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A 74-year-old White male presented with a 1-year history of depigmented patches on the hands, arms, and face, as well as white eyelashes and eyebrows
This patient showed no evidence of recurrence in the scar where the melanoma was excised, and had no enlarged lymph nodes on palpation. His complete blood count and liver function tests were normal. A positron emission tomography (PET) scan was ordered by Dr. Nasser that revealed hypermetabolic right paratracheal, right hilar, and subcarinal lymph nodes, highly suspicious for malignant lymph nodes. The patient was referred to oncology for metastatic melanoma treatment and has been doing well on ipilimumab and nivolumab.
Vitiligo is an autoimmune condition characterized by the progressive destruction of melanocytes resulting in hypopigmentation or depigmentation of the skin. Vitiligo has been associated with cutaneous melanoma. Melanoma-associated leukoderma occurs in a portion of patients with melanoma and is correlated with a favorable prognosis. Additionally, leukoderma has been described as a side effect of melanoma treatment itself. However, cases such as this one have also been reported of vitiligo-like depigmentation presenting prior to the diagnosis of metastatic melanoma.
Melanoma, like vitiligo, is considered highly immunogenic, and cytotoxic T lymphocytes (CTLs) can recognize antigens in melanoma. Furthermore, studies have shown a vitiligo-like halo around melanoma tumors, likely caused by T-cell recruitment, and this may lead to tumor destruction, but rarely total clearance. It seems that the CTL infiltrate in both diseases is similar, but regulatory T cells are decreased in vitiligo, whereas they are present in melanomas and may contribute to the immunosuppressive tumor microenvironment found at the margin of these lesions.
Leukoderma is also associated with melanoma immunotherapy which may be described as drug-induced leukoderma. Additionally, the frequency of recognition of melanoma cells by CTLs leading to hypopigmentation appears to be higher in those with metastatic disease. High immune infiltrate with CTLs and interferon-gamma (IFN-gamma) expression by type 1 T helper cells is associated with favorable prognosis. Immunotherapy with checkpoint inhibitors has shown promise in treatment augmentation for melanoma, but not all patients fully respond to therapy. Nonetheless, development of leukoderma with these treatments has been significantly associated with good therapeutic response. Depigmentation of hair and retinal epithelium has also been reported. However, drug-induced leukoderma and vitiligo seem to have clinical and biological differences, including family history of disease and serum chemokine levels. Vaccines are in production to aid in the treatment of melanoma, but researchers must first identify the appropriate antigen(s) to include.
Conversely, vitiligo-like depigmentation has been reported as a harbinger of metastatic melanoma. Patients with previous excision of primary melanoma have presented months or years later with depigmentation and, upon further evaluation, have been diagnosed with metastatic melanoma. The prevalence of depigmentation in melanoma patients is about 3%-6%, and is estimated to be 7-10 times more common in those with melanoma than in the general population. In most cases, hypopigmentation follows the diagnosis of melanoma, with an average of 4.8 years after the initial diagnosis and 1-2 years after lymph node or distant metastases. It is unclear whether hypopigmentation occurs before or after the growth of metastatic lesions, but this clinical finding in a patient with previous melanoma may serve as an important clue to conduct further investigation for metastasis.
This case and the photos were submitted by Lucas Shapiro, BS, of Nova Southeastern University College of Osteopathic Medicine, Fort Lauderdale, Florida, and Natalie Y. Nasser, MD, Kaiser Permanente Riverside Medical Center; Riverside, California. The column was edited by Donna Bilu Martin, MD.
Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Florida More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to [email protected].
References
Cerci FB et al. Cutis. 2017 Jun;99(6):E1-E2. PMID: 28686764.
Cho EA et al. Ann Dermatol. 2009 May;21(2):178-181.
Failla CM et al. Int J Mol Sci. 2019 Nov 15;20(22):5731.
This patient showed no evidence of recurrence in the scar where the melanoma was excised, and had no enlarged lymph nodes on palpation. His complete blood count and liver function tests were normal. A positron emission tomography (PET) scan was ordered by Dr. Nasser that revealed hypermetabolic right paratracheal, right hilar, and subcarinal lymph nodes, highly suspicious for malignant lymph nodes. The patient was referred to oncology for metastatic melanoma treatment and has been doing well on ipilimumab and nivolumab.
Vitiligo is an autoimmune condition characterized by the progressive destruction of melanocytes resulting in hypopigmentation or depigmentation of the skin. Vitiligo has been associated with cutaneous melanoma. Melanoma-associated leukoderma occurs in a portion of patients with melanoma and is correlated with a favorable prognosis. Additionally, leukoderma has been described as a side effect of melanoma treatment itself. However, cases such as this one have also been reported of vitiligo-like depigmentation presenting prior to the diagnosis of metastatic melanoma.
Melanoma, like vitiligo, is considered highly immunogenic, and cytotoxic T lymphocytes (CTLs) can recognize antigens in melanoma. Furthermore, studies have shown a vitiligo-like halo around melanoma tumors, likely caused by T-cell recruitment, and this may lead to tumor destruction, but rarely total clearance. It seems that the CTL infiltrate in both diseases is similar, but regulatory T cells are decreased in vitiligo, whereas they are present in melanomas and may contribute to the immunosuppressive tumor microenvironment found at the margin of these lesions.
Leukoderma is also associated with melanoma immunotherapy which may be described as drug-induced leukoderma. Additionally, the frequency of recognition of melanoma cells by CTLs leading to hypopigmentation appears to be higher in those with metastatic disease. High immune infiltrate with CTLs and interferon-gamma (IFN-gamma) expression by type 1 T helper cells is associated with favorable prognosis. Immunotherapy with checkpoint inhibitors has shown promise in treatment augmentation for melanoma, but not all patients fully respond to therapy. Nonetheless, development of leukoderma with these treatments has been significantly associated with good therapeutic response. Depigmentation of hair and retinal epithelium has also been reported. However, drug-induced leukoderma and vitiligo seem to have clinical and biological differences, including family history of disease and serum chemokine levels. Vaccines are in production to aid in the treatment of melanoma, but researchers must first identify the appropriate antigen(s) to include.
Conversely, vitiligo-like depigmentation has been reported as a harbinger of metastatic melanoma. Patients with previous excision of primary melanoma have presented months or years later with depigmentation and, upon further evaluation, have been diagnosed with metastatic melanoma. The prevalence of depigmentation in melanoma patients is about 3%-6%, and is estimated to be 7-10 times more common in those with melanoma than in the general population. In most cases, hypopigmentation follows the diagnosis of melanoma, with an average of 4.8 years after the initial diagnosis and 1-2 years after lymph node or distant metastases. It is unclear whether hypopigmentation occurs before or after the growth of metastatic lesions, but this clinical finding in a patient with previous melanoma may serve as an important clue to conduct further investigation for metastasis.
This case and the photos were submitted by Lucas Shapiro, BS, of Nova Southeastern University College of Osteopathic Medicine, Fort Lauderdale, Florida, and Natalie Y. Nasser, MD, Kaiser Permanente Riverside Medical Center; Riverside, California. The column was edited by Donna Bilu Martin, MD.
Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Florida More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to [email protected].
References
Cerci FB et al. Cutis. 2017 Jun;99(6):E1-E2. PMID: 28686764.
Cho EA et al. Ann Dermatol. 2009 May;21(2):178-181.
Failla CM et al. Int J Mol Sci. 2019 Nov 15;20(22):5731.
This patient showed no evidence of recurrence in the scar where the melanoma was excised, and had no enlarged lymph nodes on palpation. His complete blood count and liver function tests were normal. A positron emission tomography (PET) scan was ordered by Dr. Nasser that revealed hypermetabolic right paratracheal, right hilar, and subcarinal lymph nodes, highly suspicious for malignant lymph nodes. The patient was referred to oncology for metastatic melanoma treatment and has been doing well on ipilimumab and nivolumab.
Vitiligo is an autoimmune condition characterized by the progressive destruction of melanocytes resulting in hypopigmentation or depigmentation of the skin. Vitiligo has been associated with cutaneous melanoma. Melanoma-associated leukoderma occurs in a portion of patients with melanoma and is correlated with a favorable prognosis. Additionally, leukoderma has been described as a side effect of melanoma treatment itself. However, cases such as this one have also been reported of vitiligo-like depigmentation presenting prior to the diagnosis of metastatic melanoma.
Melanoma, like vitiligo, is considered highly immunogenic, and cytotoxic T lymphocytes (CTLs) can recognize antigens in melanoma. Furthermore, studies have shown a vitiligo-like halo around melanoma tumors, likely caused by T-cell recruitment, and this may lead to tumor destruction, but rarely total clearance. It seems that the CTL infiltrate in both diseases is similar, but regulatory T cells are decreased in vitiligo, whereas they are present in melanomas and may contribute to the immunosuppressive tumor microenvironment found at the margin of these lesions.
Leukoderma is also associated with melanoma immunotherapy which may be described as drug-induced leukoderma. Additionally, the frequency of recognition of melanoma cells by CTLs leading to hypopigmentation appears to be higher in those with metastatic disease. High immune infiltrate with CTLs and interferon-gamma (IFN-gamma) expression by type 1 T helper cells is associated with favorable prognosis. Immunotherapy with checkpoint inhibitors has shown promise in treatment augmentation for melanoma, but not all patients fully respond to therapy. Nonetheless, development of leukoderma with these treatments has been significantly associated with good therapeutic response. Depigmentation of hair and retinal epithelium has also been reported. However, drug-induced leukoderma and vitiligo seem to have clinical and biological differences, including family history of disease and serum chemokine levels. Vaccines are in production to aid in the treatment of melanoma, but researchers must first identify the appropriate antigen(s) to include.
Conversely, vitiligo-like depigmentation has been reported as a harbinger of metastatic melanoma. Patients with previous excision of primary melanoma have presented months or years later with depigmentation and, upon further evaluation, have been diagnosed with metastatic melanoma. The prevalence of depigmentation in melanoma patients is about 3%-6%, and is estimated to be 7-10 times more common in those with melanoma than in the general population. In most cases, hypopigmentation follows the diagnosis of melanoma, with an average of 4.8 years after the initial diagnosis and 1-2 years after lymph node or distant metastases. It is unclear whether hypopigmentation occurs before or after the growth of metastatic lesions, but this clinical finding in a patient with previous melanoma may serve as an important clue to conduct further investigation for metastasis.
This case and the photos were submitted by Lucas Shapiro, BS, of Nova Southeastern University College of Osteopathic Medicine, Fort Lauderdale, Florida, and Natalie Y. Nasser, MD, Kaiser Permanente Riverside Medical Center; Riverside, California. The column was edited by Donna Bilu Martin, MD.
Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Florida More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to [email protected].
References
Cerci FB et al. Cutis. 2017 Jun;99(6):E1-E2. PMID: 28686764.
Cho EA et al. Ann Dermatol. 2009 May;21(2):178-181.
Failla CM et al. Int J Mol Sci. 2019 Nov 15;20(22):5731.
When Babies ‘Stop Breathing,’ Who Needs Admission and a Workup?
Many infants have experienced an episode of apnea, defined as a pause in respiration of 20 seconds or more. Most episodes remain unexplained, and no underlying cause can be found. Historically, these were referred to as “near-miss SIDS,” episodes, but that label suggested that all of these events would have ended in death had someone not intervened. New descriptive terminology was needed.
In the mid-1980s, the term “apparent life-threatening event” (ALTE) was adopted. But that term, too, was an overstatement, because although scary for parents, these brief apnea episodes were not, in most cases, truly life-threatening.
In 2013, authors of a systematic review coined the term “brief resolved unexplained event” (BRUE). This review also addressed the history and physical exam features associated with risk for a subsequent episode. It was felt that hospitalization and testing might be warranted if certain infants could be identified as high risk for recurrence.
What Is Considered a BRUE?
In the current working definition of BRUE, the child must be < 1 year old. The episode must be a sudden, brief, and resolved, with one or more of these characteristics:
- Cyanosis or pallor (but not turning red)
- A change in breathing (absent, decreased, or irregular)
- A change in tone (hypertonia or hypotonia)
- A change in responsiveness.
Furthermore, to qualify as a BRUE, no explanation can be found for the event based on the history and physical examination but before any laboratory testing is done. The definition also excludes children with known potential explanatory diagnoses (such as gastroesophageal reflux or bronchiolitis) and those who are otherwise symptomatically ill at the time of the event.
Decision to Admit and Recurrence Risk
An apnea event in an otherwise healthy infant, regardless of what it’s called, puts providers and parents in a difficult position. Should the infant be hospitalized for further monitoring and potentially more invasive testing to determine the cause of the episode? And what are the chances that the episode will be repeated?
A clinical practice guideline (CPG) for BRUE, widely adopted in 2016, resulted in significant reductions in healthcare utilization. The CPG attempted to identify low-risk infants who could safely be discharged from the emergency department. Although the CPG improved outcomes, experts acknowledged that an underlying problem was not likely to be identified even among infants deemed high risk, and these infants would be hospitalized unnecessarily.
Available data were simply insufficient to support this decision. So, with the goal of identifying factors that could help predict recurrent BRUE risk, a 15-hospital collaborative study was undertaken, followed by the development and validation of a clinical decision rule for predicting the risk for a serious underlying diagnosis or event recurrence among infants presenting with BRUE.
Here’s what we learned from more than 3000 cases of BRUE.
First, it turns out that it’s not easy to determine whether an infant is at low or high risk for recurrence of BRUE. Initially, 91.5% of patients enrolled in the study would have been labeled high risk.
Furthermore, a BRUE recurred in 14.3% of the cohort, and 4.8% of high-risk infants were found to have a serious undiagnosed condition. Seizures, airway anomalies, and gastroesophageal reflux were the top three causes of BRUE, but the spectrum of underlying pathology was quite considerable.
The problem was that 4.6% of the entire cohort were found to have a serious underlying condition, nearly identical to the proportion of high-risk infants with these conditions. This prompted the question of whether simply labeling infants “high risk” was really appropriate any longer.
Revised BRUE Management
Although it hasn’t been possible to group infants neatly in low and high-risk categories, the data from that large cohort led to the development of the BRUE 2.0 criteria, which enabled more focused risk assessment of an infant who experienced a BRUE. With an app on MDCalc, these criteria allow providers to ascertain, and show families, a visual representation of their infant’s individualized risk for a subsequent BRUE and of having a serious underlying condition.
The cohort study also identified red flags from the history or physical exam of infants who experienced a BRUE: weight loss, failure to thrive, or a history of feeding problems. Exam findings such as a bulging fontanelle, forceful or bilious emesis, and evidence of gastrointestinal (GI) bleeding suggest a medical diagnosis rather than a BRUE. If GI-related causes are high on the differential, a feeding evaluation can be helpful. A feeding evaluation can be done in the outpatient setting and does not require hospitalization.
For suspicion of an underlying neurological condition (such as seizures), experts recommend obtaining a short EEG, which is highly sensitive for detecting infantile spasms and encephalopathy. They recommend reserving MRI for infants with abnormalities on EEG or physical exam. Metabolic or genetic testing should be done only if the infant looks ill, because most patients with genetic or inborn errors of metabolism will continue to have symptoms as they become older.
The approach to BRUE has moved into the realm of shared decision-making with families. The likelihood of identifying a serious diagnosis is low for most of these children. And unfortunately, no single test can diagnose the full spectrum of potential explanatory diagnoses. For example, data from 2023 demonstrate that only 1.1% of lab tests following a BRUE contributed to a diagnosis, and most of the time that was a positive viral test. Similarly, imaging was helpful in only 1.5% of cases. So, explaining the evidence and deciding along with parents what is reasonable to do (or not do) is the current state of affairs.
My Take
As I reflect back on two and a half decades of caring for these patients, I believe that recent data have helped us a great deal. We do less testing and admit fewer infants to the hospital than we did 20 years ago, and that’s a good thing. Nevertheless, looking for a few red flags, having a high index of suspicion when the clinical exam is abnormal, and engaging in shared decision-making with families can help make the caring for these challenging patients more bearable and lead to better outcomes for all involved.
Dr. Basco is Professor, Department of Pediatrics, Medical University of South Carolina (MUSC); Director, Division of General Pediatrics, Department of Pediatrics, MUSC Children’s Hospital, Charleston, South Carolina. He has disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Many infants have experienced an episode of apnea, defined as a pause in respiration of 20 seconds or more. Most episodes remain unexplained, and no underlying cause can be found. Historically, these were referred to as “near-miss SIDS,” episodes, but that label suggested that all of these events would have ended in death had someone not intervened. New descriptive terminology was needed.
In the mid-1980s, the term “apparent life-threatening event” (ALTE) was adopted. But that term, too, was an overstatement, because although scary for parents, these brief apnea episodes were not, in most cases, truly life-threatening.
In 2013, authors of a systematic review coined the term “brief resolved unexplained event” (BRUE). This review also addressed the history and physical exam features associated with risk for a subsequent episode. It was felt that hospitalization and testing might be warranted if certain infants could be identified as high risk for recurrence.
What Is Considered a BRUE?
In the current working definition of BRUE, the child must be < 1 year old. The episode must be a sudden, brief, and resolved, with one or more of these characteristics:
- Cyanosis or pallor (but not turning red)
- A change in breathing (absent, decreased, or irregular)
- A change in tone (hypertonia or hypotonia)
- A change in responsiveness.
Furthermore, to qualify as a BRUE, no explanation can be found for the event based on the history and physical examination but before any laboratory testing is done. The definition also excludes children with known potential explanatory diagnoses (such as gastroesophageal reflux or bronchiolitis) and those who are otherwise symptomatically ill at the time of the event.
Decision to Admit and Recurrence Risk
An apnea event in an otherwise healthy infant, regardless of what it’s called, puts providers and parents in a difficult position. Should the infant be hospitalized for further monitoring and potentially more invasive testing to determine the cause of the episode? And what are the chances that the episode will be repeated?
A clinical practice guideline (CPG) for BRUE, widely adopted in 2016, resulted in significant reductions in healthcare utilization. The CPG attempted to identify low-risk infants who could safely be discharged from the emergency department. Although the CPG improved outcomes, experts acknowledged that an underlying problem was not likely to be identified even among infants deemed high risk, and these infants would be hospitalized unnecessarily.
Available data were simply insufficient to support this decision. So, with the goal of identifying factors that could help predict recurrent BRUE risk, a 15-hospital collaborative study was undertaken, followed by the development and validation of a clinical decision rule for predicting the risk for a serious underlying diagnosis or event recurrence among infants presenting with BRUE.
Here’s what we learned from more than 3000 cases of BRUE.
First, it turns out that it’s not easy to determine whether an infant is at low or high risk for recurrence of BRUE. Initially, 91.5% of patients enrolled in the study would have been labeled high risk.
Furthermore, a BRUE recurred in 14.3% of the cohort, and 4.8% of high-risk infants were found to have a serious undiagnosed condition. Seizures, airway anomalies, and gastroesophageal reflux were the top three causes of BRUE, but the spectrum of underlying pathology was quite considerable.
The problem was that 4.6% of the entire cohort were found to have a serious underlying condition, nearly identical to the proportion of high-risk infants with these conditions. This prompted the question of whether simply labeling infants “high risk” was really appropriate any longer.
Revised BRUE Management
Although it hasn’t been possible to group infants neatly in low and high-risk categories, the data from that large cohort led to the development of the BRUE 2.0 criteria, which enabled more focused risk assessment of an infant who experienced a BRUE. With an app on MDCalc, these criteria allow providers to ascertain, and show families, a visual representation of their infant’s individualized risk for a subsequent BRUE and of having a serious underlying condition.
The cohort study also identified red flags from the history or physical exam of infants who experienced a BRUE: weight loss, failure to thrive, or a history of feeding problems. Exam findings such as a bulging fontanelle, forceful or bilious emesis, and evidence of gastrointestinal (GI) bleeding suggest a medical diagnosis rather than a BRUE. If GI-related causes are high on the differential, a feeding evaluation can be helpful. A feeding evaluation can be done in the outpatient setting and does not require hospitalization.
For suspicion of an underlying neurological condition (such as seizures), experts recommend obtaining a short EEG, which is highly sensitive for detecting infantile spasms and encephalopathy. They recommend reserving MRI for infants with abnormalities on EEG or physical exam. Metabolic or genetic testing should be done only if the infant looks ill, because most patients with genetic or inborn errors of metabolism will continue to have symptoms as they become older.
The approach to BRUE has moved into the realm of shared decision-making with families. The likelihood of identifying a serious diagnosis is low for most of these children. And unfortunately, no single test can diagnose the full spectrum of potential explanatory diagnoses. For example, data from 2023 demonstrate that only 1.1% of lab tests following a BRUE contributed to a diagnosis, and most of the time that was a positive viral test. Similarly, imaging was helpful in only 1.5% of cases. So, explaining the evidence and deciding along with parents what is reasonable to do (or not do) is the current state of affairs.
