether vitamin D supplements affect kidney function in people with prediabetes.

A total of 2,166 participants in D2d with complete kidney function data were included in the analysis.

The three study outcomes were change in estimated glomerular filtration rate (eGFR) from baseline, change in urine albumin-to-creatinine ratio (UACR) from baseline, and worsening Kidney Disease: Improving Global Outcomes (KDIGO) risk score (which takes eGFR and UACR into account).

At baseline, patients were a mean age of 60, had a mean body mass index (BMI) of 32 kg/m², and 44% were women.

Most (79%) had hypertension, 52% were receiving antihypertensives, and 33% were receiving an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB).

Participants had a mean serum 25(OH) level of 28 ng/mL.

They had a mean eGFR of 87 mL/min/1.73 m² and a mean UACR of 11 mg/g. Only 10% had a moderate, high, or very high KDIGO risk score.

Participants were randomized to receive a daily gel pill containing 4,000 IU vitamin D3 (cholecalciferol) or placebo.

Medication adherence was high (83%) in both groups during a median follow-up of 2.9 years.

There was no significant between-group difference in the following kidney function outcomes:

• 28 patients in the vitamin D group and 30 patients in the placebo group had a worsening KDIGO risk score.
• The mean difference in eGFR from baseline was -1.0 mL/min/1.73 m² in the vitamin D group and -0.1 mL/min/1.73 m² in the placebo group.
• The mean difference in UACR from baseline was 2.7 mg/g in the vitamin D group and 2.0 mg/g in the placebo group.  

The authors have reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Following the White House administration’s announcement to start booster COVID-19 vaccinations for American adults in September, experts weighed in on the evidence for choosing an 8-month cutoff, how breakthrough infections figure in, and why calling one mRNA vaccine better than the other could be misleading.

Timing came up more than once at the Aug. 18 White House briefing announcing the booster plans. Reporters asked about the start time of Sept. 20 and people waiting at least 8 months after their second mRNA vaccine dose to get a booster.

Anthony Fauci, MD, chief medical adviser to the president and director of the National Institute of Allergy and Infectious Diseases, explained that late September gives the United States time to set up the logistics.

Centers for Disease Control and Prevention Director Rochelle Walensky, MD, MPH, added that 8 months is in part based on data from Israel and other countries on the waning of vaccine effectiveness over time.

“It is possible that 8 [months] is associated with the amount of time that we’ve been able to follow large groups of people, especially those who are 65 and older,” Julie Swann, PhD, said during a subsequent media briefing sponsored by Newswise on Aug. 18. “I know that Pfizer has said that they think a booster sometime between 6 and 12 months would be reasonable.”

Dr. Swann supported the administration’s booster shots plan. She said it is important “that we continue to get people the full amount of protection if it’s recommended by CDC and ACIP [Advisory Committee on Immunization Practices] that would come from a booster shot.” Dr. Swann is department head and A. Doug Allison Distinguished Professor at North Carolina State University and an adjunct professor in the joint department of biomedical engineering at the University of North Carolina at Chapel Hill. 
 

Rising importance of breakthrough cases

Also on Aug. 18, news emerged that breakthrough cases are on the rise in seven U.S. states, likely because of the Delta variant.

These SARS-CoV-2 infections among the fully vaccinated account for 20% of cases in six of the seven states cited in a New York Times report, for example. Researchers also suggested that hospitalization and deaths associated with breakthrough cases could be higher than previously appreciated.

“It is expected that over time we will see more cases of Delta variant infections among vaccinated people. This points toward the need for booster vaccines and/or eventual modifications to the vaccine to capture new variants in the future,” Juan Wisnivesky, MD, DrPH, chief of the division of general internal medicine at Mount Sinai Health System in New York City, said during the briefing.
 

Vaccine comparisons unfair?

Following the release of a Mayo Clinic study reporting lower effectiveness of the Pfizer mRNA vaccine at 42% versus 76% for the Moderna product, some people started asking if one vaccine was better than the other.

“To begin with, the vaccines are not being compared side-by-side,” Dr. Wisnivesky said. “So we only know the effectiveness of each vaccine versus placebo, but we don’t know one versus the other.”

He added that different study designs, different populations, and other factors make direct comparisons difficult.

More evidence will be needed, Dr. Wisnivesky said, before public health officials can recommend that someone who received one mRNA vaccine switch to another for their booster shot.
 

Layering protections

Continuing to recommend masks is essential, Dr. Swann added. “With this Delta variant, it does appear that the possibility of reinfection or of a disease case breaking through vaccination can occur. So that makes it even more important to consider using nonpharmaceutical interventions while we continue to vaccinate people.”

Wearing or not wearing a mask is one of the behaviors that drive the transmission of disease, Dr. Swann said.

“What we saw across the board is that many people really wanted to go back to normal as much as they could. And we went back to normal a little bit too soon, especially given this new version of the virus that was circulating,” she said.
 

In poll, most favor boosters

A recent poll conducted by Medscape indicates that a majority of vaccinated physicians and nurses are ready and willing to take a COVID-19 booster vaccine. For example, 93% of 943 doctors and 87% of 1,680 nurses who responded want booster shots, either immediately or when they are authorized and recommended.

Among 510 WebMD readers responding to a similar poll, 82% indicated they wanted a booster shot.
 

A challenging task lies ahead

According to CDC data, as of Aug. 18, 2021, almost 169 million Americans are fully vaccinated, including the one-shot Johnson & Johnson adenovirus vaccine.

“I think it will be a challenge to get everyone who is fully vaccinated to come in for that booster,” Dr. Swann said.

Logistically speaking, Dr. Swann explained that many sites that were open for initial vaccinations, including drive-up locations and 24/7 vaccination sites, are no longer operating.

“We might see that rollout look a little bit differently. You might be able to go to your pharmacy or go to your primary care physician,” she said.

“But we may not see as many weekend events so it is going to be easier to get some people a booster than others.

“One interesting thing will also be whether a booster is effective in actually preventing you from giving a disease to someone else,” Dr. Swann said. “That could make a difference as well, because that might play into whether companies, hospitals, universities, or others require a booster.”

A version of this article first appeared on Medscape.com.

Following the White House administration’s announcement to start booster COVID-19 vaccinations for American adults in September, experts weighed in on the evidence for choosing an 8-month cutoff, how breakthrough infections figure in, and why calling one mRNA vaccine better than the other could be misleading.

Timing came up more than once at the Aug. 18 White House briefing announcing the booster plans. Reporters asked about the start time of Sept. 20 and people waiting at least 8 months after their second mRNA vaccine dose to get a booster.

Anthony Fauci, MD, chief medical adviser to the president and director of the National Institute of Allergy and Infectious Diseases, explained that late September gives the United States time to set up the logistics.

Centers for Disease Control and Prevention Director Rochelle Walensky, MD, MPH, added that 8 months is in part based on data from Israel and other countries on the waning of vaccine effectiveness over time.

“It is possible that 8 [months] is associated with the amount of time that we’ve been able to follow large groups of people, especially those who are 65 and older,” Julie Swann, PhD, said during a subsequent media briefing sponsored by Newswise on Aug. 18. “I know that Pfizer has said that they think a booster sometime between 6 and 12 months would be reasonable.”

Dr. Swann supported the administration’s booster shots plan. She said it is important “that we continue to get people the full amount of protection if it’s recommended by CDC and ACIP [Advisory Committee on Immunization Practices] that would come from a booster shot.” Dr. Swann is department head and A. Doug Allison Distinguished Professor at North Carolina State University and an adjunct professor in the joint department of biomedical engineering at the University of North Carolina at Chapel Hill. 
 

Rising importance of breakthrough cases

Also on Aug. 18, news emerged that breakthrough cases are on the rise in seven U.S. states, likely because of the Delta variant.

These SARS-CoV-2 infections among the fully vaccinated account for 20% of cases in six of the seven states cited in a New York Times report, for example. Researchers also suggested that hospitalization and deaths associated with breakthrough cases could be higher than previously appreciated.

“It is expected that over time we will see more cases of Delta variant infections among vaccinated people. This points toward the need for booster vaccines and/or eventual modifications to the vaccine to capture new variants in the future,” Juan Wisnivesky, MD, DrPH, chief of the division of general internal medicine at Mount Sinai Health System in New York City, said during the briefing.
 

Vaccine comparisons unfair?

Following the release of a Mayo Clinic study reporting lower effectiveness of the Pfizer mRNA vaccine at 42% versus 76% for the Moderna product, some people started asking if one vaccine was better than the other.

“To begin with, the vaccines are not being compared side-by-side,” Dr. Wisnivesky said. “So we only know the effectiveness of each vaccine versus placebo, but we don’t know one versus the other.”

He added that different study designs, different populations, and other factors make direct comparisons difficult.

More evidence will be needed, Dr. Wisnivesky said, before public health officials can recommend that someone who received one mRNA vaccine switch to another for their booster shot.
 

Layering protections

Continuing to recommend masks is essential, Dr. Swann added. “With this Delta variant, it does appear that the possibility of reinfection or of a disease case breaking through vaccination can occur. So that makes it even more important to consider using nonpharmaceutical interventions while we continue to vaccinate people.”

Wearing or not wearing a mask is one of the behaviors that drive the transmission of disease, Dr. Swann said.

“What we saw across the board is that many people really wanted to go back to normal as much as they could. And we went back to normal a little bit too soon, especially given this new version of the virus that was circulating,” she said.
 

In poll, most favor boosters

A recent poll conducted by Medscape indicates that a majority of vaccinated physicians and nurses are ready and willing to take a COVID-19 booster vaccine. For example, 93% of 943 doctors and 87% of 1,680 nurses who responded want booster shots, either immediately or when they are authorized and recommended.

Among 510 WebMD readers responding to a similar poll, 82% indicated they wanted a booster shot.
 

A challenging task lies ahead

According to CDC data, as of Aug. 18, 2021, almost 169 million Americans are fully vaccinated, including the one-shot Johnson & Johnson adenovirus vaccine.

“I think it will be a challenge to get everyone who is fully vaccinated to come in for that booster,” Dr. Swann said.

Logistically speaking, Dr. Swann explained that many sites that were open for initial vaccinations, including drive-up locations and 24/7 vaccination sites, are no longer operating.

“We might see that rollout look a little bit differently. You might be able to go to your pharmacy or go to your primary care physician,” she said.

“But we may not see as many weekend events so it is going to be easier to get some people a booster than others.

“One interesting thing will also be whether a booster is effective in actually preventing you from giving a disease to someone else,” Dr. Swann said. “That could make a difference as well, because that might play into whether companies, hospitals, universities, or others require a booster.”

