Mixed Topics

The U.S. Food and Drug Administration has approved a 2.4 mg/week subcutaneous dose of the glucagonlike peptide–1 (GLP-1) receptor agonist semaglutide (Wegovy, Novo Nordisk) for weight loss.

Specifically, this drug format and dosage are approved as an adjunct to a reduced-calorie diet and increased physical activity to treat adults who have obesity (body mass index [BMI] ≥ 30 kg/m²) or are overweight (BMI ≥ 27 kg/m²) with at least one weight-related comorbidity.

Semaglutide “induces weight loss by reducing hunger, increasing feelings of fullness, and thereby helping people eat less and reduce their calorie intake,” according to a company statement.

Novo Nordisk plans to launch Wegovy later this month in the United States. The prescribing information can be found here.

This weight-loss drug is currently under review by the European Medicines Agency.

Several experts told Medscape that they believe the approval of this drug – as long as it is reimbursed – has the potential to change the paradigm of care when it comes to weight loss.


 

‘Game changer’ drug tested in STEP clinical trial program

The favorable FDA ruling is based on results from the Semaglutide Treatment Effect in People With Obesity (STEP) program of four phase 3 clinical trials that tested the drug’s safety and efficacy in more than 4,500 adults with overweight or obesity obesity who were randomized to receive a reduced a calorie meal plan and increased physical activity (placebo) or this lifestyle intervention plus semaglutide.

The four 68-week trials of subcutaneous semaglutide 2.4 mg/week versus placebo were published in February and March 2021.

As previously reported by this news organization, all trials were in adults with overweight or obesity:

•  was in 1,961 adults (N Engl J Med. 2021 March 18;384:989-1002).
•  was in 1,210 adults who also had diabetes (Lancet. 2021 Mar 13;397;971-84).
•  was in 611 adults, where those in the treatment group also underwent an intensive lifestyle intervention (JAMA. 2021 Feb 24;325:1403-13.
•  was in 803 adults who had reached a target dose of 2.4 mg semaglutide after a 20-week run-in (and the trial examined further weight loss in the subsequent 48 weeks) (JAMA 2021 Mar 23;325:1414-25).

In the STEP 1, 2, and 4 trials of individuals with overweight and obesity, those in the semaglutide groups attained a 15%-18% weight loss over 68 weeks.

The dosage was well-tolerated. The most common side effects were gastrointestinal, and they were transient and mild or moderate in severity.

The side effects, contraindications, and a black box warning about thyroid C-cell tumors are spelled out in the prescribing information.

A coauthor of the STEP 1 trial, Rachel Batterham, MBBS, PhD, of the Centre for Obesity Research at University College London, said at the time of publication: “The findings of this study represent a major breakthrough for improving the health of people with obesity.”

“No other drug has come close to producing this level of weight loss – this really is a gamechanger. For the first time, people can achieve through drugs what was only possible through weight-loss surgery,” she added.
 

Welcome Addition, But Will Insurance Coverage, Price Thwart Access?

Thomas A. Wadden, PhD, from the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, and lead author of STEP 3, commented in an email to this news organization that “semaglutide 2.4 mg appears to be the breakthrough in weight management that healthcare providers and their patients with obesity have been waiting for.”

The mean 15% weight loss at 68 weeks is nearly twice what is seen with other FDA-approved anti-obesity medications, he noted, and moreover, 70% of patients taking semaglutide lost at least 10% of their initial weight, which is associated with clinically meaningful improvements in obesity-related type 2 diabetes, hypertension, obstructive sleep apnea, and impaired quality of life.

And “nearly one-third of users are likely to lose 20% or more of their starting weight, an outcome which eludes traditional diet and exercise interventions and which approaches weight losses produced by the most widely performed bariatric surgery, sleeve gastrectomy (with mean losses of 25% of initial weight at 1 year).” Dr. Wadden stressed.

Thus “the efficacy of semaglutide 2.4 mg, combined with its favorable safety profile, makes this medication a potential game changer,” he summarized, echoing Dr. Batterham.

However, insurance coverage and price could block uptake.

“I hope that the millions of people – in the U.S. and worldwide – who could benefit from this medication eventually will have access to it,” said Dr. Wadden. “In the U.S., the coverage of anti-obesity medications by insurers and employers will need to improve to ensure this happens, and the medication must be reasonably priced. These changes are critical to making this medication the game changer it could be.”

“This approval is an important development,” Scott Kahan, MD, director of the National Center for Weight and Wellness, Washington, who was not involved in the clinical trials of this drug, similarly wrote in an email.

“In a field with relatively few medication options, the availability of additional obesity pharmacotherapy agents is welcome,” he said. “In particular, semaglutide has shown impressive efficacy and safety data; as such it should be a valuable clinical option for many patients.”

However, it is concerning that “access to obesity treatments has traditionally been a challenge,” Dr. Kahan warned. “Novo Nordisk’s other obesity medication, Saxenda, has been a valuable tool, but one that exceedingly few patients are able to utilize due to minimal insurance reimbursement and very high cost.”

“It remains to be seen how accessible semaglutide will be for patients,” according to Dr. Kahan, “Still, if the challenge of limited coverage and high cost can be mitigated, this medication has a chance to significantly change the current paradigm of care, which until till now has included minimal use of pharmacotherapy outside specialty clinics,” he maintains.

Subcutaneous semaglutide at doses up to 1 mg/week (Ozempic, Novo Nordisk), which comes as prefilled pens at doses of 0.5 mg or 1.0 mg, is already approved for the treatment of type 2 diabetes.

The company is also applying for approval for a higher dose of semaglutide, 2 mg/week, for use in type 2 diabetes, and has just resubmitted its label expansion application to the FDA, after the agency issued a refusal to file letter in March.

And in September 2019, the FDA approved oral semaglutide (Rybelsus, Novo Nordisk), in doses of 7 and 14 mg/day, to improve glycemic control in type 2 diabetes, making it the first GLP-1 receptor agonist available in tablet form.
 

CVOT and oral format trials for obesity on the horizon

The ongoing Semaglutide Effects on Heart Disease and Stroke in Patients With Overweight or Obesity (SELECT) trial will shed light on cardiovascular outcomes after 2.5-5 years in patients with cardiovascular disease and overweight or obesity but without type 2 diabetes. Participants will receive semaglutide in doses up to a maximum of 2.4 mg/week, or placebo, as an adjunct to lifestyle recommendations focused on cardiovascular risk reduction. The study is expected to complete in 2023.

And Novo Nordisk plans to initiate a global 68-week phase 3 trial in the second half of 2021 on the efficacy and safety of oral semaglutide 50 mg compared with placebo in 1000 people with obesity or overweight and comorbidities.

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

This article was updated 6/7/21.

The U.S. Food and Drug Administration has approved a 2.4 mg/week subcutaneous dose of the glucagonlike peptide–1 (GLP-1) receptor agonist semaglutide (Wegovy, Novo Nordisk) for weight loss.

Specifically, this drug format and dosage are approved as an adjunct to a reduced-calorie diet and increased physical activity to treat adults who have obesity (body mass index [BMI] ≥ 30 kg/m²) or are overweight (BMI ≥ 27 kg/m²) with at least one weight-related comorbidity.

Semaglutide “induces weight loss by reducing hunger, increasing feelings of fullness, and thereby helping people eat less and reduce their calorie intake,” according to a company statement.

Novo Nordisk plans to launch Wegovy later this month in the United States. The prescribing information can be found here.

This weight-loss drug is currently under review by the European Medicines Agency.

Several experts told Medscape that they believe the approval of this drug – as long as it is reimbursed – has the potential to change the paradigm of care when it comes to weight loss.


 

‘Game changer’ drug tested in STEP clinical trial program

The favorable FDA ruling is based on results from the Semaglutide Treatment Effect in People With Obesity (STEP) program of four phase 3 clinical trials that tested the drug’s safety and efficacy in more than 4,500 adults with overweight or obesity obesity who were randomized to receive a reduced a calorie meal plan and increased physical activity (placebo) or this lifestyle intervention plus semaglutide.

The four 68-week trials of subcutaneous semaglutide 2.4 mg/week versus placebo were published in February and March 2021.

As previously reported by this news organization, all trials were in adults with overweight or obesity:

•  was in 1,961 adults (N Engl J Med. 2021 March 18;384:989-1002).
•  was in 1,210 adults who also had diabetes (Lancet. 2021 Mar 13;397;971-84).
•  was in 611 adults, where those in the treatment group also underwent an intensive lifestyle intervention (JAMA. 2021 Feb 24;325:1403-13.
•  was in 803 adults who had reached a target dose of 2.4 mg semaglutide after a 20-week run-in (and the trial examined further weight loss in the subsequent 48 weeks) (JAMA 2021 Mar 23;325:1414-25).

In the STEP 1, 2, and 4 trials of individuals with overweight and obesity, those in the semaglutide groups attained a 15%-18% weight loss over 68 weeks.

The dosage was well-tolerated. The most common side effects were gastrointestinal, and they were transient and mild or moderate in severity.

The side effects, contraindications, and a black box warning about thyroid C-cell tumors are spelled out in the prescribing information.

A coauthor of the STEP 1 trial, Rachel Batterham, MBBS, PhD, of the Centre for Obesity Research at University College London, said at the time of publication: “The findings of this study represent a major breakthrough for improving the health of people with obesity.”

“No other drug has come close to producing this level of weight loss – this really is a gamechanger. For the first time, people can achieve through drugs what was only possible through weight-loss surgery,” she added.
 

Welcome Addition, But Will Insurance Coverage, Price Thwart Access?

Thomas A. Wadden, PhD, from the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, and lead author of STEP 3, commented in an email to this news organization that “semaglutide 2.4 mg appears to be the breakthrough in weight management that healthcare providers and their patients with obesity have been waiting for.”

The mean 15% weight loss at 68 weeks is nearly twice what is seen with other FDA-approved anti-obesity medications, he noted, and moreover, 70% of patients taking semaglutide lost at least 10% of their initial weight, which is associated with clinically meaningful improvements in obesity-related type 2 diabetes, hypertension, obstructive sleep apnea, and impaired quality of life.

And “nearly one-third of users are likely to lose 20% or more of their starting weight, an outcome which eludes traditional diet and exercise interventions and which approaches weight losses produced by the most widely performed bariatric surgery, sleeve gastrectomy (with mean losses of 25% of initial weight at 1 year).” Dr. Wadden stressed.

Thus “the efficacy of semaglutide 2.4 mg, combined with its favorable safety profile, makes this medication a potential game changer,” he summarized, echoing Dr. Batterham.

However, insurance coverage and price could block uptake.

“I hope that the millions of people – in the U.S. and worldwide – who could benefit from this medication eventually will have access to it,” said Dr. Wadden. “In the U.S., the coverage of anti-obesity medications by insurers and employers will need to improve to ensure this happens, and the medication must be reasonably priced. These changes are critical to making this medication the game changer it could be.”

“This approval is an important development,” Scott Kahan, MD, director of the National Center for Weight and Wellness, Washington, who was not involved in the clinical trials of this drug, similarly wrote in an email.

“In a field with relatively few medication options, the availability of additional obesity pharmacotherapy agents is welcome,” he said. “In particular, semaglutide has shown impressive efficacy and safety data; as such it should be a valuable clinical option for many patients.”

However, it is concerning that “access to obesity treatments has traditionally been a challenge,” Dr. Kahan warned. “Novo Nordisk’s other obesity medication, Saxenda, has been a valuable tool, but one that exceedingly few patients are able to utilize due to minimal insurance reimbursement and very high cost.”

“It remains to be seen how accessible semaglutide will be for patients,” according to Dr. Kahan, “Still, if the challenge of limited coverage and high cost can be mitigated, this medication has a chance to significantly change the current paradigm of care, which until till now has included minimal use of pharmacotherapy outside specialty clinics,” he maintains.

Subcutaneous semaglutide at doses up to 1 mg/week (Ozempic, Novo Nordisk), which comes as prefilled pens at doses of 0.5 mg or 1.0 mg, is already approved for the treatment of type 2 diabetes.

The company is also applying for approval for a higher dose of semaglutide, 2 mg/week, for use in type 2 diabetes, and has just resubmitted its label expansion application to the FDA, after the agency issued a refusal to file letter in March.

And in September 2019, the FDA approved oral semaglutide (Rybelsus, Novo Nordisk), in doses of 7 and 14 mg/day, to improve glycemic control in type 2 diabetes, making it the first GLP-1 receptor agonist available in tablet form.
 

CVOT and oral format trials for obesity on the horizon

The ongoing Semaglutide Effects on Heart Disease and Stroke in Patients With Overweight or Obesity (SELECT) trial will shed light on cardiovascular outcomes after 2.5-5 years in patients with cardiovascular disease and overweight or obesity but without type 2 diabetes. Participants will receive semaglutide in doses up to a maximum of 2.4 mg/week, or placebo, as an adjunct to lifestyle recommendations focused on cardiovascular risk reduction. The study is expected to complete in 2023.

And Novo Nordisk plans to initiate a global 68-week phase 3 trial in the second half of 2021 on the efficacy and safety of oral semaglutide 50 mg compared with placebo in 1000 people with obesity or overweight and comorbidities.

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

This article was updated 6/7/21.

The U.S. Food and Drug Administration has approved a 2.4 mg/week subcutaneous dose of the glucagonlike peptide–1 (GLP-1) receptor agonist semaglutide (Wegovy, Novo Nordisk) for weight loss.

Specifically, this drug format and dosage are approved as an adjunct to a reduced-calorie diet and increased physical activity to treat adults who have obesity (body mass index [BMI] ≥ 30 kg/m²) or are overweight (BMI ≥ 27 kg/m²) with at least one weight-related comorbidity.

Semaglutide “induces weight loss by reducing hunger, increasing feelings of fullness, and thereby helping people eat less and reduce their calorie intake,” according to a company statement.

Novo Nordisk plans to launch Wegovy later this month in the United States. The prescribing information can be found here.

This weight-loss drug is currently under review by the European Medicines Agency.

Several experts told Medscape that they believe the approval of this drug – as long as it is reimbursed – has the potential to change the paradigm of care when it comes to weight loss.


 

‘Game changer’ drug tested in STEP clinical trial program

The favorable FDA ruling is based on results from the Semaglutide Treatment Effect in People With Obesity (STEP) program of four phase 3 clinical trials that tested the drug’s safety and efficacy in more than 4,500 adults with overweight or obesity obesity who were randomized to receive a reduced a calorie meal plan and increased physical activity (placebo) or this lifestyle intervention plus semaglutide.

The four 68-week trials of subcutaneous semaglutide 2.4 mg/week versus placebo were published in February and March 2021.

As previously reported by this news organization, all trials were in adults with overweight or obesity:

•  was in 1,961 adults (N Engl J Med. 2021 March 18;384:989-1002).
•  was in 1,210 adults who also had diabetes (Lancet. 2021 Mar 13;397;971-84).
•  was in 611 adults, where those in the treatment group also underwent an intensive lifestyle intervention (JAMA. 2021 Feb 24;325:1403-13.
•  was in 803 adults who had reached a target dose of 2.4 mg semaglutide after a 20-week run-in (and the trial examined further weight loss in the subsequent 48 weeks) (JAMA 2021 Mar 23;325:1414-25).

In the STEP 1, 2, and 4 trials of individuals with overweight and obesity, those in the semaglutide groups attained a 15%-18% weight loss over 68 weeks.

The dosage was well-tolerated. The most common side effects were gastrointestinal, and they were transient and mild or moderate in severity.

The side effects, contraindications, and a black box warning about thyroid C-cell tumors are spelled out in the prescribing information.

A coauthor of the STEP 1 trial, Rachel Batterham, MBBS, PhD, of the Centre for Obesity Research at University College London, said at the time of publication: “The findings of this study represent a major breakthrough for improving the health of people with obesity.”

“No other drug has come close to producing this level of weight loss – this really is a gamechanger. For the first time, people can achieve through drugs what was only possible through weight-loss surgery,” she added.
 

Welcome Addition, But Will Insurance Coverage, Price Thwart Access?

Thomas A. Wadden, PhD, from the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, and lead author of STEP 3, commented in an email to this news organization that “semaglutide 2.4 mg appears to be the breakthrough in weight management that healthcare providers and their patients with obesity have been waiting for.”

The mean 15% weight loss at 68 weeks is nearly twice what is seen with other FDA-approved anti-obesity medications, he noted, and moreover, 70% of patients taking semaglutide lost at least 10% of their initial weight, which is associated with clinically meaningful improvements in obesity-related type 2 diabetes, hypertension, obstructive sleep apnea, and impaired quality of life.

And “nearly one-third of users are likely to lose 20% or more of their starting weight, an outcome which eludes traditional diet and exercise interventions and which approaches weight losses produced by the most widely performed bariatric surgery, sleeve gastrectomy (with mean losses of 25% of initial weight at 1 year).” Dr. Wadden stressed.

Thus “the efficacy of semaglutide 2.4 mg, combined with its favorable safety profile, makes this medication a potential game changer,” he summarized, echoing Dr. Batterham.

However, insurance coverage and price could block uptake.

