When I was a new palliative care nurse practitioner (NP), I remember my mentor telling me that communication in our field is equivalent to surgical procedures in general surgery. Conversations need to be handled with accuracy and precision, conducted in a timely fashion, and require skills that take practice to sharpen. Over the years, I learned that unlike surgery, we do not have control over how the procedure will flow. We approach patients with a blank canvas, open to receive messages that will be shared and reacted to accordingly. The ability to communicate effectively also requires compassion, which is a trait that tends to be inherent in humans and typically is not learned from textbooks but can be cultivated with training and application.

Among the barriers identified to effective communication are avoiding emotional issues and focusing on technical topics due in part to the fear of lengthy encounters, not allowing patients or families enough time to speak, and reframing instead of validating emotions.¹ Many years later, I had the chance to help care for a patient whose story reminds me of how our choice of words and how our interpretation of what we are told can influence the way we care for patients and their families.

Case Presentation

Mr. P, aged 86 years, was admitted to a teaching hospital for pneumonia and heart failure exacerbation. He was treated with diuretics and antibiotics and discharged home on room air after 3 days. He returned to the hospital after 8 days, reporting labored breathing. He was found to be hypoxic, and a further workup revealed acute hypoxic respiratory failure that was likely from severe pulmonary hypertension and exacerbation of his heart failure. Left heart disease is a common cause of pulmonary hypertension, which can lead to right ventricular failure and increased mortality.²

After meeting with his pulmonologist and cardiologist, Mr. P elected for a do-not-resuscitate code status and declined to be intubated. He also refused further diagnostics and life-prolonging treatments for his conditions, including a stress test, cardiac catheterization, and a right heart catheterization. He required bilevel positive airway pressure (BPAP) support at bedtime, which he also declined. He agreed to the use of supplemental oxygen through a nasal cannula and always needed 5 liters of oxygen.

Palliative care was consulted to assist with goals of care discussion. This visit took place during the COVID-19 pandemic, but Mr. P had tested negative for the COVID virus, so the palliative care NP was able to meet with Mr. P in person. He shared his understanding of the serious nature of his condition and the likelihood of a limited life expectancy without further diagnostics and possible life-prolonging treatments. He said his goal was to go home and spend the remainder of his life with his wife. He had not been out of bed since his hospitalization except to transfer to a nearby chair with the help of his nurse due to exertional dyspnea and generalized weakness. Prior to his recent hospitalizations, he was independently ambulating and had no dyspnea when performing strenuous activities. Mr. P shared that his wife was aged in her 70s and was legally blind. He added that she did not require physical assistance, but he was unsure whether she could help him because they had not been in such a situation previously. They had a daughter who visited frequently and helped with driving them to doctors’ appointments and shopping. Mr. P shared that he wanted to go home. After explaining the option of home hospice, Mr. P decided he wanted to receive hospice services at home and asked palliative care NP to contact his daughter to let her know his wishes and to tell her more about how hospice can help with his care.

The palliative care NP met with Mr. P’s nurse and shared the outcome of her visit. His nurse asked the palliative care NP whether she was familiar with his daughter. The nurse added that she wanted the palliative care NP to know that Mr. P’s daughter was quite angry and upset with his doctors after being told about his prognosis. His doctors’ notes also indicated that Mr. P wanted them to contact his daughter regarding his condition and plans for discharge, concluding that he deferred to his daughter for medical decision making.

As Mr. P’s hospitalization took place during the COVID pandemic, a face-to-face meeting with his family was not possible. The NP spoke with Mr. P’s daughter over the phone to relay his wishes and goals for his care. Mr. P’s daughter cried at times during the conversation and asked whether his condition was really that serious. The NP allowed Mr. P’s daughter to express her sadness and allowed for periods of silence during the conversation while his daughter gathered her composure. The NP reinforced the clinical information she had been provided by the medical team. Mr. P’s daughter added that he was completely independent, not requiring supplemental oxygen and was otherwise healthy just a month prior. She also asked whether there was truly nothing else that could be done to prolong his life. The NP acknowledged her observations and explained how Mr. P’s body and organs had not been able to bounce back from the recent insults to his overall physical condition.

After being told that Mr. P’s options for treatment were limited not only by his advanced age and comorbidities, but also the limitations and goals for his care he had identified, his daughter supported her father’s decision. The palliative care NP provided her information on how home hospice assists in her father’s care at home, including symptom management, nursing visits, home equipment, family support, among others. Mr. P’s daughter also said she would relay the information to her mother and call the palliative care NP if they had additional questions or concerns.

The outcome of her visit with Mr. P and his daughter were relayed by the palliative care NP to his acute health care team through an official response to the consultation request via his electronic health record. The palliative care NP also alerted the palliative care social worker to follow-up with Mr. P, his daughter, and his acute health care team to coordinate hospice services at the time of his discharge from the hospital.

Mr. P was discharged from the hospital with home hospice services after a few days. Three weeks later, Mr. P passed away peacefully on the in-patient unit of his home hospice agency as his physical care needs became too much for his family to provide at home a few days before his death. The palliative care social worker later shared with the NP that Mr. P’s daughter shared her gratitude and satisfaction with the care he had received not only from palliative care, but also from everyone during his hospitalization.

Discussion

Key themes found in end-of-life (EOL) communication with families and caregivers include highlighting clinical deterioration, involvement in decision making, continuation of high-quality care after cessation of aggressive measures, tailoring to individuals, clarity, honesty, and use of techniques in delivery.² Some of the techniques identified were pacing, staging, and repetition.³ Other techniques that can be beneficial include allowing for time to express one’s feelings, being comfortable with brief periods of silence, validating observations shared, among others. These themes were evident in the interactions that his health care team had with Mr. P and his daughter. With honesty and clarity, various members of the health care team repeatedly shared information regarding his clinical deterioration.

Family Influence

EOL decision-making roles within a family tend to originate from family interactional histories, familial roles as well as decision-making situations the family faces.⁴ The US medical and legal systems also recognize formal role assignments for surrogate decision makers.⁴ In the case of Mr. P, his advance directive (AD) identified his daughter as his surrogate decision maker. ADs are written statements made in advance by patients expressing their wishes and limitations for treatment as well as appointing surrogate decision makers when they become unable to decide for themselves in the future.⁵

During discussions about the goals for his care, Mr. P made his own medical decisions and elected to pursue a comfort-focused approach to care. His request for his health care team to reach out to his daughter was largely due to his need for assistance in explaining the complexity of his clinical condition to her and how hospice services would be helpful with his EOL care. Mr. P depended on his daughter to bring him to the hospital or to his doctors’ appointments, and she had been a major source of support for him and his wife. Contrary to the belief of some of his health care practitioners, Mr. P was not deferring his medical decisions to his daughter but rather allowing for her participation as his health care partner.

Communication between nurses and patients has been found to be challenging to both parties. Nurses express difficulties in areas that include supporting patients and families after they have had a difficult conversation with their physicians and responding to patients and family members’ emotions like anger.⁶ EOL care issues, such as family barriers to prognostic understanding, can interfere with psychosocial care.⁶ Families of patients approaching the EOL describe feeling mentally worn down and being unable to think straight, leading to feelings of being overwhelmed.⁷ They feel the need to be in a place where they can accept the content of difficult EOL conversations to be able to effectively engage.⁷

Studies have shown that family members of patients at the EOL experience stress, anxiety, fatigue and depression.⁸ Reactions that can be perceived as anger may not be so nor directed to the health care team. Questions raised regarding the accuracy of prognostication and treatment recommendations may not necessarily reflect concerns about the quality of care received but an exercise of advocacy in exploring other options on behalf of the patient. Allowing time for families to process the information received and react freely are necessary steps to facilitate reaching a place where they can acknowledge the information being relayed.

Communication Skills Training

Every member of the health care team should be equipped with the basic skills to have these conversations. The academic curricula for members of the health care team focuses on developing communication skills, but there has been a lack of content on palliative and EOL care.⁹

Due to time constraints and limited opportunities in the clinical setting, there has been an increasing use of simulation-based learning activities (SBLA) to enhance communication skills among nursing students.⁹ At this time, the impact of SBLA in enhancing communication competency is not fully known, but given the lack of clinical opportunities for students, this option is worth considering.⁹ When asked, nurses recognized the need for improved EOL communication education, training, and guidelines.¹⁰ They also felt that a multidisciplinary approach in EOL communication is beneficial. The inclusion of the End-of-Life Nursing Education Consortium (ELNEC) Core training in Bachelor of Science in Nursing programs have led to improved insight on palliative care and nurses’ role in palliative care and hospice among nursing students.¹¹

The Palliative Care and Hospice Education and Training Act of 2017 amended the Public Health Service Act to include improving EOL training for health care providers, including talking about death and dying.¹² Even though the Liaison Committee of Medical Education asked medical schools to incorporate EOL care education in the medical school curricula, there is still a lack of developmentally appropriate and supervised EOL education in medical schools.¹² Training on grief also has been lacking and less likely to be mandatory among medical students and residents: Workshops are mostly conducted before they can be applied in the clinical setting.¹³ Meanwhile, resources are available to assist physicians in EOL conversations with patient and families, such as the Serious Illness Conversation Guide, The Conversation Project, and Stanford’s Letter Project.¹²

Conclusions

Palliative consultation is associated with an overall improvement in EOL care, communication, and support, according to families of deceased patients.¹⁴ It has also been shown to enhance patients’ quality of life and mood, improve documentation of resuscitation preferences, and lead to less aggressive care at the EOL, including less chemotherapy.¹⁵ Integration of palliative care in the care of patients hospitalized with acute heart failure has been associated with improved quality of life, decreased symptom burden and depressive symptoms, and increased participation in advance care planning.¹⁶

The involvement of palliative care in the care of patients and their families at EOL enhances goals of care discussions that improve understanding for everyone involved. It helps provide consistency with the message being delivered by the rest of the health care team to patients and families regarding prognosis and recommendations. Palliative care can provide an alternative when all other aggressive measures are no longer helpful and allow for the continuation of care with a shift in focus from prolonging life to promoting its quality. Furthermore, palliative care involvement for care of patients with life-limiting illness also has been found to improve symptom control, decrease hospitalizations and health care costs, and even improve mortality.¹⁷A multidisciplinary approach to palliative care EOL conversations is beneficial, but every member of the health care team should have the training, education, and skills to be ready to have these difficult conversations. These health care team members include physicians, advance practice clinicians, nurses, social workers, and chaplains, among others. Patients and families are likely to be in contact with different members of the health care team who should be able to carry out therapeutic conversations. Using validated tools and resources on communication techniques through evidence-based practice is helpful and should be encouraged. This provides a framework on how EOL conversations should be conducted in the clinical setting to augment the identified lack of training on EOL communication in schools. Repeated opportunities for its use over time will help improve the ability of clinicians to engage in effective EOL communication.

When I was a new palliative care nurse practitioner (NP), I remember my mentor telling me that communication in our field is equivalent to surgical procedures in general surgery. Conversations need to be handled with accuracy and precision, conducted in a timely fashion, and require skills that take practice to sharpen. Over the years, I learned that unlike surgery, we do not have control over how the procedure will flow. We approach patients with a blank canvas, open to receive messages that will be shared and reacted to accordingly. The ability to communicate effectively also requires compassion, which is a trait that tends to be inherent in humans and typically is not learned from textbooks but can be cultivated with training and application.

Among the barriers identified to effective communication are avoiding emotional issues and focusing on technical topics due in part to the fear of lengthy encounters, not allowing patients or families enough time to speak, and reframing instead of validating emotions.¹ Many years later, I had the chance to help care for a patient whose story reminds me of how our choice of words and how our interpretation of what we are told can influence the way we care for patients and their families.

Case Presentation

Mr. P, aged 86 years, was admitted to a teaching hospital for pneumonia and heart failure exacerbation. He was treated with diuretics and antibiotics and discharged home on room air after 3 days. He returned to the hospital after 8 days, reporting labored breathing. He was found to be hypoxic, and a further workup revealed acute hypoxic respiratory failure that was likely from severe pulmonary hypertension and exacerbation of his heart failure. Left heart disease is a common cause of pulmonary hypertension, which can lead to right ventricular failure and increased mortality.²

After meeting with his pulmonologist and cardiologist, Mr. P elected for a do-not-resuscitate code status and declined to be intubated. He also refused further diagnostics and life-prolonging treatments for his conditions, including a stress test, cardiac catheterization, and a right heart catheterization. He required bilevel positive airway pressure (BPAP) support at bedtime, which he also declined. He agreed to the use of supplemental oxygen through a nasal cannula and always needed 5 liters of oxygen.

Palliative care was consulted to assist with goals of care discussion. This visit took place during the COVID-19 pandemic, but Mr. P had tested negative for the COVID virus, so the palliative care NP was able to meet with Mr. P in person. He shared his understanding of the serious nature of his condition and the likelihood of a limited life expectancy without further diagnostics and possible life-prolonging treatments. He said his goal was to go home and spend the remainder of his life with his wife. He had not been out of bed since his hospitalization except to transfer to a nearby chair with the help of his nurse due to exertional dyspnea and generalized weakness. Prior to his recent hospitalizations, he was independently ambulating and had no dyspnea when performing strenuous activities. Mr. P shared that his wife was aged in her 70s and was legally blind. He added that she did not require physical assistance, but he was unsure whether she could help him because they had not been in such a situation previously. They had a daughter who visited frequently and helped with driving them to doctors’ appointments and shopping. Mr. P shared that he wanted to go home. After explaining the option of home hospice, Mr. P decided he wanted to receive hospice services at home and asked palliative care NP to contact his daughter to let her know his wishes and to tell her more about how hospice can help with his care.

The palliative care NP met with Mr. P’s nurse and shared the outcome of her visit. His nurse asked the palliative care NP whether she was familiar with his daughter. The nurse added that she wanted the palliative care NP to know that Mr. P’s daughter was quite angry and upset with his doctors after being told about his prognosis. His doctors’ notes also indicated that Mr. P wanted them to contact his daughter regarding his condition and plans for discharge, concluding that he deferred to his daughter for medical decision making.

As Mr. P’s hospitalization took place during the COVID pandemic, a face-to-face meeting with his family was not possible. The NP spoke with Mr. P’s daughter over the phone to relay his wishes and goals for his care. Mr. P’s daughter cried at times during the conversation and asked whether his condition was really that serious. The NP allowed Mr. P’s daughter to express her sadness and allowed for periods of silence during the conversation while his daughter gathered her composure. The NP reinforced the clinical information she had been provided by the medical team. Mr. P’s daughter added that he was completely independent, not requiring supplemental oxygen and was otherwise healthy just a month prior. She also asked whether there was truly nothing else that could be done to prolong his life. The NP acknowledged her observations and explained how Mr. P’s body and organs had not been able to bounce back from the recent insults to his overall physical condition.

After being told that Mr. P’s options for treatment were limited not only by his advanced age and comorbidities, but also the limitations and goals for his care he had identified, his daughter supported her father’s decision. The palliative care NP provided her information on how home hospice assists in her father’s care at home, including symptom management, nursing visits, home equipment, family support, among others. Mr. P’s daughter also said she would relay the information to her mother and call the palliative care NP if they had additional questions or concerns.

The outcome of her visit with Mr. P and his daughter were relayed by the palliative care NP to his acute health care team through an official response to the consultation request via his electronic health record. The palliative care NP also alerted the palliative care social worker to follow-up with Mr. P, his daughter, and his acute health care team to coordinate hospice services at the time of his discharge from the hospital.

Mr. P was discharged from the hospital with home hospice services after a few days. Three weeks later, Mr. P passed away peacefully on the in-patient unit of his home hospice agency as his physical care needs became too much for his family to provide at home a few days before his death. The palliative care social worker later shared with the NP that Mr. P’s daughter shared her gratitude and satisfaction with the care he had received not only from palliative care, but also from everyone during his hospitalization.

Discussion

Key themes found in end-of-life (EOL) communication with families and caregivers include highlighting clinical deterioration, involvement in decision making, continuation of high-quality care after cessation of aggressive measures, tailoring to individuals, clarity, honesty, and use of techniques in delivery.² Some of the techniques identified were pacing, staging, and repetition.³ Other techniques that can be beneficial include allowing for time to express one’s feelings, being comfortable with brief periods of silence, validating observations shared, among others. These themes were evident in the interactions that his health care team had with Mr. P and his daughter. With honesty and clarity, various members of the health care team repeatedly shared information regarding his clinical deterioration.

Family Influence

EOL decision-making roles within a family tend to originate from family interactional histories, familial roles as well as decision-making situations the family faces.⁴ The US medical and legal systems also recognize formal role assignments for surrogate decision makers.⁴ In the case of Mr. P, his advance directive (AD) identified his daughter as his surrogate decision maker. ADs are written statements made in advance by patients expressing their wishes and limitations for treatment as well as appointing surrogate decision makers when they become unable to decide for themselves in the future.⁵

During discussions about the goals for his care, Mr. P made his own medical decisions and elected to pursue a comfort-focused approach to care. His request for his health care team to reach out to his daughter was largely due to his need for assistance in explaining the complexity of his clinical condition to her and how hospice services would be helpful with his EOL care. Mr. P depended on his daughter to bring him to the hospital or to his doctors’ appointments, and she had been a major source of support for him and his wife. Contrary to the belief of some of his health care practitioners, Mr. P was not deferring his medical decisions to his daughter but rather allowing for her participation as his health care partner.

Communication between nurses and patients has been found to be challenging to both parties. Nurses express difficulties in areas that include supporting patients and families after they have had a difficult conversation with their physicians and responding to patients and family members’ emotions like anger.⁶ EOL care issues, such as family barriers to prognostic understanding, can interfere with psychosocial care.⁶ Families of patients approaching the EOL describe feeling mentally worn down and being unable to think straight, leading to feelings of being overwhelmed.⁷ They feel the need to be in a place where they can accept the content of difficult EOL conversations to be able to effectively engage.⁷

Studies have shown that family members of patients at the EOL experience stress, anxiety, fatigue and depression.⁸ Reactions that can be perceived as anger may not be so nor directed to the health care team. Questions raised regarding the accuracy of prognostication and treatment recommendations may not necessarily reflect concerns about the quality of care received but an exercise of advocacy in exploring other options on behalf of the patient. Allowing time for families to process the information received and react freely are necessary steps to facilitate reaching a place where they can acknowledge the information being relayed.

Communication Skills Training

Every member of the health care team should be equipped with the basic skills to have these conversations. The academic curricula for members of the health care team focuses on developing communication skills, but there has been a lack of content on palliative and EOL care.⁹

Due to time constraints and limited opportunities in the clinical setting, there has been an increasing use of simulation-based learning activities (SBLA) to enhance communication skills among nursing students.⁹ At this time, the impact of SBLA in enhancing communication competency is not fully known, but given the lack of clinical opportunities for students, this option is worth considering.⁹ When asked, nurses recognized the need for improved EOL communication education, training, and guidelines.¹⁰ They also felt that a multidisciplinary approach in EOL communication is beneficial. The inclusion of the End-of-Life Nursing Education Consortium (ELNEC) Core training in Bachelor of Science in Nursing programs have led to improved insight on palliative care and nurses’ role in palliative care and hospice among nursing students.¹¹

The Palliative Care and Hospice Education and Training Act of 2017 amended the Public Health Service Act to include improving EOL training for health care providers, including talking about death and dying.¹² Even though the Liaison Committee of Medical Education asked medical schools to incorporate EOL care education in the medical school curricula, there is still a lack of developmentally appropriate and supervised EOL education in medical schools.¹² Training on grief also has been lacking and less likely to be mandatory among medical students and residents: Workshops are mostly conducted before they can be applied in the clinical setting.¹³ Meanwhile, resources are available to assist physicians in EOL conversations with patient and families, such as the Serious Illness Conversation Guide, The Conversation Project, and Stanford’s Letter Project.¹²

Conclusions

Palliative consultation is associated with an overall improvement in EOL care, communication, and support, according to families of deceased patients.¹⁴ It has also been shown to enhance patients’ quality of life and mood, improve documentation of resuscitation preferences, and lead to less aggressive care at the EOL, including less chemotherapy.¹⁵ Integration of palliative care in the care of patients hospitalized with acute heart failure has been associated with improved quality of life, decreased symptom burden and depressive symptoms, and increased participation in advance care planning.¹⁶

The involvement of palliative care in the care of patients and their families at EOL enhances goals of care discussions that improve understanding for everyone involved. It helps provide consistency with the message being delivered by the rest of the health care team to patients and families regarding prognosis and recommendations. Palliative care can provide an alternative when all other aggressive measures are no longer helpful and allow for the continuation of care with a shift in focus from prolonging life to promoting its quality. Furthermore, palliative care involvement for care of patients with life-limiting illness also has been found to improve symptom control, decrease hospitalizations and health care costs, and even improve mortality.¹⁷A multidisciplinary approach to palliative care EOL conversations is beneficial, but every member of the health care team should have the training, education, and skills to be ready to have these difficult conversations. These health care team members include physicians, advance practice clinicians, nurses, social workers, and chaplains, among others. Patients and families are likely to be in contact with different members of the health care team who should be able to carry out therapeutic conversations. Using validated tools and resources on communication techniques through evidence-based practice is helpful and should be encouraged. This provides a framework on how EOL conversations should be conducted in the clinical setting to augment the identified lack of training on EOL communication in schools. Repeated opportunities for its use over time will help improve the ability of clinicians to engage in effective EOL communication.

When I was a new palliative care nurse practitioner (NP), I remember my mentor telling me that communication in our field is equivalent to surgical procedures in general surgery. Conversations need to be handled with accuracy and precision, conducted in a timely fashion, and require skills that take practice to sharpen. Over the years, I learned that unlike surgery, we do not have control over how the procedure will flow. We approach patients with a blank canvas, open to receive messages that will be shared and reacted to accordingly. The ability to communicate effectively also requires compassion, which is a trait that tends to be inherent in humans and typically is not learned from textbooks but can be cultivated with training and application.

Among the barriers identified to effective communication are avoiding emotional issues and focusing on technical topics due in part to the fear of lengthy encounters, not allowing patients or families enough time to speak, and reframing instead of validating emotions.¹ Many years later, I had the chance to help care for a patient whose story reminds me of how our choice of words and how our interpretation of what we are told can influence the way we care for patients and their families.

Case Presentation

Mr. P, aged 86 years, was admitted to a teaching hospital for pneumonia and heart failure exacerbation. He was treated with diuretics and antibiotics and discharged home on room air after 3 days. He returned to the hospital after 8 days, reporting labored breathing. He was found to be hypoxic, and a further workup revealed acute hypoxic respiratory failure that was likely from severe pulmonary hypertension and exacerbation of his heart failure. Left heart disease is a common cause of pulmonary hypertension, which can lead to right ventricular failure and increased mortality.²

After meeting with his pulmonologist and cardiologist, Mr. P elected for a do-not-resuscitate code status and declined to be intubated. He also refused further diagnostics and life-prolonging treatments for his conditions, including a stress test, cardiac catheterization, and a right heart catheterization. He required bilevel positive airway pressure (BPAP) support at bedtime, which he also declined. He agreed to the use of supplemental oxygen through a nasal cannula and always needed 5 liters of oxygen.