A version of this article first appeared on Medscape.com.

Following the White House administration’s announcement to start booster COVID-19 vaccinations for American adults in September, experts weighed in on the evidence for choosing an 8-month cutoff, how breakthrough infections figure in, and why calling one mRNA vaccine better than the other could be misleading.

Timing came up more than once at the Aug. 18 White House briefing announcing the booster plans. Reporters asked about the start time of Sept. 20 and people waiting at least 8 months after their second mRNA vaccine dose to get a booster.

Anthony Fauci, MD, chief medical adviser to the president and director of the National Institute of Allergy and Infectious Diseases, explained that late September gives the United States time to set up the logistics.

Centers for Disease Control and Prevention Director Rochelle Walensky, MD, MPH, added that 8 months is in part based on data from Israel and other countries on the waning of vaccine effectiveness over time.

“It is possible that 8 [months] is associated with the amount of time that we’ve been able to follow large groups of people, especially those who are 65 and older,” Julie Swann, PhD, said during a subsequent media briefing sponsored by Newswise on Aug. 18. “I know that Pfizer has said that they think a booster sometime between 6 and 12 months would be reasonable.”

Dr. Swann supported the administration’s booster shots plan. She said it is important “that we continue to get people the full amount of protection if it’s recommended by CDC and ACIP [Advisory Committee on Immunization Practices] that would come from a booster shot.” Dr. Swann is department head and A. Doug Allison Distinguished Professor at North Carolina State University and an adjunct professor in the joint department of biomedical engineering at the University of North Carolina at Chapel Hill. 
 

Rising importance of breakthrough cases

Also on Aug. 18, news emerged that breakthrough cases are on the rise in seven U.S. states, likely because of the Delta variant.

These SARS-CoV-2 infections among the fully vaccinated account for 20% of cases in six of the seven states cited in a New York Times report, for example. Researchers also suggested that hospitalization and deaths associated with breakthrough cases could be higher than previously appreciated.

“It is expected that over time we will see more cases of Delta variant infections among vaccinated people. This points toward the need for booster vaccines and/or eventual modifications to the vaccine to capture new variants in the future,” Juan Wisnivesky, MD, DrPH, chief of the division of general internal medicine at Mount Sinai Health System in New York City, said during the briefing.
 

Vaccine comparisons unfair?

Following the release of a Mayo Clinic study reporting lower effectiveness of the Pfizer mRNA vaccine at 42% versus 76% for the Moderna product, some people started asking if one vaccine was better than the other.

“To begin with, the vaccines are not being compared side-by-side,” Dr. Wisnivesky said. “So we only know the effectiveness of each vaccine versus placebo, but we don’t know one versus the other.”

He added that different study designs, different populations, and other factors make direct comparisons difficult.

More evidence will be needed, Dr. Wisnivesky said, before public health officials can recommend that someone who received one mRNA vaccine switch to another for their booster shot.
 

Layering protections

Continuing to recommend masks is essential, Dr. Swann added. “With this Delta variant, it does appear that the possibility of reinfection or of a disease case breaking through vaccination can occur. So that makes it even more important to consider using nonpharmaceutical interventions while we continue to vaccinate people.”

Wearing or not wearing a mask is one of the behaviors that drive the transmission of disease, Dr. Swann said.

“What we saw across the board is that many people really wanted to go back to normal as much as they could. And we went back to normal a little bit too soon, especially given this new version of the virus that was circulating,” she said.
 

In poll, most favor boosters

A recent poll conducted by Medscape indicates that a majority of vaccinated physicians and nurses are ready and willing to take a COVID-19 booster vaccine. For example, 93% of 943 doctors and 87% of 1,680 nurses who responded want booster shots, either immediately or when they are authorized and recommended.

Among 510 WebMD readers responding to a similar poll, 82% indicated they wanted a booster shot.
 

A challenging task lies ahead

According to CDC data, as of Aug. 18, 2021, almost 169 million Americans are fully vaccinated, including the one-shot Johnson & Johnson adenovirus vaccine.

“I think it will be a challenge to get everyone who is fully vaccinated to come in for that booster,” Dr. Swann said.

Logistically speaking, Dr. Swann explained that many sites that were open for initial vaccinations, including drive-up locations and 24/7 vaccination sites, are no longer operating.

“We might see that rollout look a little bit differently. You might be able to go to your pharmacy or go to your primary care physician,” she said.

“But we may not see as many weekend events so it is going to be easier to get some people a booster than others.

“One interesting thing will also be whether a booster is effective in actually preventing you from giving a disease to someone else,” Dr. Swann said. “That could make a difference as well, because that might play into whether companies, hospitals, universities, or others require a booster.”

A version of this article first appeared on Medscape.com.

Editor’s note: In this article, we present an archetypal ethics challenge in hospital medicine. The authors, members of the SHM’s Ethics Special Interest Group and clinical ethics consultants at their respective hospitals, will comment on the questions and practical approaches for hospitalists.

Ms. S, an 82-year-old woman with severe dementia, was initially hospitalized in the ICU with acute on chronic respiratory failure. Prior to admission, Ms. S lived with her daughter, who is her primary caregiver. Ms. S is able to say her daughter’s name, and answer “yes” and “no” to simple questions. She is bed bound, incontinent of urine and feces, and dependent on her daughter for all ADLs.

This admission, Ms. S has been re-intubated 4 times for recurrent respiratory failure. The nursing staff are distressed that she is suffering physically. Her daughter requests to continue all intensive, life-prolonging treatment including mechanical ventilation and artificial nutrition.

During sign out, your colleague remarks that his grandmother was in a similar situation and that his family chose to pursue comfort care. He questions whether Ms. S has any quality of life and asks if you think further intensive care is futile.

On your first day caring for Ms. S, you contact her primary care provider. Her PCP reports that Ms. S and her daughter completed an advance directive (AD) 10 years ago which documents a preference for all life prolonging treatment.
 

Question #1: What are the ethical challenges?

Dr. Chase: In caring for Ms. S, we face a common ethical challenge: how to respect the patient’s prior preferences (autonomy) when the currently requested treatments have diminishing benefits (beneficence) and escalating harms (non-maleficence). Life-prolonging care can have diminishing returns at the end of life. Ms. S’s loss of decision-making capacity adds a layer of complexity. Her AD was completed when she was able to consider decisions about her care, and she might make different decisions in her current state of health. Shared decision-making with a surrogate can be complicated by a surrogate’s anxiety with making life-altering decisions or their desire to avoid guilt or loneliness. Health care professionals face the limits of scientific knowledge in delivering accurate prognostic estimates, probabilities of recovery, and likelihood of benefit from interventions. In addition to the guideposts of ethical principles, some hospitals have policies which advise clinicians to avoid non-beneficial care.

Such situations are emotionally intense and can trigger distress among patients, families, caregivers and health care professionals. Conscious and unconscious bias about a patient’s perceived quality of life undermines equity and can play a role in our recommendations for patients of advanced age, with cognitive impairment, and those who live with a disability.
 

Question #2: How might you meet the patient’s medical needs in line with her goals?

Dr. Khawaja: In order to provide care consistent with the patient’s goals, the first step is to clarify these goals with Ms. S’s surrogate decision-maker, her daughter. In a previously autonomous but presently incapacitated patient, the previously expressed preferences in the form of a written AD should be respected. However, the AD is only a set of preferences completed at a particular time, not medical orders. The clinician and surrogate must consider how to apply the AD to the current clinical circumstances. The clinician should verify that the clinical circumstances specified in the AD have been met and evaluate if the patient’s preferences have changed since she originally completed the AD.

Surrogates are asked to use a Substituted Judgement Standard (i.e., what would the patient choose in this situation if known). This may differ from what the surrogate wants. If not known, surrogates are asked to use the Best Interest Standard (i.e., what would bring the most net benefit to the patient by weighing benefits and risks of treatment options). I often ask the surrogate, “Tell us about your loved one.” Or, “Knowing your loved one, what do you think would be the most important for her right now?”¹

I would also caution against bias in judging quality of life in patients with dementia, and using the term “futility,” as these concepts are inherently subjective. In general, when a colleague raises the issue of futility, I begin by asking, “…futile to achieve what goal?” That can help clarify some of the disagreement as some goals can be accomplished while others cannot.

Finally, I work to include other members of our team in these discussions. The distress of nurses, social workers, and others are important to acknowledge, validate, and involve in the problem-solving process.
 

Question #3: If you were Ms. S’s hospitalist, what would you do?

Dr. Khawaja: As the hospitalist caring for Ms. S, I would use the “four boxes” model as a helpful, clinically relevant and systematic approach to managing ethical concerns.²

This “four boxes” model gives us a practical framework to address these ethical principles by asking questions in four domains.

Medical indications: What is the nature of her current illness, and is it reversible or not? What is the probability of success of treatment options like mechanical ventilation? Are there adverse effects of treatment?

Patient preferences: Since Ms. S lacks capacity, does her daughter understand the benefits and burdens of treatment? What are the goals of treatment? Prolonging life? Minimizing discomfort? Spending time with loved ones? What burdens would the patient be willing to endure to reach her goals?

Quality of life: What would the patient’s quality of life be with and without the treatments?

Contextual features: My priorities would be building a relationship of trust with Ms. S’s daughter – by educating her about her mother’s clinical status, addressing her concerns and questions, and supporting her as we work through patient-centered decisions about what is best for her mother. Honest communication is a must, even if it means acknowledging uncertainties about the course of disease and prognosis.

These are not easy decisions for surrogates to make. They should be given time to process information and to make what they believe are the best decisions for their loved ones. It is critical for clinicians to provide honest and complete clinical information and to avoid value judgments, bias, or unreasonable time pressure. While one-on-one conversations are central, I find that multidisciplinary meetings allow all stakeholders to ask and answer vital questions and ideally to reach consensus in treatment planning.

Dr. Chase: In caring for Ms. S, I would use a structured approach to discussions with her daughter, such as the “SPIKES” protocol.³ Using open ended questions, I would ask about the patient’s and her daughter’s goals, values, and fears and provide support about the responsibility for shared-decision making and the difficulty of uncertainty. Reflecting statements can help in confirming understanding and showing attention (e.g. “I hear that avoiding discomfort would be important to your mother.”)