“I hope that the millions of people – in the U.S. and worldwide – who could benefit from this medication eventually will have access to it,” said Dr. Wadden. “In the U.S., the coverage of anti-obesity medications by insurers and employers will need to improve to ensure this happens, and the medication must be reasonably priced. These changes are critical to making this medication the game changer it could be.”

“This approval is an important development,” Scott Kahan, MD, director of the National Center for Weight and Wellness, Washington, who was not involved in the clinical trials of this drug, similarly wrote in an email.

“In a field with relatively few medication options, the availability of additional obesity pharmacotherapy agents is welcome,” he said. “In particular, semaglutide has shown impressive efficacy and safety data; as such it should be a valuable clinical option for many patients.”

However, it is concerning that “access to obesity treatments has traditionally been a challenge,” Dr. Kahan warned. “Novo Nordisk’s other obesity medication, Saxenda, has been a valuable tool, but one that exceedingly few patients are able to utilize due to minimal insurance reimbursement and very high cost.”

“It remains to be seen how accessible semaglutide will be for patients,” according to Dr. Kahan, “Still, if the challenge of limited coverage and high cost can be mitigated, this medication has a chance to significantly change the current paradigm of care, which until till now has included minimal use of pharmacotherapy outside specialty clinics,” he maintains.

Subcutaneous semaglutide at doses up to 1 mg/week (Ozempic, Novo Nordisk), which comes as prefilled pens at doses of 0.5 mg or 1.0 mg, is already approved for the treatment of type 2 diabetes.

The company is also applying for approval for a higher dose of semaglutide, 2 mg/week, for use in type 2 diabetes, and has just resubmitted its label expansion application to the FDA, after the agency issued a refusal to file letter in March.

And in September 2019, the FDA approved oral semaglutide (Rybelsus, Novo Nordisk), in doses of 7 and 14 mg/day, to improve glycemic control in type 2 diabetes, making it the first GLP-1 receptor agonist available in tablet form.
 

CVOT and oral format trials for obesity on the horizon

The ongoing Semaglutide Effects on Heart Disease and Stroke in Patients With Overweight or Obesity (SELECT) trial will shed light on cardiovascular outcomes after 2.5-5 years in patients with cardiovascular disease and overweight or obesity but without type 2 diabetes. Participants will receive semaglutide in doses up to a maximum of 2.4 mg/week, or placebo, as an adjunct to lifestyle recommendations focused on cardiovascular risk reduction. The study is expected to complete in 2023.

And Novo Nordisk plans to initiate a global 68-week phase 3 trial in the second half of 2021 on the efficacy and safety of oral semaglutide 50 mg compared with placebo in 1000 people with obesity or overweight and comorbidities.

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

This article was updated 6/7/21.

Imagine a hospitalist, part of a group with 35 hospitalists, is in her second year of practice and is caring for a 55-year-old woman with a history of congestive heart failure and cirrhosis from hepatitis C due to heroin use. The patient was hospitalized with acute back pain and found to have vertebral osteomyelitis confirmed on MRI.

The hospitalist calls a surgeon to get a biopsy so that antibiotic therapy can be chosen. The surgeon says it’s the second time the patient has been hospitalized for this condition, and asks, “Why do you need me to see this patient?” He says the hospitalist should just give IV antibiotics and consult infectious disease.

The hospitalist says, “The patient needs this biopsy. I’ll just call your chair.”

In the course of a busy day, conflicts arise all the time in the hospital – between clinicians, between patients and clinicians, and as internal battles when clinicians face uncertain situations. There are ways to make these conflicts less tense and more in tune with patient care, panelists said recently during a session at SHM Converge, the annual conference of the Society of Hospital Medicine.

In the case of vertebral osteomyelitis, for instance, the hospitalist was using a “position-based” strategy to deal with the conflict with the surgeon – she came in knowing she wanted a biopsy – rather than an “interest-based” strategy, or what is in the patient’s interest, said Patrick Rendon, MD, FHM, assistant professor in the hospital medicine division at the University of New Mexico, Albuquerque.

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

Imagine a hospitalist, part of a group with 35 hospitalists, is in her second year of practice and is caring for a 55-year-old woman with a history of congestive heart failure and cirrhosis from hepatitis C due to heroin use. The patient was hospitalized with acute back pain and found to have vertebral osteomyelitis confirmed on MRI.

The hospitalist calls a surgeon to get a biopsy so that antibiotic therapy can be chosen. The surgeon says it’s the second time the patient has been hospitalized for this condition, and asks, “Why do you need me to see this patient?” He says the hospitalist should just give IV antibiotics and consult infectious disease.

The hospitalist says, “The patient needs this biopsy. I’ll just call your chair.”

In the course of a busy day, conflicts arise all the time in the hospital – between clinicians, between patients and clinicians, and as internal battles when clinicians face uncertain situations. There are ways to make these conflicts less tense and more in tune with patient care, panelists said recently during a session at SHM Converge, the annual conference of the Society of Hospital Medicine.

In the case of vertebral osteomyelitis, for instance, the hospitalist was using a “position-based” strategy to deal with the conflict with the surgeon – she came in knowing she wanted a biopsy – rather than an “interest-based” strategy, or what is in the patient’s interest, said Patrick Rendon, MD, FHM, assistant professor in the hospital medicine division at the University of New Mexico, Albuquerque.

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

Imagine a hospitalist, part of a group with 35 hospitalists, is in her second year of practice and is caring for a 55-year-old woman with a history of congestive heart failure and cirrhosis from hepatitis C due to heroin use. The patient was hospitalized with acute back pain and found to have vertebral osteomyelitis confirmed on MRI.

The hospitalist calls a surgeon to get a biopsy so that antibiotic therapy can be chosen. The surgeon says it’s the second time the patient has been hospitalized for this condition, and asks, “Why do you need me to see this patient?” He says the hospitalist should just give IV antibiotics and consult infectious disease.

The hospitalist says, “The patient needs this biopsy. I’ll just call your chair.”

In the course of a busy day, conflicts arise all the time in the hospital – between clinicians, between patients and clinicians, and as internal battles when clinicians face uncertain situations. There are ways to make these conflicts less tense and more in tune with patient care, panelists said recently during a session at SHM Converge, the annual conference of the Society of Hospital Medicine.

In the case of vertebral osteomyelitis, for instance, the hospitalist was using a “position-based” strategy to deal with the conflict with the surgeon – she came in knowing she wanted a biopsy – rather than an “interest-based” strategy, or what is in the patient’s interest, said Patrick Rendon, MD, FHM, assistant professor in the hospital medicine division at the University of New Mexico, Albuquerque.

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

Taking more steps each day, in short spurts or longer bouts, was associated with a longer life in women older than 60 years, according to data from more than 16,000 participants in the ongoing Women’s Health Study.

The American Heart Association recommends at least 150 minutes per week of moderate physical activity, 75 minutes of vigorous physical activity, or a combination of both as fitness guidelines for adults. Walking is a safe and easy way for many adults to follow these guidelines, according to Christopher C. Moore, MS, a PhD candidate at the University of North Carolina at Chapel Hill.

The popularity of step counts reflect that they are simple and objective, and “focusing on steps can help promote an active lifestyle,” he said. Data on the impact of sporadic steps accumulated outside of longer bouts of activity on health outcomes are limited; however, technology advances in the form of fitness apps and wearable devices make it possible for researchers to track and measure the benefits of short periods of activity as well as longer periods.

In a study presented at the Epidemiology and Prevention/Lifestyle and Cardiometabolic Health meeting, sponsored by the AHA, Mr. Moore and colleagues assessed data from women older than 60 years who used wearable step-counting devices to measure their daily steps and walking patterns.

The study population included 16,732 women enrolled in the Women’s Health Study, a longstanding study of heart disease, cancer, and disease prevention among women in the United States. The participants wore waist step counters 4-7 days a week during 2011-2015. The average of the women was 72 years; 96% were non-Hispanic White, and the average BMI was 26 kg/m².

The researchers divided the total number of steps for each study participant into two groups: “bouted” steps, defined as 10 minutes or longer bouts of walking with few interruptions; and “sporadic” steps, defined as short spurts of walking during regular daily activities such as housework, taking the stairs, or walking to or from a car.

A total of 804 deaths occurred during an average of 6 years of follow-up. Each initial increase of 1,000 steps including sporadic or bouted steps was associated with a 28% decrease in death, compared with no daily steps (hazard ratio, 0.72).

Each increasing quartile of sporadic steps was linked with higher total steps per day, Mr. Moore said. “Initial increase in sporadic steps corresponded to the greatest reductions in mortality,” with a HR of 0.69 per additional sporadic steps below 3,200 per day, and the impact on reduced mortality plateaued at about 4,500 sporadic steps per day.

In further analysis, the researchers also found a roughly 32% decrease in death in participants who took more than 2,000 steps daily in uninterrupted bouts (HR, 0.69).

The study findings were limited by several factors, including the relatively short follow-up period and number of events, the assessment of steps at a single time point, and the mostly homogeneous population, Mr. Moore noted. Additional research is needed to assess whether the results are generalizable to men, younger women, and diverse racial and ethnic groups.

However, the results may have implications for public health messaging, he emphasized. The message is that, to impact longevity, the total volume of steps is more important than the type of activity through which they are accumulated.

“You can accumulate your steps through longer bouts of purposeful activity or through everyday behaviors such as walking to your car, taking the stairs, and doing housework,” Mr. Moore concluded.

Find a friend, both of you benefit

On the basis of this study and other available evidence, more steps daily are recommended for everyone, Nieca Goldberg, MD, a cardiologist at New York University Langone Health, said in an interview.

“You can increase minutes of walking and frequency of walking,” she said.

Dr. Goldberg emphasized that you don’t need a fancy app or wearable device to up your steps. She offered some tips to help overcome barriers to putting one foot in front of the other. “Take the steps instead of the elevator. Park your car farther from your destination so you can walk.” Also, you can help yourself and help a friend to better health. “Get a walking buddy so you can encourage each other to walk,” Dr. Goldberg added.

Mr. Moore and Dr. Goldberg had no financial conflicts to disclose. The Women’s Health Study is funded by Brigham and Women’s Hospital; the National Heart, Lung, and Blood Institute; and the National Cancer Institute. Mr. Moore was funded by a grant from the NHLBI but had no other financial conflicts to disclose.

Taking more steps each day, in short spurts or longer bouts, was associated with a longer life in women older than 60 years, according to data from more than 16,000 participants in the ongoing Women’s Health Study.

The American Heart Association recommends at least 150 minutes per week of moderate physical activity, 75 minutes of vigorous physical activity, or a combination of both as fitness guidelines for adults. Walking is a safe and easy way for many adults to follow these guidelines, according to Christopher C. Moore, MS, a PhD candidate at the University of North Carolina at Chapel Hill.

The popularity of step counts reflect that they are simple and objective, and “focusing on steps can help promote an active lifestyle,” he said. Data on the impact of sporadic steps accumulated outside of longer bouts of activity on health outcomes are limited; however, technology advances in the form of fitness apps and wearable devices make it possible for researchers to track and measure the benefits of short periods of activity as well as longer periods.

In a study presented at the Epidemiology and Prevention/Lifestyle and Cardiometabolic Health meeting, sponsored by the AHA, Mr. Moore and colleagues assessed data from women older than 60 years who used wearable step-counting devices to measure their daily steps and walking patterns.

The study population included 16,732 women enrolled in the Women’s Health Study, a longstanding study of heart disease, cancer, and disease prevention among women in the United States. The participants wore waist step counters 4-7 days a week during 2011-2015. The average of the women was 72 years; 96% were non-Hispanic White, and the average BMI was 26 kg/m².

The researchers divided the total number of steps for each study participant into two groups: “bouted” steps, defined as 10 minutes or longer bouts of walking with few interruptions; and “sporadic” steps, defined as short spurts of walking during regular daily activities such as housework, taking the stairs, or walking to or from a car.

A total of 804 deaths occurred during an average of 6 years of follow-up. Each initial increase of 1,000 steps including sporadic or bouted steps was associated with a 28% decrease in death, compared with no daily steps (hazard ratio, 0.72).

Each increasing quartile of sporadic steps was linked with higher total steps per day, Mr. Moore said. “Initial increase in sporadic steps corresponded to the greatest reductions in mortality,” with a HR of 0.69 per additional sporadic steps below 3,200 per day, and the impact on reduced mortality plateaued at about 4,500 sporadic steps per day.

In further analysis, the researchers also found a roughly 32% decrease in death in participants who took more than 2,000 steps daily in uninterrupted bouts (HR, 0.69).

The study findings were limited by several factors, including the relatively short follow-up period and number of events, the assessment of steps at a single time point, and the mostly homogeneous population, Mr. Moore noted. Additional research is needed to assess whether the results are generalizable to men, younger women, and diverse racial and ethnic groups.

However, the results may have implications for public health messaging, he emphasized. The message is that, to impact longevity, the total volume of steps is more important than the type of activity through which they are accumulated.

“You can accumulate your steps through longer bouts of purposeful activity or through everyday behaviors such as walking to your car, taking the stairs, and doing housework,” Mr. Moore concluded.

Find a friend, both of you benefit

On the basis of this study and other available evidence, more steps daily are recommended for everyone, Nieca Goldberg, MD, a cardiologist at New York University Langone Health, said in an interview.

“You can increase minutes of walking and frequency of walking,” she said.

Dr. Goldberg emphasized that you don’t need a fancy app or wearable device to up your steps. She offered some tips to help overcome barriers to putting one foot in front of the other. “Take the steps instead of the elevator. Park your car farther from your destination so you can walk.” Also, you can help yourself and help a friend to better health. “Get a walking buddy so you can encourage each other to walk,” Dr. Goldberg added.

Mr. Moore and Dr. Goldberg had no financial conflicts to disclose. The Women’s Health Study is funded by Brigham and Women’s Hospital; the National Heart, Lung, and Blood Institute; and the National Cancer Institute. Mr. Moore was funded by a grant from the NHLBI but had no other financial conflicts to disclose.

Taking more steps each day, in short spurts or longer bouts, was associated with a longer life in women older than 60 years, according to data from more than 16,000 participants in the ongoing Women’s Health Study.

The American Heart Association recommends at least 150 minutes per week of moderate physical activity, 75 minutes of vigorous physical activity, or a combination of both as fitness guidelines for adults. Walking is a safe and easy way for many adults to follow these guidelines, according to Christopher C. Moore, MS, a PhD candidate at the University of North Carolina at Chapel Hill.

The popularity of step counts reflect that they are simple and objective, and “focusing on steps can help promote an active lifestyle,” he said. Data on the impact of sporadic steps accumulated outside of longer bouts of activity on health outcomes are limited; however, technology advances in the form of fitness apps and wearable devices make it possible for researchers to track and measure the benefits of short periods of activity as well as longer periods.

In a study presented at the Epidemiology and Prevention/Lifestyle and Cardiometabolic Health meeting, sponsored by the AHA, Mr. Moore and colleagues assessed data from women older than 60 years who used wearable step-counting devices to measure their daily steps and walking patterns.

The study population included 16,732 women enrolled in the Women’s Health Study, a longstanding study of heart disease, cancer, and disease prevention among women in the United States. The participants wore waist step counters 4-7 days a week during 2011-2015. The average of the women was 72 years; 96% were non-Hispanic White, and the average BMI was 26 kg/m².

The researchers divided the total number of steps for each study participant into two groups: “bouted” steps, defined as 10 minutes or longer bouts of walking with few interruptions; and “sporadic” steps, defined as short spurts of walking during regular daily activities such as housework, taking the stairs, or walking to or from a car.

A total of 804 deaths occurred during an average of 6 years of follow-up. Each initial increase of 1,000 steps including sporadic or bouted steps was associated with a 28% decrease in death, compared with no daily steps (hazard ratio, 0.72).

Each increasing quartile of sporadic steps was linked with higher total steps per day, Mr. Moore said. “Initial increase in sporadic steps corresponded to the greatest reductions in mortality,” with a HR of 0.69 per additional sporadic steps below 3,200 per day, and the impact on reduced mortality plateaued at about 4,500 sporadic steps per day.

In further analysis, the researchers also found a roughly 32% decrease in death in participants who took more than 2,000 steps daily in uninterrupted bouts (HR, 0.69).

The study findings were limited by several factors, including the relatively short follow-up period and number of events, the assessment of steps at a single time point, and the mostly homogeneous population, Mr. Moore noted. Additional research is needed to assess whether the results are generalizable to men, younger women, and diverse racial and ethnic groups.

However, the results may have implications for public health messaging, he emphasized. The message is that, to impact longevity, the total volume of steps is more important than the type of activity through which they are accumulated.

“You can accumulate your steps through longer bouts of purposeful activity or through everyday behaviors such as walking to your car, taking the stairs, and doing housework,” Mr. Moore concluded.

Find a friend, both of you benefit

On the basis of this study and other available evidence, more steps daily are recommended for everyone, Nieca Goldberg, MD, a cardiologist at New York University Langone Health, said in an interview.

“You can increase minutes of walking and frequency of walking,” she said.

