Federal Practitioner

Use of cholesterol-lowering statins was linked to a lower risk of developing a subtype of diabetes that occurs after acute pancreatitis, according to a new report.

The benefits of statins depended on the consistency of usage, with regular users having a lower risk of developing postpancreatitis diabetes than irregular users. The results were similar with low, moderate, and high statin doses, as well as in cases of both mild and severe acute pancreatitis.

“About 15% of patients with acute pancreatitis will develop diabetes mellitus in the next 5 years, and although we can monitor for it, we can’t do anything to prevent it,” Nikhil Thiruvengadam, MD, the lead study author and a gastroenterologist at Loma Linda (Calif.) University, told this news organization.

iStock/ThinkStock

“This could push you as a clinician to prescribe [a statin if you have a reason to] because it could provide two benefits instead of just one,” he said.

The study was published online in Clinical Gastroenterology and Hepatology.
 

Steady use mattered, not dose

Patients with acute pancreatitis face at least a twofold increased risk of developing postpancreatitis diabetes, the study authors write. Although previous studies have shown that statins can lower the incidence and severity of acute pancreatitis, they haven’t been studied for the prevention of postpancreatitis diabetes.

In a collaborative study with several other universities, Dr. Thiruvengadam and colleagues examined commercial insurance claims from the Optum Clinformatics database to assess the impact of statins on 118,479 patients without preexisting diabetes admitted for a first episode of acute pancreatitis between 2008 and 2020.

They compared patients who consistently used statins with irregular users and nonusers. Regular statin usage was defined as patients who had statin prescriptions filled for at least 80% of the year prior to their acute pancreatitis diagnosis. The analysis included 9,048 patients (7.6%) who used statins regularly, 27,272 (23%) who used statins irregularly, and 82,159 (69.3%) nonusers.

With a median follow-up of 3.5 years, the 5-year cumulative incidence of postpancreatitis diabetes was 7.5% among regular statin users and 12.7% among nonusers. Regular statin users had a 42% lower risk of developing postpancreatitis diabetes, compared with nonusers. Irregular statin users had a 15% lower risk of postpancreatitis diabetes.

In addition, the 5-year cumulative incidence of insulin-dependent postpancreatitis diabetes was 2.4% among regular statin users and 6.6% among nonusers. Regular statin users had a 52% lower risk of developing insulin-dependent diabetes as compared with nonusers.

Daily dosage didn’t demonstrate a linear dose-response relationship. That means high-dose statins may not be more effective in preventing diabetes as compared with lower doses, the study authors write.

Statin usage was effective across additional analyses, including sex, etiologies of pancreatitis, and in both mild and severe acute pancreatitis. According to the study authors, this suggests that a broad population of these patients may benefit from statins.

“We were pleasantly surprised by the variety of findings,” Dr. Thiruvengadam said. “We’re seeing strong signals, especially with consistency of usage.”
 

Ongoing studies

The results may seem paradoxical, the study authors write, given an epidemiologic association with a slight increase in new-onset diabetes with statin initiation. But, as other researchers have reported, postpancreatitis diabetes and type 2 diabetes have different clinical features and underlying pathophysiology. For example, patients with postpancreatitis diabetes have much higher rates of requiring insulin, hospitalization, and all-cause mortality, the study authors write.

In fact, postpancreatitis diabetes is thought to be driven by chronic low-grade inflammation attributable to interleukin-6 and tumor necrosis factor–alpha. Statins have been shown to reduce tumor necrosis factor–alpha secretion and the production of C-reactive protein in response to circulating interleukin-6 in hepatocytes, they write.

The results should inform long-term prospective studies of acute pancreatitis, the study authors write, as well as randomized controlled trials of statins.

In the meantime, gastroenterologists and primary care physicians who see outpatients after hospitalization for acute pancreatitis may consider using statins, particularly in those who may have another possible indication for statin therapy, such as mild hyperlipidemia.

“There appears to be a low-dose benefit, which is another reason why providers may consider using statins, though it’s not for everyone with pancreatitis,” Dr. Thiruvengadam said. “This could be an exploratory pathway and suggested for use in the right setting.”

The Type 1 Diabetes in Acute Pancreatitis Consortium, sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases, is conducting an observational cohort study at more than a dozen locations across the country to investigate the incidence, etiology, and pathophysiology of diabetes after acute pancreatitis.

“Diabetes is surprisingly common after even a single attack of acute pancreatitis,” Chris Forsmark, MD, professor of medicine and chief of the division of gastroenterology, hepatology, and nutrition at the University of Florida, Gainesville, told this news organization.

Dr. Forsmark, who wasn’t involved with this study, is a member of T1DAPC and one of the principal investigators in Florida.

“The reduction of risk by 42% is quite substantial,” he said. “Like all such studies, there is risk of bias and confounding in determining the actual risk. Nonetheless, the results provide a strong reason for confirmation in other datasets and for further study.”

The study didn’t report funding support. Dr. Thiruvengadam and Dr. Forsmark report no relevant financial relationships.