Palliative care was consulted to assist with goals of care discussion. This visit took place during the COVID-19 pandemic, but Mr. P had tested negative for the COVID virus, so the palliative care NP was able to meet with Mr. P in person. He shared his understanding of the serious nature of his condition and the likelihood of a limited life expectancy without further diagnostics and possible life-prolonging treatments. He said his goal was to go home and spend the remainder of his life with his wife. He had not been out of bed since his hospitalization except to transfer to a nearby chair with the help of his nurse due to exertional dyspnea and generalized weakness. Prior to his recent hospitalizations, he was independently ambulating and had no dyspnea when performing strenuous activities. Mr. P shared that his wife was aged in her 70s and was legally blind. He added that she did not require physical assistance, but he was unsure whether she could help him because they had not been in such a situation previously. They had a daughter who visited frequently and helped with driving them to doctors’ appointments and shopping. Mr. P shared that he wanted to go home. After explaining the option of home hospice, Mr. P decided he wanted to receive hospice services at home and asked palliative care NP to contact his daughter to let her know his wishes and to tell her more about how hospice can help with his care.

The palliative care NP met with Mr. P’s nurse and shared the outcome of her visit. His nurse asked the palliative care NP whether she was familiar with his daughter. The nurse added that she wanted the palliative care NP to know that Mr. P’s daughter was quite angry and upset with his doctors after being told about his prognosis. His doctors’ notes also indicated that Mr. P wanted them to contact his daughter regarding his condition and plans for discharge, concluding that he deferred to his daughter for medical decision making.

As Mr. P’s hospitalization took place during the COVID pandemic, a face-to-face meeting with his family was not possible. The NP spoke with Mr. P’s daughter over the phone to relay his wishes and goals for his care. Mr. P’s daughter cried at times during the conversation and asked whether his condition was really that serious. The NP allowed Mr. P’s daughter to express her sadness and allowed for periods of silence during the conversation while his daughter gathered her composure. The NP reinforced the clinical information she had been provided by the medical team. Mr. P’s daughter added that he was completely independent, not requiring supplemental oxygen and was otherwise healthy just a month prior. She also asked whether there was truly nothing else that could be done to prolong his life. The NP acknowledged her observations and explained how Mr. P’s body and organs had not been able to bounce back from the recent insults to his overall physical condition.

After being told that Mr. P’s options for treatment were limited not only by his advanced age and comorbidities, but also the limitations and goals for his care he had identified, his daughter supported her father’s decision. The palliative care NP provided her information on how home hospice assists in her father’s care at home, including symptom management, nursing visits, home equipment, family support, among others. Mr. P’s daughter also said she would relay the information to her mother and call the palliative care NP if they had additional questions or concerns.

The outcome of her visit with Mr. P and his daughter were relayed by the palliative care NP to his acute health care team through an official response to the consultation request via his electronic health record. The palliative care NP also alerted the palliative care social worker to follow-up with Mr. P, his daughter, and his acute health care team to coordinate hospice services at the time of his discharge from the hospital.

Mr. P was discharged from the hospital with home hospice services after a few days. Three weeks later, Mr. P passed away peacefully on the in-patient unit of his home hospice agency as his physical care needs became too much for his family to provide at home a few days before his death. The palliative care social worker later shared with the NP that Mr. P’s daughter shared her gratitude and satisfaction with the care he had received not only from palliative care, but also from everyone during his hospitalization.

Discussion

Key themes found in end-of-life (EOL) communication with families and caregivers include highlighting clinical deterioration, involvement in decision making, continuation of high-quality care after cessation of aggressive measures, tailoring to individuals, clarity, honesty, and use of techniques in delivery.² Some of the techniques identified were pacing, staging, and repetition.³ Other techniques that can be beneficial include allowing for time to express one’s feelings, being comfortable with brief periods of silence, validating observations shared, among others. These themes were evident in the interactions that his health care team had with Mr. P and his daughter. With honesty and clarity, various members of the health care team repeatedly shared information regarding his clinical deterioration.

Family Influence

EOL decision-making roles within a family tend to originate from family interactional histories, familial roles as well as decision-making situations the family faces.⁴ The US medical and legal systems also recognize formal role assignments for surrogate decision makers.⁴ In the case of Mr. P, his advance directive (AD) identified his daughter as his surrogate decision maker. ADs are written statements made in advance by patients expressing their wishes and limitations for treatment as well as appointing surrogate decision makers when they become unable to decide for themselves in the future.⁵

During discussions about the goals for his care, Mr. P made his own medical decisions and elected to pursue a comfort-focused approach to care. His request for his health care team to reach out to his daughter was largely due to his need for assistance in explaining the complexity of his clinical condition to her and how hospice services would be helpful with his EOL care. Mr. P depended on his daughter to bring him to the hospital or to his doctors’ appointments, and she had been a major source of support for him and his wife. Contrary to the belief of some of his health care practitioners, Mr. P was not deferring his medical decisions to his daughter but rather allowing for her participation as his health care partner.

Communication between nurses and patients has been found to be challenging to both parties. Nurses express difficulties in areas that include supporting patients and families after they have had a difficult conversation with their physicians and responding to patients and family members’ emotions like anger.⁶ EOL care issues, such as family barriers to prognostic understanding, can interfere with psychosocial care.⁶ Families of patients approaching the EOL describe feeling mentally worn down and being unable to think straight, leading to feelings of being overwhelmed.⁷ They feel the need to be in a place where they can accept the content of difficult EOL conversations to be able to effectively engage.⁷

Studies have shown that family members of patients at the EOL experience stress, anxiety, fatigue and depression.⁸ Reactions that can be perceived as anger may not be so nor directed to the health care team. Questions raised regarding the accuracy of prognostication and treatment recommendations may not necessarily reflect concerns about the quality of care received but an exercise of advocacy in exploring other options on behalf of the patient. Allowing time for families to process the information received and react freely are necessary steps to facilitate reaching a place where they can acknowledge the information being relayed.

Communication Skills Training

Every member of the health care team should be equipped with the basic skills to have these conversations. The academic curricula for members of the health care team focuses on developing communication skills, but there has been a lack of content on palliative and EOL care.⁹

Due to time constraints and limited opportunities in the clinical setting, there has been an increasing use of simulation-based learning activities (SBLA) to enhance communication skills among nursing students.⁹ At this time, the impact of SBLA in enhancing communication competency is not fully known, but given the lack of clinical opportunities for students, this option is worth considering.⁹ When asked, nurses recognized the need for improved EOL communication education, training, and guidelines.¹⁰ They also felt that a multidisciplinary approach in EOL communication is beneficial. The inclusion of the End-of-Life Nursing Education Consortium (ELNEC) Core training in Bachelor of Science in Nursing programs have led to improved insight on palliative care and nurses’ role in palliative care and hospice among nursing students.¹¹

The Palliative Care and Hospice Education and Training Act of 2017 amended the Public Health Service Act to include improving EOL training for health care providers, including talking about death and dying.¹² Even though the Liaison Committee of Medical Education asked medical schools to incorporate EOL care education in the medical school curricula, there is still a lack of developmentally appropriate and supervised EOL education in medical schools.¹² Training on grief also has been lacking and less likely to be mandatory among medical students and residents: Workshops are mostly conducted before they can be applied in the clinical setting.¹³ Meanwhile, resources are available to assist physicians in EOL conversations with patient and families, such as the Serious Illness Conversation Guide, The Conversation Project, and Stanford’s Letter Project.¹²

Conclusions

Palliative consultation is associated with an overall improvement in EOL care, communication, and support, according to families of deceased patients.¹⁴ It has also been shown to enhance patients’ quality of life and mood, improve documentation of resuscitation preferences, and lead to less aggressive care at the EOL, including less chemotherapy.¹⁵ Integration of palliative care in the care of patients hospitalized with acute heart failure has been associated with improved quality of life, decreased symptom burden and depressive symptoms, and increased participation in advance care planning.¹⁶

The involvement of palliative care in the care of patients and their families at EOL enhances goals of care discussions that improve understanding for everyone involved. It helps provide consistency with the message being delivered by the rest of the health care team to patients and families regarding prognosis and recommendations. Palliative care can provide an alternative when all other aggressive measures are no longer helpful and allow for the continuation of care with a shift in focus from prolonging life to promoting its quality. Furthermore, palliative care involvement for care of patients with life-limiting illness also has been found to improve symptom control, decrease hospitalizations and health care costs, and even improve mortality.¹⁷A multidisciplinary approach to palliative care EOL conversations is beneficial, but every member of the health care team should have the training, education, and skills to be ready to have these difficult conversations. These health care team members include physicians, advance practice clinicians, nurses, social workers, and chaplains, among others. Patients and families are likely to be in contact with different members of the health care team who should be able to carry out therapeutic conversations. Using validated tools and resources on communication techniques through evidence-based practice is helpful and should be encouraged. This provides a framework on how EOL conversations should be conducted in the clinical setting to augment the identified lack of training on EOL communication in schools. Repeated opportunities for its use over time will help improve the ability of clinicians to engage in effective EOL communication.

Immune checkpoint inhibitors (CPIs) have revolutionized cancer therapy and improved the prognosis for a variety of advanced solid tumors and Hodgkin lymphoma, but evidence is growing regarding severe endocrine disturbances.^1,2 CPIs block inhibitory molecules on activated T cells to increase tumor cell destruction but also can breach normal tolerance, resulting in a spectrum of immune-related adverse events (irAE).^1,2 Programmed cell death-1 (PD-1) inhibitors are one type of CPIs. Pembrolizumab is a humanized monoclonal antibody that targets the PD-1 checkpoint pathway and is approved for the treatment of malignant melanoma and non-small cell lung cancer.^3,4 When the PD-1 checkpoint pathway is inhibited, T cells targeting cancer are activated, as are autoreactive T cells, such as those regulating pancreatic islet cell survival, which can lead to type 1 diabetes mellitus (T1DM).⁵

Case Presentation

A 95-year-old male veteran with long-standing, stable prediabetes was treated with pembrolizumab for stage 4 melanoma. Four months after treatment initiation and 3 weeks after completion of his sixth treatment cycle of pembrolizumab (2 mg/kg every 3 weeks), he presented for surveillance positron emission tomography (PET) and was incidentally found to have a serum glucose of 423 mg/dL. Hypothesis-driven history taking revealed polyuria, polydipsia, and a 12-lb weight loss during the previous 3 months. The patient reported no abdominal pain, nausea, or vomiting. He showed no evidence of pancreatic metastases on recent imaging. His family history was notable for a daughter with T1DM diagnosed at a young age.

On examination, the patient’s vital signs were normal aside from a blood pressure of 80/40 mm Hg. His body mass index was 30. He was alert and oriented with comfortable respirations and no Kussmaul breathing. He exhibited dry mucous membranes and poor skin turgor. Laboratory studies revealed 135 mmol/L sodium (reference, 135-145), 4.6 mmol/L potassium (reference, 3.6-5.2), 100 mmol/L chloride (reference, 99-106), bicarbonate of 26.5 mmol/L (reference, 23-29), serum blood urea nitrogen 27 mg/dL (reference, 6-24), 1.06 mg/dL creatinine (reference, 0.74-1.35), and 423 mg/dL glucose (reference, 70-100), with negative urine ketones. Further studies demonstrated 462 µmol/L fructosamine (reference, 190-270), correlating with hemoglobin A_1c (HbA_1c) close to 11.0% (HbA_1c was drawn on admission but cancelled by the laboratory for unknown reasons).^6,7 Later, an inappropriately low C-peptide level of 0.56 ng/mL (reference, 0.8-3.85) and a negative antiglutamic acid decarboxylase (GAD) antibody titer resulted. The patient was given IV hydration and admitted to the hospital. With input from endocrinology, the patient was started on 0.3 units per kg of body weight basal-prandial insulin therapy. Pembrolizumab was held. Six weeks after discharge, his HbA_1c was 7.2%, and C-peptide improved to 1.95 ng/mL and plasma glucose 116 mg/dL. After shared decision making with his health care team, the patient decided against restarting pembrolizumab. The patient reported that his functional status was preserved, and he preferred to take fewer medications at his advanced age. He died comfortably 6 months after this presentation from complications of metastatic melanoma.

Dicussion

Immunotherapy is now an integral part of cancer treatment and can result in endocrine disturbances.^1,2 Life-threatening irAEs are rare and may mimic more common conditions; thus, there is growing recognition of the need to educate health care professionals in appropriate screening and management of these conditions. CPI-induced T1DM is an uncommon but clinically significant event with an incidence of 0.4 to 1.27% and a median onset of 20 weeks after initiation of therapy (range, 1-228 weeks).^8-12In case seriesfrom 3 academic centers, 59 to81% of patients with CPI-induced T1DM presented with diabetic ketoacidosis (DKA), and only 40 to 71% of patients were autoantibody positive.^13-16 These patients are older than those presenting with classic T1DM, often require intensive care unit admission, and nearly invariably require exogenous insulin injections for metabolic control.^13-16

Based on the later age of onset of cancers that may be treated with CPI, patients with CPI-induced T1DM may be misdiagnosed with T2DM or hyperglycemia from other causes, such as medications or acute illness in the outpatient setting, risking suboptimal treatment.

Given the infrequent incidence and lack of controlled trials, screening and treatment recommendations for CPI-induced T1DM are based on principles derived from case series and expert opinion. Development of polyuria, polydipsia, weight loss, nausea, and/or vomiting should prompt investigation for possible development or worsening of hyperglycemia, suggestive of development of T1DM.¹⁷ American Society of Clinical Oncology (ASCO) guidelines recommend that serum glucose be assessed at baseline and with each treatment cycle during induction for 12 weeks, then every 3 to 6 weeks thereafter.¹⁷ There is no reported association between the number of CPI treatments and the development of DM.^8,9 Following our patient’s fifth pembrolizumab cycle, a random glucose reading was noted to be 186 mg/dL (Figure 1). Under the ASCO guidelines, ideally the patient would have received close clinical follow-up given the striking increase in plasma glucose compared with prior baseline lower values and perhaps been further evaluated with an anti-GAD antibody titer to screen for T1DM.¹⁷

Conclusions

Pembrolizumab-induced T1DM is a rare, but potentially life-threatening irAE. The acute risk of DKA requires early recognition and prompt treatment of patients taking CPIs. More than 90% of primary care physicians (PCPs) fulfill general medical care roles for patients with cancer; therefore, they play an essential role in evaluating symptoms during therapy.²⁰ Further studies evaluating the role of PCPs and outcomes when PCPs are involved in oncologic care should be conducted.

With increased index of suspicion, this clinical scenario presents an opportunity for PCPs that may help reduce irAE-associated morbidity and mortality of patients on CPIs, like pembrolizumab. Figure 2 illustrates an example addendum that can be used to alert and tag a PCP of a mutual patient after initiation of CPI therapy. Determining the optimal interface between PCPs, oncologists, and endocrinologists in delivering and coordinating high-quality cancer care in the setting of immunotherapy is an important area for ongoing quality improvement.

Acknowledgment

The authors thank all the staff and health care professionals at VA Greater Los Angeles Healthcare System who were involved in the care of this patient.

Immune checkpoint inhibitors (CPIs) have revolutionized cancer therapy and improved the prognosis for a variety of advanced solid tumors and Hodgkin lymphoma, but evidence is growing regarding severe endocrine disturbances.^1,2 CPIs block inhibitory molecules on activated T cells to increase tumor cell destruction but also can breach normal tolerance, resulting in a spectrum of immune-related adverse events (irAE).^1,2 Programmed cell death-1 (PD-1) inhibitors are one type of CPIs. Pembrolizumab is a humanized monoclonal antibody that targets the PD-1 checkpoint pathway and is approved for the treatment of malignant melanoma and non-small cell lung cancer.^3,4 When the PD-1 checkpoint pathway is inhibited, T cells targeting cancer are activated, as are autoreactive T cells, such as those regulating pancreatic islet cell survival, which can lead to type 1 diabetes mellitus (T1DM).⁵

Case Presentation

A 95-year-old male veteran with long-standing, stable prediabetes was treated with pembrolizumab for stage 4 melanoma. Four months after treatment initiation and 3 weeks after completion of his sixth treatment cycle of pembrolizumab (2 mg/kg every 3 weeks), he presented for surveillance positron emission tomography (PET) and was incidentally found to have a serum glucose of 423 mg/dL. Hypothesis-driven history taking revealed polyuria, polydipsia, and a 12-lb weight loss during the previous 3 months. The patient reported no abdominal pain, nausea, or vomiting. He showed no evidence of pancreatic metastases on recent imaging. His family history was notable for a daughter with T1DM diagnosed at a young age.

On examination, the patient’s vital signs were normal aside from a blood pressure of 80/40 mm Hg. His body mass index was 30. He was alert and oriented with comfortable respirations and no Kussmaul breathing. He exhibited dry mucous membranes and poor skin turgor. Laboratory studies revealed 135 mmol/L sodium (reference, 135-145), 4.6 mmol/L potassium (reference, 3.6-5.2), 100 mmol/L chloride (reference, 99-106), bicarbonate of 26.5 mmol/L (reference, 23-29), serum blood urea nitrogen 27 mg/dL (reference, 6-24), 1.06 mg/dL creatinine (reference, 0.74-1.35), and 423 mg/dL glucose (reference, 70-100), with negative urine ketones. Further studies demonstrated 462 µmol/L fructosamine (reference, 190-270), correlating with hemoglobin A_1c (HbA_1c) close to 11.0% (HbA_1c was drawn on admission but cancelled by the laboratory for unknown reasons).^6,7 Later, an inappropriately low C-peptide level of 0.56 ng/mL (reference, 0.8-3.85) and a negative antiglutamic acid decarboxylase (GAD) antibody titer resulted. The patient was given IV hydration and admitted to the hospital. With input from endocrinology, the patient was started on 0.3 units per kg of body weight basal-prandial insulin therapy. Pembrolizumab was held. Six weeks after discharge, his HbA_1c was 7.2%, and C-peptide improved to 1.95 ng/mL and plasma glucose 116 mg/dL. After shared decision making with his health care team, the patient decided against restarting pembrolizumab. The patient reported that his functional status was preserved, and he preferred to take fewer medications at his advanced age. He died comfortably 6 months after this presentation from complications of metastatic melanoma.

Dicussion

Immunotherapy is now an integral part of cancer treatment and can result in endocrine disturbances.^1,2 Life-threatening irAEs are rare and may mimic more common conditions; thus, there is growing recognition of the need to educate health care professionals in appropriate screening and management of these conditions. CPI-induced T1DM is an uncommon but clinically significant event with an incidence of 0.4 to 1.27% and a median onset of 20 weeks after initiation of therapy (range, 1-228 weeks).^8-12In case seriesfrom 3 academic centers, 59 to81% of patients with CPI-induced T1DM presented with diabetic ketoacidosis (DKA), and only 40 to 71% of patients were autoantibody positive.^13-16 These patients are older than those presenting with classic T1DM, often require intensive care unit admission, and nearly invariably require exogenous insulin injections for metabolic control.^13-16

Based on the later age of onset of cancers that may be treated with CPI, patients with CPI-induced T1DM may be misdiagnosed with T2DM or hyperglycemia from other causes, such as medications or acute illness in the outpatient setting, risking suboptimal treatment.

Given the infrequent incidence and lack of controlled trials, screening and treatment recommendations for CPI-induced T1DM are based on principles derived from case series and expert opinion. Development of polyuria, polydipsia, weight loss, nausea, and/or vomiting should prompt investigation for possible development or worsening of hyperglycemia, suggestive of development of T1DM.¹⁷ American Society of Clinical Oncology (ASCO) guidelines recommend that serum glucose be assessed at baseline and with each treatment cycle during induction for 12 weeks, then every 3 to 6 weeks thereafter.¹⁷ There is no reported association between the number of CPI treatments and the development of DM.^8,9 Following our patient’s fifth pembrolizumab cycle, a random glucose reading was noted to be 186 mg/dL (Figure 1). Under the ASCO guidelines, ideally the patient would have received close clinical follow-up given the striking increase in plasma glucose compared with prior baseline lower values and perhaps been further evaluated with an anti-GAD antibody titer to screen for T1DM.¹⁷

Conclusions

Pembrolizumab-induced T1DM is a rare, but potentially life-threatening irAE. The acute risk of DKA requires early recognition and prompt treatment of patients taking CPIs. More than 90% of primary care physicians (PCPs) fulfill general medical care roles for patients with cancer; therefore, they play an essential role in evaluating symptoms during therapy.²⁰ Further studies evaluating the role of PCPs and outcomes when PCPs are involved in oncologic care should be conducted.

With increased index of suspicion, this clinical scenario presents an opportunity for PCPs that may help reduce irAE-associated morbidity and mortality of patients on CPIs, like pembrolizumab. Figure 2 illustrates an example addendum that can be used to alert and tag a PCP of a mutual patient after initiation of CPI therapy. Determining the optimal interface between PCPs, oncologists, and endocrinologists in delivering and coordinating high-quality cancer care in the setting of immunotherapy is an important area for ongoing quality improvement.

Acknowledgment

The authors thank all the staff and health care professionals at VA Greater Los Angeles Healthcare System who were involved in the care of this patient.

Immune checkpoint inhibitors (CPIs) have revolutionized cancer therapy and improved the prognosis for a variety of advanced solid tumors and Hodgkin lymphoma, but evidence is growing regarding severe endocrine disturbances.^1,2 CPIs block inhibitory molecules on activated T cells to increase tumor cell destruction but also can breach normal tolerance, resulting in a spectrum of immune-related adverse events (irAE).^1,2 Programmed cell death-1 (PD-1) inhibitors are one type of CPIs. Pembrolizumab is a humanized monoclonal antibody that targets the PD-1 checkpoint pathway and is approved for the treatment of malignant melanoma and non-small cell lung cancer.^3,4 When the PD-1 checkpoint pathway is inhibited, T cells targeting cancer are activated, as are autoreactive T cells, such as those regulating pancreatic islet cell survival, which can lead to type 1 diabetes mellitus (T1DM).⁵

Case Presentation

A 95-year-old male veteran with long-standing, stable prediabetes was treated with pembrolizumab for stage 4 melanoma. Four months after treatment initiation and 3 weeks after completion of his sixth treatment cycle of pembrolizumab (2 mg/kg every 3 weeks), he presented for surveillance positron emission tomography (PET) and was incidentally found to have a serum glucose of 423 mg/dL. Hypothesis-driven history taking revealed polyuria, polydipsia, and a 12-lb weight loss during the previous 3 months. The patient reported no abdominal pain, nausea, or vomiting. He showed no evidence of pancreatic metastases on recent imaging. His family history was notable for a daughter with T1DM diagnosed at a young age.

On examination, the patient’s vital signs were normal aside from a blood pressure of 80/40 mm Hg. His body mass index was 30. He was alert and oriented with comfortable respirations and no Kussmaul breathing. He exhibited dry mucous membranes and poor skin turgor. Laboratory studies revealed 135 mmol/L sodium (reference, 135-145), 4.6 mmol/L potassium (reference, 3.6-5.2), 100 mmol/L chloride (reference, 99-106), bicarbonate of 26.5 mmol/L (reference, 23-29), serum blood urea nitrogen 27 mg/dL (reference, 6-24), 1.06 mg/dL creatinine (reference, 0.74-1.35), and 423 mg/dL glucose (reference, 70-100), with negative urine ketones. Further studies demonstrated 462 µmol/L fructosamine (reference, 190-270), correlating with hemoglobin A_1c (HbA_1c) close to 11.0% (HbA_1c was drawn on admission but cancelled by the laboratory for unknown reasons).^6,7 Later, an inappropriately low C-peptide level of 0.56 ng/mL (reference, 0.8-3.85) and a negative antiglutamic acid decarboxylase (GAD) antibody titer resulted. The patient was given IV hydration and admitted to the hospital. With input from endocrinology, the patient was started on 0.3 units per kg of body weight basal-prandial insulin therapy. Pembrolizumab was held. Six weeks after discharge, his HbA_1c was 7.2%, and C-peptide improved to 1.95 ng/mL and plasma glucose 116 mg/dL. After shared decision making with his health care team, the patient decided against restarting pembrolizumab. The patient reported that his functional status was preserved, and he preferred to take fewer medications at his advanced age. He died comfortably 6 months after this presentation from complications of metastatic melanoma.