Dr. Goldberg emphasized that you don’t need a fancy app or wearable device to up your steps. She offered some tips to help overcome barriers to putting one foot in front of the other. “Take the steps instead of the elevator. Park your car farther from your destination so you can walk.” Also, you can help yourself and help a friend to better health. “Get a walking buddy so you can encourage each other to walk,” Dr. Goldberg added.

Mr. Moore and Dr. Goldberg had no financial conflicts to disclose. The Women’s Health Study is funded by Brigham and Women’s Hospital; the National Heart, Lung, and Blood Institute; and the National Cancer Institute. Mr. Moore was funded by a grant from the NHLBI but had no other financial conflicts to disclose.

Advance care planning (ACP) is a process that supports adults at any age or stage of health in understanding and sharing their personal values, life goals, and preferences for future medical care, according to Meredith A. MacMartin, MD, director of inpatient palliative care at the Dartmouth-Hitchcock Medical Center in Lebanon, N.H.

ACP “is really about planning for care in advance,” and in many ways, the inpatient setting is uniquely suited to this process, Dr. MacMartin said in a presentation at SHM Converge 2021, the annual conference of the Society of Hospital Medicine. “The key part is the advance part. You want conversations to happen before the care is actually needed,” she said.

Dr. MacMartin emphasized the importance of distinguishing between ACP and advance directives (ADs). ACP is a process, whereas ADs are documentation, “ideally of the content of advance care planning discussions,” she explained. ACP involves discussion about what is important to the patients, their goals, what information is helpful for them, and whether their current care is aligned with their goals, Dr. MacMartin said. ADs might involve a designated power of attorney for health care, a living will, and, in some states, specific clinician-signed orders regarding resuscitation or transport to hospital.

ACP is “more than whether a patient wants CPR [cardiopulmonary resuscitation] or not,” said Dr. MacMartin. ACP matters because it helps ensure that the care a patient receives aligns with the patient’s wishes and values, she said. ACP increases the likelihood that patients will die in their preferred locations, it allows them to discuss their wishes and prepare for decline, and it relieves family members of the burden of decision making, she said. From a hospital perspective, data show that use of an ACP can decrease intensive care unit (ICU) utilization and overall health care costs. “Often, when people are given the opportunity to express their wishes, they get less unnecessary care,” Dr. MacMartin noted.

Although ACP often takes place in an outpatient setting, hospitalists are in a unique position to conduct some ACP conversations with their patients, Dr. MacMartin said. “Hospitalists are available” and are physically present at least once a day, so there is a pragmatic advantage. Also, some data suggest that patients may feel more comfortable having ACP conversations with a hospitalist than with a primary care provider with whom they have a long-standing relationship, Dr. MacMartin added.

Another important advantage of ACP in the hospital setting is that, “as hospitalists, you are the expert on inpatient illness; you know what sick looks like, and you have a unique perspective on prognostication that may be harder to recreate in the outpatient setting,” Dr. MacMartin said.
 

Barriers to ACP include patient identification, logistics, attitudes

Settings in which ACP is appropriate include those in which a patient is undergoing “sentinel hospitalization,” meaning that the patient is at a transition point in the disease course. Examples are a patient newly diagnosed with metastatic solid cancer, a patient with progressive chronic kidney disease who is considering hemodialysis, or a patient who receives treatment in the ICU for longer than 7 days, Dr. MacMartin said.

Guidelines for identifying patients who might benefit from ACP include the use of the “surprise question” (“would you be surprised if this patient dies in the next year?”) as well as functional status assessments using tools such as the Australia-modified Karnofsky Performance Status or the Eastern Cooperative Oncology Group score, said Dr. MacMartin. Some studies suggest that any hospitalized patient older than 65 years should have an ACP discussion, she added.

Time pressure remains a significant barrier to ACP conversations. Some strategies to overcome this problem include enlisting help from other specialists, particularly social workers, Dr. MacMartin said. Social workers report a higher comfort level for talking to patients about death than any other medical specialty; “this is something they want to be doing,” she said. Also, the possibility of reimbursement may act as a buffer to create more time to have ACP conversations with patients, she noted.

Addressing clinicians’ discomfort with ACP conversations can be “a tougher nut to crack,” Dr. MacMartin acknowledged. Clinicians report that they don’t want to cause their patients distress, and some report that having conversations about end-of-life care is distressing for them as well. Some of these barriers can be overcome with skills training, including use of a prepared guideline or framework to help increase the comfort level for both clinicians and patients, said Dr. MacMartin.
 

A look ahead: Training strategies and COVID-19 impact

“For hospitalists interested in developing their ACP skills, I highly recommend two resources,” Dr. MacMartin said in an interview. “The Serious Illness Conversation Guide, from Ariadne Labs, is an excellent tool for any clinician to guide discussion about a patient’s goals and values,” she said.

“For clinicians wanting to build or improve their communication, including advance care planning discussions but also topics like responding to patient’s emotions, VitalTalk training offers a deeper dive into core communications skills,” she added.

“If your hospital has a palliative care team, they may also have more local resources available to you. To learn more about billing for ACP discussions, I recommend starting with your institutional billing and coding group, as these practices vary some between practices, and they will be able to provide the best guidance for clinicians. These are new codes that aren’t yet being very widely used so it’s a chance to innovate,” Dr. MacMartin noted.

“The hospital setting is an opportunity for patients to reflect on their health, both present and in the future, with a physician who has expertise in acute illness and prognostication and who is available for discussion on a daily basis during the hospitalization,” Dr. MacMartin emphasized.

As for whether the COVID-19 pandemic has affected ACP in the inpatient setting, the data are limited, but more information is forthcoming, Dr. MacMartin said. “In my personal experience and in talking to colleagues elsewhere, the pandemic has highlighted the need for ACP in some ways, as we have tried to ensure that people who wouldn’t want things like intensive care are identified early,” she said. “I hope that some of the workflows developed to identify patients who should get ACP in the hospital stay in practice and are strengthened over time,” she added.

Dr. MacMartin has disclosed no relevant financial relationships.
 

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

Advance care planning (ACP) is a process that supports adults at any age or stage of health in understanding and sharing their personal values, life goals, and preferences for future medical care, according to Meredith A. MacMartin, MD, director of inpatient palliative care at the Dartmouth-Hitchcock Medical Center in Lebanon, N.H.

ACP “is really about planning for care in advance,” and in many ways, the inpatient setting is uniquely suited to this process, Dr. MacMartin said in a presentation at SHM Converge 2021, the annual conference of the Society of Hospital Medicine. “The key part is the advance part. You want conversations to happen before the care is actually needed,” she said.

Dr. MacMartin emphasized the importance of distinguishing between ACP and advance directives (ADs). ACP is a process, whereas ADs are documentation, “ideally of the content of advance care planning discussions,” she explained. ACP involves discussion about what is important to the patients, their goals, what information is helpful for them, and whether their current care is aligned with their goals, Dr. MacMartin said. ADs might involve a designated power of attorney for health care, a living will, and, in some states, specific clinician-signed orders regarding resuscitation or transport to hospital.

ACP is “more than whether a patient wants CPR [cardiopulmonary resuscitation] or not,” said Dr. MacMartin. ACP matters because it helps ensure that the care a patient receives aligns with the patient’s wishes and values, she said. ACP increases the likelihood that patients will die in their preferred locations, it allows them to discuss their wishes and prepare for decline, and it relieves family members of the burden of decision making, she said. From a hospital perspective, data show that use of an ACP can decrease intensive care unit (ICU) utilization and overall health care costs. “Often, when people are given the opportunity to express their wishes, they get less unnecessary care,” Dr. MacMartin noted.

Although ACP often takes place in an outpatient setting, hospitalists are in a unique position to conduct some ACP conversations with their patients, Dr. MacMartin said. “Hospitalists are available” and are physically present at least once a day, so there is a pragmatic advantage. Also, some data suggest that patients may feel more comfortable having ACP conversations with a hospitalist than with a primary care provider with whom they have a long-standing relationship, Dr. MacMartin added.

Another important advantage of ACP in the hospital setting is that, “as hospitalists, you are the expert on inpatient illness; you know what sick looks like, and you have a unique perspective on prognostication that may be harder to recreate in the outpatient setting,” Dr. MacMartin said.
 

Barriers to ACP include patient identification, logistics, attitudes

Settings in which ACP is appropriate include those in which a patient is undergoing “sentinel hospitalization,” meaning that the patient is at a transition point in the disease course. Examples are a patient newly diagnosed with metastatic solid cancer, a patient with progressive chronic kidney disease who is considering hemodialysis, or a patient who receives treatment in the ICU for longer than 7 days, Dr. MacMartin said.

Guidelines for identifying patients who might benefit from ACP include the use of the “surprise question” (“would you be surprised if this patient dies in the next year?”) as well as functional status assessments using tools such as the Australia-modified Karnofsky Performance Status or the Eastern Cooperative Oncology Group score, said Dr. MacMartin. Some studies suggest that any hospitalized patient older than 65 years should have an ACP discussion, she added.

Time pressure remains a significant barrier to ACP conversations. Some strategies to overcome this problem include enlisting help from other specialists, particularly social workers, Dr. MacMartin said. Social workers report a higher comfort level for talking to patients about death than any other medical specialty; “this is something they want to be doing,” she said. Also, the possibility of reimbursement may act as a buffer to create more time to have ACP conversations with patients, she noted.

Addressing clinicians’ discomfort with ACP conversations can be “a tougher nut to crack,” Dr. MacMartin acknowledged. Clinicians report that they don’t want to cause their patients distress, and some report that having conversations about end-of-life care is distressing for them as well. Some of these barriers can be overcome with skills training, including use of a prepared guideline or framework to help increase the comfort level for both clinicians and patients, said Dr. MacMartin.
 

A look ahead: Training strategies and COVID-19 impact

“For hospitalists interested in developing their ACP skills, I highly recommend two resources,” Dr. MacMartin said in an interview. “The Serious Illness Conversation Guide, from Ariadne Labs, is an excellent tool for any clinician to guide discussion about a patient’s goals and values,” she said.

“For clinicians wanting to build or improve their communication, including advance care planning discussions but also topics like responding to patient’s emotions, VitalTalk training offers a deeper dive into core communications skills,” she added.

“If your hospital has a palliative care team, they may also have more local resources available to you. To learn more about billing for ACP discussions, I recommend starting with your institutional billing and coding group, as these practices vary some between practices, and they will be able to provide the best guidance for clinicians. These are new codes that aren’t yet being very widely used so it’s a chance to innovate,” Dr. MacMartin noted.

“The hospital setting is an opportunity for patients to reflect on their health, both present and in the future, with a physician who has expertise in acute illness and prognostication and who is available for discussion on a daily basis during the hospitalization,” Dr. MacMartin emphasized.

As for whether the COVID-19 pandemic has affected ACP in the inpatient setting, the data are limited, but more information is forthcoming, Dr. MacMartin said. “In my personal experience and in talking to colleagues elsewhere, the pandemic has highlighted the need for ACP in some ways, as we have tried to ensure that people who wouldn’t want things like intensive care are identified early,” she said. “I hope that some of the workflows developed to identify patients who should get ACP in the hospital stay in practice and are strengthened over time,” she added.

Dr. MacMartin has disclosed no relevant financial relationships.
 

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

Advance care planning (ACP) is a process that supports adults at any age or stage of health in understanding and sharing their personal values, life goals, and preferences for future medical care, according to Meredith A. MacMartin, MD, director of inpatient palliative care at the Dartmouth-Hitchcock Medical Center in Lebanon, N.H.

ACP “is really about planning for care in advance,” and in many ways, the inpatient setting is uniquely suited to this process, Dr. MacMartin said in a presentation at SHM Converge 2021, the annual conference of the Society of Hospital Medicine. “The key part is the advance part. You want conversations to happen before the care is actually needed,” she said.

Dr. MacMartin emphasized the importance of distinguishing between ACP and advance directives (ADs). ACP is a process, whereas ADs are documentation, “ideally of the content of advance care planning discussions,” she explained. ACP involves discussion about what is important to the patients, their goals, what information is helpful for them, and whether their current care is aligned with their goals, Dr. MacMartin said. ADs might involve a designated power of attorney for health care, a living will, and, in some states, specific clinician-signed orders regarding resuscitation or transport to hospital.

ACP is “more than whether a patient wants CPR [cardiopulmonary resuscitation] or not,” said Dr. MacMartin. ACP matters because it helps ensure that the care a patient receives aligns with the patient’s wishes and values, she said. ACP increases the likelihood that patients will die in their preferred locations, it allows them to discuss their wishes and prepare for decline, and it relieves family members of the burden of decision making, she said. From a hospital perspective, data show that use of an ACP can decrease intensive care unit (ICU) utilization and overall health care costs. “Often, when people are given the opportunity to express their wishes, they get less unnecessary care,” Dr. MacMartin noted.

Although ACP often takes place in an outpatient setting, hospitalists are in a unique position to conduct some ACP conversations with their patients, Dr. MacMartin said. “Hospitalists are available” and are physically present at least once a day, so there is a pragmatic advantage. Also, some data suggest that patients may feel more comfortable having ACP conversations with a hospitalist than with a primary care provider with whom they have a long-standing relationship, Dr. MacMartin added.

Another important advantage of ACP in the hospital setting is that, “as hospitalists, you are the expert on inpatient illness; you know what sick looks like, and you have a unique perspective on prognostication that may be harder to recreate in the outpatient setting,” Dr. MacMartin said.
 

Barriers to ACP include patient identification, logistics, attitudes

Settings in which ACP is appropriate include those in which a patient is undergoing “sentinel hospitalization,” meaning that the patient is at a transition point in the disease course. Examples are a patient newly diagnosed with metastatic solid cancer, a patient with progressive chronic kidney disease who is considering hemodialysis, or a patient who receives treatment in the ICU for longer than 7 days, Dr. MacMartin said.

Guidelines for identifying patients who might benefit from ACP include the use of the “surprise question” (“would you be surprised if this patient dies in the next year?”) as well as functional status assessments using tools such as the Australia-modified Karnofsky Performance Status or the Eastern Cooperative Oncology Group score, said Dr. MacMartin. Some studies suggest that any hospitalized patient older than 65 years should have an ACP discussion, she added.

Time pressure remains a significant barrier to ACP conversations. Some strategies to overcome this problem include enlisting help from other specialists, particularly social workers, Dr. MacMartin said. Social workers report a higher comfort level for talking to patients about death than any other medical specialty; “this is something they want to be doing,” she said. Also, the possibility of reimbursement may act as a buffer to create more time to have ACP conversations with patients, she noted.

Addressing clinicians’ discomfort with ACP conversations can be “a tougher nut to crack,” Dr. MacMartin acknowledged. Clinicians report that they don’t want to cause their patients distress, and some report that having conversations about end-of-life care is distressing for them as well. Some of these barriers can be overcome with skills training, including use of a prepared guideline or framework to help increase the comfort level for both clinicians and patients, said Dr. MacMartin.
 

A look ahead: Training strategies and COVID-19 impact

“For hospitalists interested in developing their ACP skills, I highly recommend two resources,” Dr. MacMartin said in an interview. “The Serious Illness Conversation Guide, from Ariadne Labs, is an excellent tool for any clinician to guide discussion about a patient’s goals and values,” she said.

“For clinicians wanting to build or improve their communication, including advance care planning discussions but also topics like responding to patient’s emotions, VitalTalk training offers a deeper dive into core communications skills,” she added.

“If your hospital has a palliative care team, they may also have more local resources available to you. To learn more about billing for ACP discussions, I recommend starting with your institutional billing and coding group, as these practices vary some between practices, and they will be able to provide the best guidance for clinicians. These are new codes that aren’t yet being very widely used so it’s a chance to innovate,” Dr. MacMartin noted.

“The hospital setting is an opportunity for patients to reflect on their health, both present and in the future, with a physician who has expertise in acute illness and prognostication and who is available for discussion on a daily basis during the hospitalization,” Dr. MacMartin emphasized.

As for whether the COVID-19 pandemic has affected ACP in the inpatient setting, the data are limited, but more information is forthcoming, Dr. MacMartin said. “In my personal experience and in talking to colleagues elsewhere, the pandemic has highlighted the need for ACP in some ways, as we have tried to ensure that people who wouldn’t want things like intensive care are identified early,” she said. “I hope that some of the workflows developed to identify patients who should get ACP in the hospital stay in practice and are strengthened over time,” she added.

Dr. MacMartin has disclosed no relevant financial relationships.
 

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

Botulinum toxin is said to be the most lethal substance known. Inhaling just 1-3 nanograms of toxin per kilogram of body mass constitutes a lethal dose. 

Now the Centers for Disease Control and Prevention has published the first comprehensive guide to the diagnosis and treatment of botulism. The CDC has been working on these guidelines since 2015, initially establishing a technical development group and steering committee to prioritize topics for review and make recommendations. Since then, the agency published 15 systematic reviews in  Clinical Infectious Diseases early in 2018. The reviews addressed the recognition of botulism clinically, treatment with botulinum antitoxin, and complications from that treatment. They also looked at the epidemiology of botulism outbreaks and botulism in the special populations of vulnerable pediatric and pregnant patients.