I find it helpful to emphasize my commitment to honesty and non-abandonment (a common fear among patients and families). By offering to provide recommendations about both disease-directed and palliative, comfort-focused interventions, the patient’s daughter has an opportunity to engage voluntarily in discussion. When asked about care that may have marginal benefit, I suggest time-limited trials.⁴ I do not offer non-beneficial treatments and if asked about such treatments, I note the underlying motive and why the treatment is not feasible (“I see that you are hoping that your mother will live longer, but I am concerned that tube feeding will not help because…”), offer preferable alternatives, and leave space for questions and emotions. It is important not to force a premature resolution of the situation through unilateral or coercive decisions⁵ (i.e., going off service does not mean I have to wrap up the existential crisis which is occurring.) A broader challenge is the grief and other emotions which accompany illness and death. I can neither prevent death nor grief, but I can offer my professional guidance and provide a supportive space for the patient and family to experience this transition. By acknowledging this, I center myself with the patient and family and we can work together toward a common goal of providing compassionate and ethical care.

Dr. Chase is associate professor, Department of Family and Community Medicine, University of California San Francisco; and co-chair, Ethics Committee, San Francisco General Hospital. Dr. Khawaja is assistant professor, Department of Internal Medicine, Baylor College of Medicine, Houston, and a member of the Ethics Committee of the Society of General Internal Medicine.

References

1. Sulmasy DP, Snyder L. Substituted interests and best judgments: an integrated model of surrogate decision making. JAMA. 2010 Nov 3;304(17):1946-7. doi: 10.1001/jama.2010.159.

2. Jonsen AR, Siegler M, Winslade WJ. Clinical ethics: A practical approach to ethical decisions in clinical medicine. 6th ed. New York: McGraw Hill Medical; 2006.

3. Baile WF, et al. SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer. Oncologist. 2000;5(4):302–311. doi: 10.1634/theoncologist.5-4-302.

4. Chang DW, et al. Evaluation of time-limited trials among critically ill patients with advanced medical illnesses and reduction of nonbeneficial ICU treatments. JAMA Intern Med. 2021;181(6):786–794. doi: 10.1001/jamainternmed.2021.1000.

5. Sedig, L. What’s the role of autonomy in patient-and family-centered care when patients and family members don’t agree? AMA J Ethics. 2016;18(1):12-17. doi: 10.1001/journalofethics.2017.18.1.ecas2-1601.

Editor’s note: In this article, we present an archetypal ethics challenge in hospital medicine. The authors, members of the SHM’s Ethics Special Interest Group and clinical ethics consultants at their respective hospitals, will comment on the questions and practical approaches for hospitalists.

Ms. S, an 82-year-old woman with severe dementia, was initially hospitalized in the ICU with acute on chronic respiratory failure. Prior to admission, Ms. S lived with her daughter, who is her primary caregiver. Ms. S is able to say her daughter’s name, and answer “yes” and “no” to simple questions. She is bed bound, incontinent of urine and feces, and dependent on her daughter for all ADLs.

This admission, Ms. S has been re-intubated 4 times for recurrent respiratory failure. The nursing staff are distressed that she is suffering physically. Her daughter requests to continue all intensive, life-prolonging treatment including mechanical ventilation and artificial nutrition.

During sign out, your colleague remarks that his grandmother was in a similar situation and that his family chose to pursue comfort care. He questions whether Ms. S has any quality of life and asks if you think further intensive care is futile.

On your first day caring for Ms. S, you contact her primary care provider. Her PCP reports that Ms. S and her daughter completed an advance directive (AD) 10 years ago which documents a preference for all life prolonging treatment.
 

Question #1: What are the ethical challenges?

Dr. Chase: In caring for Ms. S, we face a common ethical challenge: how to respect the patient’s prior preferences (autonomy) when the currently requested treatments have diminishing benefits (beneficence) and escalating harms (non-maleficence). Life-prolonging care can have diminishing returns at the end of life. Ms. S’s loss of decision-making capacity adds a layer of complexity. Her AD was completed when she was able to consider decisions about her care, and she might make different decisions in her current state of health. Shared decision-making with a surrogate can be complicated by a surrogate’s anxiety with making life-altering decisions or their desire to avoid guilt or loneliness. Health care professionals face the limits of scientific knowledge in delivering accurate prognostic estimates, probabilities of recovery, and likelihood of benefit from interventions. In addition to the guideposts of ethical principles, some hospitals have policies which advise clinicians to avoid non-beneficial care.

Such situations are emotionally intense and can trigger distress among patients, families, caregivers and health care professionals. Conscious and unconscious bias about a patient’s perceived quality of life undermines equity and can play a role in our recommendations for patients of advanced age, with cognitive impairment, and those who live with a disability.
 

Question #2: How might you meet the patient’s medical needs in line with her goals?

Dr. Khawaja: In order to provide care consistent with the patient’s goals, the first step is to clarify these goals with Ms. S’s surrogate decision-maker, her daughter. In a previously autonomous but presently incapacitated patient, the previously expressed preferences in the form of a written AD should be respected. However, the AD is only a set of preferences completed at a particular time, not medical orders. The clinician and surrogate must consider how to apply the AD to the current clinical circumstances. The clinician should verify that the clinical circumstances specified in the AD have been met and evaluate if the patient’s preferences have changed since she originally completed the AD.

Surrogates are asked to use a Substituted Judgement Standard (i.e., what would the patient choose in this situation if known). This may differ from what the surrogate wants. If not known, surrogates are asked to use the Best Interest Standard (i.e., what would bring the most net benefit to the patient by weighing benefits and risks of treatment options). I often ask the surrogate, “Tell us about your loved one.” Or, “Knowing your loved one, what do you think would be the most important for her right now?”¹

I would also caution against bias in judging quality of life in patients with dementia, and using the term “futility,” as these concepts are inherently subjective. In general, when a colleague raises the issue of futility, I begin by asking, “…futile to achieve what goal?” That can help clarify some of the disagreement as some goals can be accomplished while others cannot.

Finally, I work to include other members of our team in these discussions. The distress of nurses, social workers, and others are important to acknowledge, validate, and involve in the problem-solving process.
 

Question #3: If you were Ms. S’s hospitalist, what would you do?

Dr. Khawaja: As the hospitalist caring for Ms. S, I would use the “four boxes” model as a helpful, clinically relevant and systematic approach to managing ethical concerns.²

This “four boxes” model gives us a practical framework to address these ethical principles by asking questions in four domains.

Medical indications: What is the nature of her current illness, and is it reversible or not? What is the probability of success of treatment options like mechanical ventilation? Are there adverse effects of treatment?

Patient preferences: Since Ms. S lacks capacity, does her daughter understand the benefits and burdens of treatment? What are the goals of treatment? Prolonging life? Minimizing discomfort? Spending time with loved ones? What burdens would the patient be willing to endure to reach her goals?

Quality of life: What would the patient’s quality of life be with and without the treatments?

Contextual features: My priorities would be building a relationship of trust with Ms. S’s daughter – by educating her about her mother’s clinical status, addressing her concerns and questions, and supporting her as we work through patient-centered decisions about what is best for her mother. Honest communication is a must, even if it means acknowledging uncertainties about the course of disease and prognosis.

These are not easy decisions for surrogates to make. They should be given time to process information and to make what they believe are the best decisions for their loved ones. It is critical for clinicians to provide honest and complete clinical information and to avoid value judgments, bias, or unreasonable time pressure. While one-on-one conversations are central, I find that multidisciplinary meetings allow all stakeholders to ask and answer vital questions and ideally to reach consensus in treatment planning.

Dr. Chase: In caring for Ms. S, I would use a structured approach to discussions with her daughter, such as the “SPIKES” protocol.³ Using open ended questions, I would ask about the patient’s and her daughter’s goals, values, and fears and provide support about the responsibility for shared-decision making and the difficulty of uncertainty. Reflecting statements can help in confirming understanding and showing attention (e.g. “I hear that avoiding discomfort would be important to your mother.”)

I find it helpful to emphasize my commitment to honesty and non-abandonment (a common fear among patients and families). By offering to provide recommendations about both disease-directed and palliative, comfort-focused interventions, the patient’s daughter has an opportunity to engage voluntarily in discussion. When asked about care that may have marginal benefit, I suggest time-limited trials.⁴ I do not offer non-beneficial treatments and if asked about such treatments, I note the underlying motive and why the treatment is not feasible (“I see that you are hoping that your mother will live longer, but I am concerned that tube feeding will not help because…”), offer preferable alternatives, and leave space for questions and emotions. It is important not to force a premature resolution of the situation through unilateral or coercive decisions⁵ (i.e., going off service does not mean I have to wrap up the existential crisis which is occurring.) A broader challenge is the grief and other emotions which accompany illness and death. I can neither prevent death nor grief, but I can offer my professional guidance and provide a supportive space for the patient and family to experience this transition. By acknowledging this, I center myself with the patient and family and we can work together toward a common goal of providing compassionate and ethical care.

Dr. Chase is associate professor, Department of Family and Community Medicine, University of California San Francisco; and co-chair, Ethics Committee, San Francisco General Hospital. Dr. Khawaja is assistant professor, Department of Internal Medicine, Baylor College of Medicine, Houston, and a member of the Ethics Committee of the Society of General Internal Medicine.

References

1. Sulmasy DP, Snyder L. Substituted interests and best judgments: an integrated model of surrogate decision making. JAMA. 2010 Nov 3;304(17):1946-7. doi: 10.1001/jama.2010.159.

2. Jonsen AR, Siegler M, Winslade WJ. Clinical ethics: A practical approach to ethical decisions in clinical medicine. 6th ed. New York: McGraw Hill Medical; 2006.

3. Baile WF, et al. SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer. Oncologist. 2000;5(4):302–311. doi: 10.1634/theoncologist.5-4-302.

4. Chang DW, et al. Evaluation of time-limited trials among critically ill patients with advanced medical illnesses and reduction of nonbeneficial ICU treatments. JAMA Intern Med. 2021;181(6):786–794. doi: 10.1001/jamainternmed.2021.1000.

5. Sedig, L. What’s the role of autonomy in patient-and family-centered care when patients and family members don’t agree? AMA J Ethics. 2016;18(1):12-17. doi: 10.1001/journalofethics.2017.18.1.ecas2-1601.

Editor’s note: In this article, we present an archetypal ethics challenge in hospital medicine. The authors, members of the SHM’s Ethics Special Interest Group and clinical ethics consultants at their respective hospitals, will comment on the questions and practical approaches for hospitalists.

Ms. S, an 82-year-old woman with severe dementia, was initially hospitalized in the ICU with acute on chronic respiratory failure. Prior to admission, Ms. S lived with her daughter, who is her primary caregiver. Ms. S is able to say her daughter’s name, and answer “yes” and “no” to simple questions. She is bed bound, incontinent of urine and feces, and dependent on her daughter for all ADLs.

This admission, Ms. S has been re-intubated 4 times for recurrent respiratory failure. The nursing staff are distressed that she is suffering physically. Her daughter requests to continue all intensive, life-prolonging treatment including mechanical ventilation and artificial nutrition.