Dicussion

Immunotherapy is now an integral part of cancer treatment and can result in endocrine disturbances.^1,2 Life-threatening irAEs are rare and may mimic more common conditions; thus, there is growing recognition of the need to educate health care professionals in appropriate screening and management of these conditions. CPI-induced T1DM is an uncommon but clinically significant event with an incidence of 0.4 to 1.27% and a median onset of 20 weeks after initiation of therapy (range, 1-228 weeks).^8-12In case seriesfrom 3 academic centers, 59 to81% of patients with CPI-induced T1DM presented with diabetic ketoacidosis (DKA), and only 40 to 71% of patients were autoantibody positive.^13-16 These patients are older than those presenting with classic T1DM, often require intensive care unit admission, and nearly invariably require exogenous insulin injections for metabolic control.^13-16

Based on the later age of onset of cancers that may be treated with CPI, patients with CPI-induced T1DM may be misdiagnosed with T2DM or hyperglycemia from other causes, such as medications or acute illness in the outpatient setting, risking suboptimal treatment.

Given the infrequent incidence and lack of controlled trials, screening and treatment recommendations for CPI-induced T1DM are based on principles derived from case series and expert opinion. Development of polyuria, polydipsia, weight loss, nausea, and/or vomiting should prompt investigation for possible development or worsening of hyperglycemia, suggestive of development of T1DM.¹⁷ American Society of Clinical Oncology (ASCO) guidelines recommend that serum glucose be assessed at baseline and with each treatment cycle during induction for 12 weeks, then every 3 to 6 weeks thereafter.¹⁷ There is no reported association between the number of CPI treatments and the development of DM.^8,9 Following our patient’s fifth pembrolizumab cycle, a random glucose reading was noted to be 186 mg/dL (Figure 1). Under the ASCO guidelines, ideally the patient would have received close clinical follow-up given the striking increase in plasma glucose compared with prior baseline lower values and perhaps been further evaluated with an anti-GAD antibody titer to screen for T1DM.¹⁷

Conclusions

Pembrolizumab-induced T1DM is a rare, but potentially life-threatening irAE. The acute risk of DKA requires early recognition and prompt treatment of patients taking CPIs. More than 90% of primary care physicians (PCPs) fulfill general medical care roles for patients with cancer; therefore, they play an essential role in evaluating symptoms during therapy.²⁰ Further studies evaluating the role of PCPs and outcomes when PCPs are involved in oncologic care should be conducted.

With increased index of suspicion, this clinical scenario presents an opportunity for PCPs that may help reduce irAE-associated morbidity and mortality of patients on CPIs, like pembrolizumab. Figure 2 illustrates an example addendum that can be used to alert and tag a PCP of a mutual patient after initiation of CPI therapy. Determining the optimal interface between PCPs, oncologists, and endocrinologists in delivering and coordinating high-quality cancer care in the setting of immunotherapy is an important area for ongoing quality improvement.

Acknowledgment

The authors thank all the staff and health care professionals at VA Greater Los Angeles Healthcare System who were involved in the care of this patient.

Since the start of the pandemic, health care systems have requested many in-services for staff on self-care and stress management to help health care workers (HCWs) cope with the heavy toll of COVID-19. The pandemic has set off a global mental health crisis, with unprecedented numbers of individuals meeting criteria for anxiety, depression, and other mental health disorders in response to the intense stressors of living through a pandemic. These calls to assist staff with self-care and burnout prevention have been especially salient for psychologists working in palliative care and geriatrics, where fears of COVID-19 infection and numbers of patient deaths have been high.

Throughout these painful times, we have been grateful for an online community of palliative care psychologists within the US Department of Veterans Affairs (VA) from across the continuum of care and across the country. This community brought together many of us who were both struggling ourselves and striving to support the teams and HCWs around us. We are psychologists who provide home-care services in North Carolina, inpatient hospice and long-term care services in California, and long-term care and outpatient palliative care services in Massachusetts. Through our shared struggles and challenges navigating the pandemic, we realized that our respective teams requested similar services, all focused on staff support.

The psychological impact of COVID-19 on HCWs was clear from the beginning. Early in the pandemic our respective teams requested us to provide staff support and education about coping to our local HCWs. Soon national groups for long-term care staff requested education programs. Through this work, we realized that the emotional needs of HCWs ran much deeper than simple self-care. At the onset of the pandemic, before realizing its chronicity, the trainings we offered focused on stress and coping strategies. We cited several frameworks for staff support and eagerly shared anything that might help us, and our colleagues, survive the immediate anxiety and tumult surrounding us.^1-3 In this paper, we briefly discuss the distress affecting the geriatric care workforce, reflect on our efforts to cope as HCWs, and offer recommendations at individual and organization levels to help address our collective grief.

Impact of COVID-19

As the death toll mounted and hospitals were pushed to the brink, we saw the suffering of our fellow HCWs. The lack of personal protective equipment (PPE) and testing supplies led to evolving and increasing anxiety for HCWs about contracting COVID-19, potentially spreading it to one’s social circle or family, fears of becoming sick and dying, and fears of inadvertently spreading the virus to medically-vulnerable patients. Increasing demands on staff required many to work outside their areas of expertise. Clinical practice guidelines changed frequently as information emerged about the virus. Staff members struggled to keep pace with the increasing number of patients, many of whom died despite heroic efforts to save them.

As the medical crisis grew, so too did social uprisings as the general public gained a strengthened awareness of the legacy and ongoing effects of systemic oppression, racism, and social inequities in the United States. Individuals grappled with their own privileges, which often hid such disparities from view. Many HCWs and clinicians of color had to navigate unsolicited questions and discussions about racial injustices while also trying to survive. As psychologists, we strove to support the HCWs around us while also struggling with our own stressors. As the magnitude of the pandemic and ongoing social injustices came into view, we realized that presentations on self-care and burnout prevention did not suffice. We needed discussions on unmasking our grief, acknowledging our traumas, and working toward collective healing.

Geriatric Care Workers

Experiences of grief and trauma hit the geriatric care workforce and especially long-term care facilities particularly hard given the high morbidity and mortality rates of COVID-19.⁴ The geriatric care workforce itself suffers from institutional vulnerabilities. Individuals are often underpaid, undertrained, and work within a system that continually experiences staffing shortages, high burnout, and consequently high levels of turnover.^5,6 Recent immigrants and racial/ethnic minorities disproportionately make up this workforce, who often live in multigenerational households and work in multiple facilities to get by.^7,8 Amid the pandemic these HCWs continued to work despite demoralizing negative media coverage of nursing homes.⁹ Notably, facilities with unionized staff were less likely to need second or third jobs to survive, thus reducing spread across facilities. This along with better access to PPE may have contributed to their lower COVID-19 infection and mortality rates relative to non-unionized staff.¹⁰

Similar to long-term care workers, home-care staff had related fears and anxieties, magnified by the need to enter multiple homes. This often overlooked but growing sector of the geriatric care workforce faced the added anxiety of the unknown as they entered multiple homes to provide care to their patients. These staff have little control over who may be in the home when they arrive, the sanitation/PPE practices of the patient/family, and therefore little control over their potential exposure to COVID-19. This also applies to home health aides who, although not providing medical services, are a critical part of home-care services and allow older adults to remain living independently in their home.

Reflection on Grief

As we witnessed the interactive effects of the pandemic and social inequities in geriatrics and palliative care, we frequently sought solace in online communities of psychologists working in similar settings. Over time, our regular community meetings developed a different tone: discussions about caring for others shifted to caring for ourselves. It seemed that in holding others’ pain, many of us neglected to address our own. We needed emotional support. We needed to acknowledge that we were not all okay; that the masks we wear for protection also reveal our vulnerabilities; and that protective equipment in hospitals do not protect us from the hate and bias targeting many of us face everywhere we go.

As we let ourselves be vulnerable with each other, we saw the true face of our pain: it was not stress, it was grief. We were sad, broken, mourning innumerable losses, and grieving, mostly alone. It felt overwhelming. Our minds and hearts often grew numb to find respite from pain. At times we found ourselves seeking haven in our offices, convincing ourselves that paperwork needed to be done when in reality we had no space to hold anyone else’s pain; we could barely contain our own. We could only take so much.

Without space to process, grief festers and eats away at our remaining compassion. How do we hold grace for ourselves, dare to be vulnerable, and allow ourselves to feel, when doing so opens the door to our own grief? How do we allow room for emotional processing when we learned to numb-out in order to function? And as women with diverse intersectional identities, how do we honor our humanity when we live in a society that reflects its indifference? We needed to process our pain in order to heal in the slow and uneven way that grief heals.

Caring During Tough Times

The pain we feel is real and it tears at us over time. Pushing it away disenfranchises ourselves of the opportunity to heal and grow. Our collective grief and trauma demand collective healing and acknowledgment of our individual suffering. We must honor our shared humanity and find commonality amid our differences. Typical self-care (healthy eating, sleep, basic hygiene) may not be enough to mitigate the enormity of these stressors. A glass of wine or a virtual dinner with friends may distract but does not heal our wounds.

Self-care, by definition, centers the self and ignores the larger systemic factors that maintain our struggles. It keeps the focus on the individual and in so doing, risks inducing self-blame should we continue feeling burnout. We must do more. We can advocate that systems acknowledge our grief and suffering as well as our strengths and resiliencies. We can demand that organizations recognize human limits and provide support, rather than promote environments that encourage silent perseverance. And we can deconstruct the cultural narrative that vulnerability is weakness or that we are the “heroes.” Heroism suggests superhuman qualities or extreme courage and often negates the fear and trepidation in its midst.^11,12 We can also recognize how intersectional aspects of our identities make navigating the pandemic and systemic racism harder and more dangerous for some than for others.

As noted by President Biden in a speech honoring those lost to COVID-19, “We have to resist becoming numb to the sorrow.”¹³ The nature of our work (and that of most clinicians) is that it is expected and sometimes necessary to compartmentalize and turn off the emotions so that we can function in a professional manner. But this way of being also serves to hold us back. It does not make space for the very real emotions of trauma and grief that have pervaded HCWs during this pandemic. We must learn a different way of functioning—one where grief is acknowledged and even actively processed while still going about our work. Grief therapist Megan Devine proposes to “tend to pain and grief by bearing witness” and notes that “when we allow the reality of grief to exist, we can focus on helping ourselves—and one another—survive inside pain.”¹⁴ She advocates for self-compassion and directs us to “find ways to show our grief to others, in ways that honor the truth of our experience” saying, “we have to be willing to stop diminishing our own pain so that others can be comfortable around us.” But what does this look like among health care teams who are traumatized and grieving?

In our experience, caring for ourselves and our teams in times of prolonged stress, trauma, and grief is essential to maintain functioning over time. We strongly believe that it must occur at both the organizational and individual levels. In the throes of a crisis, teams need support immediately. To offer a timely response, we gathered knowledge of team-based care and collaboration to develop practical strategies that can be implemented swiftly to provide support across the team.^15-19

The strategies we developed offer steps for creating and maintaining a supportive, compassionate, and psychologically safe work environment. First, the CARES Strategies for Practical Team Intervention highlights the importance of clear communication, assessing team needs regularly, recognizing the stress that is occurring, engaging staff in discussions, and ensuring psychological safety and comfort (Figure 1). Next, the SHARE approach is laid out to allow for interpersonal support among team members (Figure 2). Showing each other empathy, hoping for better days, acknowledging each other’s pain, reaching out for assistance, and expressing our needs allow HCWs to open up about their grief, stress, and trauma. Of note, we found these sets of strategies interdependent: a team that does not believe the leader/organization CARES is not likely to SHARE. Therefore, we also feel that it is especially important that team leaders work to create or enhance the sense of psychological safety for the team. If team members do not feel safe, they will not disclose their grief and remain stuck in the old mode of suffering in silence. 

Conclusions

This pandemic and the collective efforts toward social justice advocacy have revealed our vulnerabilities as well as our strengths. These experiences have forced us to reckon with our past and consider possible futures. It has revealed the inequities in our health care system, including our failure to protect those on the ground who keep our systems running, and prompted us to consider new ways of operating in low-resourced and high-demand environments. These experiences also present us with opportunities to be better and do better as both professionals and people; to reflect on our past and consider what we want different in our lives. As we yearn for better days and brace ourselves for what is to come, we hope that teams and organizations will take advantage of these opportunities for self-reflection and continue unmasking our grief, healing our wounds, and honoring our shared humanity.

Since the start of the pandemic, health care systems have requested many in-services for staff on self-care and stress management to help health care workers (HCWs) cope with the heavy toll of COVID-19. The pandemic has set off a global mental health crisis, with unprecedented numbers of individuals meeting criteria for anxiety, depression, and other mental health disorders in response to the intense stressors of living through a pandemic. These calls to assist staff with self-care and burnout prevention have been especially salient for psychologists working in palliative care and geriatrics, where fears of COVID-19 infection and numbers of patient deaths have been high.

Throughout these painful times, we have been grateful for an online community of palliative care psychologists within the US Department of Veterans Affairs (VA) from across the continuum of care and across the country. This community brought together many of us who were both struggling ourselves and striving to support the teams and HCWs around us. We are psychologists who provide home-care services in North Carolina, inpatient hospice and long-term care services in California, and long-term care and outpatient palliative care services in Massachusetts. Through our shared struggles and challenges navigating the pandemic, we realized that our respective teams requested similar services, all focused on staff support.

The psychological impact of COVID-19 on HCWs was clear from the beginning. Early in the pandemic our respective teams requested us to provide staff support and education about coping to our local HCWs. Soon national groups for long-term care staff requested education programs. Through this work, we realized that the emotional needs of HCWs ran much deeper than simple self-care. At the onset of the pandemic, before realizing its chronicity, the trainings we offered focused on stress and coping strategies. We cited several frameworks for staff support and eagerly shared anything that might help us, and our colleagues, survive the immediate anxiety and tumult surrounding us.^1-3 In this paper, we briefly discuss the distress affecting the geriatric care workforce, reflect on our efforts to cope as HCWs, and offer recommendations at individual and organization levels to help address our collective grief.

Impact of COVID-19

As the death toll mounted and hospitals were pushed to the brink, we saw the suffering of our fellow HCWs. The lack of personal protective equipment (PPE) and testing supplies led to evolving and increasing anxiety for HCWs about contracting COVID-19, potentially spreading it to one’s social circle or family, fears of becoming sick and dying, and fears of inadvertently spreading the virus to medically-vulnerable patients. Increasing demands on staff required many to work outside their areas of expertise. Clinical practice guidelines changed frequently as information emerged about the virus. Staff members struggled to keep pace with the increasing number of patients, many of whom died despite heroic efforts to save them.

As the medical crisis grew, so too did social uprisings as the general public gained a strengthened awareness of the legacy and ongoing effects of systemic oppression, racism, and social inequities in the United States. Individuals grappled with their own privileges, which often hid such disparities from view. Many HCWs and clinicians of color had to navigate unsolicited questions and discussions about racial injustices while also trying to survive. As psychologists, we strove to support the HCWs around us while also struggling with our own stressors. As the magnitude of the pandemic and ongoing social injustices came into view, we realized that presentations on self-care and burnout prevention did not suffice. We needed discussions on unmasking our grief, acknowledging our traumas, and working toward collective healing.

Geriatric Care Workers

Experiences of grief and trauma hit the geriatric care workforce and especially long-term care facilities particularly hard given the high morbidity and mortality rates of COVID-19.⁴ The geriatric care workforce itself suffers from institutional vulnerabilities. Individuals are often underpaid, undertrained, and work within a system that continually experiences staffing shortages, high burnout, and consequently high levels of turnover.^5,6 Recent immigrants and racial/ethnic minorities disproportionately make up this workforce, who often live in multigenerational households and work in multiple facilities to get by.^7,8 Amid the pandemic these HCWs continued to work despite demoralizing negative media coverage of nursing homes.⁹ Notably, facilities with unionized staff were less likely to need second or third jobs to survive, thus reducing spread across facilities. This along with better access to PPE may have contributed to their lower COVID-19 infection and mortality rates relative to non-unionized staff.¹⁰

Similar to long-term care workers, home-care staff had related fears and anxieties, magnified by the need to enter multiple homes. This often overlooked but growing sector of the geriatric care workforce faced the added anxiety of the unknown as they entered multiple homes to provide care to their patients. These staff have little control over who may be in the home when they arrive, the sanitation/PPE practices of the patient/family, and therefore little control over their potential exposure to COVID-19. This also applies to home health aides who, although not providing medical services, are a critical part of home-care services and allow older adults to remain living independently in their home.

Reflection on Grief

As we witnessed the interactive effects of the pandemic and social inequities in geriatrics and palliative care, we frequently sought solace in online communities of psychologists working in similar settings. Over time, our regular community meetings developed a different tone: discussions about caring for others shifted to caring for ourselves. It seemed that in holding others’ pain, many of us neglected to address our own. We needed emotional support. We needed to acknowledge that we were not all okay; that the masks we wear for protection also reveal our vulnerabilities; and that protective equipment in hospitals do not protect us from the hate and bias targeting many of us face everywhere we go.

As we let ourselves be vulnerable with each other, we saw the true face of our pain: it was not stress, it was grief. We were sad, broken, mourning innumerable losses, and grieving, mostly alone. It felt overwhelming. Our minds and hearts often grew numb to find respite from pain. At times we found ourselves seeking haven in our offices, convincing ourselves that paperwork needed to be done when in reality we had no space to hold anyone else’s pain; we could barely contain our own. We could only take so much.

Without space to process, grief festers and eats away at our remaining compassion. How do we hold grace for ourselves, dare to be vulnerable, and allow ourselves to feel, when doing so opens the door to our own grief? How do we allow room for emotional processing when we learned to numb-out in order to function? And as women with diverse intersectional identities, how do we honor our humanity when we live in a society that reflects its indifference? We needed to process our pain in order to heal in the slow and uneven way that grief heals.

Caring During Tough Times

The pain we feel is real and it tears at us over time. Pushing it away disenfranchises ourselves of the opportunity to heal and grow. Our collective grief and trauma demand collective healing and acknowledgment of our individual suffering. We must honor our shared humanity and find commonality amid our differences. Typical self-care (healthy eating, sleep, basic hygiene) may not be enough to mitigate the enormity of these stressors. A glass of wine or a virtual dinner with friends may distract but does not heal our wounds.

Self-care, by definition, centers the self and ignores the larger systemic factors that maintain our struggles. It keeps the focus on the individual and in so doing, risks inducing self-blame should we continue feeling burnout. We must do more. We can advocate that systems acknowledge our grief and suffering as well as our strengths and resiliencies. We can demand that organizations recognize human limits and provide support, rather than promote environments that encourage silent perseverance. And we can deconstruct the cultural narrative that vulnerability is weakness or that we are the “heroes.” Heroism suggests superhuman qualities or extreme courage and often negates the fear and trepidation in its midst.^11,12 We can also recognize how intersectional aspects of our identities make navigating the pandemic and systemic racism harder and more dangerous for some than for others.

As noted by President Biden in a speech honoring those lost to COVID-19, “We have to resist becoming numb to the sorrow.”¹³ The nature of our work (and that of most clinicians) is that it is expected and sometimes necessary to compartmentalize and turn off the emotions so that we can function in a professional manner. But this way of being also serves to hold us back. It does not make space for the very real emotions of trauma and grief that have pervaded HCWs during this pandemic. We must learn a different way of functioning—one where grief is acknowledged and even actively processed while still going about our work. Grief therapist Megan Devine proposes to “tend to pain and grief by bearing witness” and notes that “when we allow the reality of grief to exist, we can focus on helping ourselves—and one another—survive inside pain.”¹⁴ She advocates for self-compassion and directs us to “find ways to show our grief to others, in ways that honor the truth of our experience” saying, “we have to be willing to stop diminishing our own pain so that others can be comfortable around us.” But what does this look like among health care teams who are traumatized and grieving?

In our experience, caring for ourselves and our teams in times of prolonged stress, trauma, and grief is essential to maintain functioning over time. We strongly believe that it must occur at both the organizational and individual levels. In the throes of a crisis, teams need support immediately. To offer a timely response, we gathered knowledge of team-based care and collaboration to develop practical strategies that can be implemented swiftly to provide support across the team.^15-19

The strategies we developed offer steps for creating and maintaining a supportive, compassionate, and psychologically safe work environment. First, the CARES Strategies for Practical Team Intervention highlights the importance of clear communication, assessing team needs regularly, recognizing the stress that is occurring, engaging staff in discussions, and ensuring psychological safety and comfort (Figure 1). Next, the SHARE approach is laid out to allow for interpersonal support among team members (Figure 2). Showing each other empathy, hoping for better days, acknowledging each other’s pain, reaching out for assistance, and expressing our needs allow HCWs to open up about their grief, stress, and trauma. Of note, we found these sets of strategies interdependent: a team that does not believe the leader/organization CARES is not likely to SHARE. Therefore, we also feel that it is especially important that team leaders work to create or enhance the sense of psychological safety for the team. If team members do not feel safe, they will not disclose their grief and remain stuck in the old mode of suffering in silence. 

Conclusions

This pandemic and the collective efforts toward social justice advocacy have revealed our vulnerabilities as well as our strengths. These experiences have forced us to reckon with our past and consider possible futures. It has revealed the inequities in our health care system, including our failure to protect those on the ground who keep our systems running, and prompted us to consider new ways of operating in low-resourced and high-demand environments. These experiences also present us with opportunities to be better and do better as both professionals and people; to reflect on our past and consider what we want different in our lives. As we yearn for better days and brace ourselves for what is to come, we hope that teams and organizations will take advantage of these opportunities for self-reflection and continue unmasking our grief, healing our wounds, and honoring our shared humanity.

Since the start of the pandemic, health care systems have requested many in-services for staff on self-care and stress management to help health care workers (HCWs) cope with the heavy toll of COVID-19. The pandemic has set off a global mental health crisis, with unprecedented numbers of individuals meeting criteria for anxiety, depression, and other mental health disorders in response to the intense stressors of living through a pandemic. These calls to assist staff with self-care and burnout prevention have been especially salient for psychologists working in palliative care and geriatrics, where fears of COVID-19 infection and numbers of patient deaths have been high.

Throughout these painful times, we have been grateful for an online community of palliative care psychologists within the US Department of Veterans Affairs (VA) from across the continuum of care and across the country. This community brought together many of us who were both struggling ourselves and striving to support the teams and HCWs around us. We are psychologists who provide home-care services in North Carolina, inpatient hospice and long-term care services in California, and long-term care and outpatient palliative care services in Massachusetts. Through our shared struggles and challenges navigating the pandemic, we realized that our respective teams requested similar services, all focused on staff support.