My Take
As I reflect back on two and a half decades of caring for these patients, I believe that recent data have helped us a great deal. We do less testing and admit fewer infants to the hospital than we did 20 years ago, and that’s a good thing. Nevertheless, looking for a few red flags, having a high index of suspicion when the clinical exam is abnormal, and engaging in shared decision-making with families can help make the caring for these challenging patients more bearable and lead to better outcomes for all involved.
Dr. Basco is Professor, Department of Pediatrics, Medical University of South Carolina (MUSC); Director, Division of General Pediatrics, Department of Pediatrics, MUSC Children’s Hospital, Charleston, South Carolina. He has disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Many infants have experienced an episode of apnea, defined as a pause in respiration of 20 seconds or more. Most episodes remain unexplained, and no underlying cause can be found. Historically, these were referred to as “near-miss SIDS,” episodes, but that label suggested that all of these events would have ended in death had someone not intervened. New descriptive terminology was needed.
In the mid-1980s, the term “apparent life-threatening event” (ALTE) was adopted. But that term, too, was an overstatement, because although scary for parents, these brief apnea episodes were not, in most cases, truly life-threatening.
In 2013, authors of a systematic review coined the term “brief resolved unexplained event” (BRUE). This review also addressed the history and physical exam features associated with risk for a subsequent episode. It was felt that hospitalization and testing might be warranted if certain infants could be identified as high risk for recurrence.
What Is Considered a BRUE?
In the current working definition of BRUE, the child must be < 1 year old. The episode must be a sudden, brief, and resolved, with one or more of these characteristics:
- Cyanosis or pallor (but not turning red)
- A change in breathing (absent, decreased, or irregular)
- A change in tone (hypertonia or hypotonia)
- A change in responsiveness.
Furthermore, to qualify as a BRUE, no explanation can be found for the event based on the history and physical examination but before any laboratory testing is done. The definition also excludes children with known potential explanatory diagnoses (such as gastroesophageal reflux or bronchiolitis) and those who are otherwise symptomatically ill at the time of the event.
Decision to Admit and Recurrence Risk
An apnea event in an otherwise healthy infant, regardless of what it’s called, puts providers and parents in a difficult position. Should the infant be hospitalized for further monitoring and potentially more invasive testing to determine the cause of the episode? And what are the chances that the episode will be repeated?
A clinical practice guideline (CPG) for BRUE, widely adopted in 2016, resulted in significant reductions in healthcare utilization. The CPG attempted to identify low-risk infants who could safely be discharged from the emergency department. Although the CPG improved outcomes, experts acknowledged that an underlying problem was not likely to be identified even among infants deemed high risk, and these infants would be hospitalized unnecessarily.
Available data were simply insufficient to support this decision. So, with the goal of identifying factors that could help predict recurrent BRUE risk, a 15-hospital collaborative study was undertaken, followed by the development and validation of a clinical decision rule for predicting the risk for a serious underlying diagnosis or event recurrence among infants presenting with BRUE.
Here’s what we learned from more than 3000 cases of BRUE.
First, it turns out that it’s not easy to determine whether an infant is at low or high risk for recurrence of BRUE. Initially, 91.5% of patients enrolled in the study would have been labeled high risk.
Furthermore, a BRUE recurred in 14.3% of the cohort, and 4.8% of high-risk infants were found to have a serious undiagnosed condition. Seizures, airway anomalies, and gastroesophageal reflux were the top three causes of BRUE, but the spectrum of underlying pathology was quite considerable.
The problem was that 4.6% of the entire cohort were found to have a serious underlying condition, nearly identical to the proportion of high-risk infants with these conditions. This prompted the question of whether simply labeling infants “high risk” was really appropriate any longer.
Revised BRUE Management
Although it hasn’t been possible to group infants neatly in low and high-risk categories, the data from that large cohort led to the development of the BRUE 2.0 criteria, which enabled more focused risk assessment of an infant who experienced a BRUE. With an app on MDCalc, these criteria allow providers to ascertain, and show families, a visual representation of their infant’s individualized risk for a subsequent BRUE and of having a serious underlying condition.
The cohort study also identified red flags from the history or physical exam of infants who experienced a BRUE: weight loss, failure to thrive, or a history of feeding problems. Exam findings such as a bulging fontanelle, forceful or bilious emesis, and evidence of gastrointestinal (GI) bleeding suggest a medical diagnosis rather than a BRUE. If GI-related causes are high on the differential, a feeding evaluation can be helpful. A feeding evaluation can be done in the outpatient setting and does not require hospitalization.
For suspicion of an underlying neurological condition (such as seizures), experts recommend obtaining a short EEG, which is highly sensitive for detecting infantile spasms and encephalopathy. They recommend reserving MRI for infants with abnormalities on EEG or physical exam. Metabolic or genetic testing should be done only if the infant looks ill, because most patients with genetic or inborn errors of metabolism will continue to have symptoms as they become older.
The approach to BRUE has moved into the realm of shared decision-making with families. The likelihood of identifying a serious diagnosis is low for most of these children. And unfortunately, no single test can diagnose the full spectrum of potential explanatory diagnoses. For example, data from 2023 demonstrate that only 1.1% of lab tests following a BRUE contributed to a diagnosis, and most of the time that was a positive viral test. Similarly, imaging was helpful in only 1.5% of cases. So, explaining the evidence and deciding along with parents what is reasonable to do (or not do) is the current state of affairs.
My Take
As I reflect back on two and a half decades of caring for these patients, I believe that recent data have helped us a great deal. We do less testing and admit fewer infants to the hospital than we did 20 years ago, and that’s a good thing. Nevertheless, looking for a few red flags, having a high index of suspicion when the clinical exam is abnormal, and engaging in shared decision-making with families can help make the caring for these challenging patients more bearable and lead to better outcomes for all involved.
Dr. Basco is Professor, Department of Pediatrics, Medical University of South Carolina (MUSC); Director, Division of General Pediatrics, Department of Pediatrics, MUSC Children’s Hospital, Charleston, South Carolina. He has disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
New Guidelines: Brain Death Is Equal to Heart Death, Says Ethicist
This transcript has been edited for clarity.
Hi. I’m Art Caplan. I’m at the Division of Medical Ethics at the New York University Grossman School of Medicine in New York City.
I think we had a breakthrough on a very controversial subject over the past month. Over and over again, debates have been breaking out, cases have been going to court, and fights have been coming to ethics committees about brain death. How do we know what brain death is, how do we diagnose it, and what rights do families have with respect to the diagnosis?
The American Academy of Neurology decided to form a task force, and they just issued guidelines on the definition, tests to use it, and the rights of families. They did a wonderful job, in my view. They›ve achieved clarity.
First, they tried to handle both adults and children. Children are, if you will, more difficult — and that’s been known — to test for brain death. Their brains are smaller. You get more interference and false signals coming from muscle or nerve activity that might be going on elsewhere in their bodies.
The guidelines say we’re going to try to see whether a person can breathe without support. If it’s an adult, one test over a 24-hour period would be sufficient. If you had them off the ventilator and they can’t breathe and show no signs of being able to do that, that’s a very fundamental test for brain death. For children, you’re going to have to do it twice. The guidelines are saying to be cautious.
Second, they say it’s very important to know the cause of the suspected brain death condition. If someone has a massive head injury, that’s different from a situation in which someone overdoses from drugs or drowns. Those conditions can be a little deceptive. In the case of drowning, sometimes the brain has protective mechanisms to protect circulation to the brain naturally for a little bit of time. I’m talking about minutes, not hours.
You want to be careful to make sure that you know the cause of the massive brain injury or insult that makes someone believe that the patient is brain-dead, whether it’s a stroke, an embolism, a bleed, a gunshot wound, or trauma to the head. Those factors really drive the certainty with which brain death should be pronounced. I think that’s very, very important.
They also said that brain death means the permanent loss of brain function. You may get a few cells still firing or you may be in a situation, because the life support is still there, where the body looks pink and perhaps might appear to still be alive to someone. When you know that the damage to the brain is so severe that there’s nothing that can be done to bring back the support of heart function, breathing, and most likely any ability to sense or feel anything, that is death.
I believe it’s very important, when talking to families, to say there are two ways that we pronounce people dead, and they’re equal: One is to say their heart has stopped, their breathing has stopped, and there’s nothing we can do to resuscitate them, which is cardiac death. The other is to say their brain has permanently ceased to function in any kind of integrated way. That means no heartbeat, no breathing, and no mental sensations. That is death.
In approaching families, it is critical that doctors and nurses don’t say, “Your relative is brain-dead.” That gives the family a sense that maybe they’re only “partially dead” or maybe there’s one key organ that has stopped working but maybe you can bring it back. Death is death. The law recognizes both cardiac death and brain death as death.
When you approach a family, if you believe that death has occurred, you say, “I’m very sorry. With regret, I have to tell you, your loved one is dead.” If they ask how you know, you can say, “We’ve determined it through brain death or through cardiac death.” You don’t give them a sense that people could be kind of dead, sort of dead, or nearly dead. Those states are comas or permanent vegetative states; they’re not the same as death.
What if the family says, “I don’t want you to do any testing. I don’t want to find out whether my relative is dead”? The American Academy of Neurology looked at this carefully and said that any test for death can be done without the permission or consent of the family. They said that because doctors need to know what steps to take to treat someone.
If a person is dead, then treatment is going to stop. It may not stop immediately. There may be issues about organ donation. There may be issues about gathering the family to come to the bedside to say goodbye, because many people think that’s more humane than saying goodbye at the morgue or in another setting.
This is all well and good, but patients cannot protect against bad news when it comes to death. We don’t want to be doing things to the dead that cost money or are futile because of death and using resources that might go to others.
We’ve got much more clarity than we have ever had with respect to the issue of brain death and how it works in any hospital. We have certain tests, including being off the ventilator and some other tests, that the guidelines supply. We know we have to be more careful with children. We want to know the etiology of the cause of the brain trauma, the devastating brain injury, to be sure that this is something that really is permanent cessation of integrated brain function.
We know that if you believe the person has died, you don’t need the consent of the family in order to do a brain-death test. You have to do it because there is no point in continuing treatment in expensive ICU settings and denying resources to others who might want to use those resources. The family can’t hold the medical team hostage.
We do know that when we approach someone with the determination, whatever it is, we should lead by saying that the person has died and then explain how that was determined, whether it be by cardiac death pronouncement — where you tried to resuscitate and the heart’s not beating — or brain-death analysis.
I’m Art Caplan at the Division of Medical Ethics at the NYU Grossman School of Medicine. Thanks for watching.
Dr. Caplan has disclosed the following relevant financial relationships: Served as a director, officer, partner, employee, advisor, consultant, or trustee for: Johnson & Johnson’s Panel for Compassionate Drug Use (unpaid position); serves as a contributing author and adviser for this news organization.
A version of this article appeared on Medscape.com.
This transcript has been edited for clarity.
Hi. I’m Art Caplan. I’m at the Division of Medical Ethics at the New York University Grossman School of Medicine in New York City.
I think we had a breakthrough on a very controversial subject over the past month. Over and over again, debates have been breaking out, cases have been going to court, and fights have been coming to ethics committees about brain death. How do we know what brain death is, how do we diagnose it, and what rights do families have with respect to the diagnosis?
The American Academy of Neurology decided to form a task force, and they just issued guidelines on the definition, tests to use it, and the rights of families. They did a wonderful job, in my view. They›ve achieved clarity.
First, they tried to handle both adults and children. Children are, if you will, more difficult — and that’s been known — to test for brain death. Their brains are smaller. You get more interference and false signals coming from muscle or nerve activity that might be going on elsewhere in their bodies.
The guidelines say we’re going to try to see whether a person can breathe without support. If it’s an adult, one test over a 24-hour period would be sufficient. If you had them off the ventilator and they can’t breathe and show no signs of being able to do that, that’s a very fundamental test for brain death. For children, you’re going to have to do it twice. The guidelines are saying to be cautious.
Second, they say it’s very important to know the cause of the suspected brain death condition. If someone has a massive head injury, that’s different from a situation in which someone overdoses from drugs or drowns. Those conditions can be a little deceptive. In the case of drowning, sometimes the brain has protective mechanisms to protect circulation to the brain naturally for a little bit of time. I’m talking about minutes, not hours.
You want to be careful to make sure that you know the cause of the massive brain injury or insult that makes someone believe that the patient is brain-dead, whether it’s a stroke, an embolism, a bleed, a gunshot wound, or trauma to the head. Those factors really drive the certainty with which brain death should be pronounced. I think that’s very, very important.
They also said that brain death means the permanent loss of brain function. You may get a few cells still firing or you may be in a situation, because the life support is still there, where the body looks pink and perhaps might appear to still be alive to someone. When you know that the damage to the brain is so severe that there’s nothing that can be done to bring back the support of heart function, breathing, and most likely any ability to sense or feel anything, that is death.
I believe it’s very important, when talking to families, to say there are two ways that we pronounce people dead, and they’re equal: One is to say their heart has stopped, their breathing has stopped, and there’s nothing we can do to resuscitate them, which is cardiac death. The other is to say their brain has permanently ceased to function in any kind of integrated way. That means no heartbeat, no breathing, and no mental sensations. That is death.
In approaching families, it is critical that doctors and nurses don’t say, “Your relative is brain-dead.” That gives the family a sense that maybe they’re only “partially dead” or maybe there’s one key organ that has stopped working but maybe you can bring it back. Death is death. The law recognizes both cardiac death and brain death as death.
When you approach a family, if you believe that death has occurred, you say, “I’m very sorry. With regret, I have to tell you, your loved one is dead.” If they ask how you know, you can say, “We’ve determined it through brain death or through cardiac death.” You don’t give them a sense that people could be kind of dead, sort of dead, or nearly dead. Those states are comas or permanent vegetative states; they’re not the same as death.
What if the family says, “I don’t want you to do any testing. I don’t want to find out whether my relative is dead”? The American Academy of Neurology looked at this carefully and said that any test for death can be done without the permission or consent of the family. They said that because doctors need to know what steps to take to treat someone.
If a person is dead, then treatment is going to stop. It may not stop immediately. There may be issues about organ donation. There may be issues about gathering the family to come to the bedside to say goodbye, because many people think that’s more humane than saying goodbye at the morgue or in another setting.
This is all well and good, but patients cannot protect against bad news when it comes to death. We don’t want to be doing things to the dead that cost money or are futile because of death and using resources that might go to others.
We’ve got much more clarity than we have ever had with respect to the issue of brain death and how it works in any hospital. We have certain tests, including being off the ventilator and some other tests, that the guidelines supply. We know we have to be more careful with children. We want to know the etiology of the cause of the brain trauma, the devastating brain injury, to be sure that this is something that really is permanent cessation of integrated brain function.
We know that if you believe the person has died, you don’t need the consent of the family in order to do a brain-death test. You have to do it because there is no point in continuing treatment in expensive ICU settings and denying resources to others who might want to use those resources. The family can’t hold the medical team hostage.
We do know that when we approach someone with the determination, whatever it is, we should lead by saying that the person has died and then explain how that was determined, whether it be by cardiac death pronouncement — where you tried to resuscitate and the heart’s not beating — or brain-death analysis.
I’m Art Caplan at the Division of Medical Ethics at the NYU Grossman School of Medicine. Thanks for watching.
Dr. Caplan has disclosed the following relevant financial relationships: Served as a director, officer, partner, employee, advisor, consultant, or trustee for: Johnson & Johnson’s Panel for Compassionate Drug Use (unpaid position); serves as a contributing author and adviser for this news organization.
A version of this article appeared on Medscape.com.
This transcript has been edited for clarity.
Hi. I’m Art Caplan. I’m at the Division of Medical Ethics at the New York University Grossman School of Medicine in New York City.
I think we had a breakthrough on a very controversial subject over the past month. Over and over again, debates have been breaking out, cases have been going to court, and fights have been coming to ethics committees about brain death. How do we know what brain death is, how do we diagnose it, and what rights do families have with respect to the diagnosis?
The American Academy of Neurology decided to form a task force, and they just issued guidelines on the definition, tests to use it, and the rights of families. They did a wonderful job, in my view. They›ve achieved clarity.
First, they tried to handle both adults and children. Children are, if you will, more difficult — and that’s been known — to test for brain death. Their brains are smaller. You get more interference and false signals coming from muscle or nerve activity that might be going on elsewhere in their bodies.
The guidelines say we’re going to try to see whether a person can breathe without support. If it’s an adult, one test over a 24-hour period would be sufficient. If you had them off the ventilator and they can’t breathe and show no signs of being able to do that, that’s a very fundamental test for brain death. For children, you’re going to have to do it twice. The guidelines are saying to be cautious.
Second, they say it’s very important to know the cause of the suspected brain death condition. If someone has a massive head injury, that’s different from a situation in which someone overdoses from drugs or drowns. Those conditions can be a little deceptive. In the case of drowning, sometimes the brain has protective mechanisms to protect circulation to the brain naturally for a little bit of time. I’m talking about minutes, not hours.
You want to be careful to make sure that you know the cause of the massive brain injury or insult that makes someone believe that the patient is brain-dead, whether it’s a stroke, an embolism, a bleed, a gunshot wound, or trauma to the head. Those factors really drive the certainty with which brain death should be pronounced. I think that’s very, very important.
They also said that brain death means the permanent loss of brain function. You may get a few cells still firing or you may be in a situation, because the life support is still there, where the body looks pink and perhaps might appear to still be alive to someone. When you know that the damage to the brain is so severe that there’s nothing that can be done to bring back the support of heart function, breathing, and most likely any ability to sense or feel anything, that is death.
I believe it’s very important, when talking to families, to say there are two ways that we pronounce people dead, and they’re equal: One is to say their heart has stopped, their breathing has stopped, and there’s nothing we can do to resuscitate them, which is cardiac death. The other is to say their brain has permanently ceased to function in any kind of integrated way. That means no heartbeat, no breathing, and no mental sensations. That is death.
In approaching families, it is critical that doctors and nurses don’t say, “Your relative is brain-dead.” That gives the family a sense that maybe they’re only “partially dead” or maybe there’s one key organ that has stopped working but maybe you can bring it back. Death is death. The law recognizes both cardiac death and brain death as death.
When you approach a family, if you believe that death has occurred, you say, “I’m very sorry. With regret, I have to tell you, your loved one is dead.” If they ask how you know, you can say, “We’ve determined it through brain death or through cardiac death.” You don’t give them a sense that people could be kind of dead, sort of dead, or nearly dead. Those states are comas or permanent vegetative states; they’re not the same as death.
What if the family says, “I don’t want you to do any testing. I don’t want to find out whether my relative is dead”? The American Academy of Neurology looked at this carefully and said that any test for death can be done without the permission or consent of the family. They said that because doctors need to know what steps to take to treat someone.
If a person is dead, then treatment is going to stop. It may not stop immediately. There may be issues about organ donation. There may be issues about gathering the family to come to the bedside to say goodbye, because many people think that’s more humane than saying goodbye at the morgue or in another setting.
This is all well and good, but patients cannot protect against bad news when it comes to death. We don’t want to be doing things to the dead that cost money or are futile because of death and using resources that might go to others.
We’ve got much more clarity than we have ever had with respect to the issue of brain death and how it works in any hospital. We have certain tests, including being off the ventilator and some other tests, that the guidelines supply. We know we have to be more careful with children. We want to know the etiology of the cause of the brain trauma, the devastating brain injury, to be sure that this is something that really is permanent cessation of integrated brain function.
We know that if you believe the person has died, you don’t need the consent of the family in order to do a brain-death test. You have to do it because there is no point in continuing treatment in expensive ICU settings and denying resources to others who might want to use those resources. The family can’t hold the medical team hostage.
We do know that when we approach someone with the determination, whatever it is, we should lead by saying that the person has died and then explain how that was determined, whether it be by cardiac death pronouncement — where you tried to resuscitate and the heart’s not beating — or brain-death analysis.
I’m Art Caplan at the Division of Medical Ethics at the NYU Grossman School of Medicine. Thanks for watching.
Dr. Caplan has disclosed the following relevant financial relationships: Served as a director, officer, partner, employee, advisor, consultant, or trustee for: Johnson & Johnson’s Panel for Compassionate Drug Use (unpaid position); serves as a contributing author and adviser for this news organization.
A version of this article appeared on Medscape.com.
Long COVID: Another Great Pretender
Has COVID replaced syphilis as the great imitator? At the turn of the 20th century, Sir William Osler was quoted as saying, “He who knows syphilis knows medicine.”
If you have any doubts about the “imitator” analogy, simply use any broad search engine or AI portal and enter “what is the differential diagnosis of primary syphilis, or secondary syphilis, or tertiary syphilis?” A plethora of diseases across many body systems appears.
Another Great Pretender?
Did you or do you now have long COVID? How do you know? Do you even know what long COVID is? How would you diagnosis it?