During sign out, your colleague remarks that his grandmother was in a similar situation and that his family chose to pursue comfort care. He questions whether Ms. S has any quality of life and asks if you think further intensive care is futile.

On your first day caring for Ms. S, you contact her primary care provider. Her PCP reports that Ms. S and her daughter completed an advance directive (AD) 10 years ago which documents a preference for all life prolonging treatment.
 

Question #1: What are the ethical challenges?

Dr. Chase: In caring for Ms. S, we face a common ethical challenge: how to respect the patient’s prior preferences (autonomy) when the currently requested treatments have diminishing benefits (beneficence) and escalating harms (non-maleficence). Life-prolonging care can have diminishing returns at the end of life. Ms. S’s loss of decision-making capacity adds a layer of complexity. Her AD was completed when she was able to consider decisions about her care, and she might make different decisions in her current state of health. Shared decision-making with a surrogate can be complicated by a surrogate’s anxiety with making life-altering decisions or their desire to avoid guilt or loneliness. Health care professionals face the limits of scientific knowledge in delivering accurate prognostic estimates, probabilities of recovery, and likelihood of benefit from interventions. In addition to the guideposts of ethical principles, some hospitals have policies which advise clinicians to avoid non-beneficial care.

Such situations are emotionally intense and can trigger distress among patients, families, caregivers and health care professionals. Conscious and unconscious bias about a patient’s perceived quality of life undermines equity and can play a role in our recommendations for patients of advanced age, with cognitive impairment, and those who live with a disability.
 

Question #2: How might you meet the patient’s medical needs in line with her goals?

Dr. Khawaja: In order to provide care consistent with the patient’s goals, the first step is to clarify these goals with Ms. S’s surrogate decision-maker, her daughter. In a previously autonomous but presently incapacitated patient, the previously expressed preferences in the form of a written AD should be respected. However, the AD is only a set of preferences completed at a particular time, not medical orders. The clinician and surrogate must consider how to apply the AD to the current clinical circumstances. The clinician should verify that the clinical circumstances specified in the AD have been met and evaluate if the patient’s preferences have changed since she originally completed the AD.

Surrogates are asked to use a Substituted Judgement Standard (i.e., what would the patient choose in this situation if known). This may differ from what the surrogate wants. If not known, surrogates are asked to use the Best Interest Standard (i.e., what would bring the most net benefit to the patient by weighing benefits and risks of treatment options). I often ask the surrogate, “Tell us about your loved one.” Or, “Knowing your loved one, what do you think would be the most important for her right now?”¹

I would also caution against bias in judging quality of life in patients with dementia, and using the term “futility,” as these concepts are inherently subjective. In general, when a colleague raises the issue of futility, I begin by asking, “…futile to achieve what goal?” That can help clarify some of the disagreement as some goals can be accomplished while others cannot.

Finally, I work to include other members of our team in these discussions. The distress of nurses, social workers, and others are important to acknowledge, validate, and involve in the problem-solving process.
 

Question #3: If you were Ms. S’s hospitalist, what would you do?

Dr. Khawaja: As the hospitalist caring for Ms. S, I would use the “four boxes” model as a helpful, clinically relevant and systematic approach to managing ethical concerns.²

This “four boxes” model gives us a practical framework to address these ethical principles by asking questions in four domains.

Medical indications: What is the nature of her current illness, and is it reversible or not? What is the probability of success of treatment options like mechanical ventilation? Are there adverse effects of treatment?

Patient preferences: Since Ms. S lacks capacity, does her daughter understand the benefits and burdens of treatment? What are the goals of treatment? Prolonging life? Minimizing discomfort? Spending time with loved ones? What burdens would the patient be willing to endure to reach her goals?

Quality of life: What would the patient’s quality of life be with and without the treatments?

Contextual features: My priorities would be building a relationship of trust with Ms. S’s daughter – by educating her about her mother’s clinical status, addressing her concerns and questions, and supporting her as we work through patient-centered decisions about what is best for her mother. Honest communication is a must, even if it means acknowledging uncertainties about the course of disease and prognosis.

These are not easy decisions for surrogates to make. They should be given time to process information and to make what they believe are the best decisions for their loved ones. It is critical for clinicians to provide honest and complete clinical information and to avoid value judgments, bias, or unreasonable time pressure. While one-on-one conversations are central, I find that multidisciplinary meetings allow all stakeholders to ask and answer vital questions and ideally to reach consensus in treatment planning.

Dr. Chase: In caring for Ms. S, I would use a structured approach to discussions with her daughter, such as the “SPIKES” protocol.³ Using open ended questions, I would ask about the patient’s and her daughter’s goals, values, and fears and provide support about the responsibility for shared-decision making and the difficulty of uncertainty. Reflecting statements can help in confirming understanding and showing attention (e.g. “I hear that avoiding discomfort would be important to your mother.”)

I find it helpful to emphasize my commitment to honesty and non-abandonment (a common fear among patients and families). By offering to provide recommendations about both disease-directed and palliative, comfort-focused interventions, the patient’s daughter has an opportunity to engage voluntarily in discussion. When asked about care that may have marginal benefit, I suggest time-limited trials.⁴ I do not offer non-beneficial treatments and if asked about such treatments, I note the underlying motive and why the treatment is not feasible (“I see that you are hoping that your mother will live longer, but I am concerned that tube feeding will not help because…”), offer preferable alternatives, and leave space for questions and emotions. It is important not to force a premature resolution of the situation through unilateral or coercive decisions⁵ (i.e., going off service does not mean I have to wrap up the existential crisis which is occurring.) A broader challenge is the grief and other emotions which accompany illness and death. I can neither prevent death nor grief, but I can offer my professional guidance and provide a supportive space for the patient and family to experience this transition. By acknowledging this, I center myself with the patient and family and we can work together toward a common goal of providing compassionate and ethical care.

Dr. Chase is associate professor, Department of Family and Community Medicine, University of California San Francisco; and co-chair, Ethics Committee, San Francisco General Hospital. Dr. Khawaja is assistant professor, Department of Internal Medicine, Baylor College of Medicine, Houston, and a member of the Ethics Committee of the Society of General Internal Medicine.

References

1. Sulmasy DP, Snyder L. Substituted interests and best judgments: an integrated model of surrogate decision making. JAMA. 2010 Nov 3;304(17):1946-7. doi: 10.1001/jama.2010.159.

2. Jonsen AR, Siegler M, Winslade WJ. Clinical ethics: A practical approach to ethical decisions in clinical medicine. 6th ed. New York: McGraw Hill Medical; 2006.

3. Baile WF, et al. SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer. Oncologist. 2000;5(4):302–311. doi: 10.1634/theoncologist.5-4-302.

4. Chang DW, et al. Evaluation of time-limited trials among critically ill patients with advanced medical illnesses and reduction of nonbeneficial ICU treatments. JAMA Intern Med. 2021;181(6):786–794. doi: 10.1001/jamainternmed.2021.1000.

5. Sedig, L. What’s the role of autonomy in patient-and family-centered care when patients and family members don’t agree? AMA J Ethics. 2016;18(1):12-17. doi: 10.1001/journalofethics.2017.18.1.ecas2-1601.

Older patients with knee osteoarthritis (OA) who underwent lengthy diet and exercise interventions reported less pain and maintained some weight loss years after the program ended, according to a new study published in Arthritis Care & Research.

AlexRaths/Getty Images

“These data imply that clinicians who treat people with knee osteoarthritis have a variety of nonpharmacologic options that preserve clinically important effects 3.5 years after the treatments end,” wrote lead author Stephen P. Messier, PhD, professor and director of the J.B. Snow Biomechanics Laboratory at Wake Forest University, Winston-Salem, N.C.

The study involved patients with overweight or obesity aged 55 years or older who were previously enrolled in the 1.5-year Intensive Diet and Exercise for Arthritis (IDEA) trial.

“You have to remember, this is 3.5 years after the IDEA trial ended,” Dr. Messier said in an interview. “There was no contact with them for that entire time; you’d expect, based on the literature, that they’d revert back to where they were before they entered the trial. And certainly, there was some regression, there was some weight regain, but the important part of the study is that, even after 3.5 years, and even with some weight regain, there were some clinically important effects that lasted.”

“What we feel now is that if we can somehow prepare people better for that time after they finish a weight loss intervention, from a psychological standpoint, it will make a real difference,” he added. “We are very good at helping people have the confidence to lose weight. But having the confidence to lose weight is totally different than having confidence to maintain weight loss. If we can give folks an intervention that has a psychological component, hopefully we can increase their confidence to maintain the weight loss that they attained.”
 

Study details

Of the 184 participants who were contacted for a follow-up visit, 94 consented to participate, 67% of whom were females and 88% of whom were White. A total of 27 participants had completed the diet and exercise intervention, and another 35 completed the diet-only and 32 exercise-only interventions.

In the 3.5-year period between the IDEA trial’s end and follow-up, body weight increased by 5.9 kg in the diet and exercise group (P < .0001) and by 3.1 kg in the diet-only group (P = .0006) but decreased in the exercise-only group by 1.0 kg (P = .25). However, from baseline to 5-year follow-up, all groups saw a reduction in body weight. Mean weight loss was –3.7 kg for the diet and exercise group (P = .0007), –5.8 kg for the diet group (P < .0001), and –2.9 kg for the exercise group (P = .003). Body mass index also decreased in all groups: by –1.2 kg/m2 in the diet and exercise group (P = .001), by –2.0 kg/m² in the diet group (P < .0001), and by –1.0 kg/m² in the exercise group (P = .004).

Pain – as measured by the Western Ontario and McMaster Universities Arthritis Index (WOMAC) score – was reduced in all groups across 5-year follow-up: –1.2 (P = .03) for the diet and exercise group, –1.5 (P = .001) for the diet-only group, and –1.6 (P = .0008) for the exercise-only group. WOMAC function also significantly improved relative to baseline by 6.2 (P = .0001) in the diet and exercise group, by 6.1 (P < .0001) in the diet group, and by 3.7 (P = .01) in the exercise-only group.
 

Finding time to advise on weight loss, exercise

“If exercise and weight loss were easy, this country wouldn’t be in the state we’re in,” Tuhina Neogi, MD, PhD, of Boston University said in an interview. “Shared decision-making and personalized medicine are important; unfortunately, for the majority of physicians – particularly primary care physicians, where a good deal of OA management is undertaken – they don’t have a lot of time in their 20 minutes with a patient who has OA to counsel individuals toward a healthy weight and physical activity program when they’re also addressing common comorbidities seen in OA such as diabetes and heart disease.