The psychological impact of COVID-19 on HCWs was clear from the beginning. Early in the pandemic our respective teams requested us to provide staff support and education about coping to our local HCWs. Soon national groups for long-term care staff requested education programs. Through this work, we realized that the emotional needs of HCWs ran much deeper than simple self-care. At the onset of the pandemic, before realizing its chronicity, the trainings we offered focused on stress and coping strategies. We cited several frameworks for staff support and eagerly shared anything that might help us, and our colleagues, survive the immediate anxiety and tumult surrounding us.^1-3 In this paper, we briefly discuss the distress affecting the geriatric care workforce, reflect on our efforts to cope as HCWs, and offer recommendations at individual and organization levels to help address our collective grief.

Impact of COVID-19

As the death toll mounted and hospitals were pushed to the brink, we saw the suffering of our fellow HCWs. The lack of personal protective equipment (PPE) and testing supplies led to evolving and increasing anxiety for HCWs about contracting COVID-19, potentially spreading it to one’s social circle or family, fears of becoming sick and dying, and fears of inadvertently spreading the virus to medically-vulnerable patients. Increasing demands on staff required many to work outside their areas of expertise. Clinical practice guidelines changed frequently as information emerged about the virus. Staff members struggled to keep pace with the increasing number of patients, many of whom died despite heroic efforts to save them.

As the medical crisis grew, so too did social uprisings as the general public gained a strengthened awareness of the legacy and ongoing effects of systemic oppression, racism, and social inequities in the United States. Individuals grappled with their own privileges, which often hid such disparities from view. Many HCWs and clinicians of color had to navigate unsolicited questions and discussions about racial injustices while also trying to survive. As psychologists, we strove to support the HCWs around us while also struggling with our own stressors. As the magnitude of the pandemic and ongoing social injustices came into view, we realized that presentations on self-care and burnout prevention did not suffice. We needed discussions on unmasking our grief, acknowledging our traumas, and working toward collective healing.

Geriatric Care Workers

Experiences of grief and trauma hit the geriatric care workforce and especially long-term care facilities particularly hard given the high morbidity and mortality rates of COVID-19.⁴ The geriatric care workforce itself suffers from institutional vulnerabilities. Individuals are often underpaid, undertrained, and work within a system that continually experiences staffing shortages, high burnout, and consequently high levels of turnover.^5,6 Recent immigrants and racial/ethnic minorities disproportionately make up this workforce, who often live in multigenerational households and work in multiple facilities to get by.^7,8 Amid the pandemic these HCWs continued to work despite demoralizing negative media coverage of nursing homes.⁹ Notably, facilities with unionized staff were less likely to need second or third jobs to survive, thus reducing spread across facilities. This along with better access to PPE may have contributed to their lower COVID-19 infection and mortality rates relative to non-unionized staff.¹⁰

Similar to long-term care workers, home-care staff had related fears and anxieties, magnified by the need to enter multiple homes. This often overlooked but growing sector of the geriatric care workforce faced the added anxiety of the unknown as they entered multiple homes to provide care to their patients. These staff have little control over who may be in the home when they arrive, the sanitation/PPE practices of the patient/family, and therefore little control over their potential exposure to COVID-19. This also applies to home health aides who, although not providing medical services, are a critical part of home-care services and allow older adults to remain living independently in their home.

Reflection on Grief

As we witnessed the interactive effects of the pandemic and social inequities in geriatrics and palliative care, we frequently sought solace in online communities of psychologists working in similar settings. Over time, our regular community meetings developed a different tone: discussions about caring for others shifted to caring for ourselves. It seemed that in holding others’ pain, many of us neglected to address our own. We needed emotional support. We needed to acknowledge that we were not all okay; that the masks we wear for protection also reveal our vulnerabilities; and that protective equipment in hospitals do not protect us from the hate and bias targeting many of us face everywhere we go.

As we let ourselves be vulnerable with each other, we saw the true face of our pain: it was not stress, it was grief. We were sad, broken, mourning innumerable losses, and grieving, mostly alone. It felt overwhelming. Our minds and hearts often grew numb to find respite from pain. At times we found ourselves seeking haven in our offices, convincing ourselves that paperwork needed to be done when in reality we had no space to hold anyone else’s pain; we could barely contain our own. We could only take so much.

Without space to process, grief festers and eats away at our remaining compassion. How do we hold grace for ourselves, dare to be vulnerable, and allow ourselves to feel, when doing so opens the door to our own grief? How do we allow room for emotional processing when we learned to numb-out in order to function? And as women with diverse intersectional identities, how do we honor our humanity when we live in a society that reflects its indifference? We needed to process our pain in order to heal in the slow and uneven way that grief heals.

Caring During Tough Times

The pain we feel is real and it tears at us over time. Pushing it away disenfranchises ourselves of the opportunity to heal and grow. Our collective grief and trauma demand collective healing and acknowledgment of our individual suffering. We must honor our shared humanity and find commonality amid our differences. Typical self-care (healthy eating, sleep, basic hygiene) may not be enough to mitigate the enormity of these stressors. A glass of wine or a virtual dinner with friends may distract but does not heal our wounds.

Self-care, by definition, centers the self and ignores the larger systemic factors that maintain our struggles. It keeps the focus on the individual and in so doing, risks inducing self-blame should we continue feeling burnout. We must do more. We can advocate that systems acknowledge our grief and suffering as well as our strengths and resiliencies. We can demand that organizations recognize human limits and provide support, rather than promote environments that encourage silent perseverance. And we can deconstruct the cultural narrative that vulnerability is weakness or that we are the “heroes.” Heroism suggests superhuman qualities or extreme courage and often negates the fear and trepidation in its midst.^11,12 We can also recognize how intersectional aspects of our identities make navigating the pandemic and systemic racism harder and more dangerous for some than for others.

As noted by President Biden in a speech honoring those lost to COVID-19, “We have to resist becoming numb to the sorrow.”¹³ The nature of our work (and that of most clinicians) is that it is expected and sometimes necessary to compartmentalize and turn off the emotions so that we can function in a professional manner. But this way of being also serves to hold us back. It does not make space for the very real emotions of trauma and grief that have pervaded HCWs during this pandemic. We must learn a different way of functioning—one where grief is acknowledged and even actively processed while still going about our work. Grief therapist Megan Devine proposes to “tend to pain and grief by bearing witness” and notes that “when we allow the reality of grief to exist, we can focus on helping ourselves—and one another—survive inside pain.”¹⁴ She advocates for self-compassion and directs us to “find ways to show our grief to others, in ways that honor the truth of our experience” saying, “we have to be willing to stop diminishing our own pain so that others can be comfortable around us.” But what does this look like among health care teams who are traumatized and grieving?

In our experience, caring for ourselves and our teams in times of prolonged stress, trauma, and grief is essential to maintain functioning over time. We strongly believe that it must occur at both the organizational and individual levels. In the throes of a crisis, teams need support immediately. To offer a timely response, we gathered knowledge of team-based care and collaboration to develop practical strategies that can be implemented swiftly to provide support across the team.^15-19

The strategies we developed offer steps for creating and maintaining a supportive, compassionate, and psychologically safe work environment. First, the CARES Strategies for Practical Team Intervention highlights the importance of clear communication, assessing team needs regularly, recognizing the stress that is occurring, engaging staff in discussions, and ensuring psychological safety and comfort (Figure 1). Next, the SHARE approach is laid out to allow for interpersonal support among team members (Figure 2). Showing each other empathy, hoping for better days, acknowledging each other’s pain, reaching out for assistance, and expressing our needs allow HCWs to open up about their grief, stress, and trauma. Of note, we found these sets of strategies interdependent: a team that does not believe the leader/organization CARES is not likely to SHARE. Therefore, we also feel that it is especially important that team leaders work to create or enhance the sense of psychological safety for the team. If team members do not feel safe, they will not disclose their grief and remain stuck in the old mode of suffering in silence. 

Conclusions

This pandemic and the collective efforts toward social justice advocacy have revealed our vulnerabilities as well as our strengths. These experiences have forced us to reckon with our past and consider possible futures. It has revealed the inequities in our health care system, including our failure to protect those on the ground who keep our systems running, and prompted us to consider new ways of operating in low-resourced and high-demand environments. These experiences also present us with opportunities to be better and do better as both professionals and people; to reflect on our past and consider what we want different in our lives. As we yearn for better days and brace ourselves for what is to come, we hope that teams and organizations will take advantage of these opportunities for self-reflection and continue unmasking our grief, healing our wounds, and honoring our shared humanity.

A newly updated version of the Model for End-Stage Liver Disease (MELD) score was effective for predicting short-term mortality in patients with end-stage liver disease and addressed important determinants of wait list outcomes that haven’t been addressed in previous versions, according to findings from a recent study. The new model, termed MELD 3.0, includes new variables such as female sex, serum albumin, and updated creatinine cutoffs.

Thomas Northcut/Getty Images

“We believe that the new model represents an opportunity to lower wait list mortality in the United States and propose it to be considered to replace the current version of MELD in determining allocation priorities in liver transplantation,” wrote study authors W. Ray Kim, MD, of Stanford (Calif.) University and colleagues in Gastroenterology.

In patients with end-stage liver disease, the MELD score was shown to be a reliable predictor of short-term survival, according to the researchers. The original version of MELD consists of international normalized ratio of prothrombin time and serum concentrations of bilirubin and creatinine; MELDNa consists of the same with the addition of serum concentrations of total sodium. Since 2016, MELDNa has been utilized in the United States to allocate livers for transplant.

Despite the utility of the current MELD score, questions have been raised concerning the accuracy of the tool’s ability to predict mortality, including a study by Sumeet K. Asrani, MD, MSc, and colleagues. Changes in liver disease epidemiology, the introduction of newer therapies that alter prognosis, as well as increasing age and prevalence of comorbidities in transplant-eligible patients are several drivers for these concerns, according to Dr. Kim and colleagues. Also, there is an increasing concern regarding women and their potential disadvantages in the current system: At least one study has suggested that serum creatinine may overestimate renal function and consequently underestimate mortality risk in female patients, compared with men with the same creatinine level.

Dr. Kim and colleagues sought to further optimize the fit of the current MELD score by considering alternative interactions and including other variables relevant to predicting short-term mortality in patients awaiting liver transplant. The study included patients who are registered on the Organ Procurement and Transplantation Network Standard Transplant Analysis and Research files newly wait-listed from 2016 through 2018. The full cohort was divided 70:30 into a development set (n = 20,587) and a validation set (n = 8,823); there were no significant differences between the sets in respect to age, sex, race, or liver disease severity.

The investigators used univariable and multivariable regression models to predict 90-day survival following wait list registration. The 90-day Kaplan-Meier survival rate in the development set was 91.3%. Additionally, model fit was tested, and the investigators used the Liver Simulated Allocation Model to estimate the impact of replacing the current version of the MELD with MELD 3.0.

In the final MELD 3.0 model, the researchers included several additional variables such as female sex and serum albumin. Additionally, the final model was characterized by interactions between bilirubin and sodium as well as between albumin and creatinine. Also, an adjustment to the current version of MELD lowering the upper bound for creatinine from 4.0 mg/dL to 3.0 mg/dL.

The MELD 3.0 featured significantly better discrimination, compared with the MELDNa (C-statistic = 0.8693 vs. 0.8622, respectively; P < .01). In addition, the researchers wrote that the new MELD 3.0 score “correctly reclassified a net of 8.8% of decedents to a higher MELD tier, affording them a meaningfully higher chance of transplantation, particularly in women.” The MELD 3.0 score with albumin also led to fewer wait-list deaths, compared with the MELDNa, according to the Liver Simulated Allocation Model analysis (P = .02); the number for MELD 3.0 without albumin was not statistically significant.

According to the investigators, a cause of concern for the MELD 3.0 was the addition of albumin, as this variable may be vulnerable to manipulation. In addition, the researchers note that, while differences in wait list mortality and survival based on race/ethnicity were observed in the study, they were unable to describe the exact root causes of worse outcomes among patients belonging to minority groups. “Thus, inclusion in a risk prediction score without fully understanding the underlying reasons for the racial disparity may have unintended consequences,” the researchers wrote.

“Based on recent data consisting of liver transplant candidates in the United States, we identify additional variables that are meaningfully associated with short-term mortality, including female sex and serum albumin. We also found evidence to support lowering the serum creatinine ceiling to 3 mg/dL,” they wrote. “Based on these data, we created an updated version of the MELD score, which improves mortality prediction compared to the current MELDNa model, including the recognition of female sex as a risk factor for death.”

The researchers reported no conflicts of interest with the pharmaceutical industry. No funding was reported for the study.

A newly updated version of the Model for End-Stage Liver Disease (MELD) score was effective for predicting short-term mortality in patients with end-stage liver disease and addressed important determinants of wait list outcomes that haven’t been addressed in previous versions, according to findings from a recent study. The new model, termed MELD 3.0, includes new variables such as female sex, serum albumin, and updated creatinine cutoffs.

Thomas Northcut/Getty Images

“We believe that the new model represents an opportunity to lower wait list mortality in the United States and propose it to be considered to replace the current version of MELD in determining allocation priorities in liver transplantation,” wrote study authors W. Ray Kim, MD, of Stanford (Calif.) University and colleagues in Gastroenterology.

In patients with end-stage liver disease, the MELD score was shown to be a reliable predictor of short-term survival, according to the researchers. The original version of MELD consists of international normalized ratio of prothrombin time and serum concentrations of bilirubin and creatinine; MELDNa consists of the same with the addition of serum concentrations of total sodium. Since 2016, MELDNa has been utilized in the United States to allocate livers for transplant.

Despite the utility of the current MELD score, questions have been raised concerning the accuracy of the tool’s ability to predict mortality, including a study by Sumeet K. Asrani, MD, MSc, and colleagues. Changes in liver disease epidemiology, the introduction of newer therapies that alter prognosis, as well as increasing age and prevalence of comorbidities in transplant-eligible patients are several drivers for these concerns, according to Dr. Kim and colleagues. Also, there is an increasing concern regarding women and their potential disadvantages in the current system: At least one study has suggested that serum creatinine may overestimate renal function and consequently underestimate mortality risk in female patients, compared with men with the same creatinine level.

Dr. Kim and colleagues sought to further optimize the fit of the current MELD score by considering alternative interactions and including other variables relevant to predicting short-term mortality in patients awaiting liver transplant. The study included patients who are registered on the Organ Procurement and Transplantation Network Standard Transplant Analysis and Research files newly wait-listed from 2016 through 2018. The full cohort was divided 70:30 into a development set (n = 20,587) and a validation set (n = 8,823); there were no significant differences between the sets in respect to age, sex, race, or liver disease severity.

The investigators used univariable and multivariable regression models to predict 90-day survival following wait list registration. The 90-day Kaplan-Meier survival rate in the development set was 91.3%. Additionally, model fit was tested, and the investigators used the Liver Simulated Allocation Model to estimate the impact of replacing the current version of the MELD with MELD 3.0.

In the final MELD 3.0 model, the researchers included several additional variables such as female sex and serum albumin. Additionally, the final model was characterized by interactions between bilirubin and sodium as well as between albumin and creatinine. Also, an adjustment to the current version of MELD lowering the upper bound for creatinine from 4.0 mg/dL to 3.0 mg/dL.

The MELD 3.0 featured significantly better discrimination, compared with the MELDNa (C-statistic = 0.8693 vs. 0.8622, respectively; P < .01). In addition, the researchers wrote that the new MELD 3.0 score “correctly reclassified a net of 8.8% of decedents to a higher MELD tier, affording them a meaningfully higher chance of transplantation, particularly in women.” The MELD 3.0 score with albumin also led to fewer wait-list deaths, compared with the MELDNa, according to the Liver Simulated Allocation Model analysis (P = .02); the number for MELD 3.0 without albumin was not statistically significant.

According to the investigators, a cause of concern for the MELD 3.0 was the addition of albumin, as this variable may be vulnerable to manipulation. In addition, the researchers note that, while differences in wait list mortality and survival based on race/ethnicity were observed in the study, they were unable to describe the exact root causes of worse outcomes among patients belonging to minority groups. “Thus, inclusion in a risk prediction score without fully understanding the underlying reasons for the racial disparity may have unintended consequences,” the researchers wrote.

“Based on recent data consisting of liver transplant candidates in the United States, we identify additional variables that are meaningfully associated with short-term mortality, including female sex and serum albumin. We also found evidence to support lowering the serum creatinine ceiling to 3 mg/dL,” they wrote. “Based on these data, we created an updated version of the MELD score, which improves mortality prediction compared to the current MELDNa model, including the recognition of female sex as a risk factor for death.”

The researchers reported no conflicts of interest with the pharmaceutical industry. No funding was reported for the study.

A newly updated version of the Model for End-Stage Liver Disease (MELD) score was effective for predicting short-term mortality in patients with end-stage liver disease and addressed important determinants of wait list outcomes that haven’t been addressed in previous versions, according to findings from a recent study. The new model, termed MELD 3.0, includes new variables such as female sex, serum albumin, and updated creatinine cutoffs.

Thomas Northcut/Getty Images

“We believe that the new model represents an opportunity to lower wait list mortality in the United States and propose it to be considered to replace the current version of MELD in determining allocation priorities in liver transplantation,” wrote study authors W. Ray Kim, MD, of Stanford (Calif.) University and colleagues in Gastroenterology.

In patients with end-stage liver disease, the MELD score was shown to be a reliable predictor of short-term survival, according to the researchers. The original version of MELD consists of international normalized ratio of prothrombin time and serum concentrations of bilirubin and creatinine; MELDNa consists of the same with the addition of serum concentrations of total sodium. Since 2016, MELDNa has been utilized in the United States to allocate livers for transplant.

Despite the utility of the current MELD score, questions have been raised concerning the accuracy of the tool’s ability to predict mortality, including a study by Sumeet K. Asrani, MD, MSc, and colleagues. Changes in liver disease epidemiology, the introduction of newer therapies that alter prognosis, as well as increasing age and prevalence of comorbidities in transplant-eligible patients are several drivers for these concerns, according to Dr. Kim and colleagues. Also, there is an increasing concern regarding women and their potential disadvantages in the current system: At least one study has suggested that serum creatinine may overestimate renal function and consequently underestimate mortality risk in female patients, compared with men with the same creatinine level.

Dr. Kim and colleagues sought to further optimize the fit of the current MELD score by considering alternative interactions and including other variables relevant to predicting short-term mortality in patients awaiting liver transplant. The study included patients who are registered on the Organ Procurement and Transplantation Network Standard Transplant Analysis and Research files newly wait-listed from 2016 through 2018. The full cohort was divided 70:30 into a development set (n = 20,587) and a validation set (n = 8,823); there were no significant differences between the sets in respect to age, sex, race, or liver disease severity.

The investigators used univariable and multivariable regression models to predict 90-day survival following wait list registration. The 90-day Kaplan-Meier survival rate in the development set was 91.3%. Additionally, model fit was tested, and the investigators used the Liver Simulated Allocation Model to estimate the impact of replacing the current version of the MELD with MELD 3.0.

In the final MELD 3.0 model, the researchers included several additional variables such as female sex and serum albumin. Additionally, the final model was characterized by interactions between bilirubin and sodium as well as between albumin and creatinine. Also, an adjustment to the current version of MELD lowering the upper bound for creatinine from 4.0 mg/dL to 3.0 mg/dL.

The MELD 3.0 featured significantly better discrimination, compared with the MELDNa (C-statistic = 0.8693 vs. 0.8622, respectively; P < .01). In addition, the researchers wrote that the new MELD 3.0 score “correctly reclassified a net of 8.8% of decedents to a higher MELD tier, affording them a meaningfully higher chance of transplantation, particularly in women.” The MELD 3.0 score with albumin also led to fewer wait-list deaths, compared with the MELDNa, according to the Liver Simulated Allocation Model analysis (P = .02); the number for MELD 3.0 without albumin was not statistically significant.

According to the investigators, a cause of concern for the MELD 3.0 was the addition of albumin, as this variable may be vulnerable to manipulation. In addition, the researchers note that, while differences in wait list mortality and survival based on race/ethnicity were observed in the study, they were unable to describe the exact root causes of worse outcomes among patients belonging to minority groups. “Thus, inclusion in a risk prediction score without fully understanding the underlying reasons for the racial disparity may have unintended consequences,” the researchers wrote.

“Based on recent data consisting of liver transplant candidates in the United States, we identify additional variables that are meaningfully associated with short-term mortality, including female sex and serum albumin. We also found evidence to support lowering the serum creatinine ceiling to 3 mg/dL,” they wrote. “Based on these data, we created an updated version of the MELD score, which improves mortality prediction compared to the current MELDNa model, including the recognition of female sex as a risk factor for death.”

The researchers reported no conflicts of interest with the pharmaceutical industry. No funding was reported for the study.

Vineet Chopra, MD, MSc, FHM, recently became chair of the Department of Medicine at the University of Colorado School of Medicine, Aurora. He had previously been the chief of the Division of Hospital Medicine at the University of Michigan Health system. He assumed his new role in October 2021.

Dr. Chopra, who specializes in research and mentorship in patient safety, helped create innovations in care delivery at the University of Michigan, including direct care hospitalist services at VA Ann Arbor Health Care and two other community hospitals.

In his safety-conscious research, Dr. Chopra focuses on preventing complications created within the hospital environment. He also is the first hospitalist to be named deputy editor of the Annals of Internal Medicine. He has written more than 250 peer-reviewed articles. Among the myriad awards he has received, Dr. Chopra recently earned the Kaiser Permanente Award for Clinical Teaching at the UM School of Medicine.
 

Steve Phillipson, MD, FHM, has been named regional director of hospital medicine at Aspirus Health (Wausau, Wisc.). Dr. Phillipson will oversee the hospitalist programs at 17 Aspirus hospitals in Wisconsin and Michigan.

Dr. Phillipson has worked with Aspirus since 2009, with stints in the emergency department and as a hospitalist. As Aspirus Wausau Hospital director of medicine, he chaired the facility’s COVID-19 treatment team.
 

Hackensack (N.J.) Meridian University Medical Center has hired Patricia (Patti) L. Fisher, MD, MHA, to be the institution’s chief medical officer. Dr. Fisher joined the medical center from Central Vermont Medical Center where she served as chief medical officer and chief safety officer, with direct oversight of hospital risk management, operations of all hospital-based services, IS services and quality including patient safety and regulatory compliance.

As a board-certified hospitalist, Dr. Fisher also served as clinical assistant professor in the Department of Family Medicine at the University of Vermont, Burlington. Dr. Fisher earned her medical degree from The University of Texas in Houston and completed residency through Forbes Family Practice Residency in Pittsburgh.
 

Martin Chaney, MD, has been chosen by the Maury Regional Health Board of Trustees to serve as interim chief executive officer. He was formerly the chief medical officer at MRH, which is based in Columbia, Tenn. Dr. Chaney began his new role in October, replacing Alan Watson, the CEO since 2012.

Dr. Chaney has spent 18 of his 25 years in medicine with MRH, where most recently he has focused on clinical quality, physician recruitment, and establishing and expanding the hospital medicine program.
 

Hyung (Harry) Cho, MD, SFHM, has been placed on Modern Healthcare’s Top 25 Innovators list for 2021, getting recognized for innovation and leadership in creating value and safety initiatives in New York City’s public health system. Dr. Cho became NYC Health + Hospitals’ first chief value officer in 2019, and his programs have created an estimated $11 million in savings per year by preventing unnecessary testing and treatment that can lead to patient harm.