When asked about long COVID, this is what large language model source bard.google.com had to say:
Long COVID, also known as post-COVID conditions or PASC, is a complex condition that can occur in people who have had COVID-19, even if their initial illness was mild or even asymptomatic. It’s characterized by a wide range of symptoms that can last for weeks, months, or even years after the initial infection.
Symptoms of long COVID can include: fatigue, shortness of breath, brain fog (trouble thinking or concentrating), loss of smell or taste, sleep problems, muscle pain, joint pain, headache, dizziness, depression or anxiety, heart palpitations, gastrointestinal problems.
Duh!!! It reads much like a continuation of the symptoms of acute COVID. Bard continued:
The exact cause of long COVID is still unknown, but there are several theories. One possibility is that the virus itself can damage organs and tissues, leading to ongoing symptoms. Another possibility is that the immune system’s response to the virus can continue to cause inflammation even after the virus is gone.
Human intelligence source Wikipedia says this:
Long COVID or long-haul COVID is a group of health problems persisting or developing after an initial COVID-19 infection. Symptoms can last weeks, months or years and are often debilitating. The World Health Organization defines long COVID as starting three months after infection, but other definitions put the start of long COVID at four weeks.
Highly varied, including post-exertional malaise (symptoms made worse with effort), fatigue, muscle pain, shortness of breath, chest pain, and cognitive dysfunction (brain fog).
Acute COVID to Long COVID
The World Health Organization estimates that 36 million people in the European region have developed long COVID in the first 3 years of the pandemic. That›s a lot.
We all know that the common signs and symptoms of acute COVID-19 include fever or chills, a dry cough and shortness of breath, feeling very tired, muscle or body aches, headache, loss of taste or smell, sore throat, congestion, runny nose, nausea, vomiting, and diarrhea. Except for the taste and smell findings, every one of these symptoms or signs could indicate a different virus infection or even some type of allergy. My point is the nonspecificity in this list.
Uncommon signs and symptoms of acute COVID include a flat skin rash covered with small bumps, discolored swollen areas on the fingers and toes (COVID toes), and hives. The skin of hands, wrists, or ankles also can be affected. Blisters, itchiness, rough skin, or pus can be seen.
Severe confusion (delirium) might be the main or only symptom of COVID-19 in older people. This COVID-19 symptom is linked with a high risk for poor outcomes, including death. Pink eye (conjunctivitis) can be a COVID-19 symptom. Other eye problems linked to COVID-19 are light sensitivity, sore eyes, and itchy eyes. Acute myocarditis, tinnitus, vertigo, and hearing loss have been reported. And 1-4 weeks after the onset of COVID-19 infection, a patient may experience de novo reactive synovitis and arthritis of any joints.
So, take your pick. Myriad symptoms, signs, diseases, diagnoses, and organ systems — still present, recurring, just appearing, apparently de novo, or after asymptomatic infection. We have so much still to learn.
What big-time symptoms, signs, and major diseases are not on any of these lists? Obviously, cancer, atherosclerotic cardiovascular diseases, obesity, bone diseases, and competitive infections. But be patient; the lingering effects of direct tissue invasion by the virus as well as a wide range of immunologic reactions may just be getting started. Mitochondrial damage, especially in muscles, is increasingly a pathophysiologic suspect.
Human diseases can be physical or mental; and in COVID, that twain not only meet but mix and mingle freely, and may even merge into psychosoma. Don’t ever forget that. Consider “fatigue.” Who among us, COVID or NOVID, does not experience that from time to time?
Or consider brain fog as a common reported symptom of COVID. What on earth is that actually? How can a person know they have brain fog, or whether they had it and are over it?
We need one or more lab or other diagnostic tests that can objectively confirm the diagnosis of long COVID.
Useful Progress?
A recent research paper in Science reported intriguing chemical findings that seemed to point a finger at some form of complement dysregulation as a potential disease marker for long COVID. Unfortunately, some critics have pointed out that this entire study may be invalid or irrelevant because the New York cohort was recruited in 2020, before vaccines were available. The Zurich cohort was recruited up until April 2021, so some may have been vaccinated.
Then this news organization came along in early January 2024 with an article about COVID causing not only more than a million American deaths but also more than 5000 deaths from long COVID. We physicians don’t really know what long COVID even is, but we have to sign death certificates blaming thousands of deaths on it anyway? And rolling back the clock to 2020: Are patients dying from COVID or with COVID, according to death certificates?Now, armed with the knowledge that “documented serious post–COVID-19 conditions include cardiovascular, pulmonary, neurological, renal, endocrine, hematological, and gastrointestinal complications, as well as death,” CDC has published clear and fairly concise instructions on how to address post-acute COVID sequelae on death certificates.
In late January, this news organization painted a hopeful picture by naming four phenotypes of long COVID, suggesting that such divisions might further our understanding, including prognosis, and even therapy for this condition. Among the clinical phenotypes of (1) chronic fatigue–like syndrome, headache, and memory loss; (2) respiratory syndrome (which includes cough and difficulty breathing); (3) chronic pain; and (4) neurosensorial syndrome (which causes an altered sense of taste and smell), overlap is clearly possible but isn›t addressed.
I see these recent developments as needed and useful progress, but we are still left with…not much. So, when you tell me that you do or do not have long COVID, I will say to you, “How do you know?”
I also say: She/he/they who know COVID know medicine.
A version of this article first appeared on Medscape.com.
Has COVID replaced syphilis as the great imitator? At the turn of the 20th century, Sir William Osler was quoted as saying, “He who knows syphilis knows medicine.”
If you have any doubts about the “imitator” analogy, simply use any broad search engine or AI portal and enter “what is the differential diagnosis of primary syphilis, or secondary syphilis, or tertiary syphilis?” A plethora of diseases across many body systems appears.
Another Great Pretender?
Did you or do you now have long COVID? How do you know? Do you even know what long COVID is? How would you diagnosis it?
When asked about long COVID, this is what large language model source bard.google.com had to say:
Long COVID, also known as post-COVID conditions or PASC, is a complex condition that can occur in people who have had COVID-19, even if their initial illness was mild or even asymptomatic. It’s characterized by a wide range of symptoms that can last for weeks, months, or even years after the initial infection.
Symptoms of long COVID can include: fatigue, shortness of breath, brain fog (trouble thinking or concentrating), loss of smell or taste, sleep problems, muscle pain, joint pain, headache, dizziness, depression or anxiety, heart palpitations, gastrointestinal problems.
Duh!!! It reads much like a continuation of the symptoms of acute COVID. Bard continued:
The exact cause of long COVID is still unknown, but there are several theories. One possibility is that the virus itself can damage organs and tissues, leading to ongoing symptoms. Another possibility is that the immune system’s response to the virus can continue to cause inflammation even after the virus is gone.
Human intelligence source Wikipedia says this:
Long COVID or long-haul COVID is a group of health problems persisting or developing after an initial COVID-19 infection. Symptoms can last weeks, months or years and are often debilitating. The World Health Organization defines long COVID as starting three months after infection, but other definitions put the start of long COVID at four weeks.
Highly varied, including post-exertional malaise (symptoms made worse with effort), fatigue, muscle pain, shortness of breath, chest pain, and cognitive dysfunction (brain fog).
Acute COVID to Long COVID
The World Health Organization estimates that 36 million people in the European region have developed long COVID in the first 3 years of the pandemic. That›s a lot.
We all know that the common signs and symptoms of acute COVID-19 include fever or chills, a dry cough and shortness of breath, feeling very tired, muscle or body aches, headache, loss of taste or smell, sore throat, congestion, runny nose, nausea, vomiting, and diarrhea. Except for the taste and smell findings, every one of these symptoms or signs could indicate a different virus infection or even some type of allergy. My point is the nonspecificity in this list.
Uncommon signs and symptoms of acute COVID include a flat skin rash covered with small bumps, discolored swollen areas on the fingers and toes (COVID toes), and hives. The skin of hands, wrists, or ankles also can be affected. Blisters, itchiness, rough skin, or pus can be seen.
Severe confusion (delirium) might be the main or only symptom of COVID-19 in older people. This COVID-19 symptom is linked with a high risk for poor outcomes, including death. Pink eye (conjunctivitis) can be a COVID-19 symptom. Other eye problems linked to COVID-19 are light sensitivity, sore eyes, and itchy eyes. Acute myocarditis, tinnitus, vertigo, and hearing loss have been reported. And 1-4 weeks after the onset of COVID-19 infection, a patient may experience de novo reactive synovitis and arthritis of any joints.
So, take your pick. Myriad symptoms, signs, diseases, diagnoses, and organ systems — still present, recurring, just appearing, apparently de novo, or after asymptomatic infection. We have so much still to learn.
What big-time symptoms, signs, and major diseases are not on any of these lists? Obviously, cancer, atherosclerotic cardiovascular diseases, obesity, bone diseases, and competitive infections. But be patient; the lingering effects of direct tissue invasion by the virus as well as a wide range of immunologic reactions may just be getting started. Mitochondrial damage, especially in muscles, is increasingly a pathophysiologic suspect.
Human diseases can be physical or mental; and in COVID, that twain not only meet but mix and mingle freely, and may even merge into psychosoma. Don’t ever forget that. Consider “fatigue.” Who among us, COVID or NOVID, does not experience that from time to time?
Or consider brain fog as a common reported symptom of COVID. What on earth is that actually? How can a person know they have brain fog, or whether they had it and are over it?
We need one or more lab or other diagnostic tests that can objectively confirm the diagnosis of long COVID.
Useful Progress?
A recent research paper in Science reported intriguing chemical findings that seemed to point a finger at some form of complement dysregulation as a potential disease marker for long COVID. Unfortunately, some critics have pointed out that this entire study may be invalid or irrelevant because the New York cohort was recruited in 2020, before vaccines were available. The Zurich cohort was recruited up until April 2021, so some may have been vaccinated.
Then this news organization came along in early January 2024 with an article about COVID causing not only more than a million American deaths but also more than 5000 deaths from long COVID. We physicians don’t really know what long COVID even is, but we have to sign death certificates blaming thousands of deaths on it anyway? And rolling back the clock to 2020: Are patients dying from COVID or with COVID, according to death certificates?Now, armed with the knowledge that “documented serious post–COVID-19 conditions include cardiovascular, pulmonary, neurological, renal, endocrine, hematological, and gastrointestinal complications, as well as death,” CDC has published clear and fairly concise instructions on how to address post-acute COVID sequelae on death certificates.
In late January, this news organization painted a hopeful picture by naming four phenotypes of long COVID, suggesting that such divisions might further our understanding, including prognosis, and even therapy for this condition. Among the clinical phenotypes of (1) chronic fatigue–like syndrome, headache, and memory loss; (2) respiratory syndrome (which includes cough and difficulty breathing); (3) chronic pain; and (4) neurosensorial syndrome (which causes an altered sense of taste and smell), overlap is clearly possible but isn›t addressed.
I see these recent developments as needed and useful progress, but we are still left with…not much. So, when you tell me that you do or do not have long COVID, I will say to you, “How do you know?”
I also say: She/he/they who know COVID know medicine.
A version of this article first appeared on Medscape.com.
Has COVID replaced syphilis as the great imitator? At the turn of the 20th century, Sir William Osler was quoted as saying, “He who knows syphilis knows medicine.”
If you have any doubts about the “imitator” analogy, simply use any broad search engine or AI portal and enter “what is the differential diagnosis of primary syphilis, or secondary syphilis, or tertiary syphilis?” A plethora of diseases across many body systems appears.
Another Great Pretender?
Did you or do you now have long COVID? How do you know? Do you even know what long COVID is? How would you diagnosis it?
When asked about long COVID, this is what large language model source bard.google.com had to say:
Long COVID, also known as post-COVID conditions or PASC, is a complex condition that can occur in people who have had COVID-19, even if their initial illness was mild or even asymptomatic. It’s characterized by a wide range of symptoms that can last for weeks, months, or even years after the initial infection.
Symptoms of long COVID can include: fatigue, shortness of breath, brain fog (trouble thinking or concentrating), loss of smell or taste, sleep problems, muscle pain, joint pain, headache, dizziness, depression or anxiety, heart palpitations, gastrointestinal problems.
Duh!!! It reads much like a continuation of the symptoms of acute COVID. Bard continued:
The exact cause of long COVID is still unknown, but there are several theories. One possibility is that the virus itself can damage organs and tissues, leading to ongoing symptoms. Another possibility is that the immune system’s response to the virus can continue to cause inflammation even after the virus is gone.
Human intelligence source Wikipedia says this:
Long COVID or long-haul COVID is a group of health problems persisting or developing after an initial COVID-19 infection. Symptoms can last weeks, months or years and are often debilitating. The World Health Organization defines long COVID as starting three months after infection, but other definitions put the start of long COVID at four weeks.
Highly varied, including post-exertional malaise (symptoms made worse with effort), fatigue, muscle pain, shortness of breath, chest pain, and cognitive dysfunction (brain fog).
Acute COVID to Long COVID
The World Health Organization estimates that 36 million people in the European region have developed long COVID in the first 3 years of the pandemic. That›s a lot.
We all know that the common signs and symptoms of acute COVID-19 include fever or chills, a dry cough and shortness of breath, feeling very tired, muscle or body aches, headache, loss of taste or smell, sore throat, congestion, runny nose, nausea, vomiting, and diarrhea. Except for the taste and smell findings, every one of these symptoms or signs could indicate a different virus infection or even some type of allergy. My point is the nonspecificity in this list.
Uncommon signs and symptoms of acute COVID include a flat skin rash covered with small bumps, discolored swollen areas on the fingers and toes (COVID toes), and hives. The skin of hands, wrists, or ankles also can be affected. Blisters, itchiness, rough skin, or pus can be seen.
Severe confusion (delirium) might be the main or only symptom of COVID-19 in older people. This COVID-19 symptom is linked with a high risk for poor outcomes, including death. Pink eye (conjunctivitis) can be a COVID-19 symptom. Other eye problems linked to COVID-19 are light sensitivity, sore eyes, and itchy eyes. Acute myocarditis, tinnitus, vertigo, and hearing loss have been reported. And 1-4 weeks after the onset of COVID-19 infection, a patient may experience de novo reactive synovitis and arthritis of any joints.
So, take your pick. Myriad symptoms, signs, diseases, diagnoses, and organ systems — still present, recurring, just appearing, apparently de novo, or after asymptomatic infection. We have so much still to learn.
What big-time symptoms, signs, and major diseases are not on any of these lists? Obviously, cancer, atherosclerotic cardiovascular diseases, obesity, bone diseases, and competitive infections. But be patient; the lingering effects of direct tissue invasion by the virus as well as a wide range of immunologic reactions may just be getting started. Mitochondrial damage, especially in muscles, is increasingly a pathophysiologic suspect.
Human diseases can be physical or mental; and in COVID, that twain not only meet but mix and mingle freely, and may even merge into psychosoma. Don’t ever forget that. Consider “fatigue.” Who among us, COVID or NOVID, does not experience that from time to time?
Or consider brain fog as a common reported symptom of COVID. What on earth is that actually? How can a person know they have brain fog, or whether they had it and are over it?
We need one or more lab or other diagnostic tests that can objectively confirm the diagnosis of long COVID.
Useful Progress?
A recent research paper in Science reported intriguing chemical findings that seemed to point a finger at some form of complement dysregulation as a potential disease marker for long COVID. Unfortunately, some critics have pointed out that this entire study may be invalid or irrelevant because the New York cohort was recruited in 2020, before vaccines were available. The Zurich cohort was recruited up until April 2021, so some may have been vaccinated.
Then this news organization came along in early January 2024 with an article about COVID causing not only more than a million American deaths but also more than 5000 deaths from long COVID. We physicians don’t really know what long COVID even is, but we have to sign death certificates blaming thousands of deaths on it anyway? And rolling back the clock to 2020: Are patients dying from COVID or with COVID, according to death certificates?Now, armed with the knowledge that “documented serious post–COVID-19 conditions include cardiovascular, pulmonary, neurological, renal, endocrine, hematological, and gastrointestinal complications, as well as death,” CDC has published clear and fairly concise instructions on how to address post-acute COVID sequelae on death certificates.
In late January, this news organization painted a hopeful picture by naming four phenotypes of long COVID, suggesting that such divisions might further our understanding, including prognosis, and even therapy for this condition. Among the clinical phenotypes of (1) chronic fatigue–like syndrome, headache, and memory loss; (2) respiratory syndrome (which includes cough and difficulty breathing); (3) chronic pain; and (4) neurosensorial syndrome (which causes an altered sense of taste and smell), overlap is clearly possible but isn›t addressed.
I see these recent developments as needed and useful progress, but we are still left with…not much. So, when you tell me that you do or do not have long COVID, I will say to you, “How do you know?”
I also say: She/he/they who know COVID know medicine.
A version of this article first appeared on Medscape.com.
How to Prescribe Physical Activity in Patients With Obesity
Exercise should no longer be a mere “complement” or a standard recommendation within healthy lifestyle guidelines, say experts. Recent evidence confirms its physiological importance and endorses its beneficial and therapeutic effects on overall health, particularly in the case of obesity and its comorbidities. These findings emphasized the reasons to include exercise prescription in addressing this condition. This conclusion emerged from discussions among experts in Physical Activity and Sports Sciences during the XIX Congress of the Spanish Society for Obesity, where the role of physical exercise as a therapeutic strategy was analyzed from various perspectives.
Javier Butragueño, PhD, coordinator of the Exercise Working Group at the Spanish Society of Obesity, emphasized the need to “reposition” the role of exercise and the message conveyed to the population. “We must move beyond the typical recommendation to ‘just walk’ and rethink this message. When working with patients with obesity, you realize that, for example, the guideline of 10,000 steps per day makes little sense for those who weigh 140 kg, have been sedentary for a long time, and have not reached 2000 daily steps. Clinically, it becomes evident that current recommendations may not align with the needs of these patients,” he said.
Precision Focus
Dr. Butragueño highlighted the necessity of shifting the central focus from weight-related variables alone. While weight is crucial, evidence suggests that it should be evaluated along with other strategies, such as nutrition and pharmacology.
“The approach must change to view exercise as a metabolism regulator,” said Dr. Butragueño. “For specialists, this means educating the population about the need to stay active for overall health. This is a disruptive message because the prevailing idea, almost obsessive, associates exercise primarily with weight loss, a completely incorrect approach that can even be detrimental in some cases.”
Dr. Butragueño emphasized the supportive role of physical exercise in interventions for these patients. “Data show that it is both an enhancer and a co-adjuvant in strategies that also include psychology and endocrinology. It should be part of the approach to obesity but individualized and phenotyped to give physical activity the necessary dimension in each specific case.”
As an example of this adaptability in therapeutic strategy, Dr. Butragueño referred to addressing binge eating disorder. “In this case, specialists must acknowledge that sports are a third-line option, always behind the psychologist, who plays a primary role. Exercise is used to enhance the emotions triggered through its practice, considering that many of these patients maintain a very negative relationship with their bodies.”
Spanish ‘Prescription Guide’
During his presentation, Dr. Butragueño introduced the positioning document from the Exercise Group of the Spanish Society of Obesity, which is aimed at designing physical activity programs for patients with obesity. He emphasized its importance as a much-needed effort at proposing intervention strategies to guide health professionals and establish a reference framework for collaboration across different approaches to obesity.
Among the noteworthy aspects of the guidelines outlined in this document, Dr. Butragueño highlighted the assessment and classification of physical activity into four levels based on each patient’s physical condition. “This aspect should be studied by the scientific community because ‘humanizing’ exercise prescription by understanding individuals’ needs beyond their BMI is crucial.”
He also discussed the strategy outlined in the document that he said is crucial for implementing an exercise program. “Essentially, it involves two guidelines: First, engage in physical activity for at least 30-60 minutes in what we call zone 2. This includes activities like walking, cycling, or rowing, where one can speak easily with another person or sing without getting out of breath. This is a fundamental part of addressing obesity, as it improves mitochondrial biogenesis, the correct utilization of fatty acids, which is a significant concern in the pathophysiology of obesity and other diseases like cancer.”
The second strategy involves strength training alone or combined with aerobic-cardiovascular exercise. “Studies show that just 20 minutes of strength training 1 day a week for 10 consecutive weeks significantly improves strength levels in sedentary individuals.”
Dr. Butragueño emphasized that to date, there is no doubt that the most effective approach is to combine strength exercises with cardiorespiratory exercises. “This is not only to address obesity but also because, beyond weight impact, this training has proven additional benefits, such as increased oxygenation and improved cognitive capacity.”
Finally, regarding the challenges this shift in focus poses for exercise specialists, Dr. Butragueño pointed out, “Synergies in obesity treatment require sports experts to receive training in other disciplines, elevating our knowledge level and communication with the medical community to emphasize that we are indeed talking about exercise physiology applied to a condition like obesity.”