In 2016, the CDC held two extended forums and convened a workshop with 72 experts. In addition to the more standard topics of diagnosis and treatment, attention was given to crisis standards of care, caring for multiple patients at once, and ethical considerations in management.

Amesh Adalja, MD, senior scholar, Johns Hopkins Center for Health Security, Baltimore, said in an interview that the new guidance “was really specific [and] was meant to address the gap in guidance for mass casualty settings.”

While clinicians are used to focusing on an individual patient, in times of crises, with multiple patients from a food-borne outbreak or a bioterrorism attack, the focus must shift to the population rather than the individual. The workshop explored issues of triaging, adding beds, and caring for patients when a hospital is overwhelmed with an acute influx of severely ill patients.

Such a mass casualty event is similar to the stress encountered this past year with COVID-19 patients swamping the hospitals, which had too little oxygen, too few ventilators, and too few staff members to care for the sudden influx of critically ill patients.
 

Diagnosis

Leslie Edwards, MHS, BSN, a CDC epidemiologist and botulism expert, said that “botulism is rare and [so] could be difficult to diagnose.” The CDC “wanted to highlight some of those key clinical factors” to speed recognition.

Hospitals and health officials are being urged to develop crisis protocols as part of emergency preparedness plans. And clinicians should be able to recognize four major syndromes: botulism from food, wounds, and inhalation, as well as iatrogenic botulism (from exposure via injection of the neurotoxin).

Botulism has a characteristic and unusual pattern of symptoms, which begin with cranial nerve palsies. Then there is typically a descending, symmetric flaccid paralysis. Symptoms might progress to respiratory failure and death. Other critical clues that implicate botulism include a lack of sensory deficits and the absence of pain.

Symptoms are most likely to be mistaken for myasthenia gravis or Guillain-Barré syndrome, but the latter has an ascending paralysis. Cranial nerve involvement can present as blurred vision, ptosis (drooping lid), diplopia (double vision), ophthalmoplegia (weak eye muscles), or difficulty with speech and swallowing. Shortness of breath and abdominal discomfort can also occur. Respiratory failure may occur from weakness or paralysis of cranial nerves. Cranial nerve signs and symptoms in the absence of fever, along with a descending paralysis, should strongly suggest the diagnosis.

With food-borne botulism, vomiting occurs in half the patients. Improperly sterilized home-canned food is the major risk factor. While the toxin is rapidly destroyed by heat, the bacterial spores are not. Wound botulism is most commonly associated with the injection of drugs, particularly black tar heroin.

Dr. Edwards stressed that “time is of the essence when it comes to botulism diagnostics and treating. Timely administration of the botulism antitoxin early in the course of illness can arrest the progression of paralysis and possibly avert the need for intubation or ventilation.”

It’s essential to note that botulism is an urgent diagnosis that has to be made on clinical grounds. Lab assays for botulinum neurotoxins take too long and are only conducted in public health laboratories. The decision to use antitoxin must not be delayed to wait for confirmation.

Clinicians should immediately contact the local or state health department’s emergency on-call team if botulism is suspected. They will arrange for expert consultation.
 

Treatment

Botulinum antitoxin is the only specific therapy for this infection. If given early – preferably within 24-48 hours of symptom onset – it can stop the progression of paralysis. But antitoxin will not reverse existing paralysis. If paralysis is still progressing outside of that 24- to 48-hour window, the antitoxin should still provide benefit. The antitoxin is available only through state health departments and a request to the CDC.

Botulism antitoxin is made from horse serum and therefore may cause a variety of allergic reactions. The risk for anaphylaxis is less than 2%, far lower than the mortality from untreated botulism.

While these guidelines have an important focus on triaging and treating mass casualties from botulism, it’s important to note that food-borne outbreaks and prevention issues are covered elsewhere on the CDC site.

Dr. Edwards has disclosed no relevant financial relationships. Dr. Adalja is a consultant for Emergent BioSolutions, which makes the heptavalent botulism antitoxin.

Dr. Stone is an infectious disease specialist and author of “Resilience: One Family’s Story of Hope and Triumph Over Evil” and of “Conducting Clinical Research,” the essential guide to the topic. You can find her at drjudystone.com or on Twitter @drjudystone.

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

Botulinum toxin is said to be the most lethal substance known. Inhaling just 1-3 nanograms of toxin per kilogram of body mass constitutes a lethal dose. 

Now the Centers for Disease Control and Prevention has published the first comprehensive guide to the diagnosis and treatment of botulism. The CDC has been working on these guidelines since 2015, initially establishing a technical development group and steering committee to prioritize topics for review and make recommendations. Since then, the agency published 15 systematic reviews in  Clinical Infectious Diseases early in 2018. The reviews addressed the recognition of botulism clinically, treatment with botulinum antitoxin, and complications from that treatment. They also looked at the epidemiology of botulism outbreaks and botulism in the special populations of vulnerable pediatric and pregnant patients.

In 2016, the CDC held two extended forums and convened a workshop with 72 experts. In addition to the more standard topics of diagnosis and treatment, attention was given to crisis standards of care, caring for multiple patients at once, and ethical considerations in management.

Amesh Adalja, MD, senior scholar, Johns Hopkins Center for Health Security, Baltimore, said in an interview that the new guidance “was really specific [and] was meant to address the gap in guidance for mass casualty settings.”

While clinicians are used to focusing on an individual patient, in times of crises, with multiple patients from a food-borne outbreak or a bioterrorism attack, the focus must shift to the population rather than the individual. The workshop explored issues of triaging, adding beds, and caring for patients when a hospital is overwhelmed with an acute influx of severely ill patients.

Such a mass casualty event is similar to the stress encountered this past year with COVID-19 patients swamping the hospitals, which had too little oxygen, too few ventilators, and too few staff members to care for the sudden influx of critically ill patients.
 

Diagnosis

Leslie Edwards, MHS, BSN, a CDC epidemiologist and botulism expert, said that “botulism is rare and [so] could be difficult to diagnose.” The CDC “wanted to highlight some of those key clinical factors” to speed recognition.

Hospitals and health officials are being urged to develop crisis protocols as part of emergency preparedness plans. And clinicians should be able to recognize four major syndromes: botulism from food, wounds, and inhalation, as well as iatrogenic botulism (from exposure via injection of the neurotoxin).

Botulism has a characteristic and unusual pattern of symptoms, which begin with cranial nerve palsies. Then there is typically a descending, symmetric flaccid paralysis. Symptoms might progress to respiratory failure and death. Other critical clues that implicate botulism include a lack of sensory deficits and the absence of pain.

Symptoms are most likely to be mistaken for myasthenia gravis or Guillain-Barré syndrome, but the latter has an ascending paralysis. Cranial nerve involvement can present as blurred vision, ptosis (drooping lid), diplopia (double vision), ophthalmoplegia (weak eye muscles), or difficulty with speech and swallowing. Shortness of breath and abdominal discomfort can also occur. Respiratory failure may occur from weakness or paralysis of cranial nerves. Cranial nerve signs and symptoms in the absence of fever, along with a descending paralysis, should strongly suggest the diagnosis.

With food-borne botulism, vomiting occurs in half the patients. Improperly sterilized home-canned food is the major risk factor. While the toxin is rapidly destroyed by heat, the bacterial spores are not. Wound botulism is most commonly associated with the injection of drugs, particularly black tar heroin.

Dr. Edwards stressed that “time is of the essence when it comes to botulism diagnostics and treating. Timely administration of the botulism antitoxin early in the course of illness can arrest the progression of paralysis and possibly avert the need for intubation or ventilation.”

It’s essential to note that botulism is an urgent diagnosis that has to be made on clinical grounds. Lab assays for botulinum neurotoxins take too long and are only conducted in public health laboratories. The decision to use antitoxin must not be delayed to wait for confirmation.

Clinicians should immediately contact the local or state health department’s emergency on-call team if botulism is suspected. They will arrange for expert consultation.
 

Treatment

Botulinum antitoxin is the only specific therapy for this infection. If given early – preferably within 24-48 hours of symptom onset – it can stop the progression of paralysis. But antitoxin will not reverse existing paralysis. If paralysis is still progressing outside of that 24- to 48-hour window, the antitoxin should still provide benefit. The antitoxin is available only through state health departments and a request to the CDC.

Botulism antitoxin is made from horse serum and therefore may cause a variety of allergic reactions. The risk for anaphylaxis is less than 2%, far lower than the mortality from untreated botulism.

While these guidelines have an important focus on triaging and treating mass casualties from botulism, it’s important to note that food-borne outbreaks and prevention issues are covered elsewhere on the CDC site.

Dr. Edwards has disclosed no relevant financial relationships. Dr. Adalja is a consultant for Emergent BioSolutions, which makes the heptavalent botulism antitoxin.

Dr. Stone is an infectious disease specialist and author of “Resilience: One Family’s Story of Hope and Triumph Over Evil” and of “Conducting Clinical Research,” the essential guide to the topic. You can find her at drjudystone.com or on Twitter @drjudystone.

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

Botulinum toxin is said to be the most lethal substance known. Inhaling just 1-3 nanograms of toxin per kilogram of body mass constitutes a lethal dose. 

Now the Centers for Disease Control and Prevention has published the first comprehensive guide to the diagnosis and treatment of botulism. The CDC has been working on these guidelines since 2015, initially establishing a technical development group and steering committee to prioritize topics for review and make recommendations. Since then, the agency published 15 systematic reviews in  Clinical Infectious Diseases early in 2018. The reviews addressed the recognition of botulism clinically, treatment with botulinum antitoxin, and complications from that treatment. They also looked at the epidemiology of botulism outbreaks and botulism in the special populations of vulnerable pediatric and pregnant patients.

In 2016, the CDC held two extended forums and convened a workshop with 72 experts. In addition to the more standard topics of diagnosis and treatment, attention was given to crisis standards of care, caring for multiple patients at once, and ethical considerations in management.

Amesh Adalja, MD, senior scholar, Johns Hopkins Center for Health Security, Baltimore, said in an interview that the new guidance “was really specific [and] was meant to address the gap in guidance for mass casualty settings.”

While clinicians are used to focusing on an individual patient, in times of crises, with multiple patients from a food-borne outbreak or a bioterrorism attack, the focus must shift to the population rather than the individual. The workshop explored issues of triaging, adding beds, and caring for patients when a hospital is overwhelmed with an acute influx of severely ill patients.

Such a mass casualty event is similar to the stress encountered this past year with COVID-19 patients swamping the hospitals, which had too little oxygen, too few ventilators, and too few staff members to care for the sudden influx of critically ill patients.
 

Diagnosis

Leslie Edwards, MHS, BSN, a CDC epidemiologist and botulism expert, said that “botulism is rare and [so] could be difficult to diagnose.” The CDC “wanted to highlight some of those key clinical factors” to speed recognition.

Hospitals and health officials are being urged to develop crisis protocols as part of emergency preparedness plans. And clinicians should be able to recognize four major syndromes: botulism from food, wounds, and inhalation, as well as iatrogenic botulism (from exposure via injection of the neurotoxin).

Botulism has a characteristic and unusual pattern of symptoms, which begin with cranial nerve palsies. Then there is typically a descending, symmetric flaccid paralysis. Symptoms might progress to respiratory failure and death. Other critical clues that implicate botulism include a lack of sensory deficits and the absence of pain.

Symptoms are most likely to be mistaken for myasthenia gravis or Guillain-Barré syndrome, but the latter has an ascending paralysis. Cranial nerve involvement can present as blurred vision, ptosis (drooping lid), diplopia (double vision), ophthalmoplegia (weak eye muscles), or difficulty with speech and swallowing. Shortness of breath and abdominal discomfort can also occur. Respiratory failure may occur from weakness or paralysis of cranial nerves. Cranial nerve signs and symptoms in the absence of fever, along with a descending paralysis, should strongly suggest the diagnosis.

With food-borne botulism, vomiting occurs in half the patients. Improperly sterilized home-canned food is the major risk factor. While the toxin is rapidly destroyed by heat, the bacterial spores are not. Wound botulism is most commonly associated with the injection of drugs, particularly black tar heroin.

Dr. Edwards stressed that “time is of the essence when it comes to botulism diagnostics and treating. Timely administration of the botulism antitoxin early in the course of illness can arrest the progression of paralysis and possibly avert the need for intubation or ventilation.”

It’s essential to note that botulism is an urgent diagnosis that has to be made on clinical grounds. Lab assays for botulinum neurotoxins take too long and are only conducted in public health laboratories. The decision to use antitoxin must not be delayed to wait for confirmation.

Clinicians should immediately contact the local or state health department’s emergency on-call team if botulism is suspected. They will arrange for expert consultation.
 

Treatment

Botulinum antitoxin is the only specific therapy for this infection. If given early – preferably within 24-48 hours of symptom onset – it can stop the progression of paralysis. But antitoxin will not reverse existing paralysis. If paralysis is still progressing outside of that 24- to 48-hour window, the antitoxin should still provide benefit. The antitoxin is available only through state health departments and a request to the CDC.

Botulism antitoxin is made from horse serum and therefore may cause a variety of allergic reactions. The risk for anaphylaxis is less than 2%, far lower than the mortality from untreated botulism.

While these guidelines have an important focus on triaging and treating mass casualties from botulism, it’s important to note that food-borne outbreaks and prevention issues are covered elsewhere on the CDC site.

Dr. Edwards has disclosed no relevant financial relationships. Dr. Adalja is a consultant for Emergent BioSolutions, which makes the heptavalent botulism antitoxin.

Dr. Stone is an infectious disease specialist and author of “Resilience: One Family’s Story of Hope and Triumph Over Evil” and of “Conducting Clinical Research,” the essential guide to the topic. You can find her at drjudystone.com or on Twitter @drjudystone.

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

A “smart toilet” in development uses artificial intelligence (AI) to scan stool for consistency and presence of blood – and early evidence suggests it is more accurate than patient self-reporting, a study reveals.

The remote, automated, real-time analysis and reporting increase the likelihood of physicians detecting gastrointestinal issues earlier, investigators reported.

In a proof-of-concept study, the smart toilet was 85% accurate in categorizing stool consistency as loose, normal, or constipated. The findings were presented at the annual Digestive Disease Week® (DDW).

“This study highlights a very innovative and practical tool that could have major implications for patients and clinicians alike,” Andrea Shin, MD, who was not affiliated with the research, said in an interview.

“Stool form or consistency and signs of bleeding are some of the most important pieces of clinical history when it comes to GI or bowel symptoms,” added Dr. Shin, assistant professor of medicine in the department of gastroenterology and hepatology at Indiana University, Indianapolis.
 

Image analysis

The researchers tested their AI algorithm on 3,328 images. They assessed photos from the Internet and some submitted anonymously by participants in the study.

Two gastroenterologists also rated a subset of 552 images. The physicians showed “satisfactory agreement” on interrater reliability (the extent to which two or more “raters” [for example, observers, examiners] agree), the investigators noted.

The smart toilet also was 76% accurate for gross blood detection.

“It’s objective and more accurate,” study author Sonia Grego, PhD, said in an interview. In contrast to asking patients to keep a bowel movement diary or recall the frequency and consistency of their stool over time, “the system does it for you,” she added.

“Our technology – by automating the image acquisition – removes the burden of having to track your pattern for weeks or months,” added Dr. Grego, founding director of the Duke Smart Toilet Lab at Duke University in Durham, N.C.

Information provided by patients “can have a big impact on decision-making,” Dr. Shin said. “For example, if I am talking to an individual who suffers from irritable bowel syndrome [IBS], I commonly ask them about how loose or watery and hard or formed their stool is, because this information gives me clues as to the underlying problems that may be driving their symptoms.”

Dr. Shin agreed it can be challenging for people to know what is important to report to their doctor. “This tool has the potential to relieve patient burden and facilitate communication between a patient and their clinician. It’s a great example of how technology can be leveraged to enhance care.”
 

Working behind the scenes

Together with gastroenterologist Deborah Anne Fisher, MD, an associate professor of medicine at Duke, Dr. Grego and colleagues devised a prototype that positions the image analyzer in the pipes behind the toilet. So the analysis is done post flush.

“We are experts of toilets and toilet technology,” Dr. Grego said. “We have learned that people really don’t like to see anything weird around the toilet bowl.”

The smart toilet system is designed for multiple users in a residential or commercial setting. The technology could be used in hospitals or long-term care facilities, for example. A fingerprint scanner on the flush mechanism tracks each individual user.
 

Mixed reactions

Dr. Grego gets a range of reactions when she tells people she is developing smart toilet technology.

“Friends and family laugh about the concept of the smart toilet,” she said, “so all the possible jokes that have been done on poops, we know.”

In fact, the researchers also are collecting the jokes they hear. “We’re being very systematic.”

In contrast, gastroenterologists who learn of the technology in development are more enthusiastic, Dr. Grego said. “There is such a need for removing the uncertainty of the patient recall about bowel movement frequency and appearance.

“We are seeking to expand through collaboration with additional GI doctors. We want to develop a more advanced prototype and do further validation studies,” Dr. Grego said.
 

Digital health tool

There is an aversion among patients to handling stool “or even talking about it,” Dr. Grego said. Colleagues tell her that people are more willing to provide a blood sample, which requires a needle, than a stool sample.