“But as we know,” she added, “when you do address weight loss and physical activity, it has wide-ranging health benefits. This study provides support for utilizing formal diet and exercise programs to achieve important and durable benefits for people with OA.”

Dr. Neogi did note one of the study’s acknowledged limitations: Only slightly more than half of the contacted participants returned for follow-up. Though the authors stated that the individuals who returned were representative of both the pool of potential participants and the IDEA cohort as a whole, “we don’t want to make too many inferences when you don’t have the whole study population available,” she said. “The people who have agreed to come back 3.5 years later for follow-up testing, maybe they are a little more health conscious, more resilient. Those people might be systematically different than the people who [did not return], even though most of the factors were not statistically different between the groups.

“Whatever positive attributes they may have, though, we need to understand more about them,” she added. “We need to know how they maintained the benefits they had 3.5 years prior. That kind of understanding is important to inform long-term strategies in OA management.”

Dr. Messier highlighted a related, ongoing study he’s leading in which more than 800 overweight patients in North Carolina who suffer from knee pain are being led through diet and exercise interventions in a community setting. The goal is to replicate the IDEA results outside of a clinical trial setting and show skeptical physicians that diet and exercise can be enacted and maintained in this subset of patients.

“I think we know how effective weight loss is, especially when combined with exercise, in reducing pain, improving function, improving quality of life in these patients,” he said. “The next step is to allow them to maintain those benefits for a long period of time after the intervention ends.”

The study was supported by grants from the National Institutes of Health and by General Nutrition Centers. Its authors reported no potential conflicts of interest.

Older patients with knee osteoarthritis (OA) who underwent lengthy diet and exercise interventions reported less pain and maintained some weight loss years after the program ended, according to a new study published in Arthritis Care & Research.

AlexRaths/Getty Images

“These data imply that clinicians who treat people with knee osteoarthritis have a variety of nonpharmacologic options that preserve clinically important effects 3.5 years after the treatments end,” wrote lead author Stephen P. Messier, PhD, professor and director of the J.B. Snow Biomechanics Laboratory at Wake Forest University, Winston-Salem, N.C.

The study involved patients with overweight or obesity aged 55 years or older who were previously enrolled in the 1.5-year Intensive Diet and Exercise for Arthritis (IDEA) trial.

“You have to remember, this is 3.5 years after the IDEA trial ended,” Dr. Messier said in an interview. “There was no contact with them for that entire time; you’d expect, based on the literature, that they’d revert back to where they were before they entered the trial. And certainly, there was some regression, there was some weight regain, but the important part of the study is that, even after 3.5 years, and even with some weight regain, there were some clinically important effects that lasted.”

“What we feel now is that if we can somehow prepare people better for that time after they finish a weight loss intervention, from a psychological standpoint, it will make a real difference,” he added. “We are very good at helping people have the confidence to lose weight. But having the confidence to lose weight is totally different than having confidence to maintain weight loss. If we can give folks an intervention that has a psychological component, hopefully we can increase their confidence to maintain the weight loss that they attained.”
 

Study details

Of the 184 participants who were contacted for a follow-up visit, 94 consented to participate, 67% of whom were females and 88% of whom were White. A total of 27 participants had completed the diet and exercise intervention, and another 35 completed the diet-only and 32 exercise-only interventions.

In the 3.5-year period between the IDEA trial’s end and follow-up, body weight increased by 5.9 kg in the diet and exercise group (P < .0001) and by 3.1 kg in the diet-only group (P = .0006) but decreased in the exercise-only group by 1.0 kg (P = .25). However, from baseline to 5-year follow-up, all groups saw a reduction in body weight. Mean weight loss was –3.7 kg for the diet and exercise group (P = .0007), –5.8 kg for the diet group (P < .0001), and –2.9 kg for the exercise group (P = .003). Body mass index also decreased in all groups: by –1.2 kg/m2 in the diet and exercise group (P = .001), by –2.0 kg/m² in the diet group (P < .0001), and by –1.0 kg/m² in the exercise group (P = .004).

Pain – as measured by the Western Ontario and McMaster Universities Arthritis Index (WOMAC) score – was reduced in all groups across 5-year follow-up: –1.2 (P = .03) for the diet and exercise group, –1.5 (P = .001) for the diet-only group, and –1.6 (P = .0008) for the exercise-only group. WOMAC function also significantly improved relative to baseline by 6.2 (P = .0001) in the diet and exercise group, by 6.1 (P < .0001) in the diet group, and by 3.7 (P = .01) in the exercise-only group.
 

Finding time to advise on weight loss, exercise

“If exercise and weight loss were easy, this country wouldn’t be in the state we’re in,” Tuhina Neogi, MD, PhD, of Boston University said in an interview. “Shared decision-making and personalized medicine are important; unfortunately, for the majority of physicians – particularly primary care physicians, where a good deal of OA management is undertaken – they don’t have a lot of time in their 20 minutes with a patient who has OA to counsel individuals toward a healthy weight and physical activity program when they’re also addressing common comorbidities seen in OA such as diabetes and heart disease.

“But as we know,” she added, “when you do address weight loss and physical activity, it has wide-ranging health benefits. This study provides support for utilizing formal diet and exercise programs to achieve important and durable benefits for people with OA.”

Dr. Neogi did note one of the study’s acknowledged limitations: Only slightly more than half of the contacted participants returned for follow-up. Though the authors stated that the individuals who returned were representative of both the pool of potential participants and the IDEA cohort as a whole, “we don’t want to make too many inferences when you don’t have the whole study population available,” she said. “The people who have agreed to come back 3.5 years later for follow-up testing, maybe they are a little more health conscious, more resilient. Those people might be systematically different than the people who [did not return], even though most of the factors were not statistically different between the groups.

“Whatever positive attributes they may have, though, we need to understand more about them,” she added. “We need to know how they maintained the benefits they had 3.5 years prior. That kind of understanding is important to inform long-term strategies in OA management.”

Dr. Messier highlighted a related, ongoing study he’s leading in which more than 800 overweight patients in North Carolina who suffer from knee pain are being led through diet and exercise interventions in a community setting. The goal is to replicate the IDEA results outside of a clinical trial setting and show skeptical physicians that diet and exercise can be enacted and maintained in this subset of patients.

“I think we know how effective weight loss is, especially when combined with exercise, in reducing pain, improving function, improving quality of life in these patients,” he said. “The next step is to allow them to maintain those benefits for a long period of time after the intervention ends.”

The study was supported by grants from the National Institutes of Health and by General Nutrition Centers. Its authors reported no potential conflicts of interest.

Older patients with knee osteoarthritis (OA) who underwent lengthy diet and exercise interventions reported less pain and maintained some weight loss years after the program ended, according to a new study published in Arthritis Care & Research.

AlexRaths/Getty Images

“These data imply that clinicians who treat people with knee osteoarthritis have a variety of nonpharmacologic options that preserve clinically important effects 3.5 years after the treatments end,” wrote lead author Stephen P. Messier, PhD, professor and director of the J.B. Snow Biomechanics Laboratory at Wake Forest University, Winston-Salem, N.C.

The study involved patients with overweight or obesity aged 55 years or older who were previously enrolled in the 1.5-year Intensive Diet and Exercise for Arthritis (IDEA) trial.

“You have to remember, this is 3.5 years after the IDEA trial ended,” Dr. Messier said in an interview. “There was no contact with them for that entire time; you’d expect, based on the literature, that they’d revert back to where they were before they entered the trial. And certainly, there was some regression, there was some weight regain, but the important part of the study is that, even after 3.5 years, and even with some weight regain, there were some clinically important effects that lasted.”

“What we feel now is that if we can somehow prepare people better for that time after they finish a weight loss intervention, from a psychological standpoint, it will make a real difference,” he added. “We are very good at helping people have the confidence to lose weight. But having the confidence to lose weight is totally different than having confidence to maintain weight loss. If we can give folks an intervention that has a psychological component, hopefully we can increase their confidence to maintain the weight loss that they attained.”
 

Study details

Of the 184 participants who were contacted for a follow-up visit, 94 consented to participate, 67% of whom were females and 88% of whom were White. A total of 27 participants had completed the diet and exercise intervention, and another 35 completed the diet-only and 32 exercise-only interventions.

In the 3.5-year period between the IDEA trial’s end and follow-up, body weight increased by 5.9 kg in the diet and exercise group (P < .0001) and by 3.1 kg in the diet-only group (P = .0006) but decreased in the exercise-only group by 1.0 kg (P = .25). However, from baseline to 5-year follow-up, all groups saw a reduction in body weight. Mean weight loss was –3.7 kg for the diet and exercise group (P = .0007), –5.8 kg for the diet group (P < .0001), and –2.9 kg for the exercise group (P = .003). Body mass index also decreased in all groups: by –1.2 kg/m2 in the diet and exercise group (P = .001), by –2.0 kg/m² in the diet group (P < .0001), and by –1.0 kg/m² in the exercise group (P = .004).

Pain – as measured by the Western Ontario and McMaster Universities Arthritis Index (WOMAC) score – was reduced in all groups across 5-year follow-up: –1.2 (P = .03) for the diet and exercise group, –1.5 (P = .001) for the diet-only group, and –1.6 (P = .0008) for the exercise-only group. WOMAC function also significantly improved relative to baseline by 6.2 (P = .0001) in the diet and exercise group, by 6.1 (P < .0001) in the diet group, and by 3.7 (P = .01) in the exercise-only group.
 

Finding time to advise on weight loss, exercise

“If exercise and weight loss were easy, this country wouldn’t be in the state we’re in,” Tuhina Neogi, MD, PhD, of Boston University said in an interview. “Shared decision-making and personalized medicine are important; unfortunately, for the majority of physicians – particularly primary care physicians, where a good deal of OA management is undertaken – they don’t have a lot of time in their 20 minutes with a patient who has OA to counsel individuals toward a healthy weight and physical activity program when they’re also addressing common comorbidities seen in OA such as diabetes and heart disease.

“But as we know,” she added, “when you do address weight loss and physical activity, it has wide-ranging health benefits. This study provides support for utilizing formal diet and exercise programs to achieve important and durable benefits for people with OA.”

Dr. Neogi did note one of the study’s acknowledged limitations: Only slightly more than half of the contacted participants returned for follow-up. Though the authors stated that the individuals who returned were representative of both the pool of potential participants and the IDEA cohort as a whole, “we don’t want to make too many inferences when you don’t have the whole study population available,” she said. “The people who have agreed to come back 3.5 years later for follow-up testing, maybe they are a little more health conscious, more resilient. Those people might be systematically different than the people who [did not return], even though most of the factors were not statistically different between the groups.