A member of the Society of Hospital Medicine’s editorial advisory board, Dr. Cho is also SHM’s hospitalist liaison with the COVID-19 Real-Time Learning Network, which collaborates with the Centers for Disease Control and Prevention and the Infectious Diseases Society of America.
 

Raymond Kiser, MD, a hospitalist and nephrologist at Columbus (Ind.) Regional Health, has been named the Douglas J. Leonard Caregiver of the Year. The award is given by the Indiana Hospital Association to health care workers whose care is considered exemplary by both peers and patients.

Dr. Kiser has been with CRH for 7 years, including stints as associate chief medical officer and chief of staff.
 

Justin Buchholz, DO, has been elevated to medical director of the hospitalist teams at Regional Medical Center (Alamosa, Colo.) and Conejos County Hospital (La Jara, Colo.). Dr. Buchholz has been a full-time hospitalist and assistant medical director at Parkview Medical Center (Pueblo, Colo.) for the past 3 years. He also worked on a part-time basis seeing patients at the Regional Medical Center.

Dr. Buchholz completed his residency at Parkview Medical Center and was named Resident of the Year in his final year with the internal medicine program.
 

Kenneth Mishark, MD, SFHM, a hospitalist with the Mayo Clinic Hospital (Tucson, Ariz.), will serve on the board of directors for Anigent, a drug diversion-prevention company based in Chesterfield, Mo. He will be charged with helping Anigent better serve health systems with its drug-diversion software.

Dr. Mishark is vice-chair of diversion prevention across the whole Mayo Clinic. A one-time physician in the United States Air Force, Dr. Mishark previously has been the Mayo Clinic’s Healthcare Information Coordination Committee chair.
 

Core Clinical Partners (Tulsa, Okla.) has announced it will join with Hillcrest HealthCare System (Tulsa, Okla.) to provide hospitalist services to Hillcrest’s eight sites across Oklahoma. The partnership will begin at four locations in December 2021, and four others in March 2022.

In expanding its services, Core Clinical Partners will create 70 new physician positions, as well as a systemwide medical director. Core will manage hospitalist operations at Hillcrest Medical Center, Hillcrest Hospital South, Hillcrest Hospital Pryor, Hillcrest Hospital Claremore, Bailey Medical Center, Hillcrest Hospital Cushing, Hillcrest Hospital Henryetta, and Tulsa Spine and Specialty Hospital.

Vineet Chopra, MD, MSc, FHM, recently became chair of the Department of Medicine at the University of Colorado School of Medicine, Aurora. He had previously been the chief of the Division of Hospital Medicine at the University of Michigan Health system. He assumed his new role in October 2021.

Dr. Chopra, who specializes in research and mentorship in patient safety, helped create innovations in care delivery at the University of Michigan, including direct care hospitalist services at VA Ann Arbor Health Care and two other community hospitals.

In his safety-conscious research, Dr. Chopra focuses on preventing complications created within the hospital environment. He also is the first hospitalist to be named deputy editor of the Annals of Internal Medicine. He has written more than 250 peer-reviewed articles. Among the myriad awards he has received, Dr. Chopra recently earned the Kaiser Permanente Award for Clinical Teaching at the UM School of Medicine.
 

Steve Phillipson, MD, FHM, has been named regional director of hospital medicine at Aspirus Health (Wausau, Wisc.). Dr. Phillipson will oversee the hospitalist programs at 17 Aspirus hospitals in Wisconsin and Michigan.

Dr. Phillipson has worked with Aspirus since 2009, with stints in the emergency department and as a hospitalist. As Aspirus Wausau Hospital director of medicine, he chaired the facility’s COVID-19 treatment team.
 

Hackensack (N.J.) Meridian University Medical Center has hired Patricia (Patti) L. Fisher, MD, MHA, to be the institution’s chief medical officer. Dr. Fisher joined the medical center from Central Vermont Medical Center where she served as chief medical officer and chief safety officer, with direct oversight of hospital risk management, operations of all hospital-based services, IS services and quality including patient safety and regulatory compliance.

As a board-certified hospitalist, Dr. Fisher also served as clinical assistant professor in the Department of Family Medicine at the University of Vermont, Burlington. Dr. Fisher earned her medical degree from The University of Texas in Houston and completed residency through Forbes Family Practice Residency in Pittsburgh.
 

Martin Chaney, MD, has been chosen by the Maury Regional Health Board of Trustees to serve as interim chief executive officer. He was formerly the chief medical officer at MRH, which is based in Columbia, Tenn. Dr. Chaney began his new role in October, replacing Alan Watson, the CEO since 2012.

Dr. Chaney has spent 18 of his 25 years in medicine with MRH, where most recently he has focused on clinical quality, physician recruitment, and establishing and expanding the hospital medicine program.
 

Hyung (Harry) Cho, MD, SFHM, has been placed on Modern Healthcare’s Top 25 Innovators list for 2021, getting recognized for innovation and leadership in creating value and safety initiatives in New York City’s public health system. Dr. Cho became NYC Health + Hospitals’ first chief value officer in 2019, and his programs have created an estimated $11 million in savings per year by preventing unnecessary testing and treatment that can lead to patient harm.

A member of the Society of Hospital Medicine’s editorial advisory board, Dr. Cho is also SHM’s hospitalist liaison with the COVID-19 Real-Time Learning Network, which collaborates with the Centers for Disease Control and Prevention and the Infectious Diseases Society of America.
 

Raymond Kiser, MD, a hospitalist and nephrologist at Columbus (Ind.) Regional Health, has been named the Douglas J. Leonard Caregiver of the Year. The award is given by the Indiana Hospital Association to health care workers whose care is considered exemplary by both peers and patients.

Dr. Kiser has been with CRH for 7 years, including stints as associate chief medical officer and chief of staff.
 

Justin Buchholz, DO, has been elevated to medical director of the hospitalist teams at Regional Medical Center (Alamosa, Colo.) and Conejos County Hospital (La Jara, Colo.). Dr. Buchholz has been a full-time hospitalist and assistant medical director at Parkview Medical Center (Pueblo, Colo.) for the past 3 years. He also worked on a part-time basis seeing patients at the Regional Medical Center.

Dr. Buchholz completed his residency at Parkview Medical Center and was named Resident of the Year in his final year with the internal medicine program.
 

Kenneth Mishark, MD, SFHM, a hospitalist with the Mayo Clinic Hospital (Tucson, Ariz.), will serve on the board of directors for Anigent, a drug diversion-prevention company based in Chesterfield, Mo. He will be charged with helping Anigent better serve health systems with its drug-diversion software.

Dr. Mishark is vice-chair of diversion prevention across the whole Mayo Clinic. A one-time physician in the United States Air Force, Dr. Mishark previously has been the Mayo Clinic’s Healthcare Information Coordination Committee chair.
 

Core Clinical Partners (Tulsa, Okla.) has announced it will join with Hillcrest HealthCare System (Tulsa, Okla.) to provide hospitalist services to Hillcrest’s eight sites across Oklahoma. The partnership will begin at four locations in December 2021, and four others in March 2022.

In expanding its services, Core Clinical Partners will create 70 new physician positions, as well as a systemwide medical director. Core will manage hospitalist operations at Hillcrest Medical Center, Hillcrest Hospital South, Hillcrest Hospital Pryor, Hillcrest Hospital Claremore, Bailey Medical Center, Hillcrest Hospital Cushing, Hillcrest Hospital Henryetta, and Tulsa Spine and Specialty Hospital.

Vineet Chopra, MD, MSc, FHM, recently became chair of the Department of Medicine at the University of Colorado School of Medicine, Aurora. He had previously been the chief of the Division of Hospital Medicine at the University of Michigan Health system. He assumed his new role in October 2021.

Dr. Chopra, who specializes in research and mentorship in patient safety, helped create innovations in care delivery at the University of Michigan, including direct care hospitalist services at VA Ann Arbor Health Care and two other community hospitals.

In his safety-conscious research, Dr. Chopra focuses on preventing complications created within the hospital environment. He also is the first hospitalist to be named deputy editor of the Annals of Internal Medicine. He has written more than 250 peer-reviewed articles. Among the myriad awards he has received, Dr. Chopra recently earned the Kaiser Permanente Award for Clinical Teaching at the UM School of Medicine.
 

Steve Phillipson, MD, FHM, has been named regional director of hospital medicine at Aspirus Health (Wausau, Wisc.). Dr. Phillipson will oversee the hospitalist programs at 17 Aspirus hospitals in Wisconsin and Michigan.

Dr. Phillipson has worked with Aspirus since 2009, with stints in the emergency department and as a hospitalist. As Aspirus Wausau Hospital director of medicine, he chaired the facility’s COVID-19 treatment team.
 

Hackensack (N.J.) Meridian University Medical Center has hired Patricia (Patti) L. Fisher, MD, MHA, to be the institution’s chief medical officer. Dr. Fisher joined the medical center from Central Vermont Medical Center where she served as chief medical officer and chief safety officer, with direct oversight of hospital risk management, operations of all hospital-based services, IS services and quality including patient safety and regulatory compliance.

As a board-certified hospitalist, Dr. Fisher also served as clinical assistant professor in the Department of Family Medicine at the University of Vermont, Burlington. Dr. Fisher earned her medical degree from The University of Texas in Houston and completed residency through Forbes Family Practice Residency in Pittsburgh.
 

Martin Chaney, MD, has been chosen by the Maury Regional Health Board of Trustees to serve as interim chief executive officer. He was formerly the chief medical officer at MRH, which is based in Columbia, Tenn. Dr. Chaney began his new role in October, replacing Alan Watson, the CEO since 2012.

Dr. Chaney has spent 18 of his 25 years in medicine with MRH, where most recently he has focused on clinical quality, physician recruitment, and establishing and expanding the hospital medicine program.
 

Hyung (Harry) Cho, MD, SFHM, has been placed on Modern Healthcare’s Top 25 Innovators list for 2021, getting recognized for innovation and leadership in creating value and safety initiatives in New York City’s public health system. Dr. Cho became NYC Health + Hospitals’ first chief value officer in 2019, and his programs have created an estimated $11 million in savings per year by preventing unnecessary testing and treatment that can lead to patient harm.

A member of the Society of Hospital Medicine’s editorial advisory board, Dr. Cho is also SHM’s hospitalist liaison with the COVID-19 Real-Time Learning Network, which collaborates with the Centers for Disease Control and Prevention and the Infectious Diseases Society of America.
 

Raymond Kiser, MD, a hospitalist and nephrologist at Columbus (Ind.) Regional Health, has been named the Douglas J. Leonard Caregiver of the Year. The award is given by the Indiana Hospital Association to health care workers whose care is considered exemplary by both peers and patients.

Dr. Kiser has been with CRH for 7 years, including stints as associate chief medical officer and chief of staff.
 

Justin Buchholz, DO, has been elevated to medical director of the hospitalist teams at Regional Medical Center (Alamosa, Colo.) and Conejos County Hospital (La Jara, Colo.). Dr. Buchholz has been a full-time hospitalist and assistant medical director at Parkview Medical Center (Pueblo, Colo.) for the past 3 years. He also worked on a part-time basis seeing patients at the Regional Medical Center.

Dr. Buchholz completed his residency at Parkview Medical Center and was named Resident of the Year in his final year with the internal medicine program.
 

Kenneth Mishark, MD, SFHM, a hospitalist with the Mayo Clinic Hospital (Tucson, Ariz.), will serve on the board of directors for Anigent, a drug diversion-prevention company based in Chesterfield, Mo. He will be charged with helping Anigent better serve health systems with its drug-diversion software.

Dr. Mishark is vice-chair of diversion prevention across the whole Mayo Clinic. A one-time physician in the United States Air Force, Dr. Mishark previously has been the Mayo Clinic’s Healthcare Information Coordination Committee chair.
 

Core Clinical Partners (Tulsa, Okla.) has announced it will join with Hillcrest HealthCare System (Tulsa, Okla.) to provide hospitalist services to Hillcrest’s eight sites across Oklahoma. The partnership will begin at four locations in December 2021, and four others in March 2022.

In expanding its services, Core Clinical Partners will create 70 new physician positions, as well as a systemwide medical director. Core will manage hospitalist operations at Hillcrest Medical Center, Hillcrest Hospital South, Hillcrest Hospital Pryor, Hillcrest Hospital Claremore, Bailey Medical Center, Hillcrest Hospital Cushing, Hillcrest Hospital Henryetta, and Tulsa Spine and Specialty Hospital.

Over half of people who believed they were transgender, transitioned to the opposite sex, but then regretted it and transitioned back – known as detransitioners – felt they did not receive adequate evaluation from a doctor or mental health professional before starting transition, new research indicates.

In what is thought to be the first study to ask whether detransitioners informed their original clinicians of their regret at transitioning, only 24 of the 100 surveyed said they had done so.

This strongly suggests that records on detransition may understate the real numbers, said Lisa Littman, MD, MPH, president of The Institute for Comprehensive Gender Dysphoria Research (ICGDR), who is the sole author of the study, published in Archives of Sexual Behavior.

She stressed that the findings illustrate the complexity surrounding gender dysphoria. “We need to recognize that there are many different types of experiences around gender dysphoria, transition, and detransition,” she told this news organization.

She said there is some resistance among certain health care professionals, and in society in general, to the idea that transitioning is not always successful.
 

‘We need to understand why this is happening’

“Detransition exists and we need to understand why this is happening,” Dr. Littman emphasized.

She observed that some supporters of “rapid transition” do not want to accept that transitioning helps some individuals but harms others.

“In the end, our goals should be providing the right treatment for the right patient, and without a thorough evaluation, clinicians are at serious risk of giving patients the wrong treatment,” she urged.

She noted that, despite some individuals feeling better after transition, these people still felt inclined to detransition because of discrimination and pressure.

“Individuals should not be pressured to detransition, nor should they be pressured to transition. Both types of pressure were reported by respondents.” 

The recently recognized shift from mostly natal males to natal females seeking to transition was borne out by her study data, with the proportion of natal girls who detransitioned at 69%.
 

‘Shedding light’ on often ignored population

Asked to comment on the study, Laura Edwards-Leeper, PhD, a clinical psychologist from Beaverton, Ore., who specializes in gender-diverse and transgender children, welcomed Dr. Littman’s study.

It is, said Dr. Edwards-Leeper, a “critical preliminary step toward shedding light on this often-ignored and dismissed population of individuals who deserve support, compassion, and sometimes medical intervention from health care providers.”

She added that multiple online reports attest to detransitioners feeling they had not received adequate evaluation prior to medically transitioning, as well as many who expressed feeling too ashamed or angry to return to their same clinicians to detransition.

“Littman’s study provides quantitative support for both of these reported experiences, further emphasizing the importance of the field taking a closer look at the processes currently in place for those experiencing gender dysphoria,” said Dr. Edwards-Leeper.

And Miroslav L. Djordjevic, MD, PhD, professor of surgery/urology, University of Belgrade (Serbia), who is a specialist in urogenital reconstructive surgery and has performed over 2,000 gender-reassignment surgeries in transgender individuals, has recently seen many cases of regret after such surgeries, with requests for reversal operations.

“Despite the fact that medical detransition is relatively safe and without severe consequences, surgical detransition presents one of the most difficult issues in transgender medicine,” Dr. Djordjevic told this news organization.

Commending Dr. Littman on her study, he drew attention to some of the bioethical questions that arise relating to those who detransition.

“I ask what happened in the period before medical transitioning? Was there proper psychological care during medical transitioning? Who confirmed their desire for detransition – the same professionals who did the transition?” or someone else, he continued. “And who accepted these individuals for gender-affirming surgery and what were the criteria for this decision?”
 

Substantial study of reasons for both transitioning and detransitioning 

In her article, Dr. Littman describes a 100-strong population of individuals (66 Americans, 9 British, 9 Canadian, 4 Australians, and 12 from “other” nations), ranging in age from 18 years to over 60 years with a mean age of 29.2 years, who had experienced gender dysphoria, chosen to undergo medical and/or surgical transition, and then detransitioned by discontinuing medications, having reversal surgery, or both.

Participants completed a 115-question survey providing data including age at first experience of gender dysphoria, when participants first sought transitioning care and from whom, and whether they felt pressured to do so. Friendship group dynamics were also explored.

Various narratives of participants’ transitioning-detransitioning experiences were gathered and grouped, for example, those related to discrimination pressures, experiences of trauma or mental health conditions prior to transition, and reports of internalized homophobia.

Dr. Edwards-Leeper observed that the study offers a more extensive assessment of reasons for detransitioning than any other prior research in the field, which has been sparse.

A survey published in April found that detransitioners report significant unmet medical and psychological needs, and a lack of compassion and help from medical and mental health practitioners.

But another 2021 study concluded most detransitioners only reverted to their birth sex because of societal or family pressure, discrimination, or shift to a nonbinary identity.

“However, [Dr.] Littman’s study found that only a small percentage actually detransitioned for that reason [23%], whereas the majority detransitioned because of a change in how the individual understood being a male or female, resulting in becoming comfortable in their assigned gender [60%],” noted Dr. Edwards-Leeper.
 

Reasons for detransitioning

Asked to expand upon the motives for detransition identified in her study, Dr. Littman told this news organization: “We found remarkable breadth in the reasons given for detransitioning.” 

“I believe that we were able to capture the diversity of experiences around detransition because we reached out to communities that were strongly ‘protransition’ – like the World Professional Association for Transgender Health – and communities where individuals might be more skeptical about transition being universally beneficial, like detransition forums,” she said.

Speaking to the complexity of the experiences, 87% selected more than one reason for detransitioning.

The most common reason (60%) was becoming more comfortable identifying with their birth sex, followed by having concerns about potential medical complications from transitioning (49.0%).

Regarding those who became more comfortable with their natal sex, Dr. Littman noted that the finding adds “further support that gender dysphoria is not always permanent.”

She added that, “because most gender-dysphoric youth who are allowed to go through puberty grow up to be lesbian, gay, or bisexual (LGB) nontransgender adults, intervening too soon with medical treatments risks derailing their development as LGB individuals.”

Internalized homophobia or difficulty accepting themselves as lesbian, gay, or bisexual was reported by 23% of participants as a reason for transition and subsequent detransition. 

“For these people, transitioning could be interpreted as an attempt to escape the reality of being same-sex attracted and detransitioning was part of accepting themselves as homosexual or bisexual,” explained Dr. Littman.

“Exploring their distress and discomfort around sexual orientation issues may have been more helpful to them than medical and surgical transition or at least an important part of exploration,” she added in the article.
 

Societal pressure, friends, and social media also play a role

The latest first-hand reports also support prior work by Dr. Littman when she first identified the concept she termed rapid-onset gender dysphoria (ROGD) to describe a sudden transgender identification, usually in the early teenage years, and with no prior indication of any gender questioning.

ROGD, Dr. Littman believes, is strongly related to psychosocial factors, such as trauma, mental health problems, or social influence contributing to the development of gender dysphoria.

The current study found that 58% of respondents expressed the belief that the cause of their gender dysphoria was something specific, such as trauma, abuse, or a mental health condition, with respondents suggesting that transitioning prevented, or delayed, them from addressing their underlying mental health conditions. 

One participant is quoted as saying: “I was deeply uncomfortable with my secondary sex characteristics, which I now understand was a result of childhood trauma and associating my secondary sex characteristics with those events.”

Reflecting on their previous identification as transgender, more than a third of respondents reported that someone else told them their feelings meant they were transgender, and they believed them.

“This speaks to the effect social influence can have on people’s interpretation of their own feelings and their development of a transgender identity,” Dr. Littman remarked.

“Participants also listed several social media sources that encouraged them to believe that transitioning would help them,” she added.

Several friendship group dynamics suggestive of social influence were reported by a subset of respondents, including the fact that their friendship groups mocked people who were not transgender and their popularity increased when they announced they were going to transition. 
 

Pendulum has swung too far the other way

Natal females, who in recent years have made up most referrals, were younger than natal males when they sought transition and decided to detransition; and they stayed “transitioned” for a shorter period than natal males. They were also more likely to have experienced a trauma less than 1 year before the onset of gender dysphoria and were more likely to have felt pressured to transition. 

“Because the females in the study transitioned more recently than the males, they may have experienced a culture where there is more of a ‘push’ to transition,” Dr. Littman pointed out.

She added that, “20 years ago, gender-dysphoric patients were most likely to be underdiagnosed and undertreated. Now, the pendulum has swung the other way and patients are, in my opinion, more likely to be overdiagnosed and overtreated. I think we need to aim for somewhere between these two extremes and prioritize people getting the right treatment for the right reason for their distress.”

Dr. Djordjevic added that, with colleagues from Belgrade and the Netherlands, he has published accounts of the experiences of seven individuals who showed regret after gender-affirming surgery.

All of them were born male, “and we confirmed the very poor evaluation and transition process they underwent. We conclude that clinicians should be aware that not everyone with gender identity disorders need or want all elements of hormonal or surgical therapy,” he told this news organization.

Dr. Edwards-Leeper said that more long-term longitudinal studies are needed that follow individuals who undergo transition under different models of care.

“My prediction is that those who first engage in supportive, gender exploratory therapy, followed by comprehensive assessment, will have the best outcomes, perhaps even if they ultimately detransition, as these individuals will know that they did not jump into irreversible interventions too quickly and had time to make the best decision for themselves at the time,” she concluded.

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

Over half of people who believed they were transgender, transitioned to the opposite sex, but then regretted it and transitioned back – known as detransitioners – felt they did not receive adequate evaluation from a doctor or mental health professional before starting transition, new research indicates.

In what is thought to be the first study to ask whether detransitioners informed their original clinicians of their regret at transitioning, only 24 of the 100 surveyed said they had done so.

This strongly suggests that records on detransition may understate the real numbers, said Lisa Littman, MD, MPH, president of The Institute for Comprehensive Gender Dysphoria Research (ICGDR), who is the sole author of the study, published in Archives of Sexual Behavior.

She stressed that the findings illustrate the complexity surrounding gender dysphoria. “We need to recognize that there are many different types of experiences around gender dysphoria, transition, and detransition,” she told this news organization.

She said there is some resistance among certain health care professionals, and in society in general, to the idea that transitioning is not always successful.
 

‘We need to understand why this is happening’

“Detransition exists and we need to understand why this is happening,” Dr. Littman emphasized.

She observed that some supporters of “rapid transition” do not want to accept that transitioning helps some individuals but harms others.

“In the end, our goals should be providing the right treatment for the right patient, and without a thorough evaluation, clinicians are at serious risk of giving patients the wrong treatment,” she urged.

She noted that, despite some individuals feeling better after transition, these people still felt inclined to detransition because of discrimination and pressure.

“Individuals should not be pressured to detransition, nor should they be pressured to transition. Both types of pressure were reported by respondents.” 

The recently recognized shift from mostly natal males to natal females seeking to transition was borne out by her study data, with the proportion of natal girls who detransitioned at 69%.
 

‘Shedding light’ on often ignored population

Asked to comment on the study, Laura Edwards-Leeper, PhD, a clinical psychologist from Beaverton, Ore., who specializes in gender-diverse and transgender children, welcomed Dr. Littman’s study.