“But a lot of health data is there [in the stool],” she added. “We think this will empower a lot of research as well as consumer data gathering.”

For example, Dr. Grego envisions pharmaceutical companies using the technology to detect or monitor any changes in stool or gut health based on a treatment in development during clinical trials.

Furthermore, the technology might empower health-conscious consumers who want to track their own gut health. “This technology will be a whole new entry in the digital health toolkit,” Dr. Grego said.

Although not included in the research presented at this year’s DDW, the developers plan to add a sampling capability. Biochemic analysis of stool samples could provide “metabolically relevant information,” including stool biomarkers and microbiome composition.

“We have demonstrated it in the laboratory. It will be part of the technology when developed into a product,” Dr. Grego said.

This proof-of-concept study “is the first step in a path we are aggressively pursuing,” Dr. Grego said. She estimated it will take about 12-18 months to develop a prototype for use with patients. “We hope to move to a product soon after that.”

“I’m looking forward to seeing future iterations of this tool,” Dr. Shin said. “It could have a role in monitoring important GI diseases and disorders, including IBS and inflammatory bowel disease, or even for the detection of ‘alarm symptoms’ that shouldn’t be ignored.

“I could even see it having a role in preventative health in the future,” Dr. Shin added. 

The technology has been licensed to the spin-off company Coprata to develop the product further.

“We hope to have an impact on people’s health very soon,” Dr. Grego said.  

Duke University funded the study. Dr. Grego holds a management position at Coprata. Dr. Shin disclosed no relevant financial relationships.

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

A “smart toilet” in development uses artificial intelligence (AI) to scan stool for consistency and presence of blood – and early evidence suggests it is more accurate than patient self-reporting, a study reveals.

The remote, automated, real-time analysis and reporting increase the likelihood of physicians detecting gastrointestinal issues earlier, investigators reported.

In a proof-of-concept study, the smart toilet was 85% accurate in categorizing stool consistency as loose, normal, or constipated. The findings were presented at the annual Digestive Disease Week® (DDW).

“This study highlights a very innovative and practical tool that could have major implications for patients and clinicians alike,” Andrea Shin, MD, who was not affiliated with the research, said in an interview.

“Stool form or consistency and signs of bleeding are some of the most important pieces of clinical history when it comes to GI or bowel symptoms,” added Dr. Shin, assistant professor of medicine in the department of gastroenterology and hepatology at Indiana University, Indianapolis.
 

Image analysis

The researchers tested their AI algorithm on 3,328 images. They assessed photos from the Internet and some submitted anonymously by participants in the study.

Two gastroenterologists also rated a subset of 552 images. The physicians showed “satisfactory agreement” on interrater reliability (the extent to which two or more “raters” [for example, observers, examiners] agree), the investigators noted.

The smart toilet also was 76% accurate for gross blood detection.

“It’s objective and more accurate,” study author Sonia Grego, PhD, said in an interview. In contrast to asking patients to keep a bowel movement diary or recall the frequency and consistency of their stool over time, “the system does it for you,” she added.

“Our technology – by automating the image acquisition – removes the burden of having to track your pattern for weeks or months,” added Dr. Grego, founding director of the Duke Smart Toilet Lab at Duke University in Durham, N.C.

Information provided by patients “can have a big impact on decision-making,” Dr. Shin said. “For example, if I am talking to an individual who suffers from irritable bowel syndrome [IBS], I commonly ask them about how loose or watery and hard or formed their stool is, because this information gives me clues as to the underlying problems that may be driving their symptoms.”

Dr. Shin agreed it can be challenging for people to know what is important to report to their doctor. “This tool has the potential to relieve patient burden and facilitate communication between a patient and their clinician. It’s a great example of how technology can be leveraged to enhance care.”
 

Working behind the scenes

Together with gastroenterologist Deborah Anne Fisher, MD, an associate professor of medicine at Duke, Dr. Grego and colleagues devised a prototype that positions the image analyzer in the pipes behind the toilet. So the analysis is done post flush.

“We are experts of toilets and toilet technology,” Dr. Grego said. “We have learned that people really don’t like to see anything weird around the toilet bowl.”

The smart toilet system is designed for multiple users in a residential or commercial setting. The technology could be used in hospitals or long-term care facilities, for example. A fingerprint scanner on the flush mechanism tracks each individual user.
 

Mixed reactions

Dr. Grego gets a range of reactions when she tells people she is developing smart toilet technology.

“Friends and family laugh about the concept of the smart toilet,” she said, “so all the possible jokes that have been done on poops, we know.”

In fact, the researchers also are collecting the jokes they hear. “We’re being very systematic.”

In contrast, gastroenterologists who learn of the technology in development are more enthusiastic, Dr. Grego said. “There is such a need for removing the uncertainty of the patient recall about bowel movement frequency and appearance.

“We are seeking to expand through collaboration with additional GI doctors. We want to develop a more advanced prototype and do further validation studies,” Dr. Grego said.
 

Digital health tool

There is an aversion among patients to handling stool “or even talking about it,” Dr. Grego said. Colleagues tell her that people are more willing to provide a blood sample, which requires a needle, than a stool sample.

“But a lot of health data is there [in the stool],” she added. “We think this will empower a lot of research as well as consumer data gathering.”

For example, Dr. Grego envisions pharmaceutical companies using the technology to detect or monitor any changes in stool or gut health based on a treatment in development during clinical trials.

Furthermore, the technology might empower health-conscious consumers who want to track their own gut health. “This technology will be a whole new entry in the digital health toolkit,” Dr. Grego said.

Although not included in the research presented at this year’s DDW, the developers plan to add a sampling capability. Biochemic analysis of stool samples could provide “metabolically relevant information,” including stool biomarkers and microbiome composition.

“We have demonstrated it in the laboratory. It will be part of the technology when developed into a product,” Dr. Grego said.

This proof-of-concept study “is the first step in a path we are aggressively pursuing,” Dr. Grego said. She estimated it will take about 12-18 months to develop a prototype for use with patients. “We hope to move to a product soon after that.”

“I’m looking forward to seeing future iterations of this tool,” Dr. Shin said. “It could have a role in monitoring important GI diseases and disorders, including IBS and inflammatory bowel disease, or even for the detection of ‘alarm symptoms’ that shouldn’t be ignored.

“I could even see it having a role in preventative health in the future,” Dr. Shin added. 

The technology has been licensed to the spin-off company Coprata to develop the product further.

“We hope to have an impact on people’s health very soon,” Dr. Grego said.  

Duke University funded the study. Dr. Grego holds a management position at Coprata. Dr. Shin disclosed no relevant financial relationships.

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

A “smart toilet” in development uses artificial intelligence (AI) to scan stool for consistency and presence of blood – and early evidence suggests it is more accurate than patient self-reporting, a study reveals.

The remote, automated, real-time analysis and reporting increase the likelihood of physicians detecting gastrointestinal issues earlier, investigators reported.

In a proof-of-concept study, the smart toilet was 85% accurate in categorizing stool consistency as loose, normal, or constipated. The findings were presented at the annual Digestive Disease Week® (DDW).

“This study highlights a very innovative and practical tool that could have major implications for patients and clinicians alike,” Andrea Shin, MD, who was not affiliated with the research, said in an interview.

“Stool form or consistency and signs of bleeding are some of the most important pieces of clinical history when it comes to GI or bowel symptoms,” added Dr. Shin, assistant professor of medicine in the department of gastroenterology and hepatology at Indiana University, Indianapolis.
 

Image analysis

The researchers tested their AI algorithm on 3,328 images. They assessed photos from the Internet and some submitted anonymously by participants in the study.

Two gastroenterologists also rated a subset of 552 images. The physicians showed “satisfactory agreement” on interrater reliability (the extent to which two or more “raters” [for example, observers, examiners] agree), the investigators noted.

The smart toilet also was 76% accurate for gross blood detection.

“It’s objective and more accurate,” study author Sonia Grego, PhD, said in an interview. In contrast to asking patients to keep a bowel movement diary or recall the frequency and consistency of their stool over time, “the system does it for you,” she added.

“Our technology – by automating the image acquisition – removes the burden of having to track your pattern for weeks or months,” added Dr. Grego, founding director of the Duke Smart Toilet Lab at Duke University in Durham, N.C.

Information provided by patients “can have a big impact on decision-making,” Dr. Shin said. “For example, if I am talking to an individual who suffers from irritable bowel syndrome [IBS], I commonly ask them about how loose or watery and hard or formed their stool is, because this information gives me clues as to the underlying problems that may be driving their symptoms.”

Dr. Shin agreed it can be challenging for people to know what is important to report to their doctor. “This tool has the potential to relieve patient burden and facilitate communication between a patient and their clinician. It’s a great example of how technology can be leveraged to enhance care.”
 

Working behind the scenes

Together with gastroenterologist Deborah Anne Fisher, MD, an associate professor of medicine at Duke, Dr. Grego and colleagues devised a prototype that positions the image analyzer in the pipes behind the toilet. So the analysis is done post flush.

“We are experts of toilets and toilet technology,” Dr. Grego said. “We have learned that people really don’t like to see anything weird around the toilet bowl.”

The smart toilet system is designed for multiple users in a residential or commercial setting. The technology could be used in hospitals or long-term care facilities, for example. A fingerprint scanner on the flush mechanism tracks each individual user.
 

Mixed reactions

Dr. Grego gets a range of reactions when she tells people she is developing smart toilet technology.

“Friends and family laugh about the concept of the smart toilet,” she said, “so all the possible jokes that have been done on poops, we know.”

In fact, the researchers also are collecting the jokes they hear. “We’re being very systematic.”

In contrast, gastroenterologists who learn of the technology in development are more enthusiastic, Dr. Grego said. “There is such a need for removing the uncertainty of the patient recall about bowel movement frequency and appearance.

“We are seeking to expand through collaboration with additional GI doctors. We want to develop a more advanced prototype and do further validation studies,” Dr. Grego said.
 

Digital health tool

There is an aversion among patients to handling stool “or even talking about it,” Dr. Grego said. Colleagues tell her that people are more willing to provide a blood sample, which requires a needle, than a stool sample.

“But a lot of health data is there [in the stool],” she added. “We think this will empower a lot of research as well as consumer data gathering.”

For example, Dr. Grego envisions pharmaceutical companies using the technology to detect or monitor any changes in stool or gut health based on a treatment in development during clinical trials.

Furthermore, the technology might empower health-conscious consumers who want to track their own gut health. “This technology will be a whole new entry in the digital health toolkit,” Dr. Grego said.

Although not included in the research presented at this year’s DDW, the developers plan to add a sampling capability. Biochemic analysis of stool samples could provide “metabolically relevant information,” including stool biomarkers and microbiome composition.

“We have demonstrated it in the laboratory. It will be part of the technology when developed into a product,” Dr. Grego said.

This proof-of-concept study “is the first step in a path we are aggressively pursuing,” Dr. Grego said. She estimated it will take about 12-18 months to develop a prototype for use with patients. “We hope to move to a product soon after that.”

“I’m looking forward to seeing future iterations of this tool,” Dr. Shin said. “It could have a role in monitoring important GI diseases and disorders, including IBS and inflammatory bowel disease, or even for the detection of ‘alarm symptoms’ that shouldn’t be ignored.

“I could even see it having a role in preventative health in the future,” Dr. Shin added. 

The technology has been licensed to the spin-off company Coprata to develop the product further.

“We hope to have an impact on people’s health very soon,” Dr. Grego said.  

Duke University funded the study. Dr. Grego holds a management position at Coprata. Dr. Shin disclosed no relevant financial relationships.

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

The Diagnosis: Cutaneous Cryptococcosis 

Histologic examination revealed infiltration of the dermis and subcutaneous tissue with rounded basophilic cells on low magnification (Figure 1A). On higher magnification, encapsulated yeast cells (cryptococci) of varying size accompanied by chronic granulomatous inflammatory infiltration with occasional giant cells were seen (Figure 1B). Alcian blue stain showed mucinous capsular material (Figure 1C). There was no history of diabetes mellitus, tuberculosis, steroid therapy, or immunosuppression. Moreover, systemic involvement or systemic focus of infection was ruled out after computed tomography of the head, chest, and abdomen. Therefore, the diagnosis of primary cutaneous cryptococcosis (PCC) was established. The patient was started on oral itraconazole 100 mg twice daily along with 5 drops of a saturated solution of potassium iodide 3 times daily that later was increased to 20 drops 3 times daily at a weekly interval. The lesions started improving after 1 month and healed completely after 9 months of treatment (Figure 2). 

Primary cutaneous cryptococcosis is the identification of Cryptococcus neoformans in a skin lesion without evidence of simultaneous disseminated disease. Neuville et al¹ observed that skin lesions resemble cellulitis, ulcerations, or whitlows and were located on unclothed areas. In contrast, lesions from disseminated disease presented as scattered umbilicated papules resembling molluscum contagiosum. Diagnosis of PCC is based on the observation of encapsulated yeasts by direct microscopic examination, isolation of C neoformans or Cryptococcus gattii in culture, and by the demonstration of capsular antigen in various fluids, including serum and cerebrospinal fluid by latex particle agglutination or enzyme-linked immunosorbent assay. Histologically, Cryptococcus species produce a proliferative inflammatory reaction in immunocompetent hosts with the formation of compact epithelioid granulomas, with giant cells and a peripheral layer of lymphocytes. Treatment options for PCC infection range from antifungal medications and surgical debridement to observation. 

The differential diagnosis may include cutaneous leishmaniasis, cutaneous tuberculosis, cutaneous histoplasmosis, and basal cell carcinoma. These entities may have similar presentations and can only be confidently differentiated on direct microscopy and histopathologic examination. The characteristic Leishmania donovani bodies on microscopy in cutaneous leishmaniasis and tubercular granuloma with central necrosis on histology in cutaneous tuberculosis can differentiate these conditions from cryptococcosis. In some patients with cryptococcosis, the yeast may produce a less characteristic polysaccharide capsule and thus may be confused with histoplasmosis. Fontana-Masson staining may show melanin-producing yeast, which is characteristic of cryptococci.² Ulcerated basal cell carcinoma may present similar clinically; however, histopathology will rule it out. 

Cutaneous cryptococcal infection should be presumed to be disseminated until proven otherwise, and a search for other sites of involvement must immediately be undertaken. Cutaneous signs may be the first indication of infection, preceding the diagnosis of disseminated disease by 2 to 8 months, making its recognition crucial to early treatment. It is not possible to diagnose PCC on a specific clinical manifestation because a diverse range of skin lesions may be present. Therefore, culture and histology are the gold standards for diagnosis of cryptococcosis. 

The Diagnosis: Cutaneous Cryptococcosis 

Histologic examination revealed infiltration of the dermis and subcutaneous tissue with rounded basophilic cells on low magnification (Figure 1A). On higher magnification, encapsulated yeast cells (cryptococci) of varying size accompanied by chronic granulomatous inflammatory infiltration with occasional giant cells were seen (Figure 1B). Alcian blue stain showed mucinous capsular material (Figure 1C). There was no history of diabetes mellitus, tuberculosis, steroid therapy, or immunosuppression. Moreover, systemic involvement or systemic focus of infection was ruled out after computed tomography of the head, chest, and abdomen. Therefore, the diagnosis of primary cutaneous cryptococcosis (PCC) was established. The patient was started on oral itraconazole 100 mg twice daily along with 5 drops of a saturated solution of potassium iodide 3 times daily that later was increased to 20 drops 3 times daily at a weekly interval. The lesions started improving after 1 month and healed completely after 9 months of treatment (Figure 2). 

Primary cutaneous cryptococcosis is the identification of Cryptococcus neoformans in a skin lesion without evidence of simultaneous disseminated disease. Neuville et al¹ observed that skin lesions resemble cellulitis, ulcerations, or whitlows and were located on unclothed areas. In contrast, lesions from disseminated disease presented as scattered umbilicated papules resembling molluscum contagiosum. Diagnosis of PCC is based on the observation of encapsulated yeasts by direct microscopic examination, isolation of C neoformans or Cryptococcus gattii in culture, and by the demonstration of capsular antigen in various fluids, including serum and cerebrospinal fluid by latex particle agglutination or enzyme-linked immunosorbent assay. Histologically, Cryptococcus species produce a proliferative inflammatory reaction in immunocompetent hosts with the formation of compact epithelioid granulomas, with giant cells and a peripheral layer of lymphocytes. Treatment options for PCC infection range from antifungal medications and surgical debridement to observation. 

The differential diagnosis may include cutaneous leishmaniasis, cutaneous tuberculosis, cutaneous histoplasmosis, and basal cell carcinoma. These entities may have similar presentations and can only be confidently differentiated on direct microscopy and histopathologic examination. The characteristic Leishmania donovani bodies on microscopy in cutaneous leishmaniasis and tubercular granuloma with central necrosis on histology in cutaneous tuberculosis can differentiate these conditions from cryptococcosis. In some patients with cryptococcosis, the yeast may produce a less characteristic polysaccharide capsule and thus may be confused with histoplasmosis. Fontana-Masson staining may show melanin-producing yeast, which is characteristic of cryptococci.² Ulcerated basal cell carcinoma may present similar clinically; however, histopathology will rule it out. 