“In addition, as scientists, we must challenge ourselves to disseminate information at the societal level, surpassing the typical and outdated message of ‘eat less and move more,’ which we know is incorrect. This simplistic formula doesn’t help many patients resolve their issues like fatty liver, diabetes, and other metabolic disorders,” he concluded.
Active Breaks
Other topics debated during the congress included the importance of making exercise prescription a de facto reality in clinical practice and the challenge of achieving therapeutic compliance.
According to experts, one of the well-positioned trends in this regard is the concept of “active breaks” or “exercise snacks.” These breaks involve engaging in short-duration, moderate- to high-intensity activities throughout the day or working hours.
César Bustos, a board member of the Spanish Society of Obesity, mentioned that several studies have demonstrated that simple activities like climbing three flights of stairs or engaging in 1-minute training sessions can increase the metabolic equivalent of cardiovascular capacity and cardiorespiratory fitness. This approach could help reduce cardiovascular disease risk and all-cause mortality by 13%-15%.
“Cardiorespiratory fitness is the ability to engage in physical activity. It has been proven to be a more powerful predictor of mortality risk than traditional risk factors such as hypertension, smoking, obesity, hyperlipidemia, and type 2 diabetes,” said Mr. Bustos.
The expert added that these findings on the benefits of exercise snacks are particularly relevant in the current context, where lack of time is the primary obstacle cited by individuals with obesity for not engaging in regular physical activity. In addition, exercise prescription is considered the primary preventive measure for obesity and its associated diseases.
“Exercise is an essential complement to various treatments and strategies aimed at managing obesity and maintaining long-term weight reductions. However, patient compliance with recommended measures to stay active remains low. This deficiency can be overcome with the adoption of exercise snacks or small doses of exercise, which have become the most effective tool for achieving this goal,” he emphasized.
Also, in line with other experts, Mr. Bustos emphasized the importance of combined strength and cardiovascular training within the same session. “Undoubtedly, this is the most effective modality, as recent meta-analyses reflect. There is also a second effective modality for improving cardiometabolic parameters in patients with obesity: Hybrid training, including games, skipping ropes, and various devices.”
Exerkines and Poly Pills
Antonio García-Hermoso, PhD, a specialist in physical activity and sports at Navarrabiomed, University Hospital of Navarra in Pamplona, Spain, provided an update on the latest evidence regarding exerkines, which are molecules released during exercise. Research into these molecules attempts to analyze and understand the complex network of interactions between various exercise response systems.
Dr. García-Hermoso said that in the case of obesity and type 2 diabetes, research focuses on how exercise can affect patients’ exerkine levels and how these molecules can affect cardiometabolic control.
“The results demonstrate that these molecules are associated with multiple benefits, including improved insulin sensitivity and glucose homeostasis,” said Dr. García-Hermoso. “Concerning obesity, regular exercise has been shown to reduce interleukin-6 levels, positively affecting inflammation in these patients, also being associated with increased lipolysis and fatty acid utilization.”
Dr. García-Hermoso considered that studying exerkines supports the importance of individualized exercise prescription, like prescription of diet or medications.
He emphasized the importance of intensity, “which is even more crucial than the type of physical activity. Intense exercise activates physiological mechanisms, such as increased blood lactate levels, favoring the inhibition of ghrelin signaling associated with appetite. Therefore, higher exercise intensity leads to more lactate and greater inhibition of post-training hunger.”
“It is essential to understand that exercise is a poly pill with many advantages, and one of them is that even in small amounts, if intensity is increased, health benefits increase considerably,” Dr. García-Hermoso concluded.
Dr. Butragueño, Mr. Bustos, and Dr. García-Hermoso declared no relevant economic conflicts of interest.
This article was translated from the Medscape Spanish edition. A version of this article appeared on Medscape.com.
Exercise should no longer be a mere “complement” or a standard recommendation within healthy lifestyle guidelines, say experts. Recent evidence confirms its physiological importance and endorses its beneficial and therapeutic effects on overall health, particularly in the case of obesity and its comorbidities. These findings emphasized the reasons to include exercise prescription in addressing this condition. This conclusion emerged from discussions among experts in Physical Activity and Sports Sciences during the XIX Congress of the Spanish Society for Obesity, where the role of physical exercise as a therapeutic strategy was analyzed from various perspectives.
Javier Butragueño, PhD, coordinator of the Exercise Working Group at the Spanish Society of Obesity, emphasized the need to “reposition” the role of exercise and the message conveyed to the population. “We must move beyond the typical recommendation to ‘just walk’ and rethink this message. When working with patients with obesity, you realize that, for example, the guideline of 10,000 steps per day makes little sense for those who weigh 140 kg, have been sedentary for a long time, and have not reached 2000 daily steps. Clinically, it becomes evident that current recommendations may not align with the needs of these patients,” he said.
Precision Focus
Dr. Butragueño highlighted the necessity of shifting the central focus from weight-related variables alone. While weight is crucial, evidence suggests that it should be evaluated along with other strategies, such as nutrition and pharmacology.
“The approach must change to view exercise as a metabolism regulator,” said Dr. Butragueño. “For specialists, this means educating the population about the need to stay active for overall health. This is a disruptive message because the prevailing idea, almost obsessive, associates exercise primarily with weight loss, a completely incorrect approach that can even be detrimental in some cases.”
Dr. Butragueño emphasized the supportive role of physical exercise in interventions for these patients. “Data show that it is both an enhancer and a co-adjuvant in strategies that also include psychology and endocrinology. It should be part of the approach to obesity but individualized and phenotyped to give physical activity the necessary dimension in each specific case.”
As an example of this adaptability in therapeutic strategy, Dr. Butragueño referred to addressing binge eating disorder. “In this case, specialists must acknowledge that sports are a third-line option, always behind the psychologist, who plays a primary role. Exercise is used to enhance the emotions triggered through its practice, considering that many of these patients maintain a very negative relationship with their bodies.”
Spanish ‘Prescription Guide’
During his presentation, Dr. Butragueño introduced the positioning document from the Exercise Group of the Spanish Society of Obesity, which is aimed at designing physical activity programs for patients with obesity. He emphasized its importance as a much-needed effort at proposing intervention strategies to guide health professionals and establish a reference framework for collaboration across different approaches to obesity.
Among the noteworthy aspects of the guidelines outlined in this document, Dr. Butragueño highlighted the assessment and classification of physical activity into four levels based on each patient’s physical condition. “This aspect should be studied by the scientific community because ‘humanizing’ exercise prescription by understanding individuals’ needs beyond their BMI is crucial.”
He also discussed the strategy outlined in the document that he said is crucial for implementing an exercise program. “Essentially, it involves two guidelines: First, engage in physical activity for at least 30-60 minutes in what we call zone 2. This includes activities like walking, cycling, or rowing, where one can speak easily with another person or sing without getting out of breath. This is a fundamental part of addressing obesity, as it improves mitochondrial biogenesis, the correct utilization of fatty acids, which is a significant concern in the pathophysiology of obesity and other diseases like cancer.”
The second strategy involves strength training alone or combined with aerobic-cardiovascular exercise. “Studies show that just 20 minutes of strength training 1 day a week for 10 consecutive weeks significantly improves strength levels in sedentary individuals.”
Dr. Butragueño emphasized that to date, there is no doubt that the most effective approach is to combine strength exercises with cardiorespiratory exercises. “This is not only to address obesity but also because, beyond weight impact, this training has proven additional benefits, such as increased oxygenation and improved cognitive capacity.”
Finally, regarding the challenges this shift in focus poses for exercise specialists, Dr. Butragueño pointed out, “Synergies in obesity treatment require sports experts to receive training in other disciplines, elevating our knowledge level and communication with the medical community to emphasize that we are indeed talking about exercise physiology applied to a condition like obesity.”
“In addition, as scientists, we must challenge ourselves to disseminate information at the societal level, surpassing the typical and outdated message of ‘eat less and move more,’ which we know is incorrect. This simplistic formula doesn’t help many patients resolve their issues like fatty liver, diabetes, and other metabolic disorders,” he concluded.
Active Breaks
Other topics debated during the congress included the importance of making exercise prescription a de facto reality in clinical practice and the challenge of achieving therapeutic compliance.
According to experts, one of the well-positioned trends in this regard is the concept of “active breaks” or “exercise snacks.” These breaks involve engaging in short-duration, moderate- to high-intensity activities throughout the day or working hours.
César Bustos, a board member of the Spanish Society of Obesity, mentioned that several studies have demonstrated that simple activities like climbing three flights of stairs or engaging in 1-minute training sessions can increase the metabolic equivalent of cardiovascular capacity and cardiorespiratory fitness. This approach could help reduce cardiovascular disease risk and all-cause mortality by 13%-15%.
“Cardiorespiratory fitness is the ability to engage in physical activity. It has been proven to be a more powerful predictor of mortality risk than traditional risk factors such as hypertension, smoking, obesity, hyperlipidemia, and type 2 diabetes,” said Mr. Bustos.
The expert added that these findings on the benefits of exercise snacks are particularly relevant in the current context, where lack of time is the primary obstacle cited by individuals with obesity for not engaging in regular physical activity. In addition, exercise prescription is considered the primary preventive measure for obesity and its associated diseases.
“Exercise is an essential complement to various treatments and strategies aimed at managing obesity and maintaining long-term weight reductions. However, patient compliance with recommended measures to stay active remains low. This deficiency can be overcome with the adoption of exercise snacks or small doses of exercise, which have become the most effective tool for achieving this goal,” he emphasized.
Also, in line with other experts, Mr. Bustos emphasized the importance of combined strength and cardiovascular training within the same session. “Undoubtedly, this is the most effective modality, as recent meta-analyses reflect. There is also a second effective modality for improving cardiometabolic parameters in patients with obesity: Hybrid training, including games, skipping ropes, and various devices.”
Exerkines and Poly Pills
Antonio García-Hermoso, PhD, a specialist in physical activity and sports at Navarrabiomed, University Hospital of Navarra in Pamplona, Spain, provided an update on the latest evidence regarding exerkines, which are molecules released during exercise. Research into these molecules attempts to analyze and understand the complex network of interactions between various exercise response systems.
Dr. García-Hermoso said that in the case of obesity and type 2 diabetes, research focuses on how exercise can affect patients’ exerkine levels and how these molecules can affect cardiometabolic control.
“The results demonstrate that these molecules are associated with multiple benefits, including improved insulin sensitivity and glucose homeostasis,” said Dr. García-Hermoso. “Concerning obesity, regular exercise has been shown to reduce interleukin-6 levels, positively affecting inflammation in these patients, also being associated with increased lipolysis and fatty acid utilization.”
Dr. García-Hermoso considered that studying exerkines supports the importance of individualized exercise prescription, like prescription of diet or medications.
He emphasized the importance of intensity, “which is even more crucial than the type of physical activity. Intense exercise activates physiological mechanisms, such as increased blood lactate levels, favoring the inhibition of ghrelin signaling associated with appetite. Therefore, higher exercise intensity leads to more lactate and greater inhibition of post-training hunger.”
“It is essential to understand that exercise is a poly pill with many advantages, and one of them is that even in small amounts, if intensity is increased, health benefits increase considerably,” Dr. García-Hermoso concluded.
Dr. Butragueño, Mr. Bustos, and Dr. García-Hermoso declared no relevant economic conflicts of interest.
This article was translated from the Medscape Spanish edition. A version of this article appeared on Medscape.com.
Exercise should no longer be a mere “complement” or a standard recommendation within healthy lifestyle guidelines, say experts. Recent evidence confirms its physiological importance and endorses its beneficial and therapeutic effects on overall health, particularly in the case of obesity and its comorbidities. These findings emphasized the reasons to include exercise prescription in addressing this condition. This conclusion emerged from discussions among experts in Physical Activity and Sports Sciences during the XIX Congress of the Spanish Society for Obesity, where the role of physical exercise as a therapeutic strategy was analyzed from various perspectives.
Javier Butragueño, PhD, coordinator of the Exercise Working Group at the Spanish Society of Obesity, emphasized the need to “reposition” the role of exercise and the message conveyed to the population. “We must move beyond the typical recommendation to ‘just walk’ and rethink this message. When working with patients with obesity, you realize that, for example, the guideline of 10,000 steps per day makes little sense for those who weigh 140 kg, have been sedentary for a long time, and have not reached 2000 daily steps. Clinically, it becomes evident that current recommendations may not align with the needs of these patients,” he said.
Precision Focus
Dr. Butragueño highlighted the necessity of shifting the central focus from weight-related variables alone. While weight is crucial, evidence suggests that it should be evaluated along with other strategies, such as nutrition and pharmacology.
“The approach must change to view exercise as a metabolism regulator,” said Dr. Butragueño. “For specialists, this means educating the population about the need to stay active for overall health. This is a disruptive message because the prevailing idea, almost obsessive, associates exercise primarily with weight loss, a completely incorrect approach that can even be detrimental in some cases.”
Dr. Butragueño emphasized the supportive role of physical exercise in interventions for these patients. “Data show that it is both an enhancer and a co-adjuvant in strategies that also include psychology and endocrinology. It should be part of the approach to obesity but individualized and phenotyped to give physical activity the necessary dimension in each specific case.”
As an example of this adaptability in therapeutic strategy, Dr. Butragueño referred to addressing binge eating disorder. “In this case, specialists must acknowledge that sports are a third-line option, always behind the psychologist, who plays a primary role. Exercise is used to enhance the emotions triggered through its practice, considering that many of these patients maintain a very negative relationship with their bodies.”
Spanish ‘Prescription Guide’
During his presentation, Dr. Butragueño introduced the positioning document from the Exercise Group of the Spanish Society of Obesity, which is aimed at designing physical activity programs for patients with obesity. He emphasized its importance as a much-needed effort at proposing intervention strategies to guide health professionals and establish a reference framework for collaboration across different approaches to obesity.
Among the noteworthy aspects of the guidelines outlined in this document, Dr. Butragueño highlighted the assessment and classification of physical activity into four levels based on each patient’s physical condition. “This aspect should be studied by the scientific community because ‘humanizing’ exercise prescription by understanding individuals’ needs beyond their BMI is crucial.”
He also discussed the strategy outlined in the document that he said is crucial for implementing an exercise program. “Essentially, it involves two guidelines: First, engage in physical activity for at least 30-60 minutes in what we call zone 2. This includes activities like walking, cycling, or rowing, where one can speak easily with another person or sing without getting out of breath. This is a fundamental part of addressing obesity, as it improves mitochondrial biogenesis, the correct utilization of fatty acids, which is a significant concern in the pathophysiology of obesity and other diseases like cancer.”
The second strategy involves strength training alone or combined with aerobic-cardiovascular exercise. “Studies show that just 20 minutes of strength training 1 day a week for 10 consecutive weeks significantly improves strength levels in sedentary individuals.”
Dr. Butragueño emphasized that to date, there is no doubt that the most effective approach is to combine strength exercises with cardiorespiratory exercises. “This is not only to address obesity but also because, beyond weight impact, this training has proven additional benefits, such as increased oxygenation and improved cognitive capacity.”
Finally, regarding the challenges this shift in focus poses for exercise specialists, Dr. Butragueño pointed out, “Synergies in obesity treatment require sports experts to receive training in other disciplines, elevating our knowledge level and communication with the medical community to emphasize that we are indeed talking about exercise physiology applied to a condition like obesity.”
“In addition, as scientists, we must challenge ourselves to disseminate information at the societal level, surpassing the typical and outdated message of ‘eat less and move more,’ which we know is incorrect. This simplistic formula doesn’t help many patients resolve their issues like fatty liver, diabetes, and other metabolic disorders,” he concluded.
Active Breaks
Other topics debated during the congress included the importance of making exercise prescription a de facto reality in clinical practice and the challenge of achieving therapeutic compliance.
According to experts, one of the well-positioned trends in this regard is the concept of “active breaks” or “exercise snacks.” These breaks involve engaging in short-duration, moderate- to high-intensity activities throughout the day or working hours.
César Bustos, a board member of the Spanish Society of Obesity, mentioned that several studies have demonstrated that simple activities like climbing three flights of stairs or engaging in 1-minute training sessions can increase the metabolic equivalent of cardiovascular capacity and cardiorespiratory fitness. This approach could help reduce cardiovascular disease risk and all-cause mortality by 13%-15%.
“Cardiorespiratory fitness is the ability to engage in physical activity. It has been proven to be a more powerful predictor of mortality risk than traditional risk factors such as hypertension, smoking, obesity, hyperlipidemia, and type 2 diabetes,” said Mr. Bustos.
The expert added that these findings on the benefits of exercise snacks are particularly relevant in the current context, where lack of time is the primary obstacle cited by individuals with obesity for not engaging in regular physical activity. In addition, exercise prescription is considered the primary preventive measure for obesity and its associated diseases.
“Exercise is an essential complement to various treatments and strategies aimed at managing obesity and maintaining long-term weight reductions. However, patient compliance with recommended measures to stay active remains low. This deficiency can be overcome with the adoption of exercise snacks or small doses of exercise, which have become the most effective tool for achieving this goal,” he emphasized.
Also, in line with other experts, Mr. Bustos emphasized the importance of combined strength and cardiovascular training within the same session. “Undoubtedly, this is the most effective modality, as recent meta-analyses reflect. There is also a second effective modality for improving cardiometabolic parameters in patients with obesity: Hybrid training, including games, skipping ropes, and various devices.”
Exerkines and Poly Pills
Antonio García-Hermoso, PhD, a specialist in physical activity and sports at Navarrabiomed, University Hospital of Navarra in Pamplona, Spain, provided an update on the latest evidence regarding exerkines, which are molecules released during exercise. Research into these molecules attempts to analyze and understand the complex network of interactions between various exercise response systems.
Dr. García-Hermoso said that in the case of obesity and type 2 diabetes, research focuses on how exercise can affect patients’ exerkine levels and how these molecules can affect cardiometabolic control.
“The results demonstrate that these molecules are associated with multiple benefits, including improved insulin sensitivity and glucose homeostasis,” said Dr. García-Hermoso. “Concerning obesity, regular exercise has been shown to reduce interleukin-6 levels, positively affecting inflammation in these patients, also being associated with increased lipolysis and fatty acid utilization.”
Dr. García-Hermoso considered that studying exerkines supports the importance of individualized exercise prescription, like prescription of diet or medications.
He emphasized the importance of intensity, “which is even more crucial than the type of physical activity. Intense exercise activates physiological mechanisms, such as increased blood lactate levels, favoring the inhibition of ghrelin signaling associated with appetite. Therefore, higher exercise intensity leads to more lactate and greater inhibition of post-training hunger.”
“It is essential to understand that exercise is a poly pill with many advantages, and one of them is that even in small amounts, if intensity is increased, health benefits increase considerably,” Dr. García-Hermoso concluded.
Dr. Butragueño, Mr. Bustos, and Dr. García-Hermoso declared no relevant economic conflicts of interest.
This article was translated from the Medscape Spanish edition. A version of this article appeared on Medscape.com.
Two Doctors Face Down a Gunman While Saving His Victim
Emergencies happen anywhere and anytime, and sometimes, medical professionals find themselves in situations where they are the only ones who can help. 'Is There a Doctor in the House?' is a Medscape Medical News series telling these stories.
Bill Madden, MD: It was a Saturday in October of 1996. I had gone to my favorite plant nursery in Tucson with my wife, Beth, and two of my kids, Zach and Katya, who were 9 years old. I went to the back of the nursery to use the bathroom, and I heard two of the workers yelling at each other. The tone was angry.
I went back up to the front, and Zach said that he was bored. He asked if he could go to the car and get a book, so I gave him my car keys and told him to be careful crossing the street.
Ron Quintia, DDS: It was late in the afternoon, probably close to 4 PM. But no, it can’t be a gun. This is a plant nursery.
BM: When I heard the rounds being fired, I knew what that sound meant. I was in the Army for 20 years doing critical care for kids.
I turned and a young man came running toward me out of the sun. It was hard to see, but I realized a second guy was running about 10 feet behind him. Both men were screaming.
My wife was about 10 feet away behind a raised planter with Katya. I yelled for them to get down as I dove for the ground.
The first guy, a young Hispanic man, tried to escape through some bushes. But the shooter was catching up. I recognized him. He was from Ethiopia and worked at the nursery. I had talked to him a week earlier about his life; he used to be a farmer.
Now, he was holding a 9-mm automatic — silver, very shiny. He shot the Hispanic man twice in the chest. Then he ran toward the back of the nursery.
RQ: When I realized what was happening, I crouched down, so I couldn’t see very much. But I heard someone screaming, “He has a gun! He has a gun!” And then I heard more shots.
BM: I yelled at my wife, “Get out!” Then I ran for the phone at the kiosk desk to call 911. This was before most people had cell phones. But the phone was hooked up to the paging system for the nursery, and I couldn’t get it to work. I turned and ran for the wounded man.