It is, said Dr. Edwards-Leeper, a “critical preliminary step toward shedding light on this often-ignored and dismissed population of individuals who deserve support, compassion, and sometimes medical intervention from health care providers.”

She added that multiple online reports attest to detransitioners feeling they had not received adequate evaluation prior to medically transitioning, as well as many who expressed feeling too ashamed or angry to return to their same clinicians to detransition.

“Littman’s study provides quantitative support for both of these reported experiences, further emphasizing the importance of the field taking a closer look at the processes currently in place for those experiencing gender dysphoria,” said Dr. Edwards-Leeper.

And Miroslav L. Djordjevic, MD, PhD, professor of surgery/urology, University of Belgrade (Serbia), who is a specialist in urogenital reconstructive surgery and has performed over 2,000 gender-reassignment surgeries in transgender individuals, has recently seen many cases of regret after such surgeries, with requests for reversal operations.

“Despite the fact that medical detransition is relatively safe and without severe consequences, surgical detransition presents one of the most difficult issues in transgender medicine,” Dr. Djordjevic told this news organization.

Commending Dr. Littman on her study, he drew attention to some of the bioethical questions that arise relating to those who detransition.

“I ask what happened in the period before medical transitioning? Was there proper psychological care during medical transitioning? Who confirmed their desire for detransition – the same professionals who did the transition?” or someone else, he continued. “And who accepted these individuals for gender-affirming surgery and what were the criteria for this decision?”
 

Substantial study of reasons for both transitioning and detransitioning 

In her article, Dr. Littman describes a 100-strong population of individuals (66 Americans, 9 British, 9 Canadian, 4 Australians, and 12 from “other” nations), ranging in age from 18 years to over 60 years with a mean age of 29.2 years, who had experienced gender dysphoria, chosen to undergo medical and/or surgical transition, and then detransitioned by discontinuing medications, having reversal surgery, or both.

Participants completed a 115-question survey providing data including age at first experience of gender dysphoria, when participants first sought transitioning care and from whom, and whether they felt pressured to do so. Friendship group dynamics were also explored.

Various narratives of participants’ transitioning-detransitioning experiences were gathered and grouped, for example, those related to discrimination pressures, experiences of trauma or mental health conditions prior to transition, and reports of internalized homophobia.

Dr. Edwards-Leeper observed that the study offers a more extensive assessment of reasons for detransitioning than any other prior research in the field, which has been sparse.

A survey published in April found that detransitioners report significant unmet medical and psychological needs, and a lack of compassion and help from medical and mental health practitioners.

But another 2021 study concluded most detransitioners only reverted to their birth sex because of societal or family pressure, discrimination, or shift to a nonbinary identity.

“However, [Dr.] Littman’s study found that only a small percentage actually detransitioned for that reason [23%], whereas the majority detransitioned because of a change in how the individual understood being a male or female, resulting in becoming comfortable in their assigned gender [60%],” noted Dr. Edwards-Leeper.
 

Reasons for detransitioning

Asked to expand upon the motives for detransition identified in her study, Dr. Littman told this news organization: “We found remarkable breadth in the reasons given for detransitioning.” 

“I believe that we were able to capture the diversity of experiences around detransition because we reached out to communities that were strongly ‘protransition’ – like the World Professional Association for Transgender Health – and communities where individuals might be more skeptical about transition being universally beneficial, like detransition forums,” she said.

Speaking to the complexity of the experiences, 87% selected more than one reason for detransitioning.

The most common reason (60%) was becoming more comfortable identifying with their birth sex, followed by having concerns about potential medical complications from transitioning (49.0%).

Regarding those who became more comfortable with their natal sex, Dr. Littman noted that the finding adds “further support that gender dysphoria is not always permanent.”

She added that, “because most gender-dysphoric youth who are allowed to go through puberty grow up to be lesbian, gay, or bisexual (LGB) nontransgender adults, intervening too soon with medical treatments risks derailing their development as LGB individuals.”

Internalized homophobia or difficulty accepting themselves as lesbian, gay, or bisexual was reported by 23% of participants as a reason for transition and subsequent detransition. 

“For these people, transitioning could be interpreted as an attempt to escape the reality of being same-sex attracted and detransitioning was part of accepting themselves as homosexual or bisexual,” explained Dr. Littman.

“Exploring their distress and discomfort around sexual orientation issues may have been more helpful to them than medical and surgical transition or at least an important part of exploration,” she added in the article.
 

Societal pressure, friends, and social media also play a role

The latest first-hand reports also support prior work by Dr. Littman when she first identified the concept she termed rapid-onset gender dysphoria (ROGD) to describe a sudden transgender identification, usually in the early teenage years, and with no prior indication of any gender questioning.

ROGD, Dr. Littman believes, is strongly related to psychosocial factors, such as trauma, mental health problems, or social influence contributing to the development of gender dysphoria.

The current study found that 58% of respondents expressed the belief that the cause of their gender dysphoria was something specific, such as trauma, abuse, or a mental health condition, with respondents suggesting that transitioning prevented, or delayed, them from addressing their underlying mental health conditions. 

One participant is quoted as saying: “I was deeply uncomfortable with my secondary sex characteristics, which I now understand was a result of childhood trauma and associating my secondary sex characteristics with those events.”

Reflecting on their previous identification as transgender, more than a third of respondents reported that someone else told them their feelings meant they were transgender, and they believed them.

“This speaks to the effect social influence can have on people’s interpretation of their own feelings and their development of a transgender identity,” Dr. Littman remarked.

“Participants also listed several social media sources that encouraged them to believe that transitioning would help them,” she added.

Several friendship group dynamics suggestive of social influence were reported by a subset of respondents, including the fact that their friendship groups mocked people who were not transgender and their popularity increased when they announced they were going to transition. 
 

Pendulum has swung too far the other way

Natal females, who in recent years have made up most referrals, were younger than natal males when they sought transition and decided to detransition; and they stayed “transitioned” for a shorter period than natal males. They were also more likely to have experienced a trauma less than 1 year before the onset of gender dysphoria and were more likely to have felt pressured to transition. 

“Because the females in the study transitioned more recently than the males, they may have experienced a culture where there is more of a ‘push’ to transition,” Dr. Littman pointed out.

She added that, “20 years ago, gender-dysphoric patients were most likely to be underdiagnosed and undertreated. Now, the pendulum has swung the other way and patients are, in my opinion, more likely to be overdiagnosed and overtreated. I think we need to aim for somewhere between these two extremes and prioritize people getting the right treatment for the right reason for their distress.”

Dr. Djordjevic added that, with colleagues from Belgrade and the Netherlands, he has published accounts of the experiences of seven individuals who showed regret after gender-affirming surgery.

All of them were born male, “and we confirmed the very poor evaluation and transition process they underwent. We conclude that clinicians should be aware that not everyone with gender identity disorders need or want all elements of hormonal or surgical therapy,” he told this news organization.

Dr. Edwards-Leeper said that more long-term longitudinal studies are needed that follow individuals who undergo transition under different models of care.

“My prediction is that those who first engage in supportive, gender exploratory therapy, followed by comprehensive assessment, will have the best outcomes, perhaps even if they ultimately detransition, as these individuals will know that they did not jump into irreversible interventions too quickly and had time to make the best decision for themselves at the time,” she concluded.

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

Over half of people who believed they were transgender, transitioned to the opposite sex, but then regretted it and transitioned back – known as detransitioners – felt they did not receive adequate evaluation from a doctor or mental health professional before starting transition, new research indicates.

In what is thought to be the first study to ask whether detransitioners informed their original clinicians of their regret at transitioning, only 24 of the 100 surveyed said they had done so.

This strongly suggests that records on detransition may understate the real numbers, said Lisa Littman, MD, MPH, president of The Institute for Comprehensive Gender Dysphoria Research (ICGDR), who is the sole author of the study, published in Archives of Sexual Behavior.

She stressed that the findings illustrate the complexity surrounding gender dysphoria. “We need to recognize that there are many different types of experiences around gender dysphoria, transition, and detransition,” she told this news organization.

She said there is some resistance among certain health care professionals, and in society in general, to the idea that transitioning is not always successful.
 

‘We need to understand why this is happening’

“Detransition exists and we need to understand why this is happening,” Dr. Littman emphasized.

She observed that some supporters of “rapid transition” do not want to accept that transitioning helps some individuals but harms others.

“In the end, our goals should be providing the right treatment for the right patient, and without a thorough evaluation, clinicians are at serious risk of giving patients the wrong treatment,” she urged.

She noted that, despite some individuals feeling better after transition, these people still felt inclined to detransition because of discrimination and pressure.

“Individuals should not be pressured to detransition, nor should they be pressured to transition. Both types of pressure were reported by respondents.” 

The recently recognized shift from mostly natal males to natal females seeking to transition was borne out by her study data, with the proportion of natal girls who detransitioned at 69%.
 

‘Shedding light’ on often ignored population

Asked to comment on the study, Laura Edwards-Leeper, PhD, a clinical psychologist from Beaverton, Ore., who specializes in gender-diverse and transgender children, welcomed Dr. Littman’s study.

It is, said Dr. Edwards-Leeper, a “critical preliminary step toward shedding light on this often-ignored and dismissed population of individuals who deserve support, compassion, and sometimes medical intervention from health care providers.”

She added that multiple online reports attest to detransitioners feeling they had not received adequate evaluation prior to medically transitioning, as well as many who expressed feeling too ashamed or angry to return to their same clinicians to detransition.

“Littman’s study provides quantitative support for both of these reported experiences, further emphasizing the importance of the field taking a closer look at the processes currently in place for those experiencing gender dysphoria,” said Dr. Edwards-Leeper.

And Miroslav L. Djordjevic, MD, PhD, professor of surgery/urology, University of Belgrade (Serbia), who is a specialist in urogenital reconstructive surgery and has performed over 2,000 gender-reassignment surgeries in transgender individuals, has recently seen many cases of regret after such surgeries, with requests for reversal operations.

“Despite the fact that medical detransition is relatively safe and without severe consequences, surgical detransition presents one of the most difficult issues in transgender medicine,” Dr. Djordjevic told this news organization.

Commending Dr. Littman on her study, he drew attention to some of the bioethical questions that arise relating to those who detransition.

“I ask what happened in the period before medical transitioning? Was there proper psychological care during medical transitioning? Who confirmed their desire for detransition – the same professionals who did the transition?” or someone else, he continued. “And who accepted these individuals for gender-affirming surgery and what were the criteria for this decision?”
 

Substantial study of reasons for both transitioning and detransitioning 

In her article, Dr. Littman describes a 100-strong population of individuals (66 Americans, 9 British, 9 Canadian, 4 Australians, and 12 from “other” nations), ranging in age from 18 years to over 60 years with a mean age of 29.2 years, who had experienced gender dysphoria, chosen to undergo medical and/or surgical transition, and then detransitioned by discontinuing medications, having reversal surgery, or both.

Participants completed a 115-question survey providing data including age at first experience of gender dysphoria, when participants first sought transitioning care and from whom, and whether they felt pressured to do so. Friendship group dynamics were also explored.

Various narratives of participants’ transitioning-detransitioning experiences were gathered and grouped, for example, those related to discrimination pressures, experiences of trauma or mental health conditions prior to transition, and reports of internalized homophobia.

Dr. Edwards-Leeper observed that the study offers a more extensive assessment of reasons for detransitioning than any other prior research in the field, which has been sparse.

A survey published in April found that detransitioners report significant unmet medical and psychological needs, and a lack of compassion and help from medical and mental health practitioners.

But another 2021 study concluded most detransitioners only reverted to their birth sex because of societal or family pressure, discrimination, or shift to a nonbinary identity.

“However, [Dr.] Littman’s study found that only a small percentage actually detransitioned for that reason [23%], whereas the majority detransitioned because of a change in how the individual understood being a male or female, resulting in becoming comfortable in their assigned gender [60%],” noted Dr. Edwards-Leeper.
 

Reasons for detransitioning

Asked to expand upon the motives for detransition identified in her study, Dr. Littman told this news organization: “We found remarkable breadth in the reasons given for detransitioning.” 

“I believe that we were able to capture the diversity of experiences around detransition because we reached out to communities that were strongly ‘protransition’ – like the World Professional Association for Transgender Health – and communities where individuals might be more skeptical about transition being universally beneficial, like detransition forums,” she said.

Speaking to the complexity of the experiences, 87% selected more than one reason for detransitioning.

The most common reason (60%) was becoming more comfortable identifying with their birth sex, followed by having concerns about potential medical complications from transitioning (49.0%).

Regarding those who became more comfortable with their natal sex, Dr. Littman noted that the finding adds “further support that gender dysphoria is not always permanent.”

She added that, “because most gender-dysphoric youth who are allowed to go through puberty grow up to be lesbian, gay, or bisexual (LGB) nontransgender adults, intervening too soon with medical treatments risks derailing their development as LGB individuals.”

Internalized homophobia or difficulty accepting themselves as lesbian, gay, or bisexual was reported by 23% of participants as a reason for transition and subsequent detransition. 

“For these people, transitioning could be interpreted as an attempt to escape the reality of being same-sex attracted and detransitioning was part of accepting themselves as homosexual or bisexual,” explained Dr. Littman.

“Exploring their distress and discomfort around sexual orientation issues may have been more helpful to them than medical and surgical transition or at least an important part of exploration,” she added in the article.
 

Societal pressure, friends, and social media also play a role

The latest first-hand reports also support prior work by Dr. Littman when she first identified the concept she termed rapid-onset gender dysphoria (ROGD) to describe a sudden transgender identification, usually in the early teenage years, and with no prior indication of any gender questioning.

ROGD, Dr. Littman believes, is strongly related to psychosocial factors, such as trauma, mental health problems, or social influence contributing to the development of gender dysphoria.

The current study found that 58% of respondents expressed the belief that the cause of their gender dysphoria was something specific, such as trauma, abuse, or a mental health condition, with respondents suggesting that transitioning prevented, or delayed, them from addressing their underlying mental health conditions. 

One participant is quoted as saying: “I was deeply uncomfortable with my secondary sex characteristics, which I now understand was a result of childhood trauma and associating my secondary sex characteristics with those events.”

Reflecting on their previous identification as transgender, more than a third of respondents reported that someone else told them their feelings meant they were transgender, and they believed them.

“This speaks to the effect social influence can have on people’s interpretation of their own feelings and their development of a transgender identity,” Dr. Littman remarked.

“Participants also listed several social media sources that encouraged them to believe that transitioning would help them,” she added.

Several friendship group dynamics suggestive of social influence were reported by a subset of respondents, including the fact that their friendship groups mocked people who were not transgender and their popularity increased when they announced they were going to transition. 
 

Pendulum has swung too far the other way

Natal females, who in recent years have made up most referrals, were younger than natal males when they sought transition and decided to detransition; and they stayed “transitioned” for a shorter period than natal males. They were also more likely to have experienced a trauma less than 1 year before the onset of gender dysphoria and were more likely to have felt pressured to transition. 

“Because the females in the study transitioned more recently than the males, they may have experienced a culture where there is more of a ‘push’ to transition,” Dr. Littman pointed out.

She added that, “20 years ago, gender-dysphoric patients were most likely to be underdiagnosed and undertreated. Now, the pendulum has swung the other way and patients are, in my opinion, more likely to be overdiagnosed and overtreated. I think we need to aim for somewhere between these two extremes and prioritize people getting the right treatment for the right reason for their distress.”

Dr. Djordjevic added that, with colleagues from Belgrade and the Netherlands, he has published accounts of the experiences of seven individuals who showed regret after gender-affirming surgery.

All of them were born male, “and we confirmed the very poor evaluation and transition process they underwent. We conclude that clinicians should be aware that not everyone with gender identity disorders need or want all elements of hormonal or surgical therapy,” he told this news organization.

Dr. Edwards-Leeper said that more long-term longitudinal studies are needed that follow individuals who undergo transition under different models of care.

“My prediction is that those who first engage in supportive, gender exploratory therapy, followed by comprehensive assessment, will have the best outcomes, perhaps even if they ultimately detransition, as these individuals will know that they did not jump into irreversible interventions too quickly and had time to make the best decision for themselves at the time,” she concluded.

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

Certain antihypertensive medications, particularly diuretics, are linked to lower Alzheimer’s disease neuropathology and other brain disease processes, new research shows.

Investigators found that use of any antihypertensive was associated with an 18% decrease in Alzheimer’s disease neuropathology, a 22% decrease in Lewy bodies, and a 40% decrease in TAR DNA-binding protein 43 (TDP-43), a protein relevant to several neurodegenerative diseases. Diuretics in particular appear to be driving the association.

Although diuretics might be a better option for preventing brain neuropathology, it’s too early to make firm recommendations solely on the basis of these results as to what blood pressure–lowering agent to prescribe a particular patient, said study investigator Ahmad Sajjadi, MD, assistant professor of neurology, University of California, Irvine.

“This is early stages and preliminary results,” said Dr. Sajjadi, “but it’s food for thought.”

The findings were presented at the 2021 annual meeting of the American Neurological Association.
 

Autopsy data

The study included 3,315 individuals who had donated their brains to research. The National Alzheimer’s Coordinating Center maintains a database that includes data from 32 Alzheimer’s disease research centers in the United States. Participants in the study must have visited one of these centers within 4 years of death. Each person whose brain was included in the study underwent two or more BP measurements on at least 50% of visits.

The mean age at death was 81.7 years, and the mean time between last visit and death was 13.1 months. About 44.4% of participants were women, 57.0% had at least a college degree, and 84.7% had cognitive impairment.

Researchers defined hypertension as systolic BP of at least 130 mm Hg, diastolic BP of at least 80 mm Hg, mean arterial pressure of at least 100 mm Hg, and pulse pressure of at least 60 mm Hg.

Antihypertensive medications that were evaluated included antiadrenergic agents, ACE inhibitors, angiotensin II receptor blockers, beta blockers, calcium channel blockers, diuretics, vasodilators, and combination therapies.

The investigators assessed the number of neuropathologies. In addition to Alzheimer’s disease neuropathology, which included amyloid-beta, tau, Lewy bodies, and TDP-43, they also assessed for atherosclerosis, arteriolosclerosis, cerebral amyloid angiopathy, frontotemporal lobar degeneration, and hippocampal sclerosis.

Results showed that use of any antihypertensive was associated with a lower likelihood of Alzheimer’s disease neuropathology (odds ratio, 0.822), Lewy bodies (OR, 0.786), and TDP 43 (OR, 0.597). Use of antihypertensives was also associated with increased odds of atherosclerosis (OR, 1.217) (all P < .5.)

The study showed that hypertensive systolic BP was associated with higher odds of Alzheimer’s disease neuropathology (OR, 1.28; P < .5).

Differences by drug type

Results differed in accordance with antihypertensive class. Angiotensin II receptor blockers decreased the odds of Alzheimer’s disease neuropathology by 40% (OR, 0.60; P < .5). Diuretics decreased the odds of Alzheimer’s disease by 36% (OR, 0.64; P < .001) and of hippocampal sclerosis by 32% (OR, 0.68; P < .5).

“We see diuretics are a main driver, especially for lower odds of Alzheimer’s disease and lower odds of hippocampal sclerosis,” said lead author Hanna L. Nguyen, a first-year medical student at the University of California, Irvine.

The results indicate that it is the medications, not BP levels, that account for these associations, she added.

One potential mechanism linking antihypertensives to brain pathology is that with these agents, BP is maintained in the target zone. Blood pressure that’s too high can damage blood vessels, whereas BP that’s too low may result in less than adequate perfusion, said Ms. Nguyen.

These medications may also alter pathways leading to degeneration and could, for example, affect the apo E mechanism of Alzheimer’s disease, she added.

The researchers plan to conduct subset analyses using apo E genetic status and age of death.

Although this is a “massive database,” it has limitations. For example, said Dr. Sajjadi, it does not reveal when patients started taking BP medication, how long they had been taking it, or why.

“We don’t know the exact the reason they were taking these medications. Was it just hypertension, or did they also have heart disease, stroke, a kidney problem, or was there another explanation,” he said.

Following the study presentation, session comoderator Krish Sathian, MBBS, PhD, professor of neurology, neural, and behavioral sciences, and psychology and director of the Neuroscience Institute, Penn State University, Hershey, called this work “fascinating. It provides a lot of data that really touches on everyday practice,” inasmuch as clinicians often prescribe antihypertensive medications and see patients with these kinds of brain disorders.

The investigators and Dr. Sathian reported no relevant financial relationships.

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

Certain antihypertensive medications, particularly diuretics, are linked to lower Alzheimer’s disease neuropathology and other brain disease processes, new research shows.

Investigators found that use of any antihypertensive was associated with an 18% decrease in Alzheimer’s disease neuropathology, a 22% decrease in Lewy bodies, and a 40% decrease in TAR DNA-binding protein 43 (TDP-43), a protein relevant to several neurodegenerative diseases. Diuretics in particular appear to be driving the association.

Although diuretics might be a better option for preventing brain neuropathology, it’s too early to make firm recommendations solely on the basis of these results as to what blood pressure–lowering agent to prescribe a particular patient, said study investigator Ahmad Sajjadi, MD, assistant professor of neurology, University of California, Irvine.

“This is early stages and preliminary results,” said Dr. Sajjadi, “but it’s food for thought.”

The findings were presented at the 2021 annual meeting of the American Neurological Association.
 

Autopsy data

The study included 3,315 individuals who had donated their brains to research. The National Alzheimer’s Coordinating Center maintains a database that includes data from 32 Alzheimer’s disease research centers in the United States. Participants in the study must have visited one of these centers within 4 years of death. Each person whose brain was included in the study underwent two or more BP measurements on at least 50% of visits.

The mean age at death was 81.7 years, and the mean time between last visit and death was 13.1 months. About 44.4% of participants were women, 57.0% had at least a college degree, and 84.7% had cognitive impairment.

Researchers defined hypertension as systolic BP of at least 130 mm Hg, diastolic BP of at least 80 mm Hg, mean arterial pressure of at least 100 mm Hg, and pulse pressure of at least 60 mm Hg.

Antihypertensive medications that were evaluated included antiadrenergic agents, ACE inhibitors, angiotensin II receptor blockers, beta blockers, calcium channel blockers, diuretics, vasodilators, and combination therapies.

The investigators assessed the number of neuropathologies. In addition to Alzheimer’s disease neuropathology, which included amyloid-beta, tau, Lewy bodies, and TDP-43, they also assessed for atherosclerosis, arteriolosclerosis, cerebral amyloid angiopathy, frontotemporal lobar degeneration, and hippocampal sclerosis.

Results showed that use of any antihypertensive was associated with a lower likelihood of Alzheimer’s disease neuropathology (odds ratio, 0.822), Lewy bodies (OR, 0.786), and TDP 43 (OR, 0.597). Use of antihypertensives was also associated with increased odds of atherosclerosis (OR, 1.217) (all P < .5.)

The study showed that hypertensive systolic BP was associated with higher odds of Alzheimer’s disease neuropathology (OR, 1.28; P < .5).

Differences by drug type

Results differed in accordance with antihypertensive class. Angiotensin II receptor blockers decreased the odds of Alzheimer’s disease neuropathology by 40% (OR, 0.60; P < .5). Diuretics decreased the odds of Alzheimer’s disease by 36% (OR, 0.64; P < .001) and of hippocampal sclerosis by 32% (OR, 0.68; P < .5).