“Whatever positive attributes they may have, though, we need to understand more about them,” she added. “We need to know how they maintained the benefits they had 3.5 years prior. That kind of understanding is important to inform long-term strategies in OA management.”

Dr. Messier highlighted a related, ongoing study he’s leading in which more than 800 overweight patients in North Carolina who suffer from knee pain are being led through diet and exercise interventions in a community setting. The goal is to replicate the IDEA results outside of a clinical trial setting and show skeptical physicians that diet and exercise can be enacted and maintained in this subset of patients.

“I think we know how effective weight loss is, especially when combined with exercise, in reducing pain, improving function, improving quality of life in these patients,” he said. “The next step is to allow them to maintain those benefits for a long period of time after the intervention ends.”

The study was supported by grants from the National Institutes of Health and by General Nutrition Centers. Its authors reported no potential conflicts of interest.

Drink to your health?

Whether you drink or not, most of us can agree that liquor is not the first thing that comes to mind when looking to make health improvements. But researchers have found a small exception in something traditional.

Xvision/Moment

We’ve added buckwheat to pancakes, bread, and other baked goodies we made during the height of quarantine, but it’s also used to create a traditional liquor in some East Asian countries, where it is used medicinally.

Investigators have found that extracts in the Tartary buckwheat used to make the liquor induce autophagy, a process cells go through to remove proteins that are damaged or not needed anymore – sort of like a cellular spring cleaning.

To test this, the researchers treated liver and skin cells with Tartary buckwheat extract and looked to see how the cells responded with fluorescent markers. The results were clear.

“Treating cells with the extract stimulated the formation of autophagosomes, specialized cellular structures that carry out autophagy, and altered the location of proteins involved in regulating autophagy,” said senior author Takeshi Noda of Osaka (Japan) University.

Looking deeper, the researchers found that quercetin, a component of the buckwheat extract, had the same autophagic effect. And both the buckwheat and the quercetin gave the green light for liver cells to induce aggrephagy, the process of cleaning up protein aggregates.

Those protein aggregates in liver cells are closely linked to alcoholic liver disease, suggesting that quercetin could be a game changer in its treatment. In other words, liquor could help fix the problem that liquor started. Go figure.
 

From hospital bills to X-rated

Ralph Puglisi was an accounting manager for the University Medical Service Association (UMSA), a nonprofit that supports the massive University of South Florida health system. The association took in over $300 million in revenue in the 2019-2020 fiscal year, which is a rather large sum of money, but we’ll glide over the ethics of a “nonprofit” making a few hundred million for now.

wakila/Getty Images

Mr. Puglisi was in very close proximity to the money, generated from patient care, and he pled guilty to stealing it using UMSA credit cards. Now, that wouldn’t be LOTME worthy on its own, but what elevates this above garden-variety embezzlement is how the intrepid Mr. Puglisi chose to spend the millions he stole from the university health system: Adult entertainment.

And before you ask, he didn’t spend $11.5 million on something most people so inclined can find for free with judicious Google searches. What Mr. Puglisi actually did was invest in a website providing adult content through individual user profiles, one of which is believed to belong to his stepson’s fiancée, which brings a whole new level of sleaze to this enterprise. Over the course of 2 years, he visited her profile 2,800 times, an amount some might view as excessive.

While the vast majority of the embezzled money went to the adult website, Mr. Puglisi also used thousands of UMSA dollars to pay for travel, household improvements, rent, the works. Almost $44,000 was spent at a resort sometimes known as the happiest place on earth.

Then there’s Mr. Puglisi’s wife. Oh yes, this guy is married. He poured over $600,000 into a company he and his wife owned, which is a lot, but how much do you think went to the woman he married? Probably quite a bit. Go ahead, try to think of a number. It’s not like it was his money.

Did you guess $100 went into his wife’s PayPal account? No? Clearly you don’t understand the criminal mind. His stepson’s fiancée got millions, and his wife got a hundred. Now there are some priorities.
 

Step 1: Sit at desk. Step 2: Get in shape

Being a physician is not really a desk job, but doctors must spend a fair share of their time sitting, yes? Dealing with recalcitrant EHRs or talking on the phone to insurers or PBMs? If you are one of these physicians, or if you have patients who spend a lot of time sitting at their desks and might need to get a bit of exercise, then we’ve got a multitasking tip for you.

Mohamed Hassan/pxhere

It came to us via one of our favorite websites, Sad and Useless. It’s the site that declares itself “the most depressive humor site on the Internet” and they’re offering up the “12 Best Exercises To Do At Your Desk.” It may not sound like much, but we think that the gang at Dunder-Mifflin would approve. And besides, who couldn’t stand to burn a few calories without having to leave the chair?

We won’t spoil your fun by going through all 12 – each one comes with step-by-step instructions and a helpful illustration or GIF – but here are just a few:

• Bending over backwards: “Agree to do something you don’t want to do. Spend twice as long as expected doing that thing. Hate yourself.”
• Fake laughter: “Hear a joke that isn’t even remotely funny. Open your mouth and make laughing sounds.”
• Bang your head: Feel the “pointlessness of your job overwhelm you” and then “bring your head forcefully down to your desk.”

Now, we here at LOTME are, of course [Bang!], highly skilled, professional wordsmithing humorists [Bang!], so when we tell you that this is a great workout [Bang!] … that this is a great workout [Bang!] … it’s great … uggh.

Wooooo. Feel the burn.
 

One order of mosquitoes, extra Crispr

What would it be like to have a barbecue in your backyard on a humid summer night and not get eaten alive by mosquitoes? If you’re like us, you probably thought you’d never see that day.

©TacioPhilip/Thinkstock

Mosquitoes cause itchy bites, but, more importantly, they can carry dengue, malaria, yellow fever, and Zika virus. New research shows that protection from these diseases may be possible with use of the Crispr-Cas9 gene-editing tool, which could make humans invisible to mosquitoes by taking away their light-sensing abilities and, thus, their ability to find us.

“The better we understand how they sense the human, the better we can control the mosquito in an eco-friendly manner,” Yinpeng Zhan, a postdoctoral researcher at the University of California, Santa Barbara, and the study’s lead author, told the New York Times.

After studying the mosquitoes and figuring out their hunting patterns, the researchers found that mosquitoes are attracted to dark spots more than white spots and used this to their advantage. After knocking out two of the proteins that mosquitoes need for vision – via Crispr – the little suckers could not distinguish the difference between the white and dark spots.

We’re sure mosquitoes don’t mean any harm – they’re just trying to survive and reproduce like any other species – but thanks to this new tool, gone might be the days of having to douse yourself in bug spray that smells like a mix of chemicals and melon.

Drink to your health?

Whether you drink or not, most of us can agree that liquor is not the first thing that comes to mind when looking to make health improvements. But researchers have found a small exception in something traditional.

Xvision/Moment

We’ve added buckwheat to pancakes, bread, and other baked goodies we made during the height of quarantine, but it’s also used to create a traditional liquor in some East Asian countries, where it is used medicinally.

Investigators have found that extracts in the Tartary buckwheat used to make the liquor induce autophagy, a process cells go through to remove proteins that are damaged or not needed anymore – sort of like a cellular spring cleaning.

To test this, the researchers treated liver and skin cells with Tartary buckwheat extract and looked to see how the cells responded with fluorescent markers. The results were clear.

“Treating cells with the extract stimulated the formation of autophagosomes, specialized cellular structures that carry out autophagy, and altered the location of proteins involved in regulating autophagy,” said senior author Takeshi Noda of Osaka (Japan) University.

Looking deeper, the researchers found that quercetin, a component of the buckwheat extract, had the same autophagic effect. And both the buckwheat and the quercetin gave the green light for liver cells to induce aggrephagy, the process of cleaning up protein aggregates.

Those protein aggregates in liver cells are closely linked to alcoholic liver disease, suggesting that quercetin could be a game changer in its treatment. In other words, liquor could help fix the problem that liquor started. Go figure.
 

From hospital bills to X-rated

Ralph Puglisi was an accounting manager for the University Medical Service Association (UMSA), a nonprofit that supports the massive University of South Florida health system. The association took in over $300 million in revenue in the 2019-2020 fiscal year, which is a rather large sum of money, but we’ll glide over the ethics of a “nonprofit” making a few hundred million for now.

wakila/Getty Images

Mr. Puglisi was in very close proximity to the money, generated from patient care, and he pled guilty to stealing it using UMSA credit cards. Now, that wouldn’t be LOTME worthy on its own, but what elevates this above garden-variety embezzlement is how the intrepid Mr. Puglisi chose to spend the millions he stole from the university health system: Adult entertainment.

And before you ask, he didn’t spend $11.5 million on something most people so inclined can find for free with judicious Google searches. What Mr. Puglisi actually did was invest in a website providing adult content through individual user profiles, one of which is believed to belong to his stepson’s fiancée, which brings a whole new level of sleaze to this enterprise. Over the course of 2 years, he visited her profile 2,800 times, an amount some might view as excessive.

While the vast majority of the embezzled money went to the adult website, Mr. Puglisi also used thousands of UMSA dollars to pay for travel, household improvements, rent, the works. Almost $44,000 was spent at a resort sometimes known as the happiest place on earth.

Then there’s Mr. Puglisi’s wife. Oh yes, this guy is married. He poured over $600,000 into a company he and his wife owned, which is a lot, but how much do you think went to the woman he married? Probably quite a bit. Go ahead, try to think of a number. It’s not like it was his money.

Did you guess $100 went into his wife’s PayPal account? No? Clearly you don’t understand the criminal mind. His stepson’s fiancée got millions, and his wife got a hundred. Now there are some priorities.
 

Step 1: Sit at desk. Step 2: Get in shape

Being a physician is not really a desk job, but doctors must spend a fair share of their time sitting, yes? Dealing with recalcitrant EHRs or talking on the phone to insurers or PBMs? If you are one of these physicians, or if you have patients who spend a lot of time sitting at their desks and might need to get a bit of exercise, then we’ve got a multitasking tip for you.

Mohamed Hassan/pxhere

It came to us via one of our favorite websites, Sad and Useless. It’s the site that declares itself “the most depressive humor site on the Internet” and they’re offering up the “12 Best Exercises To Do At Your Desk.” It may not sound like much, but we think that the gang at Dunder-Mifflin would approve. And besides, who couldn’t stand to burn a few calories without having to leave the chair?

We won’t spoil your fun by going through all 12 – each one comes with step-by-step instructions and a helpful illustration or GIF – but here are just a few:

• Bending over backwards: “Agree to do something you don’t want to do. Spend twice as long as expected doing that thing. Hate yourself.”
• Fake laughter: “Hear a joke that isn’t even remotely funny. Open your mouth and make laughing sounds.”
• Bang your head: Feel the “pointlessness of your job overwhelm you” and then “bring your head forcefully down to your desk.”