Cutaneous cryptococcal infection should be presumed to be disseminated until proven otherwise, and a search for other sites of involvement must immediately be undertaken. Cutaneous signs may be the first indication of infection, preceding the diagnosis of disseminated disease by 2 to 8 months, making its recognition crucial to early treatment. It is not possible to diagnose PCC on a specific clinical manifestation because a diverse range of skin lesions may be present. Therefore, culture and histology are the gold standards for diagnosis of cryptococcosis. 

The Diagnosis: Cutaneous Cryptococcosis 

Histologic examination revealed infiltration of the dermis and subcutaneous tissue with rounded basophilic cells on low magnification (Figure 1A). On higher magnification, encapsulated yeast cells (cryptococci) of varying size accompanied by chronic granulomatous inflammatory infiltration with occasional giant cells were seen (Figure 1B). Alcian blue stain showed mucinous capsular material (Figure 1C). There was no history of diabetes mellitus, tuberculosis, steroid therapy, or immunosuppression. Moreover, systemic involvement or systemic focus of infection was ruled out after computed tomography of the head, chest, and abdomen. Therefore, the diagnosis of primary cutaneous cryptococcosis (PCC) was established. The patient was started on oral itraconazole 100 mg twice daily along with 5 drops of a saturated solution of potassium iodide 3 times daily that later was increased to 20 drops 3 times daily at a weekly interval. The lesions started improving after 1 month and healed completely after 9 months of treatment (Figure 2). 

Primary cutaneous cryptococcosis is the identification of Cryptococcus neoformans in a skin lesion without evidence of simultaneous disseminated disease. Neuville et al¹ observed that skin lesions resemble cellulitis, ulcerations, or whitlows and were located on unclothed areas. In contrast, lesions from disseminated disease presented as scattered umbilicated papules resembling molluscum contagiosum. Diagnosis of PCC is based on the observation of encapsulated yeasts by direct microscopic examination, isolation of C neoformans or Cryptococcus gattii in culture, and by the demonstration of capsular antigen in various fluids, including serum and cerebrospinal fluid by latex particle agglutination or enzyme-linked immunosorbent assay. Histologically, Cryptococcus species produce a proliferative inflammatory reaction in immunocompetent hosts with the formation of compact epithelioid granulomas, with giant cells and a peripheral layer of lymphocytes. Treatment options for PCC infection range from antifungal medications and surgical debridement to observation. 

The differential diagnosis may include cutaneous leishmaniasis, cutaneous tuberculosis, cutaneous histoplasmosis, and basal cell carcinoma. These entities may have similar presentations and can only be confidently differentiated on direct microscopy and histopathologic examination. The characteristic Leishmania donovani bodies on microscopy in cutaneous leishmaniasis and tubercular granuloma with central necrosis on histology in cutaneous tuberculosis can differentiate these conditions from cryptococcosis. In some patients with cryptococcosis, the yeast may produce a less characteristic polysaccharide capsule and thus may be confused with histoplasmosis. Fontana-Masson staining may show melanin-producing yeast, which is characteristic of cryptococci.² Ulcerated basal cell carcinoma may present similar clinically; however, histopathology will rule it out. 

Cutaneous cryptococcal infection should be presumed to be disseminated until proven otherwise, and a search for other sites of involvement must immediately be undertaken. Cutaneous signs may be the first indication of infection, preceding the diagnosis of disseminated disease by 2 to 8 months, making its recognition crucial to early treatment. It is not possible to diagnose PCC on a specific clinical manifestation because a diverse range of skin lesions may be present. Therefore, culture and histology are the gold standards for diagnosis of cryptococcosis. 

The COVID-19 pandemic has been difficult for all hospitalists, especially those who are parents of young children. For hospitalist moms who are also immigrants working on temporary H1-B visas, this stress is exacerbated. Though each story is unique, the underlying themes are the same: Worries over visa renewals, the immigration process, family members back home, and the risk of illness, job loss, and deportation.

Supporting the family

Like all health care workers, Prasanna Palabindela, MD, a hospitalist at Jennie Stuart Health in Hopkinsville, Ky., has been worried about bringing COVID-19 home to her family, especially in the beginning. Her in-laws had just arrived from India for a visit in March 2020 when the pandemic began, everything was shut down, and her in-laws were forced to settle in for an unexpected months-long stay.

Along with her elderly in-laws, who also have chronic conditions, Dr. Palabindela had two small children to worry about – a then-5-month-old daughter and a 5-year-old son. “I was more worried about them than me,” she said. “I used to take showers before coming home and just do all precautions as much as I can. I’m glad that I did not bring COVID, so far, to the family.”

Once she could safely send her in-laws back to India, Dr. Palabindela began searching for a nanny. Daycare was out of the question because she didn’t want her children to be exposed to illness. After a long search, she found a nanny who could also help her son with virtual school. “It’s expensive, but still, my family and my family’s health is my priority,” she said.

Working on visas has caused multiple issues for Dr. Palabindela and her husband. After living in different states because of their jobs, her husband joined her in West Virginia for her residency and found a job there. When Dr. Palabindela took her current position, her husband had to quit his job in West Virginia and move with her to Kentucky for them to stay together. Unfortunately, he couldn’t find a good fit for work in Kentucky, so the couple decided to put him on her visa so they wouldn’t have to live apart.

Now Dr. Palabindela is the family’s sole breadwinner. “That means if something happens to me, I always worry what’s going to happen with my family because legally, my husband cannot work. Technically, everyone is deported back to home,” she said. Not being able to work is hard for her husband too. “It’s just so much stress in the family because he worked for 11 years,” said Dr. Palabindela.

Through all the upheavals, Dr. Palabindela has had support from all sides. Her husband has been the biggest source. “He’s my backbone. Every time, he supported me in each and every aspect,” she said. Her parents and her brothers check in on her constantly to make sure she’s staying safe. Even the chief at her hospital has played a significant role, going to bat for his physicians to ensure their safety.

Dr. Palabindela credits everyone who works with COVID-19 patients as heroes. “The nurses, the physicians, the housekeeping, respiratory therapist, speech therapist, physical therapy ... everybody has a role. Everybody is a hero,” she said. “Whoever is wearing a mask is a hero, too, because they are contributing to this community.”
 

Advocating for immigration reform

A lack of transparency and information in the beginning of the pandemic significantly contributed to anxiety, said Anuradha Amara, MD, MBBS, a hospitalist in Wilmington, Del. She felt that what was on the news and what was actually going on in the hospitals were quite different. Colleagues were getting sick, there wasn’t enough personal protective equipment, and planning went out the window. “It’s like a meteor hitting a place and then we start dealing with the aftermath, but we weren’t ready before,” Dr. Amara said. “We didn’t have a plan for a pandemic.”

Then there was the concern of either her or her husband, a cardiologist, getting sick and potentially losing their jobs and immigration status. “How am I going to go back to my country if I had to? What will happen to my family if I die? If I go on the ventilator? Those are the insecurities we found additional to the pandemic challenges we had,” Dr. Amara said.

Not being able to go see their family in India or have them come visit was difficult – “it was pretty bad up there,” said Dr. Amara. Fortunately, her family members in India remained safe, but there’s a very real uneasiness about returning should an emergency arise. “Should I go back and then take the risk of losing my job and losing my position and my kids are here, they’re going to school here. How do you decide that?” she asked.

One of the worst effects of her visa restrictions was not being able to help in New York when hospitals were so short-staffed, and the morgues were overflowing. “New York is 3 hours away from where I live, but I was in chains. I couldn’t help them because of these visa restrictions,” Dr. Amara said. During the emergency, the state allowed physicians from other states to practice without being licensed in New York, but immigrant physicians were not included. “Even if we wanted to, we couldn’t volunteer,” said Dr. Amara. “I have family in New York, and I was really worried. Out of compassion I wanted to help, but I couldn’t do anything.”

Before the pandemic, Dr. Amara joined in advocacy efforts for immigrant physicians through Physicians for American Healthcare Access (PAHA). “In uncertain times, like COVID, it gets worse that you’re challenged with everything on top of your health, your family, and you have to be worried about deportation,” she said. “We need to strengthen legislation. Nobody should suffer with immigration processes during an active pandemic or otherwise.”

In the United States, 28% of physicians are immigrants. Dr. Amara pointed out that these physicians go through years of expensive training with extensive background checks at every level, yet they’re classified as second preference (EB-2) workers. She believes that physicians as a group should be excluded from this category and allowed to automatically become citizens after 5 years of living in the United States and working in an underserved area.

There have been an estimated 15,000 unused green cards since 2005. And if Congress went back to 1992, there could be more than 220,000 previously unused green cards recaptured. These unused green cards are the basis behind bills H.R.2255 and S.1024, the Healthcare Workforce Resiliency Act, which has been championed by SHM and PAHA. “It will allow the frontline physicians, 15,000 of them, and 25,000 nurses, to obtain their permanent residency,” said Dr. Amara. “These are people who already applied for their permanent residencies and they’re still waiting.”

SHM has consistently advocated for the Act since it was first introduced, written multiple letters on the issue, and supported it both on and off Capitol Hill. The society says the legislation would be an “important first step toward addressing a critical shortage” in the U.S. health care system by “recognizing the vital role immigrant physicians and nurses are playing in the fight against COVID-19.”

Currently, SHM has a live action alert open for the reintroduced bill, and encourages members to contact their legislators and urge them to support the reintroduction of the Act by cosponsoring and working to pass the legislation

Dr. Amara encourages physicians to start engaging in advocacy efforts early. Though she didn’t begin participating until late in her career, she said being aware of and part of policies that affect medicine is important. If more physicians get involved, “there are so many things we can take care of,” said Dr. Amara. “The medical profession doesn’t have to be so difficult and so busy. There are ways we can make it better and I believe that. And obviously I’ll continue to work and advocate for the entire medical profession, their problems, their health and well-being, to prevent burnout.”
 

Making time for positivity and self-care

Sandhya Tagaram, MD, a hospitalist at UMass Memorial Medical Center in Worcester, Mass., and her husband, also a hospitalist physician, had only ever read about pandemics in books. They certainly never expected to be in the middle of one. “That was a totally different level of anxiety to work as frontline physicians with two kids under 5 years and families away back home in India,” she said.

UMass Memorial Medical Center

Dr. Tagaram and her husband work opposite shifts so that one of them is always home with their two young children. “Our schedules became more challenging when the pandemic started. Between both of our schedules and with minimal childcare facilities, we managed to strike a decent work-family balance, although we experience less vacation time together. We are fortunate to have an understanding work group,” said Dr. Tagaram.

Even before COVID-19, Dr. Tagaram found working on the temporary work visa challenging. “I think the pandemic has exposed the layer of uncertainty associated with it,” she said. “It’s incredibly stressful to imagine any minor turbulence that could alter our family and work lives. As a frontline physician mom, I take pride in raising my kids and taking care of my patients. We want to serve our communities and at the same time secure our families.”

Not being able to visit family back home and travel is exceedingly difficult. Dr. Tagaram said it would be helpful if there was a separate permanent residence pathway for physicians because they play a critical role in public health and they have been an integral part of the COVID-19 pandemic response team. A separate pathway could help keep their families secure and enable them to give their best to their communities.

Amid all the anxiety, Dr. Tagaram said she and her husband realized they could not keep living with so much pressure. As parents and as physicians, they did not want their stress to leak out and affect their ability and commitment to care for their children or their patients. They decided they needed to figure out how to be positive and constructive.

“We try some daily fun activities with the kids after returning home from work,” said Dr. Tagaram. They also formed a bubble group with two other physician families so the children could interact safely. She said that it’s critical that physicians take time for themselves. “We have to cultivate a serious hobby that helps to rejuvenate and calm our busy minds,” said Dr. Tagaram.

She makes time every day to exercise and to read at least a few pages from a good book. She is also learning Carnatic music along with one of her daughters. And every month since March 2020, she has journaled about her work and what she learned so her daughters can read it someday. “These things keep me jazzed up,” she said.

The pandemic has highlighted the fact that we are all part of one global community. “Although we hail from different backgrounds, we learned that we do have some common goals of being kind and supportive to each other and to give back to our communities. Hopefully we will continue this spirit,” said Dr. Tagaram. As a physician mother, “I feel it’s a privilege and honor to take care of my family and my community.”
 

Soldiering on in the COVID-19 war

The uncertainty everyone felt at the beginning of the pandemic was “very, very scary,” said Mamtha Balla, MD, MPH, a hospitalist and clinical assistant professor in northwest Ohio. “Initially, I was so involved in it and I felt like it was like a war, a COVID-19 war, and we are soldiers in that and trying to protect and do whatever we can.”

She and her husband, a geriatrician also working on an H-1B visa, have worked hard not to bring the virus home to their 2-year-old daughter. Going into 2021, the past 2 years have been “the most hectic and emotionally draining – and physically exhausting – years of my life,” said Dr. Balla.

The COVID-19 vaccine has helped reduce some pressure, but Dr. Balla is still concerned about the high risk to health care workers and the new COVID-19 strains coming out. “We are really not sure what we are dealing with and how the COVID will calm,” she said. “It is pretty challenging being a health care worker because not only are you responsible for your patients at the end of the day, but you are also responsible for your families.”

Initially in the United States from India on a student visa in 2008, Dr. Balla was placed on an H-1B visa when she started her residency. It was during this time that her mother was diagnosed with cancer and went through surgeries and chemotherapy. “She was pretty ill,” recalled Dr. Balla.

Despite the situation, Dr. Balla was afraid to go stay with her mother in case her visa application was rejected, and she couldn’t complete her third year of education. “I opted not to go to India at that time because I did not want to take a chance,” Dr. Balla said. “I have tears in my eyes because those are not easy moments, to withhold from seeing your parents, or to be in any other emergency where you cannot travel. That especially puts us at a higher risk emotionally and physically.”

She has not seen her parents in 2½ years. Between the very real possibility of not being able to get her visa stamp and the unpredictability of how other countries are dealing with COVID-19, Dr. Balla feels it is impossible to even think of going to visit. “Even if I go, what if something happens where my visa gets stuck, or the visa office is not open?” she said. If she could not get back to the United States as planned, she would have patients left behind here.

Recently, Dr. Balla did travel to India and her passport stamp did not come on time, so her husband had to come back to the United States by himself. She had to wait for her stamp for a couple more weeks before she could leave and, in the meantime, had to make arrangements at her hospital. “It is so much trauma,” she said.

There’s also the worry she has about getting sick or disabled and not being able to work anymore, resulting in deportation. “Is that what we are doing for people who are working like soldiers? Are we really treating them the correct way?” Dr. Balla asked.

Dr. Balla considers all health care workers to be soldiers in the COVID-19 war. As such, she believes the government should step up to make sure they are supporting and helping these immigrant physician-soldiers who are so necessary. She applauds France’s recent decision to grant citizenship to its frontline immigrant health care workers and feels that the same should be done in the United States. She filed her green card application in 2012, but she is nowhere close to getting it. (The backlog for employment-based green cards is more than 900,000 now.)

As people putting their own and their family’s lives at risk to care for patients with COVID-19, Dr. Balla and her husband have talked about moving to another country or even back to India. “I am a taxpayer; I am a good human being working for the community and for the job. This is my 13th year here. If I am not eligible [for citizenship] still, then I am not sure what else I have to do to prove myself,” she said. “I am owning United States citizens as my people, so please own us and help us out in this difficult scenario.”

The COVID-19 pandemic has been difficult for all hospitalists, especially those who are parents of young children. For hospitalist moms who are also immigrants working on temporary H1-B visas, this stress is exacerbated. Though each story is unique, the underlying themes are the same: Worries over visa renewals, the immigration process, family members back home, and the risk of illness, job loss, and deportation.

Supporting the family

Like all health care workers, Prasanna Palabindela, MD, a hospitalist at Jennie Stuart Health in Hopkinsville, Ky., has been worried about bringing COVID-19 home to her family, especially in the beginning. Her in-laws had just arrived from India for a visit in March 2020 when the pandemic began, everything was shut down, and her in-laws were forced to settle in for an unexpected months-long stay.

Along with her elderly in-laws, who also have chronic conditions, Dr. Palabindela had two small children to worry about – a then-5-month-old daughter and a 5-year-old son. “I was more worried about them than me,” she said. “I used to take showers before coming home and just do all precautions as much as I can. I’m glad that I did not bring COVID, so far, to the family.”

Once she could safely send her in-laws back to India, Dr. Palabindela began searching for a nanny. Daycare was out of the question because she didn’t want her children to be exposed to illness. After a long search, she found a nanny who could also help her son with virtual school. “It’s expensive, but still, my family and my family’s health is my priority,” she said.

Working on visas has caused multiple issues for Dr. Palabindela and her husband. After living in different states because of their jobs, her husband joined her in West Virginia for her residency and found a job there. When Dr. Palabindela took her current position, her husband had to quit his job in West Virginia and move with her to Kentucky for them to stay together. Unfortunately, he couldn’t find a good fit for work in Kentucky, so the couple decided to put him on her visa so they wouldn’t have to live apart.