RQ: I got to the victim first. Both lungs had been hit, and I could hear he had sucking chest wounds. He was bleeding out of his mouth, saying, “I’m going to die. I’m going to die.” I told him, “You’re not going to die,” while thinking to myself, He’s going to die.
BM: I had never met Ron before, but we started working on the patient together. Both of his lungs were collapsing. With sucking chest wounds, the critical issue is to seal up the holes. So normally, you slap a Vaseline dressing on and tape it up real good. But obviously, we didn’t have anything.
Ron and I took off our shirts and used them to bandage the man’s chest. He wasn’t looking good, starting to turn blue. He was dying. We were yelling for someone to call an ambulance.
And then suddenly, the shooter was back. He was standing there yelling at us to leave so he could kill the man we were helping. The 9-mil was in his hand, ready to fire. He kept screaming, “I’m not a monkey! I’m not a monkey!”
RQ: The guy was less than 10 feet from us, and we were facing down this gun that looked like a cannon. I thought, This is it. It’s curtains. I’m going to die. We’re all going to die.
BM: I had decided I would die too. I wasn’t frightened though. It’s hard to explain. Dying was okay because I’d gotten my family away. I just had to stay alive as long as I could in order to provide for the victim.
It’s what I signed up for when I chose to be a doc — to do whatever was needed. And if I got killed in the process, that was just part of the story. So we started talking to the shooter.
I said, “No, you’re not a monkey. You’re a man, a human being. It’s okay.” We pleaded with him to put the weapon down and not to shoot. We did not leave the patient. Finally, the shooter ran off toward the back of the nursery.
RQ: About 30 seconds after that, we heard two more shots from that direction.
Then there were sirens, and the place was suddenly crawling with police. The paramedics came and took over. I got up and got out of the way.
BM: A young woman ran up, her mouth covered with blood. She said that there was another victim in the back. I asked a police officer to go with us to check. We started for the back when suddenly, we heard yelling and many rounds being fired. The officer ran in the direction of the shooting.
The woman and I kept walking through rows of plants and trees. It was like moving through a jungle. Finally, we reached the other victim, an American Indian man, lying on his back. He had a chest wound and a head wound. No respirations. No radial pulse. No carotid pulse. I pronounced him dead.
Then I heard a voice calling for help. There were two women hiding nearby in the bushes. I led them to where the police cars were.
Another officer came over and told me that they had the shooter. The police had shot him in the leg and arrested him.
RQ: The police kept us there for quite some time. Meanwhile, the TV crews arrived. I had a black Toyota 4Runner at the time. My family was home watching the news, and a bulletin came on about a shooting in Midtown. The camera panned around the area, and my wife saw our car on the street! They were all worried until I could call and let them know that I was okay.
BM: As we waited, the sun went down, and I was getting cold. My shirt was a bloody mess. Ron and I just sat there quietly, not saying a whole heck of a lot.
Finally, an officer took our statements, a detective interviewed us, and they let us leave. I called Beth, and she and the kids came and got me.
At home, we talked to the kids, letting them express their fears. We put them to bed. I didn’t sleep that night.
RQ: I can’t describe how weird it was going home with this guy’s blood on my body. Needing to take a bath. Trying to get rid of the stench of what could have been a brutal killing. But it wasn’t. At least, not for our patient.
Thankfully, there are three hospitals within a stone’s throw of the nursery. The paramedics got the man we helped to Tucson Medical Center and into the OR immediately. Then the general surgeons could get chest tubes in him to reinflate his lungs.
BM: The doctor who treated him called me later. He said that when they put the chest tubes in, they got a liter and a half of blood out of him. If it had taken another 10 minutes or so to get there, he very likely would’ve been dead on arrival in the emergency room.
RQ: I checked on him at the hospital the next day, and he was doing okay. That was the last time I saw him.
I only saw the shooter again in court. Dr. Madden and I were both called as witnesses at his trial. He was tried for capital murder and 12 charges of aggravated assault for every person who was at the nursery. He was found guilty on all of them and sentenced to 35 years to life in prison.
BM: I don’t think the shooter was very well represented in court. It’s not that he didn’t kill one person and critically wound another. He did, and he deserves to be punished for that. But his story wasn’t told.
I knew that during the civil war in Ethiopia, his family had been killed by Cuban soldiers sent there to help the pro-communist government. In a way, I thought of him as two different people: the shooter and the farmer. They are both in prison, but only one of them deserves to be there.
After it happened, I wanted to visit the farmer in the hospital and tell him that, despite what he had done, he was not alone. Our family cared about him. The police wouldn’t let me see him, so I asked the Catholic chaplain of the hospital to go. He gave him my message: that despite all the sorrow and pain, in some distant way, I understood. I respected him as a human being. And I was praying for him.
RQ: It’s safe to say that the experience will affect me forever. For months, even years afterward, if somebody would ask me about what happened, I would start to cry. I would sit in the parking lot of my favorite running trail and worry about the people driving in. If I heard a car backfire, I thought about gunshots.
It was terrifying. And thank God I’ve never found myself in that position again. But I suspect I’d probably react the same way. This is our calling. It’s what we do — protecting other people and taking care of them.
BM: I’d always wondered what I would do in a situation like this. I knew I could function in a critical care situation, a child in a hospital or in the back of an ambulance. But could I do it when my own life was threatened? I found out that I could, and that was really important to me.
RQ: It was one of those great lessons in life. You realize how lucky you are and that your life can be snatched away from you in a millisecond. I went to a nursery to buy plants for my yard, and instead I ended up helping to save a life.Bill Madden, MD, is a retired US Army colonel and pediatrician, formerly an associate professor of Clinical Pediatrics at the College of Medicine of the University of Arizona, Tucson.
Ron Quintia, DDS, is an oral and maxillofacial surgeon at Southern Arizona Oral & Maxillofacial Surgery in Tucson, Arizona.
A version of this article appeared on Medscape.com .
Emergencies happen anywhere and anytime, and sometimes, medical professionals find themselves in situations where they are the only ones who can help. 'Is There a Doctor in the House?' is a Medscape Medical News series telling these stories.
Bill Madden, MD: It was a Saturday in October of 1996. I had gone to my favorite plant nursery in Tucson with my wife, Beth, and two of my kids, Zach and Katya, who were 9 years old. I went to the back of the nursery to use the bathroom, and I heard two of the workers yelling at each other. The tone was angry.
I went back up to the front, and Zach said that he was bored. He asked if he could go to the car and get a book, so I gave him my car keys and told him to be careful crossing the street.
Ron Quintia, DDS: It was late in the afternoon, probably close to 4 PM. But no, it can’t be a gun. This is a plant nursery.
BM: When I heard the rounds being fired, I knew what that sound meant. I was in the Army for 20 years doing critical care for kids.
I turned and a young man came running toward me out of the sun. It was hard to see, but I realized a second guy was running about 10 feet behind him. Both men were screaming.
My wife was about 10 feet away behind a raised planter with Katya. I yelled for them to get down as I dove for the ground.
The first guy, a young Hispanic man, tried to escape through some bushes. But the shooter was catching up. I recognized him. He was from Ethiopia and worked at the nursery. I had talked to him a week earlier about his life; he used to be a farmer.
Now, he was holding a 9-mm automatic — silver, very shiny. He shot the Hispanic man twice in the chest. Then he ran toward the back of the nursery.
RQ: When I realized what was happening, I crouched down, so I couldn’t see very much. But I heard someone screaming, “He has a gun! He has a gun!” And then I heard more shots.
BM: I yelled at my wife, “Get out!” Then I ran for the phone at the kiosk desk to call 911. This was before most people had cell phones. But the phone was hooked up to the paging system for the nursery, and I couldn’t get it to work. I turned and ran for the wounded man.
RQ: I got to the victim first. Both lungs had been hit, and I could hear he had sucking chest wounds. He was bleeding out of his mouth, saying, “I’m going to die. I’m going to die.” I told him, “You’re not going to die,” while thinking to myself, He’s going to die.
BM: I had never met Ron before, but we started working on the patient together. Both of his lungs were collapsing. With sucking chest wounds, the critical issue is to seal up the holes. So normally, you slap a Vaseline dressing on and tape it up real good. But obviously, we didn’t have anything.
Ron and I took off our shirts and used them to bandage the man’s chest. He wasn’t looking good, starting to turn blue. He was dying. We were yelling for someone to call an ambulance.
And then suddenly, the shooter was back. He was standing there yelling at us to leave so he could kill the man we were helping. The 9-mil was in his hand, ready to fire. He kept screaming, “I’m not a monkey! I’m not a monkey!”
RQ: The guy was less than 10 feet from us, and we were facing down this gun that looked like a cannon. I thought, This is it. It’s curtains. I’m going to die. We’re all going to die.
BM: I had decided I would die too. I wasn’t frightened though. It’s hard to explain. Dying was okay because I’d gotten my family away. I just had to stay alive as long as I could in order to provide for the victim.
It’s what I signed up for when I chose to be a doc — to do whatever was needed. And if I got killed in the process, that was just part of the story. So we started talking to the shooter.
I said, “No, you’re not a monkey. You’re a man, a human being. It’s okay.” We pleaded with him to put the weapon down and not to shoot. We did not leave the patient. Finally, the shooter ran off toward the back of the nursery.
RQ: About 30 seconds after that, we heard two more shots from that direction.
Then there were sirens, and the place was suddenly crawling with police. The paramedics came and took over. I got up and got out of the way.
BM: A young woman ran up, her mouth covered with blood. She said that there was another victim in the back. I asked a police officer to go with us to check. We started for the back when suddenly, we heard yelling and many rounds being fired. The officer ran in the direction of the shooting.
The woman and I kept walking through rows of plants and trees. It was like moving through a jungle. Finally, we reached the other victim, an American Indian man, lying on his back. He had a chest wound and a head wound. No respirations. No radial pulse. No carotid pulse. I pronounced him dead.
Then I heard a voice calling for help. There were two women hiding nearby in the bushes. I led them to where the police cars were.
Another officer came over and told me that they had the shooter. The police had shot him in the leg and arrested him.
RQ: The police kept us there for quite some time. Meanwhile, the TV crews arrived. I had a black Toyota 4Runner at the time. My family was home watching the news, and a bulletin came on about a shooting in Midtown. The camera panned around the area, and my wife saw our car on the street! They were all worried until I could call and let them know that I was okay.
BM: As we waited, the sun went down, and I was getting cold. My shirt was a bloody mess. Ron and I just sat there quietly, not saying a whole heck of a lot.
Finally, an officer took our statements, a detective interviewed us, and they let us leave. I called Beth, and she and the kids came and got me.
At home, we talked to the kids, letting them express their fears. We put them to bed. I didn’t sleep that night.
RQ: I can’t describe how weird it was going home with this guy’s blood on my body. Needing to take a bath. Trying to get rid of the stench of what could have been a brutal killing. But it wasn’t. At least, not for our patient.
Thankfully, there are three hospitals within a stone’s throw of the nursery. The paramedics got the man we helped to Tucson Medical Center and into the OR immediately. Then the general surgeons could get chest tubes in him to reinflate his lungs.
BM: The doctor who treated him called me later. He said that when they put the chest tubes in, they got a liter and a half of blood out of him. If it had taken another 10 minutes or so to get there, he very likely would’ve been dead on arrival in the emergency room.
RQ: I checked on him at the hospital the next day, and he was doing okay. That was the last time I saw him.
I only saw the shooter again in court. Dr. Madden and I were both called as witnesses at his trial. He was tried for capital murder and 12 charges of aggravated assault for every person who was at the nursery. He was found guilty on all of them and sentenced to 35 years to life in prison.
BM: I don’t think the shooter was very well represented in court. It’s not that he didn’t kill one person and critically wound another. He did, and he deserves to be punished for that. But his story wasn’t told.
I knew that during the civil war in Ethiopia, his family had been killed by Cuban soldiers sent there to help the pro-communist government. In a way, I thought of him as two different people: the shooter and the farmer. They are both in prison, but only one of them deserves to be there.
After it happened, I wanted to visit the farmer in the hospital and tell him that, despite what he had done, he was not alone. Our family cared about him. The police wouldn’t let me see him, so I asked the Catholic chaplain of the hospital to go. He gave him my message: that despite all the sorrow and pain, in some distant way, I understood. I respected him as a human being. And I was praying for him.
RQ: It’s safe to say that the experience will affect me forever. For months, even years afterward, if somebody would ask me about what happened, I would start to cry. I would sit in the parking lot of my favorite running trail and worry about the people driving in. If I heard a car backfire, I thought about gunshots.
It was terrifying. And thank God I’ve never found myself in that position again. But I suspect I’d probably react the same way. This is our calling. It’s what we do — protecting other people and taking care of them.
BM: I’d always wondered what I would do in a situation like this. I knew I could function in a critical care situation, a child in a hospital or in the back of an ambulance. But could I do it when my own life was threatened? I found out that I could, and that was really important to me.
RQ: It was one of those great lessons in life. You realize how lucky you are and that your life can be snatched away from you in a millisecond. I went to a nursery to buy plants for my yard, and instead I ended up helping to save a life.Bill Madden, MD, is a retired US Army colonel and pediatrician, formerly an associate professor of Clinical Pediatrics at the College of Medicine of the University of Arizona, Tucson.
Ron Quintia, DDS, is an oral and maxillofacial surgeon at Southern Arizona Oral & Maxillofacial Surgery in Tucson, Arizona.
A version of this article appeared on Medscape.com .
Emergencies happen anywhere and anytime, and sometimes, medical professionals find themselves in situations where they are the only ones who can help. 'Is There a Doctor in the House?' is a Medscape Medical News series telling these stories.
Bill Madden, MD: It was a Saturday in October of 1996. I had gone to my favorite plant nursery in Tucson with my wife, Beth, and two of my kids, Zach and Katya, who were 9 years old. I went to the back of the nursery to use the bathroom, and I heard two of the workers yelling at each other. The tone was angry.
I went back up to the front, and Zach said that he was bored. He asked if he could go to the car and get a book, so I gave him my car keys and told him to be careful crossing the street.
Ron Quintia, DDS: It was late in the afternoon, probably close to 4 PM. But no, it can’t be a gun. This is a plant nursery.
BM: When I heard the rounds being fired, I knew what that sound meant. I was in the Army for 20 years doing critical care for kids.
I turned and a young man came running toward me out of the sun. It was hard to see, but I realized a second guy was running about 10 feet behind him. Both men were screaming.
My wife was about 10 feet away behind a raised planter with Katya. I yelled for them to get down as I dove for the ground.
The first guy, a young Hispanic man, tried to escape through some bushes. But the shooter was catching up. I recognized him. He was from Ethiopia and worked at the nursery. I had talked to him a week earlier about his life; he used to be a farmer.
Now, he was holding a 9-mm automatic — silver, very shiny. He shot the Hispanic man twice in the chest. Then he ran toward the back of the nursery.
RQ: When I realized what was happening, I crouched down, so I couldn’t see very much. But I heard someone screaming, “He has a gun! He has a gun!” And then I heard more shots.
BM: I yelled at my wife, “Get out!” Then I ran for the phone at the kiosk desk to call 911. This was before most people had cell phones. But the phone was hooked up to the paging system for the nursery, and I couldn’t get it to work. I turned and ran for the wounded man.
RQ: I got to the victim first. Both lungs had been hit, and I could hear he had sucking chest wounds. He was bleeding out of his mouth, saying, “I’m going to die. I’m going to die.” I told him, “You’re not going to die,” while thinking to myself, He’s going to die.
BM: I had never met Ron before, but we started working on the patient together. Both of his lungs were collapsing. With sucking chest wounds, the critical issue is to seal up the holes. So normally, you slap a Vaseline dressing on and tape it up real good. But obviously, we didn’t have anything.
Ron and I took off our shirts and used them to bandage the man’s chest. He wasn’t looking good, starting to turn blue. He was dying. We were yelling for someone to call an ambulance.
And then suddenly, the shooter was back. He was standing there yelling at us to leave so he could kill the man we were helping. The 9-mil was in his hand, ready to fire. He kept screaming, “I’m not a monkey! I’m not a monkey!”
RQ: The guy was less than 10 feet from us, and we were facing down this gun that looked like a cannon. I thought, This is it. It’s curtains. I’m going to die. We’re all going to die.
BM: I had decided I would die too. I wasn’t frightened though. It’s hard to explain. Dying was okay because I’d gotten my family away. I just had to stay alive as long as I could in order to provide for the victim.
It’s what I signed up for when I chose to be a doc — to do whatever was needed. And if I got killed in the process, that was just part of the story. So we started talking to the shooter.
I said, “No, you’re not a monkey. You’re a man, a human being. It’s okay.” We pleaded with him to put the weapon down and not to shoot. We did not leave the patient. Finally, the shooter ran off toward the back of the nursery.
RQ: About 30 seconds after that, we heard two more shots from that direction.
Then there were sirens, and the place was suddenly crawling with police. The paramedics came and took over. I got up and got out of the way.
BM: A young woman ran up, her mouth covered with blood. She said that there was another victim in the back. I asked a police officer to go with us to check. We started for the back when suddenly, we heard yelling and many rounds being fired. The officer ran in the direction of the shooting.
The woman and I kept walking through rows of plants and trees. It was like moving through a jungle. Finally, we reached the other victim, an American Indian man, lying on his back. He had a chest wound and a head wound. No respirations. No radial pulse. No carotid pulse. I pronounced him dead.
Then I heard a voice calling for help. There were two women hiding nearby in the bushes. I led them to where the police cars were.
Another officer came over and told me that they had the shooter. The police had shot him in the leg and arrested him.
RQ: The police kept us there for quite some time. Meanwhile, the TV crews arrived. I had a black Toyota 4Runner at the time. My family was home watching the news, and a bulletin came on about a shooting in Midtown. The camera panned around the area, and my wife saw our car on the street! They were all worried until I could call and let them know that I was okay.
BM: As we waited, the sun went down, and I was getting cold. My shirt was a bloody mess. Ron and I just sat there quietly, not saying a whole heck of a lot.
Finally, an officer took our statements, a detective interviewed us, and they let us leave. I called Beth, and she and the kids came and got me.
At home, we talked to the kids, letting them express their fears. We put them to bed. I didn’t sleep that night.
RQ: I can’t describe how weird it was going home with this guy’s blood on my body. Needing to take a bath. Trying to get rid of the stench of what could have been a brutal killing. But it wasn’t. At least, not for our patient.
Thankfully, there are three hospitals within a stone’s throw of the nursery. The paramedics got the man we helped to Tucson Medical Center and into the OR immediately. Then the general surgeons could get chest tubes in him to reinflate his lungs.
BM: The doctor who treated him called me later. He said that when they put the chest tubes in, they got a liter and a half of blood out of him. If it had taken another 10 minutes or so to get there, he very likely would’ve been dead on arrival in the emergency room.
RQ: I checked on him at the hospital the next day, and he was doing okay. That was the last time I saw him.
I only saw the shooter again in court. Dr. Madden and I were both called as witnesses at his trial. He was tried for capital murder and 12 charges of aggravated assault for every person who was at the nursery. He was found guilty on all of them and sentenced to 35 years to life in prison.
BM: I don’t think the shooter was very well represented in court. It’s not that he didn’t kill one person and critically wound another. He did, and he deserves to be punished for that. But his story wasn’t told.
I knew that during the civil war in Ethiopia, his family had been killed by Cuban soldiers sent there to help the pro-communist government. In a way, I thought of him as two different people: the shooter and the farmer. They are both in prison, but only one of them deserves to be there.
After it happened, I wanted to visit the farmer in the hospital and tell him that, despite what he had done, he was not alone. Our family cared about him. The police wouldn’t let me see him, so I asked the Catholic chaplain of the hospital to go. He gave him my message: that despite all the sorrow and pain, in some distant way, I understood. I respected him as a human being. And I was praying for him.
RQ: It’s safe to say that the experience will affect me forever. For months, even years afterward, if somebody would ask me about what happened, I would start to cry. I would sit in the parking lot of my favorite running trail and worry about the people driving in. If I heard a car backfire, I thought about gunshots.
It was terrifying. And thank God I’ve never found myself in that position again. But I suspect I’d probably react the same way. This is our calling. It’s what we do — protecting other people and taking care of them.
BM: I’d always wondered what I would do in a situation like this. I knew I could function in a critical care situation, a child in a hospital or in the back of an ambulance. But could I do it when my own life was threatened? I found out that I could, and that was really important to me.
RQ: It was one of those great lessons in life. You realize how lucky you are and that your life can be snatched away from you in a millisecond. I went to a nursery to buy plants for my yard, and instead I ended up helping to save a life.Bill Madden, MD, is a retired US Army colonel and pediatrician, formerly an associate professor of Clinical Pediatrics at the College of Medicine of the University of Arizona, Tucson.
Ron Quintia, DDS, is an oral and maxillofacial surgeon at Southern Arizona Oral & Maxillofacial Surgery in Tucson, Arizona.
A version of this article appeared on Medscape.com .