Now, we here at LOTME are, of course [Bang!], highly skilled, professional wordsmithing humorists [Bang!], so when we tell you that this is a great workout [Bang!] … that this is a great workout [Bang!] … it’s great … uggh.

Wooooo. Feel the burn.
 

One order of mosquitoes, extra Crispr

What would it be like to have a barbecue in your backyard on a humid summer night and not get eaten alive by mosquitoes? If you’re like us, you probably thought you’d never see that day.

©TacioPhilip/Thinkstock

Mosquitoes cause itchy bites, but, more importantly, they can carry dengue, malaria, yellow fever, and Zika virus. New research shows that protection from these diseases may be possible with use of the Crispr-Cas9 gene-editing tool, which could make humans invisible to mosquitoes by taking away their light-sensing abilities and, thus, their ability to find us.

“The better we understand how they sense the human, the better we can control the mosquito in an eco-friendly manner,” Yinpeng Zhan, a postdoctoral researcher at the University of California, Santa Barbara, and the study’s lead author, told the New York Times.

After studying the mosquitoes and figuring out their hunting patterns, the researchers found that mosquitoes are attracted to dark spots more than white spots and used this to their advantage. After knocking out two of the proteins that mosquitoes need for vision – via Crispr – the little suckers could not distinguish the difference between the white and dark spots.

We’re sure mosquitoes don’t mean any harm – they’re just trying to survive and reproduce like any other species – but thanks to this new tool, gone might be the days of having to douse yourself in bug spray that smells like a mix of chemicals and melon.

Drink to your health?

Whether you drink or not, most of us can agree that liquor is not the first thing that comes to mind when looking to make health improvements. But researchers have found a small exception in something traditional.

Xvision/Moment

We’ve added buckwheat to pancakes, bread, and other baked goodies we made during the height of quarantine, but it’s also used to create a traditional liquor in some East Asian countries, where it is used medicinally.

Investigators have found that extracts in the Tartary buckwheat used to make the liquor induce autophagy, a process cells go through to remove proteins that are damaged or not needed anymore – sort of like a cellular spring cleaning.

To test this, the researchers treated liver and skin cells with Tartary buckwheat extract and looked to see how the cells responded with fluorescent markers. The results were clear.

“Treating cells with the extract stimulated the formation of autophagosomes, specialized cellular structures that carry out autophagy, and altered the location of proteins involved in regulating autophagy,” said senior author Takeshi Noda of Osaka (Japan) University.

Looking deeper, the researchers found that quercetin, a component of the buckwheat extract, had the same autophagic effect. And both the buckwheat and the quercetin gave the green light for liver cells to induce aggrephagy, the process of cleaning up protein aggregates.

Those protein aggregates in liver cells are closely linked to alcoholic liver disease, suggesting that quercetin could be a game changer in its treatment. In other words, liquor could help fix the problem that liquor started. Go figure.
 

From hospital bills to X-rated

Ralph Puglisi was an accounting manager for the University Medical Service Association (UMSA), a nonprofit that supports the massive University of South Florida health system. The association took in over $300 million in revenue in the 2019-2020 fiscal year, which is a rather large sum of money, but we’ll glide over the ethics of a “nonprofit” making a few hundred million for now.

wakila/Getty Images

Mr. Puglisi was in very close proximity to the money, generated from patient care, and he pled guilty to stealing it using UMSA credit cards. Now, that wouldn’t be LOTME worthy on its own, but what elevates this above garden-variety embezzlement is how the intrepid Mr. Puglisi chose to spend the millions he stole from the university health system: Adult entertainment.

And before you ask, he didn’t spend $11.5 million on something most people so inclined can find for free with judicious Google searches. What Mr. Puglisi actually did was invest in a website providing adult content through individual user profiles, one of which is believed to belong to his stepson’s fiancée, which brings a whole new level of sleaze to this enterprise. Over the course of 2 years, he visited her profile 2,800 times, an amount some might view as excessive.

While the vast majority of the embezzled money went to the adult website, Mr. Puglisi also used thousands of UMSA dollars to pay for travel, household improvements, rent, the works. Almost $44,000 was spent at a resort sometimes known as the happiest place on earth.

Then there’s Mr. Puglisi’s wife. Oh yes, this guy is married. He poured over $600,000 into a company he and his wife owned, which is a lot, but how much do you think went to the woman he married? Probably quite a bit. Go ahead, try to think of a number. It’s not like it was his money.

Did you guess $100 went into his wife’s PayPal account? No? Clearly you don’t understand the criminal mind. His stepson’s fiancée got millions, and his wife got a hundred. Now there are some priorities.
 

Step 1: Sit at desk. Step 2: Get in shape

Being a physician is not really a desk job, but doctors must spend a fair share of their time sitting, yes? Dealing with recalcitrant EHRs or talking on the phone to insurers or PBMs? If you are one of these physicians, or if you have patients who spend a lot of time sitting at their desks and might need to get a bit of exercise, then we’ve got a multitasking tip for you.

Mohamed Hassan/pxhere

It came to us via one of our favorite websites, Sad and Useless. It’s the site that declares itself “the most depressive humor site on the Internet” and they’re offering up the “12 Best Exercises To Do At Your Desk.” It may not sound like much, but we think that the gang at Dunder-Mifflin would approve. And besides, who couldn’t stand to burn a few calories without having to leave the chair?

We won’t spoil your fun by going through all 12 – each one comes with step-by-step instructions and a helpful illustration or GIF – but here are just a few:

• Bending over backwards: “Agree to do something you don’t want to do. Spend twice as long as expected doing that thing. Hate yourself.”
• Fake laughter: “Hear a joke that isn’t even remotely funny. Open your mouth and make laughing sounds.”
• Bang your head: Feel the “pointlessness of your job overwhelm you” and then “bring your head forcefully down to your desk.”

Now, we here at LOTME are, of course [Bang!], highly skilled, professional wordsmithing humorists [Bang!], so when we tell you that this is a great workout [Bang!] … that this is a great workout [Bang!] … it’s great … uggh.

Wooooo. Feel the burn.
 

One order of mosquitoes, extra Crispr

What would it be like to have a barbecue in your backyard on a humid summer night and not get eaten alive by mosquitoes? If you’re like us, you probably thought you’d never see that day.

©TacioPhilip/Thinkstock

Mosquitoes cause itchy bites, but, more importantly, they can carry dengue, malaria, yellow fever, and Zika virus. New research shows that protection from these diseases may be possible with use of the Crispr-Cas9 gene-editing tool, which could make humans invisible to mosquitoes by taking away their light-sensing abilities and, thus, their ability to find us.

“The better we understand how they sense the human, the better we can control the mosquito in an eco-friendly manner,” Yinpeng Zhan, a postdoctoral researcher at the University of California, Santa Barbara, and the study’s lead author, told the New York Times.

After studying the mosquitoes and figuring out their hunting patterns, the researchers found that mosquitoes are attracted to dark spots more than white spots and used this to their advantage. After knocking out two of the proteins that mosquitoes need for vision – via Crispr – the little suckers could not distinguish the difference between the white and dark spots.

We’re sure mosquitoes don’t mean any harm – they’re just trying to survive and reproduce like any other species – but thanks to this new tool, gone might be the days of having to douse yourself in bug spray that smells like a mix of chemicals and melon.

This patient was given a diagnosis of disseminated granuloma annulare (DGA). While granuloma annulare usually manifests as a single lesion with a raised erythematous border (often with central pallor or hypopigmentation) it can also manifest as multiple large annular lesions on the extremities and occasionally the trunk, as was seen with this case of DGA.

Although the etiology of DGA is unknown, infections including HIV and hepatitis have been reported as possible triggers. Laboratory testing should be considered if the history or physical examination raises suspicion for either condition. Diabetes has also been associated with the disseminated form and the literature suggests a connection with autoimmune diseases of the liver and thyroid.¹

Watchful waiting is usually the best treatment for localized disease, which can spontaneously regress within a year and is usually asymptomatic. Intralesional steroid injections into the raised annulus are more effective than topical steroids, as the effects of the topical steroids are sometimes augmented by occlusion.

Multiple treatments have been proposed for DGA, including UVA treatments, systemic retinoids, doxycycline, and hydroxychloroquine.¹ Unfortunately, the disseminated form can persist for many years—even with treatment.

Due to the extent of the lesions, the patient in this case was not interested in intralesional steroid injections, and she had already tried topical steroids. She was prescribed topical tacrolimus to reduce the highly visible nature of her lesions.

‌

Photo and text courtesy of Daniel Stulberg, MD, FAAFP, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.

This patient was given a diagnosis of disseminated granuloma annulare (DGA). While granuloma annulare usually manifests as a single lesion with a raised erythematous border (often with central pallor or hypopigmentation) it can also manifest as multiple large annular lesions on the extremities and occasionally the trunk, as was seen with this case of DGA.

Although the etiology of DGA is unknown, infections including HIV and hepatitis have been reported as possible triggers. Laboratory testing should be considered if the history or physical examination raises suspicion for either condition. Diabetes has also been associated with the disseminated form and the literature suggests a connection with autoimmune diseases of the liver and thyroid.¹

Watchful waiting is usually the best treatment for localized disease, which can spontaneously regress within a year and is usually asymptomatic. Intralesional steroid injections into the raised annulus are more effective than topical steroids, as the effects of the topical steroids are sometimes augmented by occlusion.

Multiple treatments have been proposed for DGA, including UVA treatments, systemic retinoids, doxycycline, and hydroxychloroquine.¹ Unfortunately, the disseminated form can persist for many years—even with treatment.

Due to the extent of the lesions, the patient in this case was not interested in intralesional steroid injections, and she had already tried topical steroids. She was prescribed topical tacrolimus to reduce the highly visible nature of her lesions.

‌

Photo and text courtesy of Daniel Stulberg, MD, FAAFP, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.

This patient was given a diagnosis of disseminated granuloma annulare (DGA). While granuloma annulare usually manifests as a single lesion with a raised erythematous border (often with central pallor or hypopigmentation) it can also manifest as multiple large annular lesions on the extremities and occasionally the trunk, as was seen with this case of DGA.

Although the etiology of DGA is unknown, infections including HIV and hepatitis have been reported as possible triggers. Laboratory testing should be considered if the history or physical examination raises suspicion for either condition. Diabetes has also been associated with the disseminated form and the literature suggests a connection with autoimmune diseases of the liver and thyroid.¹

Watchful waiting is usually the best treatment for localized disease, which can spontaneously regress within a year and is usually asymptomatic. Intralesional steroid injections into the raised annulus are more effective than topical steroids, as the effects of the topical steroids are sometimes augmented by occlusion.