“We see diuretics are a main driver, especially for lower odds of Alzheimer’s disease and lower odds of hippocampal sclerosis,” said lead author Hanna L. Nguyen, a first-year medical student at the University of California, Irvine.

The results indicate that it is the medications, not BP levels, that account for these associations, she added.

One potential mechanism linking antihypertensives to brain pathology is that with these agents, BP is maintained in the target zone. Blood pressure that’s too high can damage blood vessels, whereas BP that’s too low may result in less than adequate perfusion, said Ms. Nguyen.

These medications may also alter pathways leading to degeneration and could, for example, affect the apo E mechanism of Alzheimer’s disease, she added.

The researchers plan to conduct subset analyses using apo E genetic status and age of death.

Although this is a “massive database,” it has limitations. For example, said Dr. Sajjadi, it does not reveal when patients started taking BP medication, how long they had been taking it, or why.

“We don’t know the exact the reason they were taking these medications. Was it just hypertension, or did they also have heart disease, stroke, a kidney problem, or was there another explanation,” he said.

Following the study presentation, session comoderator Krish Sathian, MBBS, PhD, professor of neurology, neural, and behavioral sciences, and psychology and director of the Neuroscience Institute, Penn State University, Hershey, called this work “fascinating. It provides a lot of data that really touches on everyday practice,” inasmuch as clinicians often prescribe antihypertensive medications and see patients with these kinds of brain disorders.

The investigators and Dr. Sathian reported no relevant financial relationships.

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

Certain antihypertensive medications, particularly diuretics, are linked to lower Alzheimer’s disease neuropathology and other brain disease processes, new research shows.

Investigators found that use of any antihypertensive was associated with an 18% decrease in Alzheimer’s disease neuropathology, a 22% decrease in Lewy bodies, and a 40% decrease in TAR DNA-binding protein 43 (TDP-43), a protein relevant to several neurodegenerative diseases. Diuretics in particular appear to be driving the association.

Although diuretics might be a better option for preventing brain neuropathology, it’s too early to make firm recommendations solely on the basis of these results as to what blood pressure–lowering agent to prescribe a particular patient, said study investigator Ahmad Sajjadi, MD, assistant professor of neurology, University of California, Irvine.

“This is early stages and preliminary results,” said Dr. Sajjadi, “but it’s food for thought.”

The findings were presented at the 2021 annual meeting of the American Neurological Association.
 

Autopsy data

The study included 3,315 individuals who had donated their brains to research. The National Alzheimer’s Coordinating Center maintains a database that includes data from 32 Alzheimer’s disease research centers in the United States. Participants in the study must have visited one of these centers within 4 years of death. Each person whose brain was included in the study underwent two or more BP measurements on at least 50% of visits.

The mean age at death was 81.7 years, and the mean time between last visit and death was 13.1 months. About 44.4% of participants were women, 57.0% had at least a college degree, and 84.7% had cognitive impairment.

Researchers defined hypertension as systolic BP of at least 130 mm Hg, diastolic BP of at least 80 mm Hg, mean arterial pressure of at least 100 mm Hg, and pulse pressure of at least 60 mm Hg.

Antihypertensive medications that were evaluated included antiadrenergic agents, ACE inhibitors, angiotensin II receptor blockers, beta blockers, calcium channel blockers, diuretics, vasodilators, and combination therapies.

The investigators assessed the number of neuropathologies. In addition to Alzheimer’s disease neuropathology, which included amyloid-beta, tau, Lewy bodies, and TDP-43, they also assessed for atherosclerosis, arteriolosclerosis, cerebral amyloid angiopathy, frontotemporal lobar degeneration, and hippocampal sclerosis.

Results showed that use of any antihypertensive was associated with a lower likelihood of Alzheimer’s disease neuropathology (odds ratio, 0.822), Lewy bodies (OR, 0.786), and TDP 43 (OR, 0.597). Use of antihypertensives was also associated with increased odds of atherosclerosis (OR, 1.217) (all P < .5.)

The study showed that hypertensive systolic BP was associated with higher odds of Alzheimer’s disease neuropathology (OR, 1.28; P < .5).

Differences by drug type

Results differed in accordance with antihypertensive class. Angiotensin II receptor blockers decreased the odds of Alzheimer’s disease neuropathology by 40% (OR, 0.60; P < .5). Diuretics decreased the odds of Alzheimer’s disease by 36% (OR, 0.64; P < .001) and of hippocampal sclerosis by 32% (OR, 0.68; P < .5).

“We see diuretics are a main driver, especially for lower odds of Alzheimer’s disease and lower odds of hippocampal sclerosis,” said lead author Hanna L. Nguyen, a first-year medical student at the University of California, Irvine.

The results indicate that it is the medications, not BP levels, that account for these associations, she added.

One potential mechanism linking antihypertensives to brain pathology is that with these agents, BP is maintained in the target zone. Blood pressure that’s too high can damage blood vessels, whereas BP that’s too low may result in less than adequate perfusion, said Ms. Nguyen.

These medications may also alter pathways leading to degeneration and could, for example, affect the apo E mechanism of Alzheimer’s disease, she added.

The researchers plan to conduct subset analyses using apo E genetic status and age of death.

Although this is a “massive database,” it has limitations. For example, said Dr. Sajjadi, it does not reveal when patients started taking BP medication, how long they had been taking it, or why.

“We don’t know the exact the reason they were taking these medications. Was it just hypertension, or did they also have heart disease, stroke, a kidney problem, or was there another explanation,” he said.

Following the study presentation, session comoderator Krish Sathian, MBBS, PhD, professor of neurology, neural, and behavioral sciences, and psychology and director of the Neuroscience Institute, Penn State University, Hershey, called this work “fascinating. It provides a lot of data that really touches on everyday practice,” inasmuch as clinicians often prescribe antihypertensive medications and see patients with these kinds of brain disorders.

The investigators and Dr. Sathian reported no relevant financial relationships.

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

The MAVMET study, the first randomized controlled trial of maraviroc (Selzentry) with or without metformin, failed to reduce liver fat in people living with HIV and nonalcoholic fatty liver disease compared with placebo – and in some cases, prolonged use actually increased liver fat.

And that means clinicians like Yvonne Gilleece, MB BCh, who was not involved in the study but does run a liver clinic in England for people living with HIV, are returning to the one intervention proven to work. “As yet, the only thing that is proven to have a very positive effect that is published is weight loss,” said Dr. Gilleece, who runs the clinic at Brighton and Sussex University Hospital. “You don’t put someone on these particular drugs, particularly this combination, easily. MAVMET has really demonstrated that, actually, it’s not effective, and it’s not particularly beneficial to patients.”

The MAVMET trial data was presented at the 18th European AIDS Conference,

There was good reason to think maraviroc might work. A 2018 study in the journal Hepatology found that one of maraviroc’s molecular cousins, cenicriviroc, significantly reduced fibrosis in people with NAFLD. Dr. Gilleece is co-investigator of another study of maraviroc in NAFLD, the HEPMARC trial, which is wrapping up now. In addition to those studies, there are other potential treatments in ongoing trials, including semaglutide, which is being studied in the United States under the study name SLIM LIVER.

MAVMET enrolled 90 people living with HIV from six clinical sites in London who were 35 or older and who had at least one marker for NAFLD, such as abnormal liver lab results. But 70% qualified via imaging- and/or biopsy-confirmed NAFLD. Almost all participants (93%) were men and 81% were White. The trial excluded people who were pregnant or breastfeeding. The median age was 52, and the participants met the criteria for overweight but not obesity, with a median BMI of 28.

In other words, participants generally had fatty livers without the inflammation that characterizes the more aggressive nonalcoholic steatohepatitis (NASH). Clinicians can’t yet differentiate between those who will continue to have asymptomatic fatty liver and those who will progress to NASH and potentially need a liver transplant.

All people living with HIV in the trial had undetectable viral loads and were on HIV treatment. Nearly 1 in 5 (19%) were using a treatment regimen containing tenofovir alafenamide (TAF), which has been associated with weight gain. Nearly half were on integrase strand inhibitors.

Investigators divided the participants up into four groups: 24 people stayed on their HIV treatment and added nothing else; 23 people took maraviroc only; 21 took metformin only; and the final group took both maraviroc and metformin. Across groups, liver fat at baseline was 8.9%, and 78% had mild hepatic steatosis.

After taking the medications for 48 weeks, participants returned to clinic to be scanned via MRI proton density fat fraction (MRI-PDFF), which has been found to successfully measure liver fat. However, because of the COVID-19 pandemic, 20 of the 83 people who returned to the clinic came later than 48 weeks after the trial began.

When investigators looked at the results, they didn’t see what they hypothesized, said Sarah Pett, professor of infectious diseases at University College, London: The scatter plot graph of change in weight looked, well, scattershot: People who didn’t take any additional treatment sometimes lost more liver fat than those on treatment. In fact, the mean liver fat percentage rose by 2.2% in the maraviroc group, 1.3% in the metformin group, and 0.8% in the combination group. The control group saw an increase of 1.4% – meaning that there was no difference between the change in fat between those on treatment and those not.

What’s more, those who had delayed scans – and stayed on their treatment for a median of an additional 16 weeks – saw their liver fat increase even more.

In an interview, Dr. Pett called the results “disappointing.” “The numbers are quite small, but we still didn’t expect this,” she said. “It’s not explained by lockdown weight gain, although we still have to look in detail at how alcohol consumption could have contributed.”

There were also some limits to what the design of this particular trial could tell the researchers. For instance, nearly half of the participants in the maraviroc group, a third of the people in the metformin group, and 36% of those in the combination group had hepatic steatosis grades of 0, meaning that their livers were healthy. And MRI-PDFF becomes less reliable at that level.

“One of the regrets is that perhaps we should have done FibroScan [ultrasound], as well,” Dr. Pett said. The consequence is that the study may have undercounted the fat level by using MRI-PFDD.

“This suggests that the surrogate markers of NAFLD used in MAVMET were not very sensitive to those with a higher percentage of fat,” Dr. Pett said during her presentation. “We were really trying to be pragmatic and not require an MRI at screening.”

Whatever the case, she said that the failure of this particular treatment just highlights the growing need to look more seriously, and more collaboratively, at fat and liver health in people living with HIV.

“We need to really focus on setting up large cohorts of people living with HIV to look in a rigorous way at weight gain, changes in waist circumference, ectopic fat, capture fatty liver disease index scores, and cardiovascular risk, to acquire some longitudinal data,” she said. “And [we need to] join with our fellow researchers in overweight and obesity medicine and hepatology to make sure that people living with HIV are included in new treatments for NASH, as several large RCTs have excluded [people living with HIV].”

From Dr. Gilleece’s perspective, it also just speaks to how far the field has to go in identifying those with asymptomatic fatty livers from those who will progress to fibrosis and potentially need liver transplants.

“MAVMET shows the difficulty in managing NAFLD,” she said. “It seems quite an innocuous disease, because for the majority of people it’s not going to cause a problem in their lifetime. But the reality is, for some it will, and we don’t really know how to treat it.”

Dr. Gilleece has disclosed no relevant financial relationships. Dr. Pett reported receiving funding for trials from Gilead Sciences and Janssen-Cilag. ViiV Healthcare funded the MAVMET trial.

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

The MAVMET study, the first randomized controlled trial of maraviroc (Selzentry) with or without metformin, failed to reduce liver fat in people living with HIV and nonalcoholic fatty liver disease compared with placebo – and in some cases, prolonged use actually increased liver fat.

And that means clinicians like Yvonne Gilleece, MB BCh, who was not involved in the study but does run a liver clinic in England for people living with HIV, are returning to the one intervention proven to work. “As yet, the only thing that is proven to have a very positive effect that is published is weight loss,” said Dr. Gilleece, who runs the clinic at Brighton and Sussex University Hospital. “You don’t put someone on these particular drugs, particularly this combination, easily. MAVMET has really demonstrated that, actually, it’s not effective, and it’s not particularly beneficial to patients.”

The MAVMET trial data was presented at the 18th European AIDS Conference,

There was good reason to think maraviroc might work. A 2018 study in the journal Hepatology found that one of maraviroc’s molecular cousins, cenicriviroc, significantly reduced fibrosis in people with NAFLD. Dr. Gilleece is co-investigator of another study of maraviroc in NAFLD, the HEPMARC trial, which is wrapping up now. In addition to those studies, there are other potential treatments in ongoing trials, including semaglutide, which is being studied in the United States under the study name SLIM LIVER.

MAVMET enrolled 90 people living with HIV from six clinical sites in London who were 35 or older and who had at least one marker for NAFLD, such as abnormal liver lab results. But 70% qualified via imaging- and/or biopsy-confirmed NAFLD. Almost all participants (93%) were men and 81% were White. The trial excluded people who were pregnant or breastfeeding. The median age was 52, and the participants met the criteria for overweight but not obesity, with a median BMI of 28.

In other words, participants generally had fatty livers without the inflammation that characterizes the more aggressive nonalcoholic steatohepatitis (NASH). Clinicians can’t yet differentiate between those who will continue to have asymptomatic fatty liver and those who will progress to NASH and potentially need a liver transplant.

All people living with HIV in the trial had undetectable viral loads and were on HIV treatment. Nearly 1 in 5 (19%) were using a treatment regimen containing tenofovir alafenamide (TAF), which has been associated with weight gain. Nearly half were on integrase strand inhibitors.

Investigators divided the participants up into four groups: 24 people stayed on their HIV treatment and added nothing else; 23 people took maraviroc only; 21 took metformin only; and the final group took both maraviroc and metformin. Across groups, liver fat at baseline was 8.9%, and 78% had mild hepatic steatosis.

After taking the medications for 48 weeks, participants returned to clinic to be scanned via MRI proton density fat fraction (MRI-PDFF), which has been found to successfully measure liver fat. However, because of the COVID-19 pandemic, 20 of the 83 people who returned to the clinic came later than 48 weeks after the trial began.

When investigators looked at the results, they didn’t see what they hypothesized, said Sarah Pett, professor of infectious diseases at University College, London: The scatter plot graph of change in weight looked, well, scattershot: People who didn’t take any additional treatment sometimes lost more liver fat than those on treatment. In fact, the mean liver fat percentage rose by 2.2% in the maraviroc group, 1.3% in the metformin group, and 0.8% in the combination group. The control group saw an increase of 1.4% – meaning that there was no difference between the change in fat between those on treatment and those not.

What’s more, those who had delayed scans – and stayed on their treatment for a median of an additional 16 weeks – saw their liver fat increase even more.

In an interview, Dr. Pett called the results “disappointing.” “The numbers are quite small, but we still didn’t expect this,” she said. “It’s not explained by lockdown weight gain, although we still have to look in detail at how alcohol consumption could have contributed.”

There were also some limits to what the design of this particular trial could tell the researchers. For instance, nearly half of the participants in the maraviroc group, a third of the people in the metformin group, and 36% of those in the combination group had hepatic steatosis grades of 0, meaning that their livers were healthy. And MRI-PDFF becomes less reliable at that level.

“One of the regrets is that perhaps we should have done FibroScan [ultrasound], as well,” Dr. Pett said. The consequence is that the study may have undercounted the fat level by using MRI-PFDD.

“This suggests that the surrogate markers of NAFLD used in MAVMET were not very sensitive to those with a higher percentage of fat,” Dr. Pett said during her presentation. “We were really trying to be pragmatic and not require an MRI at screening.”

Whatever the case, she said that the failure of this particular treatment just highlights the growing need to look more seriously, and more collaboratively, at fat and liver health in people living with HIV.

“We need to really focus on setting up large cohorts of people living with HIV to look in a rigorous way at weight gain, changes in waist circumference, ectopic fat, capture fatty liver disease index scores, and cardiovascular risk, to acquire some longitudinal data,” she said. “And [we need to] join with our fellow researchers in overweight and obesity medicine and hepatology to make sure that people living with HIV are included in new treatments for NASH, as several large RCTs have excluded [people living with HIV].”

From Dr. Gilleece’s perspective, it also just speaks to how far the field has to go in identifying those with asymptomatic fatty livers from those who will progress to fibrosis and potentially need liver transplants.

“MAVMET shows the difficulty in managing NAFLD,” she said. “It seems quite an innocuous disease, because for the majority of people it’s not going to cause a problem in their lifetime. But the reality is, for some it will, and we don’t really know how to treat it.”

Dr. Gilleece has disclosed no relevant financial relationships. Dr. Pett reported receiving funding for trials from Gilead Sciences and Janssen-Cilag. ViiV Healthcare funded the MAVMET trial.

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

The MAVMET study, the first randomized controlled trial of maraviroc (Selzentry) with or without metformin, failed to reduce liver fat in people living with HIV and nonalcoholic fatty liver disease compared with placebo – and in some cases, prolonged use actually increased liver fat.

And that means clinicians like Yvonne Gilleece, MB BCh, who was not involved in the study but does run a liver clinic in England for people living with HIV, are returning to the one intervention proven to work. “As yet, the only thing that is proven to have a very positive effect that is published is weight loss,” said Dr. Gilleece, who runs the clinic at Brighton and Sussex University Hospital. “You don’t put someone on these particular drugs, particularly this combination, easily. MAVMET has really demonstrated that, actually, it’s not effective, and it’s not particularly beneficial to patients.”

The MAVMET trial data was presented at the 18th European AIDS Conference,

There was good reason to think maraviroc might work. A 2018 study in the journal Hepatology found that one of maraviroc’s molecular cousins, cenicriviroc, significantly reduced fibrosis in people with NAFLD. Dr. Gilleece is co-investigator of another study of maraviroc in NAFLD, the HEPMARC trial, which is wrapping up now. In addition to those studies, there are other potential treatments in ongoing trials, including semaglutide, which is being studied in the United States under the study name SLIM LIVER.

MAVMET enrolled 90 people living with HIV from six clinical sites in London who were 35 or older and who had at least one marker for NAFLD, such as abnormal liver lab results. But 70% qualified via imaging- and/or biopsy-confirmed NAFLD. Almost all participants (93%) were men and 81% were White. The trial excluded people who were pregnant or breastfeeding. The median age was 52, and the participants met the criteria for overweight but not obesity, with a median BMI of 28.

In other words, participants generally had fatty livers without the inflammation that characterizes the more aggressive nonalcoholic steatohepatitis (NASH). Clinicians can’t yet differentiate between those who will continue to have asymptomatic fatty liver and those who will progress to NASH and potentially need a liver transplant.

All people living with HIV in the trial had undetectable viral loads and were on HIV treatment. Nearly 1 in 5 (19%) were using a treatment regimen containing tenofovir alafenamide (TAF), which has been associated with weight gain. Nearly half were on integrase strand inhibitors.

Investigators divided the participants up into four groups: 24 people stayed on their HIV treatment and added nothing else; 23 people took maraviroc only; 21 took metformin only; and the final group took both maraviroc and metformin. Across groups, liver fat at baseline was 8.9%, and 78% had mild hepatic steatosis.

After taking the medications for 48 weeks, participants returned to clinic to be scanned via MRI proton density fat fraction (MRI-PDFF), which has been found to successfully measure liver fat. However, because of the COVID-19 pandemic, 20 of the 83 people who returned to the clinic came later than 48 weeks after the trial began.

When investigators looked at the results, they didn’t see what they hypothesized, said Sarah Pett, professor of infectious diseases at University College, London: The scatter plot graph of change in weight looked, well, scattershot: People who didn’t take any additional treatment sometimes lost more liver fat than those on treatment. In fact, the mean liver fat percentage rose by 2.2% in the maraviroc group, 1.3% in the metformin group, and 0.8% in the combination group. The control group saw an increase of 1.4% – meaning that there was no difference between the change in fat between those on treatment and those not.

What’s more, those who had delayed scans – and stayed on their treatment for a median of an additional 16 weeks – saw their liver fat increase even more.

In an interview, Dr. Pett called the results “disappointing.” “The numbers are quite small, but we still didn’t expect this,” she said. “It’s not explained by lockdown weight gain, although we still have to look in detail at how alcohol consumption could have contributed.”

There were also some limits to what the design of this particular trial could tell the researchers. For instance, nearly half of the participants in the maraviroc group, a third of the people in the metformin group, and 36% of those in the combination group had hepatic steatosis grades of 0, meaning that their livers were healthy. And MRI-PDFF becomes less reliable at that level.

“One of the regrets is that perhaps we should have done FibroScan [ultrasound], as well,” Dr. Pett said. The consequence is that the study may have undercounted the fat level by using MRI-PFDD.

“This suggests that the surrogate markers of NAFLD used in MAVMET were not very sensitive to those with a higher percentage of fat,” Dr. Pett said during her presentation. “We were really trying to be pragmatic and not require an MRI at screening.”

Whatever the case, she said that the failure of this particular treatment just highlights the growing need to look more seriously, and more collaboratively, at fat and liver health in people living with HIV.

“We need to really focus on setting up large cohorts of people living with HIV to look in a rigorous way at weight gain, changes in waist circumference, ectopic fat, capture fatty liver disease index scores, and cardiovascular risk, to acquire some longitudinal data,” she said. “And [we need to] join with our fellow researchers in overweight and obesity medicine and hepatology to make sure that people living with HIV are included in new treatments for NASH, as several large RCTs have excluded [people living with HIV].”

From Dr. Gilleece’s perspective, it also just speaks to how far the field has to go in identifying those with asymptomatic fatty livers from those who will progress to fibrosis and potentially need liver transplants.

“MAVMET shows the difficulty in managing NAFLD,” she said. “It seems quite an innocuous disease, because for the majority of people it’s not going to cause a problem in their lifetime. But the reality is, for some it will, and we don’t really know how to treat it.”

Dr. Gilleece has disclosed no relevant financial relationships. Dr. Pett reported receiving funding for trials from Gilead Sciences and Janssen-Cilag. ViiV Healthcare funded the MAVMET trial.

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

Chemical peels are an effective and well-tolerated field treatment for actinic keratoses (AKs), according to the authors of a systematic review of five studies including 88 patients.

AKs remain an ongoing health concern because of their potential to become malignant, and chemical peels are among the recommended options for field therapy, wrote Angela J. Jiang, MD, from the department of dermatology at the Henry Ford Health System, Detroit, and colleagues. “Although most dermatologists agree on the importance of field treatment, cryotherapy still remains the standard of care for treatment of AKs,” they noted, adding that the safety and efficacy of chemical peels for AK field therapy have not been well studied.

Chemical peels offer the benefit of a single treatment for patients, which eliminates the patient compliance issue needed for successful topical therapy, the researchers said. In fact, “patients report preference for the tolerability of treatment with chemical peels and the shorter downtime, compared with other field treatments,” they added.

In the study published in Dermatologic Surgery, they reviewed data from five prospective studies on the safety and efficacy of chemical peels as AK field treatments published from 1946 to March 2020 in the National Library of Medicine’s PubMed database. Of the 151 articles on the use of chemical peels for AKs, the 5 studies met the criteria for their review.

One split-face study evaluated glycolic acid peels (published in 1998), two split-face studies evaluated a combination of Jessner’s and 35% trichloroacetic acid (TCA) peels (published in 1995 and 1997), and two randomized studies evaluated TCA peels alone (published in 2006 and 2016).

Overall, the studies showed efficacy of peels in reducing AK counts, with minimal adverse events. In the glycolic acid study, 70% glycolic acid plus 5-fluorouracil (5-FU) yielded a 91.9% mean reduction in AKs at 6 months’ follow-up. A combination of Jessner’s solution and 35% TCA showed a significant reduction in AKs at 12 and at 32 months post treatment – a 75% reduction at 12 months in one study and 78% at 32 months in the other – similar to results achieved with 5-FU.