Now Dr. Palabindela is the family’s sole breadwinner. “That means if something happens to me, I always worry what’s going to happen with my family because legally, my husband cannot work. Technically, everyone is deported back to home,” she said. Not being able to work is hard for her husband too. “It’s just so much stress in the family because he worked for 11 years,” said Dr. Palabindela.

Through all the upheavals, Dr. Palabindela has had support from all sides. Her husband has been the biggest source. “He’s my backbone. Every time, he supported me in each and every aspect,” she said. Her parents and her brothers check in on her constantly to make sure she’s staying safe. Even the chief at her hospital has played a significant role, going to bat for his physicians to ensure their safety.

Dr. Palabindela credits everyone who works with COVID-19 patients as heroes. “The nurses, the physicians, the housekeeping, respiratory therapist, speech therapist, physical therapy ... everybody has a role. Everybody is a hero,” she said. “Whoever is wearing a mask is a hero, too, because they are contributing to this community.”
 

Advocating for immigration reform

A lack of transparency and information in the beginning of the pandemic significantly contributed to anxiety, said Anuradha Amara, MD, MBBS, a hospitalist in Wilmington, Del. She felt that what was on the news and what was actually going on in the hospitals were quite different. Colleagues were getting sick, there wasn’t enough personal protective equipment, and planning went out the window. “It’s like a meteor hitting a place and then we start dealing with the aftermath, but we weren’t ready before,” Dr. Amara said. “We didn’t have a plan for a pandemic.”

Then there was the concern of either her or her husband, a cardiologist, getting sick and potentially losing their jobs and immigration status. “How am I going to go back to my country if I had to? What will happen to my family if I die? If I go on the ventilator? Those are the insecurities we found additional to the pandemic challenges we had,” Dr. Amara said.

Not being able to go see their family in India or have them come visit was difficult – “it was pretty bad up there,” said Dr. Amara. Fortunately, her family members in India remained safe, but there’s a very real uneasiness about returning should an emergency arise. “Should I go back and then take the risk of losing my job and losing my position and my kids are here, they’re going to school here. How do you decide that?” she asked.

One of the worst effects of her visa restrictions was not being able to help in New York when hospitals were so short-staffed, and the morgues were overflowing. “New York is 3 hours away from where I live, but I was in chains. I couldn’t help them because of these visa restrictions,” Dr. Amara said. During the emergency, the state allowed physicians from other states to practice without being licensed in New York, but immigrant physicians were not included. “Even if we wanted to, we couldn’t volunteer,” said Dr. Amara. “I have family in New York, and I was really worried. Out of compassion I wanted to help, but I couldn’t do anything.”

Before the pandemic, Dr. Amara joined in advocacy efforts for immigrant physicians through Physicians for American Healthcare Access (PAHA). “In uncertain times, like COVID, it gets worse that you’re challenged with everything on top of your health, your family, and you have to be worried about deportation,” she said. “We need to strengthen legislation. Nobody should suffer with immigration processes during an active pandemic or otherwise.”

In the United States, 28% of physicians are immigrants. Dr. Amara pointed out that these physicians go through years of expensive training with extensive background checks at every level, yet they’re classified as second preference (EB-2) workers. She believes that physicians as a group should be excluded from this category and allowed to automatically become citizens after 5 years of living in the United States and working in an underserved area.

There have been an estimated 15,000 unused green cards since 2005. And if Congress went back to 1992, there could be more than 220,000 previously unused green cards recaptured. These unused green cards are the basis behind bills H.R.2255 and S.1024, the Healthcare Workforce Resiliency Act, which has been championed by SHM and PAHA. “It will allow the frontline physicians, 15,000 of them, and 25,000 nurses, to obtain their permanent residency,” said Dr. Amara. “These are people who already applied for their permanent residencies and they’re still waiting.”

SHM has consistently advocated for the Act since it was first introduced, written multiple letters on the issue, and supported it both on and off Capitol Hill. The society says the legislation would be an “important first step toward addressing a critical shortage” in the U.S. health care system by “recognizing the vital role immigrant physicians and nurses are playing in the fight against COVID-19.”

Currently, SHM has a live action alert open for the reintroduced bill, and encourages members to contact their legislators and urge them to support the reintroduction of the Act by cosponsoring and working to pass the legislation

Dr. Amara encourages physicians to start engaging in advocacy efforts early. Though she didn’t begin participating until late in her career, she said being aware of and part of policies that affect medicine is important. If more physicians get involved, “there are so many things we can take care of,” said Dr. Amara. “The medical profession doesn’t have to be so difficult and so busy. There are ways we can make it better and I believe that. And obviously I’ll continue to work and advocate for the entire medical profession, their problems, their health and well-being, to prevent burnout.”
 

Making time for positivity and self-care

Sandhya Tagaram, MD, a hospitalist at UMass Memorial Medical Center in Worcester, Mass., and her husband, also a hospitalist physician, had only ever read about pandemics in books. They certainly never expected to be in the middle of one. “That was a totally different level of anxiety to work as frontline physicians with two kids under 5 years and families away back home in India,” she said.

UMass Memorial Medical Center

Dr. Tagaram and her husband work opposite shifts so that one of them is always home with their two young children. “Our schedules became more challenging when the pandemic started. Between both of our schedules and with minimal childcare facilities, we managed to strike a decent work-family balance, although we experience less vacation time together. We are fortunate to have an understanding work group,” said Dr. Tagaram.

Even before COVID-19, Dr. Tagaram found working on the temporary work visa challenging. “I think the pandemic has exposed the layer of uncertainty associated with it,” she said. “It’s incredibly stressful to imagine any minor turbulence that could alter our family and work lives. As a frontline physician mom, I take pride in raising my kids and taking care of my patients. We want to serve our communities and at the same time secure our families.”

Not being able to visit family back home and travel is exceedingly difficult. Dr. Tagaram said it would be helpful if there was a separate permanent residence pathway for physicians because they play a critical role in public health and they have been an integral part of the COVID-19 pandemic response team. A separate pathway could help keep their families secure and enable them to give their best to their communities.

Amid all the anxiety, Dr. Tagaram said she and her husband realized they could not keep living with so much pressure. As parents and as physicians, they did not want their stress to leak out and affect their ability and commitment to care for their children or their patients. They decided they needed to figure out how to be positive and constructive.

“We try some daily fun activities with the kids after returning home from work,” said Dr. Tagaram. They also formed a bubble group with two other physician families so the children could interact safely. She said that it’s critical that physicians take time for themselves. “We have to cultivate a serious hobby that helps to rejuvenate and calm our busy minds,” said Dr. Tagaram.

She makes time every day to exercise and to read at least a few pages from a good book. She is also learning Carnatic music along with one of her daughters. And every month since March 2020, she has journaled about her work and what she learned so her daughters can read it someday. “These things keep me jazzed up,” she said.

The pandemic has highlighted the fact that we are all part of one global community. “Although we hail from different backgrounds, we learned that we do have some common goals of being kind and supportive to each other and to give back to our communities. Hopefully we will continue this spirit,” said Dr. Tagaram. As a physician mother, “I feel it’s a privilege and honor to take care of my family and my community.”
 

Soldiering on in the COVID-19 war

The uncertainty everyone felt at the beginning of the pandemic was “very, very scary,” said Mamtha Balla, MD, MPH, a hospitalist and clinical assistant professor in northwest Ohio. “Initially, I was so involved in it and I felt like it was like a war, a COVID-19 war, and we are soldiers in that and trying to protect and do whatever we can.”

She and her husband, a geriatrician also working on an H-1B visa, have worked hard not to bring the virus home to their 2-year-old daughter. Going into 2021, the past 2 years have been “the most hectic and emotionally draining – and physically exhausting – years of my life,” said Dr. Balla.

The COVID-19 vaccine has helped reduce some pressure, but Dr. Balla is still concerned about the high risk to health care workers and the new COVID-19 strains coming out. “We are really not sure what we are dealing with and how the COVID will calm,” she said. “It is pretty challenging being a health care worker because not only are you responsible for your patients at the end of the day, but you are also responsible for your families.”

Initially in the United States from India on a student visa in 2008, Dr. Balla was placed on an H-1B visa when she started her residency. It was during this time that her mother was diagnosed with cancer and went through surgeries and chemotherapy. “She was pretty ill,” recalled Dr. Balla.

Despite the situation, Dr. Balla was afraid to go stay with her mother in case her visa application was rejected, and she couldn’t complete her third year of education. “I opted not to go to India at that time because I did not want to take a chance,” Dr. Balla said. “I have tears in my eyes because those are not easy moments, to withhold from seeing your parents, or to be in any other emergency where you cannot travel. That especially puts us at a higher risk emotionally and physically.”

She has not seen her parents in 2½ years. Between the very real possibility of not being able to get her visa stamp and the unpredictability of how other countries are dealing with COVID-19, Dr. Balla feels it is impossible to even think of going to visit. “Even if I go, what if something happens where my visa gets stuck, or the visa office is not open?” she said. If she could not get back to the United States as planned, she would have patients left behind here.

Recently, Dr. Balla did travel to India and her passport stamp did not come on time, so her husband had to come back to the United States by himself. She had to wait for her stamp for a couple more weeks before she could leave and, in the meantime, had to make arrangements at her hospital. “It is so much trauma,” she said.

There’s also the worry she has about getting sick or disabled and not being able to work anymore, resulting in deportation. “Is that what we are doing for people who are working like soldiers? Are we really treating them the correct way?” Dr. Balla asked.

Dr. Balla considers all health care workers to be soldiers in the COVID-19 war. As such, she believes the government should step up to make sure they are supporting and helping these immigrant physician-soldiers who are so necessary. She applauds France’s recent decision to grant citizenship to its frontline immigrant health care workers and feels that the same should be done in the United States. She filed her green card application in 2012, but she is nowhere close to getting it. (The backlog for employment-based green cards is more than 900,000 now.)

As people putting their own and their family’s lives at risk to care for patients with COVID-19, Dr. Balla and her husband have talked about moving to another country or even back to India. “I am a taxpayer; I am a good human being working for the community and for the job. This is my 13th year here. If I am not eligible [for citizenship] still, then I am not sure what else I have to do to prove myself,” she said. “I am owning United States citizens as my people, so please own us and help us out in this difficult scenario.”

The COVID-19 pandemic has been difficult for all hospitalists, especially those who are parents of young children. For hospitalist moms who are also immigrants working on temporary H1-B visas, this stress is exacerbated. Though each story is unique, the underlying themes are the same: Worries over visa renewals, the immigration process, family members back home, and the risk of illness, job loss, and deportation.

Supporting the family

Like all health care workers, Prasanna Palabindela, MD, a hospitalist at Jennie Stuart Health in Hopkinsville, Ky., has been worried about bringing COVID-19 home to her family, especially in the beginning. Her in-laws had just arrived from India for a visit in March 2020 when the pandemic began, everything was shut down, and her in-laws were forced to settle in for an unexpected months-long stay.

Along with her elderly in-laws, who also have chronic conditions, Dr. Palabindela had two small children to worry about – a then-5-month-old daughter and a 5-year-old son. “I was more worried about them than me,” she said. “I used to take showers before coming home and just do all precautions as much as I can. I’m glad that I did not bring COVID, so far, to the family.”

Once she could safely send her in-laws back to India, Dr. Palabindela began searching for a nanny. Daycare was out of the question because she didn’t want her children to be exposed to illness. After a long search, she found a nanny who could also help her son with virtual school. “It’s expensive, but still, my family and my family’s health is my priority,” she said.

Working on visas has caused multiple issues for Dr. Palabindela and her husband. After living in different states because of their jobs, her husband joined her in West Virginia for her residency and found a job there. When Dr. Palabindela took her current position, her husband had to quit his job in West Virginia and move with her to Kentucky for them to stay together. Unfortunately, he couldn’t find a good fit for work in Kentucky, so the couple decided to put him on her visa so they wouldn’t have to live apart.

Now Dr. Palabindela is the family’s sole breadwinner. “That means if something happens to me, I always worry what’s going to happen with my family because legally, my husband cannot work. Technically, everyone is deported back to home,” she said. Not being able to work is hard for her husband too. “It’s just so much stress in the family because he worked for 11 years,” said Dr. Palabindela.

Through all the upheavals, Dr. Palabindela has had support from all sides. Her husband has been the biggest source. “He’s my backbone. Every time, he supported me in each and every aspect,” she said. Her parents and her brothers check in on her constantly to make sure she’s staying safe. Even the chief at her hospital has played a significant role, going to bat for his physicians to ensure their safety.

Dr. Palabindela credits everyone who works with COVID-19 patients as heroes. “The nurses, the physicians, the housekeeping, respiratory therapist, speech therapist, physical therapy ... everybody has a role. Everybody is a hero,” she said. “Whoever is wearing a mask is a hero, too, because they are contributing to this community.”
 

Advocating for immigration reform

A lack of transparency and information in the beginning of the pandemic significantly contributed to anxiety, said Anuradha Amara, MD, MBBS, a hospitalist in Wilmington, Del. She felt that what was on the news and what was actually going on in the hospitals were quite different. Colleagues were getting sick, there wasn’t enough personal protective equipment, and planning went out the window. “It’s like a meteor hitting a place and then we start dealing with the aftermath, but we weren’t ready before,” Dr. Amara said. “We didn’t have a plan for a pandemic.”

Then there was the concern of either her or her husband, a cardiologist, getting sick and potentially losing their jobs and immigration status. “How am I going to go back to my country if I had to? What will happen to my family if I die? If I go on the ventilator? Those are the insecurities we found additional to the pandemic challenges we had,” Dr. Amara said.

Not being able to go see their family in India or have them come visit was difficult – “it was pretty bad up there,” said Dr. Amara. Fortunately, her family members in India remained safe, but there’s a very real uneasiness about returning should an emergency arise. “Should I go back and then take the risk of losing my job and losing my position and my kids are here, they’re going to school here. How do you decide that?” she asked.

One of the worst effects of her visa restrictions was not being able to help in New York when hospitals were so short-staffed, and the morgues were overflowing. “New York is 3 hours away from where I live, but I was in chains. I couldn’t help them because of these visa restrictions,” Dr. Amara said. During the emergency, the state allowed physicians from other states to practice without being licensed in New York, but immigrant physicians were not included. “Even if we wanted to, we couldn’t volunteer,” said Dr. Amara. “I have family in New York, and I was really worried. Out of compassion I wanted to help, but I couldn’t do anything.”

Before the pandemic, Dr. Amara joined in advocacy efforts for immigrant physicians through Physicians for American Healthcare Access (PAHA). “In uncertain times, like COVID, it gets worse that you’re challenged with everything on top of your health, your family, and you have to be worried about deportation,” she said. “We need to strengthen legislation. Nobody should suffer with immigration processes during an active pandemic or otherwise.”

In the United States, 28% of physicians are immigrants. Dr. Amara pointed out that these physicians go through years of expensive training with extensive background checks at every level, yet they’re classified as second preference (EB-2) workers. She believes that physicians as a group should be excluded from this category and allowed to automatically become citizens after 5 years of living in the United States and working in an underserved area.

There have been an estimated 15,000 unused green cards since 2005. And if Congress went back to 1992, there could be more than 220,000 previously unused green cards recaptured. These unused green cards are the basis behind bills H.R.2255 and S.1024, the Healthcare Workforce Resiliency Act, which has been championed by SHM and PAHA. “It will allow the frontline physicians, 15,000 of them, and 25,000 nurses, to obtain their permanent residency,” said Dr. Amara. “These are people who already applied for their permanent residencies and they’re still waiting.”

SHM has consistently advocated for the Act since it was first introduced, written multiple letters on the issue, and supported it both on and off Capitol Hill. The society says the legislation would be an “important first step toward addressing a critical shortage” in the U.S. health care system by “recognizing the vital role immigrant physicians and nurses are playing in the fight against COVID-19.”

Currently, SHM has a live action alert open for the reintroduced bill, and encourages members to contact their legislators and urge them to support the reintroduction of the Act by cosponsoring and working to pass the legislation

Dr. Amara encourages physicians to start engaging in advocacy efforts early. Though she didn’t begin participating until late in her career, she said being aware of and part of policies that affect medicine is important. If more physicians get involved, “there are so many things we can take care of,” said Dr. Amara. “The medical profession doesn’t have to be so difficult and so busy. There are ways we can make it better and I believe that. And obviously I’ll continue to work and advocate for the entire medical profession, their problems, their health and well-being, to prevent burnout.”
 

Making time for positivity and self-care

Sandhya Tagaram, MD, a hospitalist at UMass Memorial Medical Center in Worcester, Mass., and her husband, also a hospitalist physician, had only ever read about pandemics in books. They certainly never expected to be in the middle of one. “That was a totally different level of anxiety to work as frontline physicians with two kids under 5 years and families away back home in India,” she said.

UMass Memorial Medical Center

Dr. Tagaram and her husband work opposite shifts so that one of them is always home with their two young children. “Our schedules became more challenging when the pandemic started. Between both of our schedules and with minimal childcare facilities, we managed to strike a decent work-family balance, although we experience less vacation time together. We are fortunate to have an understanding work group,” said Dr. Tagaram.