10 Reasons to Refer Your Patient to an Endocrinologist
The blockbuster drugs of the century have arrived: glucagon-like peptide 1 receptor agonists (GLP-1 RAs). These drugs were developed to control blood sugar but have gained immense popularity for weight loss. Patients are clamoring for the drugs, and physicians are inundated with patient inquiries.
As doctors in primary care and other specialties are discovering, the GLP-1 RA drugs add another layer of complexity to the long-term management of a chronic disease. Managing diabetes and obesity requires a multidisciplinary team and a multispecialty treatment approach.
That’s why it’s more important than ever to know when and why to refer patients to an endocrinologist, who can offer unparalleled expertise as part of a multidisciplinary treatment approach.
Here are 10 reasons to refer your patients with diabetes to an endocrinologist.
1. To help make an optimal medication choice. Endocrinologists navigate diabetes management by considering individualized glycemic, cardiorenal, and weight goals as per guidelines, incorporating knowledge of medication side effects, simplifying regimens for adherence, and addressing practical factors like access and cost. Optimal medication selection is crucial, as a recent study found that nearly two thirds of patients altered their treatment by discontinuing their medication, switching their medication, or changing the dose of their medication within 12 months. Whether diabetes is controlled or uncontrolled, patients should consult an endocrinologist due to the potential complexity of cases, including late autoimmune onset of diabetes; medication-induced diabetes; and factors such as age, fragility, and chronic illnesses.
2. To facilitate medication approvals, alternatives, and authorizations. Attaining medication approval for patients entails a nuanced understanding and resources. Through experience and careful consideration, endocrinologists develop insights into potential barriers, especially in cases where approval for specific medications necessitates prior failures with multiple GLP-1 RAs or antihyperglycemic agents. This expertise positions them to advocate effectively for alternative options, often involving the meticulous process of prior authorizations. Certain endocrinology practices may augment this endeavor by offering dedicated resources, such as a specialized prior authorization team.
3. To deal with diabetes complications. Endocrinologists can help address emerging issues in GLP-1 RA drugs such as retinopathy, gastroparesis, and mental health effects. They can also help manage coexisting conditions, such as addressing thyroid nodules before considering the use of GLP-1 RAs. Recognizing the interconnected nature of diabetes and its influence on diverse body systems, endocrinologists ensure a thorough and integrated management strategy for their patients.
4. To titrate other glucose-lowering agents. Patients with diabetes are often on combination therapy. Endocrinologists adeptly adjust and titrate these treatments to optimize glucose control while minimizing side effects like hypoglycemia. Beyond insulin, their expertise encompasses various glucose-lowering agents. Notably, patients who use GLP-1 RAs in combination with medications such as insulin secretagogues (eg, sulfonylurea) and insulin face an elevated risk for hypoglycemia, including severe cases, necessitating careful titration to mitigate these effects.
5. To integrate advances in diabetes technology. Endocrinologists stay abreast of technological advancements in diabetes care, incorporating innovations in monitoring and treatment strategies such as continuous glucose monitors and insulin pumps. This ensures that patients benefit from the latest technologies for more precise management of their condition.
6. To ensure a comprehensive care team. Endocrinologists engage in collaborative efforts with a multidisciplinary team composed of professionals like nurses, diabetes educators, and nutritionists. These experts may be situated within endocrinology offices or accessible through a well-established referral network. Together, the team delivers thorough counseling on medication use and effectively addresses essential lifestyle factors, ensuring a comprehensive approach to diabetes management.
7. To counsel on side effects and management. Ensuring adherence and persistence with medication therapy poses considerable challenges. One study noted discontinuation rates for non-insulin diabetes medications of about 38%, with a higher 50% rate for GLP-1 RA drugs. The study didn›t provide specific reasons for discontinuation, but discontinuation was lower when medications were prescribed by an endocrinologist. Endocrinologists can provide valuable guidance on potential medication side effects and their management. This proactive approach not only fosters patient understanding but also empowers individuals to promptly address side effects, significantly enhancing treatment adherence and overall effectiveness.
8. To work around drug shortages. Given their frequent involvement in prescribing and obtaining medications for patients, endocrinologists adeptly utilize community relationships to navigate medication shortages. Their awareness of drug availability provides patients with a strategic advantage in overcoming supply challenges.
9. To determine dosing equivalents. In situations where supply-chain shortages persist, a thorough understanding of alternative options and dosing equivalents becomes paramount for ensuring uninterrupted care.
To provide follow-up. Endocrinologists prioritize regular follow-ups, providing patients with dedicated time slots for 10. ongoing monitoring and adjustments to their treatment plans. This commitment to follow-up care contributes to sustained, optimal outcomes in diabetes management.
Navigating the intricate healthcare landscape requires a delicate balance between primary care proficiency and specialist expertise, with endocrinologists playing a pivotal role in diabetes management. Our collaborative strength lies in acknowledging challenges and resource limitations, especially a physician’s familiarity with the latest diabetes medications.
Dr. Jaisinghani has disclosed the following relevant financial relationships: Received income in an amount equal to or greater than $250 from Novo Nordisk.
A version of this article appeared on Medscape.com.
The blockbuster drugs of the century have arrived: glucagon-like peptide 1 receptor agonists (GLP-1 RAs). These drugs were developed to control blood sugar but have gained immense popularity for weight loss. Patients are clamoring for the drugs, and physicians are inundated with patient inquiries.
As doctors in primary care and other specialties are discovering, the GLP-1 RA drugs add another layer of complexity to the long-term management of a chronic disease. Managing diabetes and obesity requires a multidisciplinary team and a multispecialty treatment approach.
That’s why it’s more important than ever to know when and why to refer patients to an endocrinologist, who can offer unparalleled expertise as part of a multidisciplinary treatment approach.
Here are 10 reasons to refer your patients with diabetes to an endocrinologist.
1. To help make an optimal medication choice. Endocrinologists navigate diabetes management by considering individualized glycemic, cardiorenal, and weight goals as per guidelines, incorporating knowledge of medication side effects, simplifying regimens for adherence, and addressing practical factors like access and cost. Optimal medication selection is crucial, as a recent study found that nearly two thirds of patients altered their treatment by discontinuing their medication, switching their medication, or changing the dose of their medication within 12 months. Whether diabetes is controlled or uncontrolled, patients should consult an endocrinologist due to the potential complexity of cases, including late autoimmune onset of diabetes; medication-induced diabetes; and factors such as age, fragility, and chronic illnesses.
2. To facilitate medication approvals, alternatives, and authorizations. Attaining medication approval for patients entails a nuanced understanding and resources. Through experience and careful consideration, endocrinologists develop insights into potential barriers, especially in cases where approval for specific medications necessitates prior failures with multiple GLP-1 RAs or antihyperglycemic agents. This expertise positions them to advocate effectively for alternative options, often involving the meticulous process of prior authorizations. Certain endocrinology practices may augment this endeavor by offering dedicated resources, such as a specialized prior authorization team.
3. To deal with diabetes complications. Endocrinologists can help address emerging issues in GLP-1 RA drugs such as retinopathy, gastroparesis, and mental health effects. They can also help manage coexisting conditions, such as addressing thyroid nodules before considering the use of GLP-1 RAs. Recognizing the interconnected nature of diabetes and its influence on diverse body systems, endocrinologists ensure a thorough and integrated management strategy for their patients.
4. To titrate other glucose-lowering agents. Patients with diabetes are often on combination therapy. Endocrinologists adeptly adjust and titrate these treatments to optimize glucose control while minimizing side effects like hypoglycemia. Beyond insulin, their expertise encompasses various glucose-lowering agents. Notably, patients who use GLP-1 RAs in combination with medications such as insulin secretagogues (eg, sulfonylurea) and insulin face an elevated risk for hypoglycemia, including severe cases, necessitating careful titration to mitigate these effects.
5. To integrate advances in diabetes technology. Endocrinologists stay abreast of technological advancements in diabetes care, incorporating innovations in monitoring and treatment strategies such as continuous glucose monitors and insulin pumps. This ensures that patients benefit from the latest technologies for more precise management of their condition.
6. To ensure a comprehensive care team. Endocrinologists engage in collaborative efforts with a multidisciplinary team composed of professionals like nurses, diabetes educators, and nutritionists. These experts may be situated within endocrinology offices or accessible through a well-established referral network. Together, the team delivers thorough counseling on medication use and effectively addresses essential lifestyle factors, ensuring a comprehensive approach to diabetes management.
7. To counsel on side effects and management. Ensuring adherence and persistence with medication therapy poses considerable challenges. One study noted discontinuation rates for non-insulin diabetes medications of about 38%, with a higher 50% rate for GLP-1 RA drugs. The study didn›t provide specific reasons for discontinuation, but discontinuation was lower when medications were prescribed by an endocrinologist. Endocrinologists can provide valuable guidance on potential medication side effects and their management. This proactive approach not only fosters patient understanding but also empowers individuals to promptly address side effects, significantly enhancing treatment adherence and overall effectiveness.
8. To work around drug shortages. Given their frequent involvement in prescribing and obtaining medications for patients, endocrinologists adeptly utilize community relationships to navigate medication shortages. Their awareness of drug availability provides patients with a strategic advantage in overcoming supply challenges.
9. To determine dosing equivalents. In situations where supply-chain shortages persist, a thorough understanding of alternative options and dosing equivalents becomes paramount for ensuring uninterrupted care.
To provide follow-up. Endocrinologists prioritize regular follow-ups, providing patients with dedicated time slots for 10. ongoing monitoring and adjustments to their treatment plans. This commitment to follow-up care contributes to sustained, optimal outcomes in diabetes management.
Navigating the intricate healthcare landscape requires a delicate balance between primary care proficiency and specialist expertise, with endocrinologists playing a pivotal role in diabetes management. Our collaborative strength lies in acknowledging challenges and resource limitations, especially a physician’s familiarity with the latest diabetes medications.
Dr. Jaisinghani has disclosed the following relevant financial relationships: Received income in an amount equal to or greater than $250 from Novo Nordisk.
A version of this article appeared on Medscape.com.
The blockbuster drugs of the century have arrived: glucagon-like peptide 1 receptor agonists (GLP-1 RAs). These drugs were developed to control blood sugar but have gained immense popularity for weight loss. Patients are clamoring for the drugs, and physicians are inundated with patient inquiries.
As doctors in primary care and other specialties are discovering, the GLP-1 RA drugs add another layer of complexity to the long-term management of a chronic disease. Managing diabetes and obesity requires a multidisciplinary team and a multispecialty treatment approach.
That’s why it’s more important than ever to know when and why to refer patients to an endocrinologist, who can offer unparalleled expertise as part of a multidisciplinary treatment approach.
Here are 10 reasons to refer your patients with diabetes to an endocrinologist.
1. To help make an optimal medication choice. Endocrinologists navigate diabetes management by considering individualized glycemic, cardiorenal, and weight goals as per guidelines, incorporating knowledge of medication side effects, simplifying regimens for adherence, and addressing practical factors like access and cost. Optimal medication selection is crucial, as a recent study found that nearly two thirds of patients altered their treatment by discontinuing their medication, switching their medication, or changing the dose of their medication within 12 months. Whether diabetes is controlled or uncontrolled, patients should consult an endocrinologist due to the potential complexity of cases, including late autoimmune onset of diabetes; medication-induced diabetes; and factors such as age, fragility, and chronic illnesses.
2. To facilitate medication approvals, alternatives, and authorizations. Attaining medication approval for patients entails a nuanced understanding and resources. Through experience and careful consideration, endocrinologists develop insights into potential barriers, especially in cases where approval for specific medications necessitates prior failures with multiple GLP-1 RAs or antihyperglycemic agents. This expertise positions them to advocate effectively for alternative options, often involving the meticulous process of prior authorizations. Certain endocrinology practices may augment this endeavor by offering dedicated resources, such as a specialized prior authorization team.
3. To deal with diabetes complications. Endocrinologists can help address emerging issues in GLP-1 RA drugs such as retinopathy, gastroparesis, and mental health effects. They can also help manage coexisting conditions, such as addressing thyroid nodules before considering the use of GLP-1 RAs. Recognizing the interconnected nature of diabetes and its influence on diverse body systems, endocrinologists ensure a thorough and integrated management strategy for their patients.
4. To titrate other glucose-lowering agents. Patients with diabetes are often on combination therapy. Endocrinologists adeptly adjust and titrate these treatments to optimize glucose control while minimizing side effects like hypoglycemia. Beyond insulin, their expertise encompasses various glucose-lowering agents. Notably, patients who use GLP-1 RAs in combination with medications such as insulin secretagogues (eg, sulfonylurea) and insulin face an elevated risk for hypoglycemia, including severe cases, necessitating careful titration to mitigate these effects.
5. To integrate advances in diabetes technology. Endocrinologists stay abreast of technological advancements in diabetes care, incorporating innovations in monitoring and treatment strategies such as continuous glucose monitors and insulin pumps. This ensures that patients benefit from the latest technologies for more precise management of their condition.
6. To ensure a comprehensive care team. Endocrinologists engage in collaborative efforts with a multidisciplinary team composed of professionals like nurses, diabetes educators, and nutritionists. These experts may be situated within endocrinology offices or accessible through a well-established referral network. Together, the team delivers thorough counseling on medication use and effectively addresses essential lifestyle factors, ensuring a comprehensive approach to diabetes management.
7. To counsel on side effects and management. Ensuring adherence and persistence with medication therapy poses considerable challenges. One study noted discontinuation rates for non-insulin diabetes medications of about 38%, with a higher 50% rate for GLP-1 RA drugs. The study didn›t provide specific reasons for discontinuation, but discontinuation was lower when medications were prescribed by an endocrinologist. Endocrinologists can provide valuable guidance on potential medication side effects and their management. This proactive approach not only fosters patient understanding but also empowers individuals to promptly address side effects, significantly enhancing treatment adherence and overall effectiveness.
8. To work around drug shortages. Given their frequent involvement in prescribing and obtaining medications for patients, endocrinologists adeptly utilize community relationships to navigate medication shortages. Their awareness of drug availability provides patients with a strategic advantage in overcoming supply challenges.
9. To determine dosing equivalents. In situations where supply-chain shortages persist, a thorough understanding of alternative options and dosing equivalents becomes paramount for ensuring uninterrupted care.
To provide follow-up. Endocrinologists prioritize regular follow-ups, providing patients with dedicated time slots for 10. ongoing monitoring and adjustments to their treatment plans. This commitment to follow-up care contributes to sustained, optimal outcomes in diabetes management.
Navigating the intricate healthcare landscape requires a delicate balance between primary care proficiency and specialist expertise, with endocrinologists playing a pivotal role in diabetes management. Our collaborative strength lies in acknowledging challenges and resource limitations, especially a physician’s familiarity with the latest diabetes medications.
Dr. Jaisinghani has disclosed the following relevant financial relationships: Received income in an amount equal to or greater than $250 from Novo Nordisk.
A version of this article appeared on Medscape.com.
How to Avoid the $400,000 Med School Debt Mistakes I Made
It’s not always great to be tops among your peers.
, according to Medscape Medical News’ 2023 Residents Salary and Debt Report.
I’m smack in that upper percentile. I amassed nearly a half million dollars in student debt and currently stand at roughly $400,000. Yay me.
As a naive twentysomething making a major life decision, I never thought my loans would amount to this inconceivable figure, the proverbial “mortgage without a roof” you hear student debt experts talk about.
This isn’t a story about how the student loan industry needs to be reformed or how education has become increasingly expensive or regrets about going to medical school.
It’s also not a story about how you should be handling basics like consolidating and refinancing and paying extra toward your principal.
It’s about my experience as a physician 13 years after signing that first promissory note. In short: I completely miscalculated the impact loans would have on my life.
I bought money to go to school. I can’t undo that. But over the past decade, I have learned a lot, particularly how those with their own mountain of debt — or who will inevitably wind up with one — can manage things better than I have.
Mistake #1: Loan Forgiveness Is More Complicated Than it Seems
My parents and I were aware of the Public Service Loan Forgiveness (PSLF) program which began in 2007 shortly before I started exploring medical school options. I wanted to help people, so working in the nonprofit sector sounded like a no-brainer. Making 120 payments while practicing at a qualifying institution didn’t sound hard.
Newsflash: Not all healthcare organizations are 501(c)3 programs that qualify as nonprofit for the PSLF program. You can’t just snap your fingers and land at one. I graduated from fellowship just as the COVID-19 pandemic began, which meant I was launching my medical career in the midst of hiring freezes and an overnight disappearance of job opportunities.
I had to take a 2-year hiatus from the nonprofit sector and found a part-time position with a local private practice group. It still stings. Had I been working for a qualified employer, I could have benefited from the student loan payment pause and been closer to applying for loan forgiveness.
Avoid it: Be brutally honest with yourself about what kind of medicine you want to practice — especially within the opportunities you have on hand. Private practice is very different from working for the nonprofit sector. I didn›t know that. When weighing career choices, immediately ask, “How will this impact how I pay my loans?” You may not like the answer, but you›ll always know where you stand financially.
Mistake #2: I Forgot to Factor in Life Goals
To be fair, some things were out of my control: Not getting into a state school with cheaper tuition rates, graduating at the start of a once-in-a-lifetime global pandemic. I wasn’t prepared for a changing job landscape. But there were also “expected” life events like getting married, developing a geographical preference, and having a child. I didn’t consider those either.
How about the “expected” goal of buying a home? For years I didn’t feel financially comfortable enough to take on a mortgage. For so long, my attitude has been don’t take on any more debt. (A special shout-out to my 6.8% interest rate which has contributed over a third of my total loan amount.)
This even affected how my husband and I would talk about what a future home might look like. There’s always a giant unwelcome guest casting a shadow over my thoughts.
Avoid it: Don’t compartmentalize your personal and professional lives. Your student loans will hang over both, and you need to be honest with yourself about what “upward mobility” really means to you while in debt. There’s a reason people say “live like a resident” until your loans are paid off. My husband and I finally worked our numbers to where we bought our first home this past year — a moment years in the making. I still drive around in my beloved Honda CR-V like it’s a Mercedes G-Wagon.
Mistake #3: I Didn’t Ask Questions
I regret not talking to a practicing physician about their experience with student loans. I didn’t know any. There weren’t any physicians in my extended family or my community network. I was a first-generation Pakistani American kid trying to figure it out.
It’s difficult because even today, many physicians aren’t comfortable discussing their financial circumstances. The lack of financial transparency and even financial literacy is astounding among young medical professionals. We live in a medical culture where no one talks about the money. I was too diffident and nervous to even try.
Avoid it: Don’t be afraid to have uncomfortable conversations about money. Don’t allow yourself to make even one passive decision. It’s your life.
If you can’t find someone in medicine to talk to about their financial journey, there are plenty of credible resources. Medscape Medical News has a Physician Business Academy with hot topics like personal finance. The White Coat Investor is literally bookmarked on all my electronic devices. KevinMD.com has a ton of resources and articles answering common financial questions about retirement, savings, and house buying. And Travis Hornsby with www.studentloanplanner.com has wonderful advice on all kinds of different loans.
There are no stupid questions. Just ask. You might be surprised by what people are willing to share.
Mistake #4: Playing it Casual With My Lenders
If $400,000 in debt doesn’t sound bad enough, imagine lots more. It turns out my loan carrier had me at a much higher loan balance because they’d inadvertently duplicated one of my loans in the total. I didn’t know that until I transferred my loans to another handler and it came to light.
Imagine my relief at having a lower total. Imagine my anger at myself for not checking sooner.
Avoid it: Do a thorough self-audit on all your loans more than once a year. Pretend they’re a patient with odd symptoms you can’t pin down and you have the luxury of doing every diagnostic test available. It’s not fun studying your own debt, but it’s the only way to really know how much you have.
Mistake #5: Not Leaving Room to Change My Mind
I underestimated how I would evolve and how my goals would change after having the letters “MD” after my name. I never dreamed that a nonprofit salary might not be enough.
A lot of us assume that the bedside is where we will find professional satisfaction. But you might be surprised. In a climate where we’re constantly being pushed to do more in a broken healthcare system, a landscape where misinformation and technology are forcing medicine to change, there might be little joy in working clinically full time. Then what do you do?
Because I elected to go the PSLF route, I’m tied to this decision. And while it still makes the most economic sense for me personally, it now limits my professional exploration and freedom.
Avoid it: Consider how much time you really want to spend in clinical medicine. Be mindful that you have to work at least 0.8 full time equivalent to qualify for the PSLF program. It’s very hard to predict the future, let alone your future, but just know you›ll have moments where you ask, “Do I really want to stay on this career track?” Will you be able to pivot? Can you live with it if the answer is no?
Looking Ahead
Let me be clear about one thing. Despite all the negativity I feel toward my student loans — guilt about the burden I brought to my marriage and my adult life, disappointment about the cost of becoming a successful physician, and frustration that this has turned out to be the most influential factor shaping my professional and personal choices — the one thing I don’t feel is shame.