In studies of TCA alone, 30% TCA peels were similar in AK reduction (89%) to 5-FU (83%) and carbon dioxide laser resurfacing (92%). In another TCA study, 35% TCA was less effective at AK reduction at 12 months, compared with aminolevulinic acid photodynamic therapy (ALA-PDT), but the 35% peel was applied at a more superficial level than in the study of 30% TCA, the authors wrote.

Chemical peels also demonstrated effectiveness in preventing keratinocytic carcinomas, the researchers wrote. In the 30% TCA study, the rate of keratinocyte carcinoma development was 3.75-5.25 times lower in patients treated with 30% TCA peels, compared with 5-FU and carbon dioxide laser resurfacing (CO₂) after 5 years.

Chemical peels were well tolerated overall, although side effects varied among the studies. Patients in one study reported no side effects, while patients in other studies reported transient erythema and discomfort. In the study comparing TCA with PDT treatment, PDT was associated with greater pain, erythema, and pustules, the researchers wrote; however, patients treated with 35% TCA reported scarring.

From patients’ perspectives, chemical peels were preferable because of the single application, brief downtime, and minimal adverse effects. From the provider perspective, chemical peels are a more cost-effective way to treat large surface areas for AKs, compared with 5-FU or lasers, the researchers said.

The study findings were limited by several factors including the small number of prospective studies and relatively small number of patients, they noted. “The small number of included studies is partially due to the lack of studies that performed AK counts before and after treatments,” they said. The dearth of literature on chemical peels for AKs may stem from lack of residency training on the use of peels, they added.

However, the results support the use of chemical peels as an effective option for field treatment of AKs, with the added benefits of convenience and cost-effectiveness for patients, they concluded.

The study received no outside funding. The researchers had no financial conflicts to disclose.

Chemical peels are an effective and well-tolerated field treatment for actinic keratoses (AKs), according to the authors of a systematic review of five studies including 88 patients.

AKs remain an ongoing health concern because of their potential to become malignant, and chemical peels are among the recommended options for field therapy, wrote Angela J. Jiang, MD, from the department of dermatology at the Henry Ford Health System, Detroit, and colleagues. “Although most dermatologists agree on the importance of field treatment, cryotherapy still remains the standard of care for treatment of AKs,” they noted, adding that the safety and efficacy of chemical peels for AK field therapy have not been well studied.

Chemical peels offer the benefit of a single treatment for patients, which eliminates the patient compliance issue needed for successful topical therapy, the researchers said. In fact, “patients report preference for the tolerability of treatment with chemical peels and the shorter downtime, compared with other field treatments,” they added.

In the study published in Dermatologic Surgery, they reviewed data from five prospective studies on the safety and efficacy of chemical peels as AK field treatments published from 1946 to March 2020 in the National Library of Medicine’s PubMed database. Of the 151 articles on the use of chemical peels for AKs, the 5 studies met the criteria for their review.

One split-face study evaluated glycolic acid peels (published in 1998), two split-face studies evaluated a combination of Jessner’s and 35% trichloroacetic acid (TCA) peels (published in 1995 and 1997), and two randomized studies evaluated TCA peels alone (published in 2006 and 2016).

Overall, the studies showed efficacy of peels in reducing AK counts, with minimal adverse events. In the glycolic acid study, 70% glycolic acid plus 5-fluorouracil (5-FU) yielded a 91.9% mean reduction in AKs at 6 months’ follow-up. A combination of Jessner’s solution and 35% TCA showed a significant reduction in AKs at 12 and at 32 months post treatment – a 75% reduction at 12 months in one study and 78% at 32 months in the other – similar to results achieved with 5-FU.

In studies of TCA alone, 30% TCA peels were similar in AK reduction (89%) to 5-FU (83%) and carbon dioxide laser resurfacing (92%). In another TCA study, 35% TCA was less effective at AK reduction at 12 months, compared with aminolevulinic acid photodynamic therapy (ALA-PDT), but the 35% peel was applied at a more superficial level than in the study of 30% TCA, the authors wrote.

Chemical peels also demonstrated effectiveness in preventing keratinocytic carcinomas, the researchers wrote. In the 30% TCA study, the rate of keratinocyte carcinoma development was 3.75-5.25 times lower in patients treated with 30% TCA peels, compared with 5-FU and carbon dioxide laser resurfacing (CO₂) after 5 years.

Chemical peels were well tolerated overall, although side effects varied among the studies. Patients in one study reported no side effects, while patients in other studies reported transient erythema and discomfort. In the study comparing TCA with PDT treatment, PDT was associated with greater pain, erythema, and pustules, the researchers wrote; however, patients treated with 35% TCA reported scarring.

From patients’ perspectives, chemical peels were preferable because of the single application, brief downtime, and minimal adverse effects. From the provider perspective, chemical peels are a more cost-effective way to treat large surface areas for AKs, compared with 5-FU or lasers, the researchers said.

The study findings were limited by several factors including the small number of prospective studies and relatively small number of patients, they noted. “The small number of included studies is partially due to the lack of studies that performed AK counts before and after treatments,” they said. The dearth of literature on chemical peels for AKs may stem from lack of residency training on the use of peels, they added.

However, the results support the use of chemical peels as an effective option for field treatment of AKs, with the added benefits of convenience and cost-effectiveness for patients, they concluded.

The study received no outside funding. The researchers had no financial conflicts to disclose.

Chemical peels are an effective and well-tolerated field treatment for actinic keratoses (AKs), according to the authors of a systematic review of five studies including 88 patients.

AKs remain an ongoing health concern because of their potential to become malignant, and chemical peels are among the recommended options for field therapy, wrote Angela J. Jiang, MD, from the department of dermatology at the Henry Ford Health System, Detroit, and colleagues. “Although most dermatologists agree on the importance of field treatment, cryotherapy still remains the standard of care for treatment of AKs,” they noted, adding that the safety and efficacy of chemical peels for AK field therapy have not been well studied.

Chemical peels offer the benefit of a single treatment for patients, which eliminates the patient compliance issue needed for successful topical therapy, the researchers said. In fact, “patients report preference for the tolerability of treatment with chemical peels and the shorter downtime, compared with other field treatments,” they added.

In the study published in Dermatologic Surgery, they reviewed data from five prospective studies on the safety and efficacy of chemical peels as AK field treatments published from 1946 to March 2020 in the National Library of Medicine’s PubMed database. Of the 151 articles on the use of chemical peels for AKs, the 5 studies met the criteria for their review.

One split-face study evaluated glycolic acid peels (published in 1998), two split-face studies evaluated a combination of Jessner’s and 35% trichloroacetic acid (TCA) peels (published in 1995 and 1997), and two randomized studies evaluated TCA peels alone (published in 2006 and 2016).

Overall, the studies showed efficacy of peels in reducing AK counts, with minimal adverse events. In the glycolic acid study, 70% glycolic acid plus 5-fluorouracil (5-FU) yielded a 91.9% mean reduction in AKs at 6 months’ follow-up. A combination of Jessner’s solution and 35% TCA showed a significant reduction in AKs at 12 and at 32 months post treatment – a 75% reduction at 12 months in one study and 78% at 32 months in the other – similar to results achieved with 5-FU.

In studies of TCA alone, 30% TCA peels were similar in AK reduction (89%) to 5-FU (83%) and carbon dioxide laser resurfacing (92%). In another TCA study, 35% TCA was less effective at AK reduction at 12 months, compared with aminolevulinic acid photodynamic therapy (ALA-PDT), but the 35% peel was applied at a more superficial level than in the study of 30% TCA, the authors wrote.

Chemical peels also demonstrated effectiveness in preventing keratinocytic carcinomas, the researchers wrote. In the 30% TCA study, the rate of keratinocyte carcinoma development was 3.75-5.25 times lower in patients treated with 30% TCA peels, compared with 5-FU and carbon dioxide laser resurfacing (CO₂) after 5 years.

Chemical peels were well tolerated overall, although side effects varied among the studies. Patients in one study reported no side effects, while patients in other studies reported transient erythema and discomfort. In the study comparing TCA with PDT treatment, PDT was associated with greater pain, erythema, and pustules, the researchers wrote; however, patients treated with 35% TCA reported scarring.

From patients’ perspectives, chemical peels were preferable because of the single application, brief downtime, and minimal adverse effects. From the provider perspective, chemical peels are a more cost-effective way to treat large surface areas for AKs, compared with 5-FU or lasers, the researchers said.

The study findings were limited by several factors including the small number of prospective studies and relatively small number of patients, they noted. “The small number of included studies is partially due to the lack of studies that performed AK counts before and after treatments,” they said. The dearth of literature on chemical peels for AKs may stem from lack of residency training on the use of peels, they added.

However, the results support the use of chemical peels as an effective option for field treatment of AKs, with the added benefits of convenience and cost-effectiveness for patients, they concluded.

The study received no outside funding. The researchers had no financial conflicts to disclose.

Universal screening for adolescent depression in schools, compared with the usual process of targeting students for referral after observing behaviors, resulted in significantly higher odds of identifying major depressive disorder (MDD) and of starting treatment for it, a study of more than 12,000 students suggests. Findings were published online in JAMA Network Open.

Deepa L. Sekhar, MD, MSc, with the department of pediatrics at Pennsylvania State College of Medicine in Hershey, Pa., and colleagues conducted a randomized clinical trial comparing the two screening methods from November 2018 to November 2020.

The trial included students in grades 9 through 12 enrolled at any of the 14 participating Pennsylvania public high schools. Researchers compared the two groups using mixed-effects logistic regression.

They found that adolescents in the universal screening intervention group had 5.92 times higher odds (95% confidence interval [CI], 5.07-6.93) of being identified with MDD symptoms, 3.30 times higher odds (95% CI, 2.49-4.38) of the Student Assistance Program (SAP) confirming follow-up needs, and 2.07 times higher odds (95% CI, 1.39-3.10) of starting MDD treatment.

The study comprised 12,909 students, with an average age of 16 years. Of those students, 2,687 (20.8%) were Hispanic; 2,891 (22.4%) were non-Hispanic Black, 5,842 (45.3%) were non-Hispanic White; and 1,489 (11.5%) were multiracial or of other race or ethnicity.

In the universal screening intervention (n = 6,473) all students completed the Patient Health Questionnaire–9 (PHQ-9). Students who screened positive proceeded to the Student Assistance Program. Students could receive a targeted referral to SAP if they had concerning behavior beyond the PHQ-9.

In the targeted screening group (n = 6,436), students with behaviors prompting concern for MDD were referred to the Student Assistance Program (SAP), mandated in all Pennsylvania schools. The SAP determined follow-up.

The U.S. Preventive Services Task Force (USPSTF) endorsed primary care screening in 2009 and again in 2016 for all adolescents 12-18 years old.

However, the study authors wrote, most U.S. adolescents (more than 60%) don’t have routine access to preventive health care, which limits primary care offices’ ability to properly address the growing numbers.

“[S]creening is inconsistent, with inequalities by race and ethnicity and region, and potential worsening with the COVID-19 pandemic,” they noted.

Depression rates see sharp increase

Meanwhile, the prevalence of adolescents reporting MDD symptoms has “nearly doubled in the last decade, increasing from 8.3% in 2008 to 14.4% in 2018.”

The American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, and Children’s Hospital Association recently declared a national emergency in children’s mental health, citing COVID-19’s toll on top of existing challenges.

This study provides further evidence that universal screening is the better approach to identify and treat adolescent depression to save lives, Andres Pumariega, MD, a child and adolescent psychiatrist at University of Florida in Gainesville, told this news organization.

“If you catch these kids early, you can prevent suicide attempts and suicide. You can also prevent complicating costs of care,” he said.

He noted the universal screening removes the potential for bias.

“Relying purely on referral and clinical identification means a lot of kids in minority groups will not be identified and will not be treated accurately. Many clinicians have a problem identifying depression in diverse kids,” he said.

Pushback for universal screening likely

However, he said he has been part of such efforts to implement such programs in Mexico and the United States and said in the Unites States, the political climate will guarantee pushback from having schools more involved in health care and prevention. Recent controversy around COVID-19 vaccines for children illustrates the potential backlash, he said.

Parents often fight such programs as attempts to “label” their children, he said.

“If I have cancer, I sure want to be labeled. A label is used to get them help. We need to find ways to educate parents and support them in facing these issues,” he added.

One concern he has with this intervention is having the SAPs, composed largely of nonclinicians, be the triage point “instead of doing that objectively through objective criteria and by clinicians,” he said. “If we are to have a comprehensive health system where we can serve all kids and manage costs, schools need to be a major part of it.”

School settings offer the chance to see more children, collaborate with teachers and counselors, and integrate results with educational outcomes, he added.

In the study by Sekhar and colleagues, 7 of the 14 schools were classified as urban, with a median size of 370 students.

Researchers noted that the benefit of the universal screening is likely understated because of COVID-19–related school closures during the study period. The closures meant screening wasn’t completed for 7% of students.

The authors concluded that universal screening finds teens living with depression who otherwise would not be found. They said such a program likely works best in schools with strong SAP.

“Adolescents’ consistent contact with schools has been used to support physical health screenings that affect academic success,” the authors wrote. “Major depressive disorder similarly affects academic success, suggesting school-based screening may be especially beneficial.”

In the past 3 years, Dr. Sekhar reported receiving funding from Pfizer through the American Academy of Pediatrics, the Penn State Clinical and Translational Science Awards Program, and a Eugene Washington Patient-Centered Outcomes Research Institute Engagement Award. Full disclosures for coauthors are available in the journal article.

This work was supported in part by the Patient-Centered Outcomes Research Institute. The use of REDCap (Research Electronic Data Capture) in this project was supported by the National Institutes of Health.

Universal screening for adolescent depression in schools, compared with the usual process of targeting students for referral after observing behaviors, resulted in significantly higher odds of identifying major depressive disorder (MDD) and of starting treatment for it, a study of more than 12,000 students suggests. Findings were published online in JAMA Network Open.

Deepa L. Sekhar, MD, MSc, with the department of pediatrics at Pennsylvania State College of Medicine in Hershey, Pa., and colleagues conducted a randomized clinical trial comparing the two screening methods from November 2018 to November 2020.

The trial included students in grades 9 through 12 enrolled at any of the 14 participating Pennsylvania public high schools. Researchers compared the two groups using mixed-effects logistic regression.

They found that adolescents in the universal screening intervention group had 5.92 times higher odds (95% confidence interval [CI], 5.07-6.93) of being identified with MDD symptoms, 3.30 times higher odds (95% CI, 2.49-4.38) of the Student Assistance Program (SAP) confirming follow-up needs, and 2.07 times higher odds (95% CI, 1.39-3.10) of starting MDD treatment.

The study comprised 12,909 students, with an average age of 16 years. Of those students, 2,687 (20.8%) were Hispanic; 2,891 (22.4%) were non-Hispanic Black, 5,842 (45.3%) were non-Hispanic White; and 1,489 (11.5%) were multiracial or of other race or ethnicity.

In the universal screening intervention (n = 6,473) all students completed the Patient Health Questionnaire–9 (PHQ-9). Students who screened positive proceeded to the Student Assistance Program. Students could receive a targeted referral to SAP if they had concerning behavior beyond the PHQ-9.

In the targeted screening group (n = 6,436), students with behaviors prompting concern for MDD were referred to the Student Assistance Program (SAP), mandated in all Pennsylvania schools. The SAP determined follow-up.

The U.S. Preventive Services Task Force (USPSTF) endorsed primary care screening in 2009 and again in 2016 for all adolescents 12-18 years old.

However, the study authors wrote, most U.S. adolescents (more than 60%) don’t have routine access to preventive health care, which limits primary care offices’ ability to properly address the growing numbers.

“[S]creening is inconsistent, with inequalities by race and ethnicity and region, and potential worsening with the COVID-19 pandemic,” they noted.

Depression rates see sharp increase

Meanwhile, the prevalence of adolescents reporting MDD symptoms has “nearly doubled in the last decade, increasing from 8.3% in 2008 to 14.4% in 2018.”

The American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, and Children’s Hospital Association recently declared a national emergency in children’s mental health, citing COVID-19’s toll on top of existing challenges.

This study provides further evidence that universal screening is the better approach to identify and treat adolescent depression to save lives, Andres Pumariega, MD, a child and adolescent psychiatrist at University of Florida in Gainesville, told this news organization.

“If you catch these kids early, you can prevent suicide attempts and suicide. You can also prevent complicating costs of care,” he said.

He noted the universal screening removes the potential for bias.

“Relying purely on referral and clinical identification means a lot of kids in minority groups will not be identified and will not be treated accurately. Many clinicians have a problem identifying depression in diverse kids,” he said.

Pushback for universal screening likely

However, he said he has been part of such efforts to implement such programs in Mexico and the United States and said in the Unites States, the political climate will guarantee pushback from having schools more involved in health care and prevention. Recent controversy around COVID-19 vaccines for children illustrates the potential backlash, he said.

Parents often fight such programs as attempts to “label” their children, he said.

“If I have cancer, I sure want to be labeled. A label is used to get them help. We need to find ways to educate parents and support them in facing these issues,” he added.

One concern he has with this intervention is having the SAPs, composed largely of nonclinicians, be the triage point “instead of doing that objectively through objective criteria and by clinicians,” he said. “If we are to have a comprehensive health system where we can serve all kids and manage costs, schools need to be a major part of it.”

School settings offer the chance to see more children, collaborate with teachers and counselors, and integrate results with educational outcomes, he added.

In the study by Sekhar and colleagues, 7 of the 14 schools were classified as urban, with a median size of 370 students.

Researchers noted that the benefit of the universal screening is likely understated because of COVID-19–related school closures during the study period. The closures meant screening wasn’t completed for 7% of students.

The authors concluded that universal screening finds teens living with depression who otherwise would not be found. They said such a program likely works best in schools with strong SAP.

“Adolescents’ consistent contact with schools has been used to support physical health screenings that affect academic success,” the authors wrote. “Major depressive disorder similarly affects academic success, suggesting school-based screening may be especially beneficial.”

In the past 3 years, Dr. Sekhar reported receiving funding from Pfizer through the American Academy of Pediatrics, the Penn State Clinical and Translational Science Awards Program, and a Eugene Washington Patient-Centered Outcomes Research Institute Engagement Award. Full disclosures for coauthors are available in the journal article.

This work was supported in part by the Patient-Centered Outcomes Research Institute. The use of REDCap (Research Electronic Data Capture) in this project was supported by the National Institutes of Health.

Universal screening for adolescent depression in schools, compared with the usual process of targeting students for referral after observing behaviors, resulted in significantly higher odds of identifying major depressive disorder (MDD) and of starting treatment for it, a study of more than 12,000 students suggests. Findings were published online in JAMA Network Open.

Deepa L. Sekhar, MD, MSc, with the department of pediatrics at Pennsylvania State College of Medicine in Hershey, Pa., and colleagues conducted a randomized clinical trial comparing the two screening methods from November 2018 to November 2020.

The trial included students in grades 9 through 12 enrolled at any of the 14 participating Pennsylvania public high schools. Researchers compared the two groups using mixed-effects logistic regression.

They found that adolescents in the universal screening intervention group had 5.92 times higher odds (95% confidence interval [CI], 5.07-6.93) of being identified with MDD symptoms, 3.30 times higher odds (95% CI, 2.49-4.38) of the Student Assistance Program (SAP) confirming follow-up needs, and 2.07 times higher odds (95% CI, 1.39-3.10) of starting MDD treatment.

The study comprised 12,909 students, with an average age of 16 years. Of those students, 2,687 (20.8%) were Hispanic; 2,891 (22.4%) were non-Hispanic Black, 5,842 (45.3%) were non-Hispanic White; and 1,489 (11.5%) were multiracial or of other race or ethnicity.

In the universal screening intervention (n = 6,473) all students completed the Patient Health Questionnaire–9 (PHQ-9). Students who screened positive proceeded to the Student Assistance Program. Students could receive a targeted referral to SAP if they had concerning behavior beyond the PHQ-9.

In the targeted screening group (n = 6,436), students with behaviors prompting concern for MDD were referred to the Student Assistance Program (SAP), mandated in all Pennsylvania schools. The SAP determined follow-up.

The U.S. Preventive Services Task Force (USPSTF) endorsed primary care screening in 2009 and again in 2016 for all adolescents 12-18 years old.

However, the study authors wrote, most U.S. adolescents (more than 60%) don’t have routine access to preventive health care, which limits primary care offices’ ability to properly address the growing numbers.

“[S]creening is inconsistent, with inequalities by race and ethnicity and region, and potential worsening with the COVID-19 pandemic,” they noted.

Depression rates see sharp increase

Meanwhile, the prevalence of adolescents reporting MDD symptoms has “nearly doubled in the last decade, increasing from 8.3% in 2008 to 14.4% in 2018.”

The American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, and Children’s Hospital Association recently declared a national emergency in children’s mental health, citing COVID-19’s toll on top of existing challenges.

This study provides further evidence that universal screening is the better approach to identify and treat adolescent depression to save lives, Andres Pumariega, MD, a child and adolescent psychiatrist at University of Florida in Gainesville, told this news organization.

“If you catch these kids early, you can prevent suicide attempts and suicide. You can also prevent complicating costs of care,” he said.

He noted the universal screening removes the potential for bias.

“Relying purely on referral and clinical identification means a lot of kids in minority groups will not be identified and will not be treated accurately. Many clinicians have a problem identifying depression in diverse kids,” he said.

Pushback for universal screening likely

However, he said he has been part of such efforts to implement such programs in Mexico and the United States and said in the Unites States, the political climate will guarantee pushback from having schools more involved in health care and prevention. Recent controversy around COVID-19 vaccines for children illustrates the potential backlash, he said.

Parents often fight such programs as attempts to “label” their children, he said.

“If I have cancer, I sure want to be labeled. A label is used to get them help. We need to find ways to educate parents and support them in facing these issues,” he added.

One concern he has with this intervention is having the SAPs, composed largely of nonclinicians, be the triage point “instead of doing that objectively through objective criteria and by clinicians,” he said. “If we are to have a comprehensive health system where we can serve all kids and manage costs, schools need to be a major part of it.”

School settings offer the chance to see more children, collaborate with teachers and counselors, and integrate results with educational outcomes, he added.

In the study by Sekhar and colleagues, 7 of the 14 schools were classified as urban, with a median size of 370 students.

Researchers noted that the benefit of the universal screening is likely understated because of COVID-19–related school closures during the study period. The closures meant screening wasn’t completed for 7% of students.

The authors concluded that universal screening finds teens living with depression who otherwise would not be found. They said such a program likely works best in schools with strong SAP.

“Adolescents’ consistent contact with schools has been used to support physical health screenings that affect academic success,” the authors wrote. “Major depressive disorder similarly affects academic success, suggesting school-based screening may be especially beneficial.”

In the past 3 years, Dr. Sekhar reported receiving funding from Pfizer through the American Academy of Pediatrics, the Penn State Clinical and Translational Science Awards Program, and a Eugene Washington Patient-Centered Outcomes Research Institute Engagement Award. Full disclosures for coauthors are available in the journal article.

This work was supported in part by the Patient-Centered Outcomes Research Institute. The use of REDCap (Research Electronic Data Capture) in this project was supported by the National Institutes of Health.