Multiple treatments have been proposed for DGA, including UVA treatments, systemic retinoids, doxycycline, and hydroxychloroquine.¹ Unfortunately, the disseminated form can persist for many years—even with treatment.

Due to the extent of the lesions, the patient in this case was not interested in intralesional steroid injections, and she had already tried topical steroids. She was prescribed topical tacrolimus to reduce the highly visible nature of her lesions.

‌

Photo and text courtesy of Daniel Stulberg, MD, FAAFP, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.

A 64-year-old White woman with very few medical problems complains of bug bites. She had seen no bugs and had no visible bites. There is no rash. “So what bit me?” she asked, pulling her mask down for emphasis. How should I know? I thought, but didn’t say. She and I have been through this many times.

Before I could respond, she filled the pause with her usual complaints including how hard it is to get an appointment with me and how every appointment with me is a waste of her time. Ignoring the contradistinction of her charges, I took some satisfaction realizing she has just given me a topic to write about: The hateful patient.

Hateful patients are not diagnostic dilemmas, they are the patients whose name on your schedule evokes fury. They are frustrating, troublesome, rude, sometimes racist, misogynistic, depressing, hopeless, and disheartening. They call you, email you, and come to see you just to annoy you (so it seems). And they’re everywhere. According to one study, nearly one in six are “difficult patients.” It feels like more lately because the vaccine has brought haters back into clinic, just to get us.

But hateful patients aren’t new. In 1978, James E. Groves, MD, a Harvard psychiatrist, wrote a now-classic New England Journal of Medicine article about them called: Taking Care of the Hateful Patient. Even Osler, back in 1889, covered these patients in his lecture to University of Pennsylvania students, advising us to “deal gently with this deliciously credulous old human nature in which we work ... restrain your indignation.” But like much of Osler’s advice, it is easier said than done.

Dr. Groves is more helpful, and presents a model to understand them. Difficult patients, as we’d now call them, fall into four stereotypes: dependent clingers, entitled demanders, manipulative help-rejectors, and self-destructive deniers. It’s Dr. Groves’s bottom line I found insightful. He says that, when patients create negative feelings in us, we’re more likely to make errors. He then gives sound advice: Set firm boundaries and learn to counter the countertransference these patients provoke. Don’t disavow or discharge, Dr. Groves advises, redirect these emotions to motivate you to dig deeper. There you’ll find clinical data that will facilitate understanding and enable better patient management. Yes, easier said.

In addition to Dr. Groves’s analysis of how we harm these patients, I’d add that these disagreeable, malingering patients also harm us doctors. The hangover from a difficult patient encounter can linger for several appointments later or, worse, carryover to home. And now with patient emails proliferating, demanding patients behave as if we have an inexhaustible ability to engage them. We don’t. Many physicians are struggling to care at all; their low empathy battery warnings are blinking red, less than 1% remaining.

What is toxic to us doctors is the maelstrom of cognitive dissonance these patients create in us. Have you ever felt relief to learn a difficult patient has “finally” died? How could we think such a thing?! Didn’t we choose medicine instead of Wall Street because we care about people? But manipulative patients can make us care less. We even use secret language with each other to protect ourselves from them, those GOMERs (get out of my emergency room), bouncebacks, patients with status dramaticus, and those ornery FTDs (failure to die). Save yourself, we say to each other, this patient will kill you.

Caring for my somatizing 64-year-old patient has been difficult, but writing this has helped me reframe our interaction. Unsurprisingly, at the end of her failed visit she asked when she could see me again. “I need to schedule now because I have to find a neighbor to watch my dogs. It takes two buses to come here and I can’t take them with me.” Ah, there’s the clinical data Dr. Groves said I’d find – she’s not here to hurt me, she’s here because I’m all she’s got. At least for this difficult patient, I have a plan. At the bottom of my note I type “RTC 3 mo.”

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.

A 64-year-old White woman with very few medical problems complains of bug bites. She had seen no bugs and had no visible bites. There is no rash. “So what bit me?” she asked, pulling her mask down for emphasis. How should I know? I thought, but didn’t say. She and I have been through this many times.

Before I could respond, she filled the pause with her usual complaints including how hard it is to get an appointment with me and how every appointment with me is a waste of her time. Ignoring the contradistinction of her charges, I took some satisfaction realizing she has just given me a topic to write about: The hateful patient.

Hateful patients are not diagnostic dilemmas, they are the patients whose name on your schedule evokes fury. They are frustrating, troublesome, rude, sometimes racist, misogynistic, depressing, hopeless, and disheartening. They call you, email you, and come to see you just to annoy you (so it seems). And they’re everywhere. According to one study, nearly one in six are “difficult patients.” It feels like more lately because the vaccine has brought haters back into clinic, just to get us.

But hateful patients aren’t new. In 1978, James E. Groves, MD, a Harvard psychiatrist, wrote a now-classic New England Journal of Medicine article about them called: Taking Care of the Hateful Patient. Even Osler, back in 1889, covered these patients in his lecture to University of Pennsylvania students, advising us to “deal gently with this deliciously credulous old human nature in which we work ... restrain your indignation.” But like much of Osler’s advice, it is easier said than done.

Dr. Groves is more helpful, and presents a model to understand them. Difficult patients, as we’d now call them, fall into four stereotypes: dependent clingers, entitled demanders, manipulative help-rejectors, and self-destructive deniers. It’s Dr. Groves’s bottom line I found insightful. He says that, when patients create negative feelings in us, we’re more likely to make errors. He then gives sound advice: Set firm boundaries and learn to counter the countertransference these patients provoke. Don’t disavow or discharge, Dr. Groves advises, redirect these emotions to motivate you to dig deeper. There you’ll find clinical data that will facilitate understanding and enable better patient management. Yes, easier said.

In addition to Dr. Groves’s analysis of how we harm these patients, I’d add that these disagreeable, malingering patients also harm us doctors. The hangover from a difficult patient encounter can linger for several appointments later or, worse, carryover to home. And now with patient emails proliferating, demanding patients behave as if we have an inexhaustible ability to engage them. We don’t. Many physicians are struggling to care at all; their low empathy battery warnings are blinking red, less than 1% remaining.

What is toxic to us doctors is the maelstrom of cognitive dissonance these patients create in us. Have you ever felt relief to learn a difficult patient has “finally” died? How could we think such a thing?! Didn’t we choose medicine instead of Wall Street because we care about people? But manipulative patients can make us care less. We even use secret language with each other to protect ourselves from them, those GOMERs (get out of my emergency room), bouncebacks, patients with status dramaticus, and those ornery FTDs (failure to die). Save yourself, we say to each other, this patient will kill you.

Caring for my somatizing 64-year-old patient has been difficult, but writing this has helped me reframe our interaction. Unsurprisingly, at the end of her failed visit she asked when she could see me again. “I need to schedule now because I have to find a neighbor to watch my dogs. It takes two buses to come here and I can’t take them with me.” Ah, there’s the clinical data Dr. Groves said I’d find – she’s not here to hurt me, she’s here because I’m all she’s got. At least for this difficult patient, I have a plan. At the bottom of my note I type “RTC 3 mo.”

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.

A 64-year-old White woman with very few medical problems complains of bug bites. She had seen no bugs and had no visible bites. There is no rash. “So what bit me?” she asked, pulling her mask down for emphasis. How should I know? I thought, but didn’t say. She and I have been through this many times.

Before I could respond, she filled the pause with her usual complaints including how hard it is to get an appointment with me and how every appointment with me is a waste of her time. Ignoring the contradistinction of her charges, I took some satisfaction realizing she has just given me a topic to write about: The hateful patient.

Hateful patients are not diagnostic dilemmas, they are the patients whose name on your schedule evokes fury. They are frustrating, troublesome, rude, sometimes racist, misogynistic, depressing, hopeless, and disheartening. They call you, email you, and come to see you just to annoy you (so it seems). And they’re everywhere. According to one study, nearly one in six are “difficult patients.” It feels like more lately because the vaccine has brought haters back into clinic, just to get us.

But hateful patients aren’t new. In 1978, James E. Groves, MD, a Harvard psychiatrist, wrote a now-classic New England Journal of Medicine article about them called: Taking Care of the Hateful Patient. Even Osler, back in 1889, covered these patients in his lecture to University of Pennsylvania students, advising us to “deal gently with this deliciously credulous old human nature in which we work ... restrain your indignation.” But like much of Osler’s advice, it is easier said than done.

Dr. Groves is more helpful, and presents a model to understand them. Difficult patients, as we’d now call them, fall into four stereotypes: dependent clingers, entitled demanders, manipulative help-rejectors, and self-destructive deniers. It’s Dr. Groves’s bottom line I found insightful. He says that, when patients create negative feelings in us, we’re more likely to make errors. He then gives sound advice: Set firm boundaries and learn to counter the countertransference these patients provoke. Don’t disavow or discharge, Dr. Groves advises, redirect these emotions to motivate you to dig deeper. There you’ll find clinical data that will facilitate understanding and enable better patient management. Yes, easier said.

In addition to Dr. Groves’s analysis of how we harm these patients, I’d add that these disagreeable, malingering patients also harm us doctors. The hangover from a difficult patient encounter can linger for several appointments later or, worse, carryover to home. And now with patient emails proliferating, demanding patients behave as if we have an inexhaustible ability to engage them. We don’t. Many physicians are struggling to care at all; their low empathy battery warnings are blinking red, less than 1% remaining.

What is toxic to us doctors is the maelstrom of cognitive dissonance these patients create in us. Have you ever felt relief to learn a difficult patient has “finally” died? How could we think such a thing?! Didn’t we choose medicine instead of Wall Street because we care about people? But manipulative patients can make us care less. We even use secret language with each other to protect ourselves from them, those GOMERs (get out of my emergency room), bouncebacks, patients with status dramaticus, and those ornery FTDs (failure to die). Save yourself, we say to each other, this patient will kill you.

Caring for my somatizing 64-year-old patient has been difficult, but writing this has helped me reframe our interaction. Unsurprisingly, at the end of her failed visit she asked when she could see me again. “I need to schedule now because I have to find a neighbor to watch my dogs. It takes two buses to come here and I can’t take them with me.” Ah, there’s the clinical data Dr. Groves said I’d find – she’s not here to hurt me, she’s here because I’m all she’s got. At least for this difficult patient, I have a plan. At the bottom of my note I type “RTC 3 mo.”

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.