I worked hard to get to this point in my life. I am proud of being a physician.
My student loan burden will follow me to the grave. But progress is also possible. I have friends that have paid their loans down by hustling, working hard, and dropping every penny toward them.
I also have friends that have had their loans forgiven. There are options. Everyone’s experience looks a little different. But don’t be naive: Student loans will color every financial decision you make.
I’m finding solace now in recently moving and finding work at a nonprofit institution. I’m back at it; 77 payments made, and 43 to go.
Well, technically I’ve made 93 payments. I’m still waiting for my loan servicer to get around to updating my account.
You really have to stay on top of those folks.
A version of this article appeared on Medscape.com.
It’s not always great to be tops among your peers.
, according to Medscape Medical News’ 2023 Residents Salary and Debt Report.
I’m smack in that upper percentile. I amassed nearly a half million dollars in student debt and currently stand at roughly $400,000. Yay me.
As a naive twentysomething making a major life decision, I never thought my loans would amount to this inconceivable figure, the proverbial “mortgage without a roof” you hear student debt experts talk about.
This isn’t a story about how the student loan industry needs to be reformed or how education has become increasingly expensive or regrets about going to medical school.
It’s also not a story about how you should be handling basics like consolidating and refinancing and paying extra toward your principal.
It’s about my experience as a physician 13 years after signing that first promissory note. In short: I completely miscalculated the impact loans would have on my life.
I bought money to go to school. I can’t undo that. But over the past decade, I have learned a lot, particularly how those with their own mountain of debt — or who will inevitably wind up with one — can manage things better than I have.
Mistake #1: Loan Forgiveness Is More Complicated Than it Seems
My parents and I were aware of the Public Service Loan Forgiveness (PSLF) program which began in 2007 shortly before I started exploring medical school options. I wanted to help people, so working in the nonprofit sector sounded like a no-brainer. Making 120 payments while practicing at a qualifying institution didn’t sound hard.
Newsflash: Not all healthcare organizations are 501(c)3 programs that qualify as nonprofit for the PSLF program. You can’t just snap your fingers and land at one. I graduated from fellowship just as the COVID-19 pandemic began, which meant I was launching my medical career in the midst of hiring freezes and an overnight disappearance of job opportunities.
I had to take a 2-year hiatus from the nonprofit sector and found a part-time position with a local private practice group. It still stings. Had I been working for a qualified employer, I could have benefited from the student loan payment pause and been closer to applying for loan forgiveness.
Avoid it: Be brutally honest with yourself about what kind of medicine you want to practice — especially within the opportunities you have on hand. Private practice is very different from working for the nonprofit sector. I didn›t know that. When weighing career choices, immediately ask, “How will this impact how I pay my loans?” You may not like the answer, but you›ll always know where you stand financially.
Mistake #2: I Forgot to Factor in Life Goals
To be fair, some things were out of my control: Not getting into a state school with cheaper tuition rates, graduating at the start of a once-in-a-lifetime global pandemic. I wasn’t prepared for a changing job landscape. But there were also “expected” life events like getting married, developing a geographical preference, and having a child. I didn’t consider those either.
How about the “expected” goal of buying a home? For years I didn’t feel financially comfortable enough to take on a mortgage. For so long, my attitude has been don’t take on any more debt. (A special shout-out to my 6.8% interest rate which has contributed over a third of my total loan amount.)
This even affected how my husband and I would talk about what a future home might look like. There’s always a giant unwelcome guest casting a shadow over my thoughts.
Avoid it: Don’t compartmentalize your personal and professional lives. Your student loans will hang over both, and you need to be honest with yourself about what “upward mobility” really means to you while in debt. There’s a reason people say “live like a resident” until your loans are paid off. My husband and I finally worked our numbers to where we bought our first home this past year — a moment years in the making. I still drive around in my beloved Honda CR-V like it’s a Mercedes G-Wagon.
Mistake #3: I Didn’t Ask Questions
I regret not talking to a practicing physician about their experience with student loans. I didn’t know any. There weren’t any physicians in my extended family or my community network. I was a first-generation Pakistani American kid trying to figure it out.
It’s difficult because even today, many physicians aren’t comfortable discussing their financial circumstances. The lack of financial transparency and even financial literacy is astounding among young medical professionals. We live in a medical culture where no one talks about the money. I was too diffident and nervous to even try.
Avoid it: Don’t be afraid to have uncomfortable conversations about money. Don’t allow yourself to make even one passive decision. It’s your life.
If you can’t find someone in medicine to talk to about their financial journey, there are plenty of credible resources. Medscape Medical News has a Physician Business Academy with hot topics like personal finance. The White Coat Investor is literally bookmarked on all my electronic devices. KevinMD.com has a ton of resources and articles answering common financial questions about retirement, savings, and house buying. And Travis Hornsby with www.studentloanplanner.com has wonderful advice on all kinds of different loans.
There are no stupid questions. Just ask. You might be surprised by what people are willing to share.
Mistake #4: Playing it Casual With My Lenders
If $400,000 in debt doesn’t sound bad enough, imagine lots more. It turns out my loan carrier had me at a much higher loan balance because they’d inadvertently duplicated one of my loans in the total. I didn’t know that until I transferred my loans to another handler and it came to light.
Imagine my relief at having a lower total. Imagine my anger at myself for not checking sooner.
Avoid it: Do a thorough self-audit on all your loans more than once a year. Pretend they’re a patient with odd symptoms you can’t pin down and you have the luxury of doing every diagnostic test available. It’s not fun studying your own debt, but it’s the only way to really know how much you have.
Mistake #5: Not Leaving Room to Change My Mind
I underestimated how I would evolve and how my goals would change after having the letters “MD” after my name. I never dreamed that a nonprofit salary might not be enough.
A lot of us assume that the bedside is where we will find professional satisfaction. But you might be surprised. In a climate where we’re constantly being pushed to do more in a broken healthcare system, a landscape where misinformation and technology are forcing medicine to change, there might be little joy in working clinically full time. Then what do you do?
Because I elected to go the PSLF route, I’m tied to this decision. And while it still makes the most economic sense for me personally, it now limits my professional exploration and freedom.
Avoid it: Consider how much time you really want to spend in clinical medicine. Be mindful that you have to work at least 0.8 full time equivalent to qualify for the PSLF program. It’s very hard to predict the future, let alone your future, but just know you›ll have moments where you ask, “Do I really want to stay on this career track?” Will you be able to pivot? Can you live with it if the answer is no?
Looking Ahead
Let me be clear about one thing. Despite all the negativity I feel toward my student loans — guilt about the burden I brought to my marriage and my adult life, disappointment about the cost of becoming a successful physician, and frustration that this has turned out to be the most influential factor shaping my professional and personal choices — the one thing I don’t feel is shame.
I worked hard to get to this point in my life. I am proud of being a physician.
My student loan burden will follow me to the grave. But progress is also possible. I have friends that have paid their loans down by hustling, working hard, and dropping every penny toward them.
I also have friends that have had their loans forgiven. There are options. Everyone’s experience looks a little different. But don’t be naive: Student loans will color every financial decision you make.
I’m finding solace now in recently moving and finding work at a nonprofit institution. I’m back at it; 77 payments made, and 43 to go.
Well, technically I’ve made 93 payments. I’m still waiting for my loan servicer to get around to updating my account.
You really have to stay on top of those folks.
A version of this article appeared on Medscape.com.
It’s not always great to be tops among your peers.
, according to Medscape Medical News’ 2023 Residents Salary and Debt Report.
I’m smack in that upper percentile. I amassed nearly a half million dollars in student debt and currently stand at roughly $400,000. Yay me.
As a naive twentysomething making a major life decision, I never thought my loans would amount to this inconceivable figure, the proverbial “mortgage without a roof” you hear student debt experts talk about.
This isn’t a story about how the student loan industry needs to be reformed or how education has become increasingly expensive or regrets about going to medical school.
It’s also not a story about how you should be handling basics like consolidating and refinancing and paying extra toward your principal.
It’s about my experience as a physician 13 years after signing that first promissory note. In short: I completely miscalculated the impact loans would have on my life.
I bought money to go to school. I can’t undo that. But over the past decade, I have learned a lot, particularly how those with their own mountain of debt — or who will inevitably wind up with one — can manage things better than I have.
Mistake #1: Loan Forgiveness Is More Complicated Than it Seems
My parents and I were aware of the Public Service Loan Forgiveness (PSLF) program which began in 2007 shortly before I started exploring medical school options. I wanted to help people, so working in the nonprofit sector sounded like a no-brainer. Making 120 payments while practicing at a qualifying institution didn’t sound hard.
Newsflash: Not all healthcare organizations are 501(c)3 programs that qualify as nonprofit for the PSLF program. You can’t just snap your fingers and land at one. I graduated from fellowship just as the COVID-19 pandemic began, which meant I was launching my medical career in the midst of hiring freezes and an overnight disappearance of job opportunities.
I had to take a 2-year hiatus from the nonprofit sector and found a part-time position with a local private practice group. It still stings. Had I been working for a qualified employer, I could have benefited from the student loan payment pause and been closer to applying for loan forgiveness.
Avoid it: Be brutally honest with yourself about what kind of medicine you want to practice — especially within the opportunities you have on hand. Private practice is very different from working for the nonprofit sector. I didn›t know that. When weighing career choices, immediately ask, “How will this impact how I pay my loans?” You may not like the answer, but you›ll always know where you stand financially.
Mistake #2: I Forgot to Factor in Life Goals
To be fair, some things were out of my control: Not getting into a state school with cheaper tuition rates, graduating at the start of a once-in-a-lifetime global pandemic. I wasn’t prepared for a changing job landscape. But there were also “expected” life events like getting married, developing a geographical preference, and having a child. I didn’t consider those either.
How about the “expected” goal of buying a home? For years I didn’t feel financially comfortable enough to take on a mortgage. For so long, my attitude has been don’t take on any more debt. (A special shout-out to my 6.8% interest rate which has contributed over a third of my total loan amount.)
This even affected how my husband and I would talk about what a future home might look like. There’s always a giant unwelcome guest casting a shadow over my thoughts.
Avoid it: Don’t compartmentalize your personal and professional lives. Your student loans will hang over both, and you need to be honest with yourself about what “upward mobility” really means to you while in debt. There’s a reason people say “live like a resident” until your loans are paid off. My husband and I finally worked our numbers to where we bought our first home this past year — a moment years in the making. I still drive around in my beloved Honda CR-V like it’s a Mercedes G-Wagon.
Mistake #3: I Didn’t Ask Questions
I regret not talking to a practicing physician about their experience with student loans. I didn’t know any. There weren’t any physicians in my extended family or my community network. I was a first-generation Pakistani American kid trying to figure it out.
It’s difficult because even today, many physicians aren’t comfortable discussing their financial circumstances. The lack of financial transparency and even financial literacy is astounding among young medical professionals. We live in a medical culture where no one talks about the money. I was too diffident and nervous to even try.
Avoid it: Don’t be afraid to have uncomfortable conversations about money. Don’t allow yourself to make even one passive decision. It’s your life.
If you can’t find someone in medicine to talk to about their financial journey, there are plenty of credible resources. Medscape Medical News has a Physician Business Academy with hot topics like personal finance. The White Coat Investor is literally bookmarked on all my electronic devices. KevinMD.com has a ton of resources and articles answering common financial questions about retirement, savings, and house buying. And Travis Hornsby with www.studentloanplanner.com has wonderful advice on all kinds of different loans.
There are no stupid questions. Just ask. You might be surprised by what people are willing to share.
Mistake #4: Playing it Casual With My Lenders
If $400,000 in debt doesn’t sound bad enough, imagine lots more. It turns out my loan carrier had me at a much higher loan balance because they’d inadvertently duplicated one of my loans in the total. I didn’t know that until I transferred my loans to another handler and it came to light.
Imagine my relief at having a lower total. Imagine my anger at myself for not checking sooner.
Avoid it: Do a thorough self-audit on all your loans more than once a year. Pretend they’re a patient with odd symptoms you can’t pin down and you have the luxury of doing every diagnostic test available. It’s not fun studying your own debt, but it’s the only way to really know how much you have.
Mistake #5: Not Leaving Room to Change My Mind
I underestimated how I would evolve and how my goals would change after having the letters “MD” after my name. I never dreamed that a nonprofit salary might not be enough.
A lot of us assume that the bedside is where we will find professional satisfaction. But you might be surprised. In a climate where we’re constantly being pushed to do more in a broken healthcare system, a landscape where misinformation and technology are forcing medicine to change, there might be little joy in working clinically full time. Then what do you do?
Because I elected to go the PSLF route, I’m tied to this decision. And while it still makes the most economic sense for me personally, it now limits my professional exploration and freedom.
Avoid it: Consider how much time you really want to spend in clinical medicine. Be mindful that you have to work at least 0.8 full time equivalent to qualify for the PSLF program. It’s very hard to predict the future, let alone your future, but just know you›ll have moments where you ask, “Do I really want to stay on this career track?” Will you be able to pivot? Can you live with it if the answer is no?
Looking Ahead
Let me be clear about one thing. Despite all the negativity I feel toward my student loans — guilt about the burden I brought to my marriage and my adult life, disappointment about the cost of becoming a successful physician, and frustration that this has turned out to be the most influential factor shaping my professional and personal choices — the one thing I don’t feel is shame.
I worked hard to get to this point in my life. I am proud of being a physician.
My student loan burden will follow me to the grave. But progress is also possible. I have friends that have paid their loans down by hustling, working hard, and dropping every penny toward them.
I also have friends that have had their loans forgiven. There are options. Everyone’s experience looks a little different. But don’t be naive: Student loans will color every financial decision you make.
I’m finding solace now in recently moving and finding work at a nonprofit institution. I’m back at it; 77 payments made, and 43 to go.
Well, technically I’ve made 93 payments. I’m still waiting for my loan servicer to get around to updating my account.
You really have to stay on top of those folks.
A version of this article appeared on Medscape.com.
‘It’s Time’ to Empower Care for Patients With Obesity
A few weeks ago, I made a patient who lost 100 pounds following a sleeve gastrectomy 9 months prior feel bad because I told her she lost too much weight. As I spoke to her, I realized that she found it hard to make life changes and that the surgery was a huge aide in changing her life and her lifestyle. I ended up apologizing for initially saying she lost too much weight.
For the first time in her life, she was successful in losing weight and keeping it off. The surgery allowed her body to defend a lower body weight by altering the secretion of gut hormones that lead to satiety in the brain. It’s not her fault that her body responded so well!
I asked her to be on my next orientation virtual meeting with prospective weight management patients to urge those with a body mass index (BMI) > 40 to consider bariatric surgery as the most effective durable and safe treatment for their degree of obesity.
Metabolic bariatric surgery, primarily sleeve gastrectomy and Roux-en-Y gastric bypass , alters the gut hormone milieu such that the body defends a lower mass of adipose tissue and a lower weight. We have learned what it takes to alter body weight defense to a healthy lower weight by studying why metabolic bariatric surgery works so well. It turns out that there are several hormones secreted by the gut that allow the brain to register fullness.
One of these gut hormones, glucagon-like peptide (GLP)-1, has been researched as an analog to help reduce body weight by 16% and has also been shown to reduce cardiovascular risk in the SELECT trial, as published in The New England Journal of Medicine (NEJM).
It’s the first weight loss medication to be shown in a cardiovascular outcomes trial to be superior to placebo in reduction of major cardiovascular events, including cardiovascular deaths, nonfatal myocardial infarction, and nonfatal stroke. The results presented at the 2023 American Heart Association meetings in Philadelphia ended in wholehearted applause by a “standing only” audience even before the presentation’s conclusion.
As we pave the way for nutrient-stimulated hormone (NuSH) therapies to be prescribed to all Americans with a BMI > 30 to improve health, we need to remember what these medications actually do. We used to think that metabolic bariatric surgery worked by restricting the stomach contents and malabsorbing nutrients. We now know that the surgeries work by altering NuSH secretion, allowing for less secretion of the hunger hormone ghrelin and more secretion of GLP-1, glucose-dependent insulinotropic polypeptide (GIP), peptide YY (PYY), cholecystokinin (CCK), oxyntomodulin (OXM), and other satiety hormones with less food ingestion.
They have pleiotropic effects on many organ systems in the body, including the brain, heart, adipose tissue, and liver. They decrease inflammation and also increase satiety and delay gastric emptying. None of these effects automatically produce weight loss, but they certainly aid in the adoption of a healthier body weight and better health. The weight loss occurs because these medications steer the body toward behavioral changes that promote weight loss.
As we delve into the SELECT trial results, a 20% reduction in major cardiovascular events was accompanied by an average weight loss of 9.6%, without a behavioral component added to either the placebo or intervention arms, as is usual in antiobesity agent trials.
Does this mean that primary care providers (PCPs) don’t have to educate patients on behavior change, diet, and exercise therapy? Well, if we consider obesity a disease as we do type 2 diabetes and dyslipidemia or hypertension, then no — PCPs don’t have to, just like they don’t in treating these other diseases.
However, we should rethink this practice. The recently published SURMOUNT-3 trial looked at another NuSH, tirzepatide, with intensive behavioral therapy; it resulted in a 26.6% weight loss, which is comparable to results with bariatric surgery. The SURMOUNT-1 trial of tirzepatide with nonintensive behavioral therapy resulted in a 20.9% weight loss, which is still substantial, but SURMOUNT-3 showed how much more is achievable with robust behavior-change therapy.
In other words, it’s time that PCPs provide education on behavior change to maximize the power of the medications prescribed in practice for the most common diseases suffered in the United States: obesity, type 2 diabetes, cardiovascular disease, and hypertension. These are all chronic, relapsing diseases. Medication alone will improve numbers (weight, blood glucose, A1c, and blood pressure), but a relapsing disease continues relentlessly as patients age to overcome the medications prescribed.
Today I made another patient feel bad because she lost over 100 pounds on semaglutide (Wegovy) 2.4 mg over 1 year, reducing her BMI from 57 to 36. She wanted to keep losing, so I recommended sleeve gastrectomy to lose more weight. I told her she could always restart the Wegovy after the procedure if needed.
We really don’t have an answer to this issue of NuSH therapy not getting to goal and bariatric surgery following medication therapy. The reality is that bariatric surgery should be considered a safe, effective treatment for extreme obesity somewhere along the trajectory of treatments starting with behavior (diet, exercise) and medications. It is still considered a last resort, and for some, just too aggressive.
We have learned much about the incretin hormones and what they can accomplish for obesity from studying bariatric — now called metabolic — surgery. Surgery should be seen as we see stent placement for angina, only more effective for longevity. The COURAGE trial, published in 2007 in NEJM, showed that when compared with medication treatment alone for angina, stent placement plus medications resulted in no difference in mortality after a 7-year follow-up period. Compare this to bariatric surgery, which in many retrospective analyses shows a 20% reduction in cardiovascular mortality after 20-year follow-up (Swedish Obesity Study). In the United States, there are 2 million stent procedures performed per year vs 250,000 bariatric surgical procedures. There are millions of Americans with a BMI > 40 and, yes, millions of Americans with angina. I think I make my point that we need to do more bariatric surgeries to effectively treat extreme obesity.
The solution to this negligent medical practice in obesity treatment is to empower PCPs to treat obesity (at least uncomplicated obesity) and refer to obesity medicine practices for complicated obesity with multiple complications, such as type 2 diabetes and cardiovascular disease, and to refer to obesity medicine practices with a surgical component for BMIs > 40 or > 35 with type 2 diabetes, sleep apnea, and/or cardiovascular disease or other serious conditions.
How do we empower PCPs? Insurance coverage of NuSH therapies due to life-saving properties — as evidenced by the SELECT trial — without prior authorizations; and education on how and why metabolic surgery works, as well as education on behavioral approaches, such as healthy diet and exercise, as a core therapy for all BMI categories.
It’s time.
Caroline Apovian, MD, has disclosed the following relevant financial relationships: Serve(d) as a director, officer, partner, employee, adviser, consultant, or trustee for Altimmune; Cowen and Company; Currax Pharmaceuticals; EPG Communication Holdings; Gelesis, Srl; L-Nutra; and NeuroBo Pharmaceuticals. Received research grant from: National Institutes of Health; Patient-Centered Outcomes Research Institute; and GI Dynamics. Received income in an amount equal to or greater than $250 from: Altimmune; Cowen and Company; NeuroBo Pharmaceuticals; and Novo Nordisk.
A version of this article appeared on Medscape.com.
A few weeks ago, I made a patient who lost 100 pounds following a sleeve gastrectomy 9 months prior feel bad because I told her she lost too much weight. As I spoke to her, I realized that she found it hard to make life changes and that the surgery was a huge aide in changing her life and her lifestyle. I ended up apologizing for initially saying she lost too much weight.