Even before COVID-19, Dr. Tagaram found working on the temporary work visa challenging. “I think the pandemic has exposed the layer of uncertainty associated with it,” she said. “It’s incredibly stressful to imagine any minor turbulence that could alter our family and work lives. As a frontline physician mom, I take pride in raising my kids and taking care of my patients. We want to serve our communities and at the same time secure our families.”

Not being able to visit family back home and travel is exceedingly difficult. Dr. Tagaram said it would be helpful if there was a separate permanent residence pathway for physicians because they play a critical role in public health and they have been an integral part of the COVID-19 pandemic response team. A separate pathway could help keep their families secure and enable them to give their best to their communities.

Amid all the anxiety, Dr. Tagaram said she and her husband realized they could not keep living with so much pressure. As parents and as physicians, they did not want their stress to leak out and affect their ability and commitment to care for their children or their patients. They decided they needed to figure out how to be positive and constructive.

“We try some daily fun activities with the kids after returning home from work,” said Dr. Tagaram. They also formed a bubble group with two other physician families so the children could interact safely. She said that it’s critical that physicians take time for themselves. “We have to cultivate a serious hobby that helps to rejuvenate and calm our busy minds,” said Dr. Tagaram.

She makes time every day to exercise and to read at least a few pages from a good book. She is also learning Carnatic music along with one of her daughters. And every month since March 2020, she has journaled about her work and what she learned so her daughters can read it someday. “These things keep me jazzed up,” she said.

The pandemic has highlighted the fact that we are all part of one global community. “Although we hail from different backgrounds, we learned that we do have some common goals of being kind and supportive to each other and to give back to our communities. Hopefully we will continue this spirit,” said Dr. Tagaram. As a physician mother, “I feel it’s a privilege and honor to take care of my family and my community.”
 

Soldiering on in the COVID-19 war

The uncertainty everyone felt at the beginning of the pandemic was “very, very scary,” said Mamtha Balla, MD, MPH, a hospitalist and clinical assistant professor in northwest Ohio. “Initially, I was so involved in it and I felt like it was like a war, a COVID-19 war, and we are soldiers in that and trying to protect and do whatever we can.”

She and her husband, a geriatrician also working on an H-1B visa, have worked hard not to bring the virus home to their 2-year-old daughter. Going into 2021, the past 2 years have been “the most hectic and emotionally draining – and physically exhausting – years of my life,” said Dr. Balla.

The COVID-19 vaccine has helped reduce some pressure, but Dr. Balla is still concerned about the high risk to health care workers and the new COVID-19 strains coming out. “We are really not sure what we are dealing with and how the COVID will calm,” she said. “It is pretty challenging being a health care worker because not only are you responsible for your patients at the end of the day, but you are also responsible for your families.”

Initially in the United States from India on a student visa in 2008, Dr. Balla was placed on an H-1B visa when she started her residency. It was during this time that her mother was diagnosed with cancer and went through surgeries and chemotherapy. “She was pretty ill,” recalled Dr. Balla.

Despite the situation, Dr. Balla was afraid to go stay with her mother in case her visa application was rejected, and she couldn’t complete her third year of education. “I opted not to go to India at that time because I did not want to take a chance,” Dr. Balla said. “I have tears in my eyes because those are not easy moments, to withhold from seeing your parents, or to be in any other emergency where you cannot travel. That especially puts us at a higher risk emotionally and physically.”

She has not seen her parents in 2½ years. Between the very real possibility of not being able to get her visa stamp and the unpredictability of how other countries are dealing with COVID-19, Dr. Balla feels it is impossible to even think of going to visit. “Even if I go, what if something happens where my visa gets stuck, or the visa office is not open?” she said. If she could not get back to the United States as planned, she would have patients left behind here.

Recently, Dr. Balla did travel to India and her passport stamp did not come on time, so her husband had to come back to the United States by himself. She had to wait for her stamp for a couple more weeks before she could leave and, in the meantime, had to make arrangements at her hospital. “It is so much trauma,” she said.

There’s also the worry she has about getting sick or disabled and not being able to work anymore, resulting in deportation. “Is that what we are doing for people who are working like soldiers? Are we really treating them the correct way?” Dr. Balla asked.

Dr. Balla considers all health care workers to be soldiers in the COVID-19 war. As such, she believes the government should step up to make sure they are supporting and helping these immigrant physician-soldiers who are so necessary. She applauds France’s recent decision to grant citizenship to its frontline immigrant health care workers and feels that the same should be done in the United States. She filed her green card application in 2012, but she is nowhere close to getting it. (The backlog for employment-based green cards is more than 900,000 now.)

As people putting their own and their family’s lives at risk to care for patients with COVID-19, Dr. Balla and her husband have talked about moving to another country or even back to India. “I am a taxpayer; I am a good human being working for the community and for the job. This is my 13th year here. If I am not eligible [for citizenship] still, then I am not sure what else I have to do to prove myself,” she said. “I am owning United States citizens as my people, so please own us and help us out in this difficult scenario.”

Valisure, an online pharmacy known for testing every batch of medication it sells, announced that it has petitioned the Food and Drug Administration to recall 40 batches of sunscreens and after-sun products they say tested for high levels of the chemical benzene.

The company tested 294 batches from 69 companies and found benzene in 27% – many in major national brands like Neutrogena and Banana Boat. Some batches contained as much as three times the emergency FDA limit of 2 parts per million.

Long-term exposure to benzene is known to cause cancer in humans.

“This is especially concerning with sunscreen because multiple FDA studies have shown that sunscreen ingredients absorb through the skin and end up in the blood at high levels,” said David Light, CEO of Valisure.

The FDA is seeking more information about the potential risks from common sunscreen ingredients.

“There is not a safe level of benzene that can exist in sunscreen products,” Christopher Bunick, MD, PhD, associate professor of dermatology at Yale University, New Haven, Conn., said in Valisure’s FDA petition. “The total mass of sunscreen required to cover and protect the human body, in single daily application or repeated applications daily, means that even benzene at 0.1 ppm in a sunscreen could expose people to excessively high nanogram amounts of benzene.”

Valisure’s testing previously led to FDA recalls of heartburn medications and hand sanitizers.
 

Examining sunscreen’s environmental impact

Chemicals in sunscreen may be harmful to other forms of life, too. For years, scientists have been examining whether certain chemicals in sunscreen could be causing damage to marine life, in particular the world’s coral reefs. Specific ingredients, including oxybenzone, benzophenone-1, benzophenone-8, OD-PABA, 4-methylbenzylidene camphor, 3-benzylidene camphor, nano-titanium dioxide, nano-zinc oxide, octinoxate, and octocrylene, have been identified as potential risks.

Earlier this year, the National Academies of Sciences, Engineering, and Medicine created a committee to review the existing science about the potential environmental hazards. Over the next 2 years, they’ll also consider the public health implications if people stopped using sunscreen.

Valisure’s announcement included this message: “It is important to note that not all sunscreen products contain benzene and that uncontaminated products are available, should continue to be used, and are important for protecting against potentially harmful solar radiation.”

Using sunscreen with SPF 15 every day can lower risk of squamous cell carcinoma by around 40% and melanoma by 50%. The American Academy of Dermatology recommends a broad-spectrum, water-resistant sunscreen with an SPF of 30 or higher.

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

Valisure, an online pharmacy known for testing every batch of medication it sells, announced that it has petitioned the Food and Drug Administration to recall 40 batches of sunscreens and after-sun products they say tested for high levels of the chemical benzene.

The company tested 294 batches from 69 companies and found benzene in 27% – many in major national brands like Neutrogena and Banana Boat. Some batches contained as much as three times the emergency FDA limit of 2 parts per million.

Long-term exposure to benzene is known to cause cancer in humans.

“This is especially concerning with sunscreen because multiple FDA studies have shown that sunscreen ingredients absorb through the skin and end up in the blood at high levels,” said David Light, CEO of Valisure.

The FDA is seeking more information about the potential risks from common sunscreen ingredients.

“There is not a safe level of benzene that can exist in sunscreen products,” Christopher Bunick, MD, PhD, associate professor of dermatology at Yale University, New Haven, Conn., said in Valisure’s FDA petition. “The total mass of sunscreen required to cover and protect the human body, in single daily application or repeated applications daily, means that even benzene at 0.1 ppm in a sunscreen could expose people to excessively high nanogram amounts of benzene.”

Valisure’s testing previously led to FDA recalls of heartburn medications and hand sanitizers.
 

Examining sunscreen’s environmental impact

Chemicals in sunscreen may be harmful to other forms of life, too. For years, scientists have been examining whether certain chemicals in sunscreen could be causing damage to marine life, in particular the world’s coral reefs. Specific ingredients, including oxybenzone, benzophenone-1, benzophenone-8, OD-PABA, 4-methylbenzylidene camphor, 3-benzylidene camphor, nano-titanium dioxide, nano-zinc oxide, octinoxate, and octocrylene, have been identified as potential risks.

Earlier this year, the National Academies of Sciences, Engineering, and Medicine created a committee to review the existing science about the potential environmental hazards. Over the next 2 years, they’ll also consider the public health implications if people stopped using sunscreen.

Valisure’s announcement included this message: “It is important to note that not all sunscreen products contain benzene and that uncontaminated products are available, should continue to be used, and are important for protecting against potentially harmful solar radiation.”

Using sunscreen with SPF 15 every day can lower risk of squamous cell carcinoma by around 40% and melanoma by 50%. The American Academy of Dermatology recommends a broad-spectrum, water-resistant sunscreen with an SPF of 30 or higher.

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

Valisure, an online pharmacy known for testing every batch of medication it sells, announced that it has petitioned the Food and Drug Administration to recall 40 batches of sunscreens and after-sun products they say tested for high levels of the chemical benzene.

The company tested 294 batches from 69 companies and found benzene in 27% – many in major national brands like Neutrogena and Banana Boat. Some batches contained as much as three times the emergency FDA limit of 2 parts per million.

Long-term exposure to benzene is known to cause cancer in humans.

“This is especially concerning with sunscreen because multiple FDA studies have shown that sunscreen ingredients absorb through the skin and end up in the blood at high levels,” said David Light, CEO of Valisure.

The FDA is seeking more information about the potential risks from common sunscreen ingredients.

“There is not a safe level of benzene that can exist in sunscreen products,” Christopher Bunick, MD, PhD, associate professor of dermatology at Yale University, New Haven, Conn., said in Valisure’s FDA petition. “The total mass of sunscreen required to cover and protect the human body, in single daily application or repeated applications daily, means that even benzene at 0.1 ppm in a sunscreen could expose people to excessively high nanogram amounts of benzene.”

Valisure’s testing previously led to FDA recalls of heartburn medications and hand sanitizers.
 

Examining sunscreen’s environmental impact

Chemicals in sunscreen may be harmful to other forms of life, too. For years, scientists have been examining whether certain chemicals in sunscreen could be causing damage to marine life, in particular the world’s coral reefs. Specific ingredients, including oxybenzone, benzophenone-1, benzophenone-8, OD-PABA, 4-methylbenzylidene camphor, 3-benzylidene camphor, nano-titanium dioxide, nano-zinc oxide, octinoxate, and octocrylene, have been identified as potential risks.

Earlier this year, the National Academies of Sciences, Engineering, and Medicine created a committee to review the existing science about the potential environmental hazards. Over the next 2 years, they’ll also consider the public health implications if people stopped using sunscreen.

Valisure’s announcement included this message: “It is important to note that not all sunscreen products contain benzene and that uncontaminated products are available, should continue to be used, and are important for protecting against potentially harmful solar radiation.”

Using sunscreen with SPF 15 every day can lower risk of squamous cell carcinoma by around 40% and melanoma by 50%. The American Academy of Dermatology recommends a broad-spectrum, water-resistant sunscreen with an SPF of 30 or higher.

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

DDW is now history. While rejoicing that DDW happened (as opposed to when it couldn’t in 2020), the virtual format precluded all those hallway conversations, meetings with mentors and small group (after hour) discussions. This year, AGA saved substantial monies in travel costs. Of note, at Michigan Medicine, we track the miles patients did not have to travel because of our conversion to virtual care (currently about 30% of all ambulatory visits). To date, our “virtual first” protocol has saved over 24 million patient travel-miles since February 2020 (average of 62 miles per patient visit).

The pandemic forced rapid adoption of virtual care and alternative care delivery models. As patients adapted to telehealth, businesses saw opportunities. Health systems have begun to downsize their brick-and-mortar footprints for both clinical and office space. Hospital at Home models are developing as viable alternatives to inpatient care using a hybrid system of on-site nurses and remote physician supervision.

Digital health start-ups are developing rapidly, and equity funding for digital health companies has reached an all-time high of $26.5 billion in 2020. Multiple companies went public through traditional initial public offerings or special purpose acquisition companies. Sameer Berry, MD, recently collected an inventory of major GI digital health companies counted at least 16 with more appearing each month. These companies focus on management of a single condition (for example IBS or Celiac) or full-service virtual GI care that includes “at-risk” financial contracts

I am delighted to announce that Megan Adams, MD, JD, MSc, has been chosen to be the fourth editor in chief of GI & Hepatology News. She and her team will transition into editorial control during Fall 2021. I have known Megan since meeting her at an AGA young faculty function almost 10 years ago. She is extremely talented and knowledgeable about gastroenterology from a variety of viewpoints. She has recruited a strong and dedicated editorial board.

I have enjoyed the last 5 years leading the current board as we have brought breaking news to the GI community. I wish to publicly thank our editorial board and the Frontline staff who monthly publish AGA’s official newspaper.

John I. Allen, MD, MBA, AGAF
Editor in Chief

DDW is now history. While rejoicing that DDW happened (as opposed to when it couldn’t in 2020), the virtual format precluded all those hallway conversations, meetings with mentors and small group (after hour) discussions. This year, AGA saved substantial monies in travel costs. Of note, at Michigan Medicine, we track the miles patients did not have to travel because of our conversion to virtual care (currently about 30% of all ambulatory visits). To date, our “virtual first” protocol has saved over 24 million patient travel-miles since February 2020 (average of 62 miles per patient visit).

The pandemic forced rapid adoption of virtual care and alternative care delivery models. As patients adapted to telehealth, businesses saw opportunities. Health systems have begun to downsize their brick-and-mortar footprints for both clinical and office space. Hospital at Home models are developing as viable alternatives to inpatient care using a hybrid system of on-site nurses and remote physician supervision.

Digital health start-ups are developing rapidly, and equity funding for digital health companies has reached an all-time high of $26.5 billion in 2020. Multiple companies went public through traditional initial public offerings or special purpose acquisition companies. Sameer Berry, MD, recently collected an inventory of major GI digital health companies counted at least 16 with more appearing each month. These companies focus on management of a single condition (for example IBS or Celiac) or full-service virtual GI care that includes “at-risk” financial contracts

I am delighted to announce that Megan Adams, MD, JD, MSc, has been chosen to be the fourth editor in chief of GI & Hepatology News. She and her team will transition into editorial control during Fall 2021. I have known Megan since meeting her at an AGA young faculty function almost 10 years ago. She is extremely talented and knowledgeable about gastroenterology from a variety of viewpoints. She has recruited a strong and dedicated editorial board.

I have enjoyed the last 5 years leading the current board as we have brought breaking news to the GI community. I wish to publicly thank our editorial board and the Frontline staff who monthly publish AGA’s official newspaper.

John I. Allen, MD, MBA, AGAF
Editor in Chief

DDW is now history. While rejoicing that DDW happened (as opposed to when it couldn’t in 2020), the virtual format precluded all those hallway conversations, meetings with mentors and small group (after hour) discussions. This year, AGA saved substantial monies in travel costs. Of note, at Michigan Medicine, we track the miles patients did not have to travel because of our conversion to virtual care (currently about 30% of all ambulatory visits). To date, our “virtual first” protocol has saved over 24 million patient travel-miles since February 2020 (average of 62 miles per patient visit).

The pandemic forced rapid adoption of virtual care and alternative care delivery models. As patients adapted to telehealth, businesses saw opportunities. Health systems have begun to downsize their brick-and-mortar footprints for both clinical and office space. Hospital at Home models are developing as viable alternatives to inpatient care using a hybrid system of on-site nurses and remote physician supervision.

Digital health start-ups are developing rapidly, and equity funding for digital health companies has reached an all-time high of $26.5 billion in 2020. Multiple companies went public through traditional initial public offerings or special purpose acquisition companies. Sameer Berry, MD, recently collected an inventory of major GI digital health companies counted at least 16 with more appearing each month. These companies focus on management of a single condition (for example IBS or Celiac) or full-service virtual GI care that includes “at-risk” financial contracts

I am delighted to announce that Megan Adams, MD, JD, MSc, has been chosen to be the fourth editor in chief of GI & Hepatology News. She and her team will transition into editorial control during Fall 2021. I have known Megan since meeting her at an AGA young faculty function almost 10 years ago. She is extremely talented and knowledgeable about gastroenterology from a variety of viewpoints. She has recruited a strong and dedicated editorial board.

I have enjoyed the last 5 years leading the current board as we have brought breaking news to the GI community. I wish to publicly thank our editorial board and the Frontline staff who monthly publish AGA’s official newspaper.

John I. Allen, MD, MBA, AGAF
Editor in Chief