For the first time in her life, she was successful in losing weight and keeping it off. The surgery allowed her body to defend a lower body weight by altering the secretion of gut hormones that lead to satiety in the brain. It’s not her fault that her body responded so well!
I asked her to be on my next orientation virtual meeting with prospective weight management patients to urge those with a body mass index (BMI) > 40 to consider bariatric surgery as the most effective durable and safe treatment for their degree of obesity.
Metabolic bariatric surgery, primarily sleeve gastrectomy and Roux-en-Y gastric bypass , alters the gut hormone milieu such that the body defends a lower mass of adipose tissue and a lower weight. We have learned what it takes to alter body weight defense to a healthy lower weight by studying why metabolic bariatric surgery works so well. It turns out that there are several hormones secreted by the gut that allow the brain to register fullness.
One of these gut hormones, glucagon-like peptide (GLP)-1, has been researched as an analog to help reduce body weight by 16% and has also been shown to reduce cardiovascular risk in the SELECT trial, as published in The New England Journal of Medicine (NEJM).
It’s the first weight loss medication to be shown in a cardiovascular outcomes trial to be superior to placebo in reduction of major cardiovascular events, including cardiovascular deaths, nonfatal myocardial infarction, and nonfatal stroke. The results presented at the 2023 American Heart Association meetings in Philadelphia ended in wholehearted applause by a “standing only” audience even before the presentation’s conclusion.
As we pave the way for nutrient-stimulated hormone (NuSH) therapies to be prescribed to all Americans with a BMI > 30 to improve health, we need to remember what these medications actually do. We used to think that metabolic bariatric surgery worked by restricting the stomach contents and malabsorbing nutrients. We now know that the surgeries work by altering NuSH secretion, allowing for less secretion of the hunger hormone ghrelin and more secretion of GLP-1, glucose-dependent insulinotropic polypeptide (GIP), peptide YY (PYY), cholecystokinin (CCK), oxyntomodulin (OXM), and other satiety hormones with less food ingestion.
They have pleiotropic effects on many organ systems in the body, including the brain, heart, adipose tissue, and liver. They decrease inflammation and also increase satiety and delay gastric emptying. None of these effects automatically produce weight loss, but they certainly aid in the adoption of a healthier body weight and better health. The weight loss occurs because these medications steer the body toward behavioral changes that promote weight loss.
As we delve into the SELECT trial results, a 20% reduction in major cardiovascular events was accompanied by an average weight loss of 9.6%, without a behavioral component added to either the placebo or intervention arms, as is usual in antiobesity agent trials.
Does this mean that primary care providers (PCPs) don’t have to educate patients on behavior change, diet, and exercise therapy? Well, if we consider obesity a disease as we do type 2 diabetes and dyslipidemia or hypertension, then no — PCPs don’t have to, just like they don’t in treating these other diseases.
However, we should rethink this practice. The recently published SURMOUNT-3 trial looked at another NuSH, tirzepatide, with intensive behavioral therapy; it resulted in a 26.6% weight loss, which is comparable to results with bariatric surgery. The SURMOUNT-1 trial of tirzepatide with nonintensive behavioral therapy resulted in a 20.9% weight loss, which is still substantial, but SURMOUNT-3 showed how much more is achievable with robust behavior-change therapy.
In other words, it’s time that PCPs provide education on behavior change to maximize the power of the medications prescribed in practice for the most common diseases suffered in the United States: obesity, type 2 diabetes, cardiovascular disease, and hypertension. These are all chronic, relapsing diseases. Medication alone will improve numbers (weight, blood glucose, A1c, and blood pressure), but a relapsing disease continues relentlessly as patients age to overcome the medications prescribed.
Today I made another patient feel bad because she lost over 100 pounds on semaglutide (Wegovy) 2.4 mg over 1 year, reducing her BMI from 57 to 36. She wanted to keep losing, so I recommended sleeve gastrectomy to lose more weight. I told her she could always restart the Wegovy after the procedure if needed.
We really don’t have an answer to this issue of NuSH therapy not getting to goal and bariatric surgery following medication therapy. The reality is that bariatric surgery should be considered a safe, effective treatment for extreme obesity somewhere along the trajectory of treatments starting with behavior (diet, exercise) and medications. It is still considered a last resort, and for some, just too aggressive.
We have learned much about the incretin hormones and what they can accomplish for obesity from studying bariatric — now called metabolic — surgery. Surgery should be seen as we see stent placement for angina, only more effective for longevity. The COURAGE trial, published in 2007 in NEJM, showed that when compared with medication treatment alone for angina, stent placement plus medications resulted in no difference in mortality after a 7-year follow-up period. Compare this to bariatric surgery, which in many retrospective analyses shows a 20% reduction in cardiovascular mortality after 20-year follow-up (Swedish Obesity Study). In the United States, there are 2 million stent procedures performed per year vs 250,000 bariatric surgical procedures. There are millions of Americans with a BMI > 40 and, yes, millions of Americans with angina. I think I make my point that we need to do more bariatric surgeries to effectively treat extreme obesity.
The solution to this negligent medical practice in obesity treatment is to empower PCPs to treat obesity (at least uncomplicated obesity) and refer to obesity medicine practices for complicated obesity with multiple complications, such as type 2 diabetes and cardiovascular disease, and to refer to obesity medicine practices with a surgical component for BMIs > 40 or > 35 with type 2 diabetes, sleep apnea, and/or cardiovascular disease or other serious conditions.
How do we empower PCPs? Insurance coverage of NuSH therapies due to life-saving properties — as evidenced by the SELECT trial — without prior authorizations; and education on how and why metabolic surgery works, as well as education on behavioral approaches, such as healthy diet and exercise, as a core therapy for all BMI categories.
It’s time.
Caroline Apovian, MD, has disclosed the following relevant financial relationships: Serve(d) as a director, officer, partner, employee, adviser, consultant, or trustee for Altimmune; Cowen and Company; Currax Pharmaceuticals; EPG Communication Holdings; Gelesis, Srl; L-Nutra; and NeuroBo Pharmaceuticals. Received research grant from: National Institutes of Health; Patient-Centered Outcomes Research Institute; and GI Dynamics. Received income in an amount equal to or greater than $250 from: Altimmune; Cowen and Company; NeuroBo Pharmaceuticals; and Novo Nordisk.
A version of this article appeared on Medscape.com.
A few weeks ago, I made a patient who lost 100 pounds following a sleeve gastrectomy 9 months prior feel bad because I told her she lost too much weight. As I spoke to her, I realized that she found it hard to make life changes and that the surgery was a huge aide in changing her life and her lifestyle. I ended up apologizing for initially saying she lost too much weight.
For the first time in her life, she was successful in losing weight and keeping it off. The surgery allowed her body to defend a lower body weight by altering the secretion of gut hormones that lead to satiety in the brain. It’s not her fault that her body responded so well!
I asked her to be on my next orientation virtual meeting with prospective weight management patients to urge those with a body mass index (BMI) > 40 to consider bariatric surgery as the most effective durable and safe treatment for their degree of obesity.
Metabolic bariatric surgery, primarily sleeve gastrectomy and Roux-en-Y gastric bypass , alters the gut hormone milieu such that the body defends a lower mass of adipose tissue and a lower weight. We have learned what it takes to alter body weight defense to a healthy lower weight by studying why metabolic bariatric surgery works so well. It turns out that there are several hormones secreted by the gut that allow the brain to register fullness.
One of these gut hormones, glucagon-like peptide (GLP)-1, has been researched as an analog to help reduce body weight by 16% and has also been shown to reduce cardiovascular risk in the SELECT trial, as published in The New England Journal of Medicine (NEJM).
It’s the first weight loss medication to be shown in a cardiovascular outcomes trial to be superior to placebo in reduction of major cardiovascular events, including cardiovascular deaths, nonfatal myocardial infarction, and nonfatal stroke. The results presented at the 2023 American Heart Association meetings in Philadelphia ended in wholehearted applause by a “standing only” audience even before the presentation’s conclusion.
As we pave the way for nutrient-stimulated hormone (NuSH) therapies to be prescribed to all Americans with a BMI > 30 to improve health, we need to remember what these medications actually do. We used to think that metabolic bariatric surgery worked by restricting the stomach contents and malabsorbing nutrients. We now know that the surgeries work by altering NuSH secretion, allowing for less secretion of the hunger hormone ghrelin and more secretion of GLP-1, glucose-dependent insulinotropic polypeptide (GIP), peptide YY (PYY), cholecystokinin (CCK), oxyntomodulin (OXM), and other satiety hormones with less food ingestion.
They have pleiotropic effects on many organ systems in the body, including the brain, heart, adipose tissue, and liver. They decrease inflammation and also increase satiety and delay gastric emptying. None of these effects automatically produce weight loss, but they certainly aid in the adoption of a healthier body weight and better health. The weight loss occurs because these medications steer the body toward behavioral changes that promote weight loss.
As we delve into the SELECT trial results, a 20% reduction in major cardiovascular events was accompanied by an average weight loss of 9.6%, without a behavioral component added to either the placebo or intervention arms, as is usual in antiobesity agent trials.
Does this mean that primary care providers (PCPs) don’t have to educate patients on behavior change, diet, and exercise therapy? Well, if we consider obesity a disease as we do type 2 diabetes and dyslipidemia or hypertension, then no — PCPs don’t have to, just like they don’t in treating these other diseases.
However, we should rethink this practice. The recently published SURMOUNT-3 trial looked at another NuSH, tirzepatide, with intensive behavioral therapy; it resulted in a 26.6% weight loss, which is comparable to results with bariatric surgery. The SURMOUNT-1 trial of tirzepatide with nonintensive behavioral therapy resulted in a 20.9% weight loss, which is still substantial, but SURMOUNT-3 showed how much more is achievable with robust behavior-change therapy.
In other words, it’s time that PCPs provide education on behavior change to maximize the power of the medications prescribed in practice for the most common diseases suffered in the United States: obesity, type 2 diabetes, cardiovascular disease, and hypertension. These are all chronic, relapsing diseases. Medication alone will improve numbers (weight, blood glucose, A1c, and blood pressure), but a relapsing disease continues relentlessly as patients age to overcome the medications prescribed.
Today I made another patient feel bad because she lost over 100 pounds on semaglutide (Wegovy) 2.4 mg over 1 year, reducing her BMI from 57 to 36. She wanted to keep losing, so I recommended sleeve gastrectomy to lose more weight. I told her she could always restart the Wegovy after the procedure if needed.
We really don’t have an answer to this issue of NuSH therapy not getting to goal and bariatric surgery following medication therapy. The reality is that bariatric surgery should be considered a safe, effective treatment for extreme obesity somewhere along the trajectory of treatments starting with behavior (diet, exercise) and medications. It is still considered a last resort, and for some, just too aggressive.
We have learned much about the incretin hormones and what they can accomplish for obesity from studying bariatric — now called metabolic — surgery. Surgery should be seen as we see stent placement for angina, only more effective for longevity. The COURAGE trial, published in 2007 in NEJM, showed that when compared with medication treatment alone for angina, stent placement plus medications resulted in no difference in mortality after a 7-year follow-up period. Compare this to bariatric surgery, which in many retrospective analyses shows a 20% reduction in cardiovascular mortality after 20-year follow-up (Swedish Obesity Study). In the United States, there are 2 million stent procedures performed per year vs 250,000 bariatric surgical procedures. There are millions of Americans with a BMI > 40 and, yes, millions of Americans with angina. I think I make my point that we need to do more bariatric surgeries to effectively treat extreme obesity.
The solution to this negligent medical practice in obesity treatment is to empower PCPs to treat obesity (at least uncomplicated obesity) and refer to obesity medicine practices for complicated obesity with multiple complications, such as type 2 diabetes and cardiovascular disease, and to refer to obesity medicine practices with a surgical component for BMIs > 40 or > 35 with type 2 diabetes, sleep apnea, and/or cardiovascular disease or other serious conditions.
How do we empower PCPs? Insurance coverage of NuSH therapies due to life-saving properties — as evidenced by the SELECT trial — without prior authorizations; and education on how and why metabolic surgery works, as well as education on behavioral approaches, such as healthy diet and exercise, as a core therapy for all BMI categories.
It’s time.
Caroline Apovian, MD, has disclosed the following relevant financial relationships: Serve(d) as a director, officer, partner, employee, adviser, consultant, or trustee for Altimmune; Cowen and Company; Currax Pharmaceuticals; EPG Communication Holdings; Gelesis, Srl; L-Nutra; and NeuroBo Pharmaceuticals. Received research grant from: National Institutes of Health; Patient-Centered Outcomes Research Institute; and GI Dynamics. Received income in an amount equal to or greater than $250 from: Altimmune; Cowen and Company; NeuroBo Pharmaceuticals; and Novo Nordisk.
A version of this article appeared on Medscape.com.
Why I No Longer Remove Ingrown Toenails in Primary Care
A former colleague once told me that there are few primary care procedures more satisfying for the patient and physician than removing part of an ingrown toenail. I disagree, but I performed this procedure quite a few times during my residency and first few years in practice. The patient would usually have been in pain for days to weeks and have tried soaking their foot or putting wisps of cotton under the ingrown nail edge, without relief. I would draw up a syringe of lidocaine with epinephrine and perform a digital block on the affected toe. After waiting 5-10 minutes for the toe to become numb, I would clean the area, use a nail elevator to push the cuticle off the nail plate, and lift up the lateral edge of the plate. I would then cut the lateral edge with a nail splitter and remove the cut nail fragment with a hemostat. Finally, after an inspection to make sure that I hadn›t left any pieces behind, I or my nurse would apply petrolatum gauze and a bandage.
Adding up the time it took to obtain consent, wait for the local anesthetic to take effect, and do the procedure, it was more efficient for me to see two or three patients for medication checkups and refer toenail problems to a podiatrist instead. The same thing happened with circumcisions on infants who, for whatever reason, hadn›t had them done in the hospital. After a few years of doing these, I decided it would be easier to send these patients to pediatric urologists.
My choice to reduce my scope of practice during the early part of my career mirrored a national trend among graduating family medicine residents. I value the joint injections, laceration repairs, biopsies, and other skin procedures that remain in my repertoire for the change of pace and saving my patients more costly visits to specialists with long waiting lists. In fact, a previous study showed that family physicians who provide more comprehensive care generate lower healthcare spending and fewer hospitalizations than those with a narrower scope of practice.
A recent evaluation of Comprehensive Primary Care Plus, one of several alternative payment models that the Centers for Medicare & Medicaid Services has piloted over the past decade, found that it modestly reduced emergency department visits and inpatient costs but didn’t save money after accounting for additional dollars going to primary care. However, when researchers looked at six specific services — immunizations, behavioral counseling, laceration management, skin lesion removal, joint or tendon injections, and point-of-care ultrasound — they found that patients who saw physicians who provided more of these had lower care costs and sought less acute care outside of the office. On average, independent-practice physicians provided more services than physicians who practiced at sites affiliated with hospitals or health systems. That makes sense: While health systems bring in more income for procedures performed in their operating rooms and subspecialists› offices, private practices do better by keeping services in-house.
Supporting physicians in maintaining the broadest possible scope of practice is, in my opinion, the missing piece in the federal government’s initiatives to strengthen primary care. Investing in primary care training programs and paying practices for care coordination are necessary but insufficient steps if family physicians are expected to improve population health and bend the cost curve.
Dr. Lin is Associate Director, Family Medicine Residency Program, Lancaster General Hospital, Lancaster, Pennsylvania. He has disclosed no relevant financial relationships.
A version of this article appeared on Medscape.com.
A former colleague once told me that there are few primary care procedures more satisfying for the patient and physician than removing part of an ingrown toenail. I disagree, but I performed this procedure quite a few times during my residency and first few years in practice. The patient would usually have been in pain for days to weeks and have tried soaking their foot or putting wisps of cotton under the ingrown nail edge, without relief. I would draw up a syringe of lidocaine with epinephrine and perform a digital block on the affected toe. After waiting 5-10 minutes for the toe to become numb, I would clean the area, use a nail elevator to push the cuticle off the nail plate, and lift up the lateral edge of the plate. I would then cut the lateral edge with a nail splitter and remove the cut nail fragment with a hemostat. Finally, after an inspection to make sure that I hadn›t left any pieces behind, I or my nurse would apply petrolatum gauze and a bandage.
Adding up the time it took to obtain consent, wait for the local anesthetic to take effect, and do the procedure, it was more efficient for me to see two or three patients for medication checkups and refer toenail problems to a podiatrist instead. The same thing happened with circumcisions on infants who, for whatever reason, hadn›t had them done in the hospital. After a few years of doing these, I decided it would be easier to send these patients to pediatric urologists.
My choice to reduce my scope of practice during the early part of my career mirrored a national trend among graduating family medicine residents. I value the joint injections, laceration repairs, biopsies, and other skin procedures that remain in my repertoire for the change of pace and saving my patients more costly visits to specialists with long waiting lists. In fact, a previous study showed that family physicians who provide more comprehensive care generate lower healthcare spending and fewer hospitalizations than those with a narrower scope of practice.
A recent evaluation of Comprehensive Primary Care Plus, one of several alternative payment models that the Centers for Medicare & Medicaid Services has piloted over the past decade, found that it modestly reduced emergency department visits and inpatient costs but didn’t save money after accounting for additional dollars going to primary care. However, when researchers looked at six specific services — immunizations, behavioral counseling, laceration management, skin lesion removal, joint or tendon injections, and point-of-care ultrasound — they found that patients who saw physicians who provided more of these had lower care costs and sought less acute care outside of the office. On average, independent-practice physicians provided more services than physicians who practiced at sites affiliated with hospitals or health systems. That makes sense: While health systems bring in more income for procedures performed in their operating rooms and subspecialists› offices, private practices do better by keeping services in-house.
Supporting physicians in maintaining the broadest possible scope of practice is, in my opinion, the missing piece in the federal government’s initiatives to strengthen primary care. Investing in primary care training programs and paying practices for care coordination are necessary but insufficient steps if family physicians are expected to improve population health and bend the cost curve.
Dr. Lin is Associate Director, Family Medicine Residency Program, Lancaster General Hospital, Lancaster, Pennsylvania. He has disclosed no relevant financial relationships.
A version of this article appeared on Medscape.com.
A former colleague once told me that there are few primary care procedures more satisfying for the patient and physician than removing part of an ingrown toenail. I disagree, but I performed this procedure quite a few times during my residency and first few years in practice. The patient would usually have been in pain for days to weeks and have tried soaking their foot or putting wisps of cotton under the ingrown nail edge, without relief. I would draw up a syringe of lidocaine with epinephrine and perform a digital block on the affected toe. After waiting 5-10 minutes for the toe to become numb, I would clean the area, use a nail elevator to push the cuticle off the nail plate, and lift up the lateral edge of the plate. I would then cut the lateral edge with a nail splitter and remove the cut nail fragment with a hemostat. Finally, after an inspection to make sure that I hadn›t left any pieces behind, I or my nurse would apply petrolatum gauze and a bandage.
Adding up the time it took to obtain consent, wait for the local anesthetic to take effect, and do the procedure, it was more efficient for me to see two or three patients for medication checkups and refer toenail problems to a podiatrist instead. The same thing happened with circumcisions on infants who, for whatever reason, hadn›t had them done in the hospital. After a few years of doing these, I decided it would be easier to send these patients to pediatric urologists.
My choice to reduce my scope of practice during the early part of my career mirrored a national trend among graduating family medicine residents. I value the joint injections, laceration repairs, biopsies, and other skin procedures that remain in my repertoire for the change of pace and saving my patients more costly visits to specialists with long waiting lists. In fact, a previous study showed that family physicians who provide more comprehensive care generate lower healthcare spending and fewer hospitalizations than those with a narrower scope of practice.
A recent evaluation of Comprehensive Primary Care Plus, one of several alternative payment models that the Centers for Medicare & Medicaid Services has piloted over the past decade, found that it modestly reduced emergency department visits and inpatient costs but didn’t save money after accounting for additional dollars going to primary care. However, when researchers looked at six specific services — immunizations, behavioral counseling, laceration management, skin lesion removal, joint or tendon injections, and point-of-care ultrasound — they found that patients who saw physicians who provided more of these had lower care costs and sought less acute care outside of the office. On average, independent-practice physicians provided more services than physicians who practiced at sites affiliated with hospitals or health systems. That makes sense: While health systems bring in more income for procedures performed in their operating rooms and subspecialists› offices, private practices do better by keeping services in-house.
Supporting physicians in maintaining the broadest possible scope of practice is, in my opinion, the missing piece in the federal government’s initiatives to strengthen primary care. Investing in primary care training programs and paying practices for care coordination are necessary but insufficient steps if family physicians are expected to improve population health and bend the cost curve.
Dr. Lin is Associate Director, Family Medicine Residency Program, Lancaster General Hospital, Lancaster, Pennsylvania. He has disclosed no relevant financial relationships.
A version of this article appeared on Medscape.com.