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

Use of cholesterol-lowering statins was linked to a lower risk of developing a subtype of diabetes that occurs after acute pancreatitis, according to a new report.

The benefits of statins depended on the consistency of usage, with regular users having a lower risk of developing postpancreatitis diabetes than irregular users. The results were similar with low, moderate, and high statin doses, as well as in cases of both mild and severe acute pancreatitis.

“About 15% of patients with acute pancreatitis will develop diabetes mellitus in the next 5 years, and although we can monitor for it, we can’t do anything to prevent it,” Nikhil Thiruvengadam, MD, the lead study author and a gastroenterologist at Loma Linda (Calif.) University, told this news organization.

iStock/ThinkStock

“This could push you as a clinician to prescribe [a statin if you have a reason to] because it could provide two benefits instead of just one,” he said.

The study was published online in Clinical Gastroenterology and Hepatology.
 

Steady use mattered, not dose

Patients with acute pancreatitis face at least a twofold increased risk of developing postpancreatitis diabetes, the study authors write. Although previous studies have shown that statins can lower the incidence and severity of acute pancreatitis, they haven’t been studied for the prevention of postpancreatitis diabetes.

In a collaborative study with several other universities, Dr. Thiruvengadam and colleagues examined commercial insurance claims from the Optum Clinformatics database to assess the impact of statins on 118,479 patients without preexisting diabetes admitted for a first episode of acute pancreatitis between 2008 and 2020.

They compared patients who consistently used statins with irregular users and nonusers. Regular statin usage was defined as patients who had statin prescriptions filled for at least 80% of the year prior to their acute pancreatitis diagnosis. The analysis included 9,048 patients (7.6%) who used statins regularly, 27,272 (23%) who used statins irregularly, and 82,159 (69.3%) nonusers.

With a median follow-up of 3.5 years, the 5-year cumulative incidence of postpancreatitis diabetes was 7.5% among regular statin users and 12.7% among nonusers. Regular statin users had a 42% lower risk of developing postpancreatitis diabetes, compared with nonusers. Irregular statin users had a 15% lower risk of postpancreatitis diabetes.

In addition, the 5-year cumulative incidence of insulin-dependent postpancreatitis diabetes was 2.4% among regular statin users and 6.6% among nonusers. Regular statin users had a 52% lower risk of developing insulin-dependent diabetes as compared with nonusers.

Daily dosage didn’t demonstrate a linear dose-response relationship. That means high-dose statins may not be more effective in preventing diabetes as compared with lower doses, the study authors write.

Statin usage was effective across additional analyses, including sex, etiologies of pancreatitis, and in both mild and severe acute pancreatitis. According to the study authors, this suggests that a broad population of these patients may benefit from statins.

“We were pleasantly surprised by the variety of findings,” Dr. Thiruvengadam said. “We’re seeing strong signals, especially with consistency of usage.”
 

Ongoing studies

The results may seem paradoxical, the study authors write, given an epidemiologic association with a slight increase in new-onset diabetes with statin initiation. But, as other researchers have reported, postpancreatitis diabetes and type 2 diabetes have different clinical features and underlying pathophysiology. For example, patients with postpancreatitis diabetes have much higher rates of requiring insulin, hospitalization, and all-cause mortality, the study authors write.

In fact, postpancreatitis diabetes is thought to be driven by chronic low-grade inflammation attributable to interleukin-6 and tumor necrosis factor–alpha. Statins have been shown to reduce tumor necrosis factor–alpha secretion and the production of C-reactive protein in response to circulating interleukin-6 in hepatocytes, they write.

The results should inform long-term prospective studies of acute pancreatitis, the study authors write, as well as randomized controlled trials of statins.

In the meantime, gastroenterologists and primary care physicians who see outpatients after hospitalization for acute pancreatitis may consider using statins, particularly in those who may have another possible indication for statin therapy, such as mild hyperlipidemia.

“There appears to be a low-dose benefit, which is another reason why providers may consider using statins, though it’s not for everyone with pancreatitis,” Dr. Thiruvengadam said. “This could be an exploratory pathway and suggested for use in the right setting.”

The Type 1 Diabetes in Acute Pancreatitis Consortium, sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases, is conducting an observational cohort study at more than a dozen locations across the country to investigate the incidence, etiology, and pathophysiology of diabetes after acute pancreatitis.

“Diabetes is surprisingly common after even a single attack of acute pancreatitis,” Chris Forsmark, MD, professor of medicine and chief of the division of gastroenterology, hepatology, and nutrition at the University of Florida, Gainesville, told this news organization.

Dr. Forsmark, who wasn’t involved with this study, is a member of T1DAPC and one of the principal investigators in Florida.

“The reduction of risk by 42% is quite substantial,” he said. “Like all such studies, there is risk of bias and confounding in determining the actual risk. Nonetheless, the results provide a strong reason for confirmation in other datasets and for further study.”

The study didn’t report funding support. Dr. Thiruvengadam and Dr. Forsmark report no relevant financial relationships.

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

Use of cholesterol-lowering statins was linked to a lower risk of developing a subtype of diabetes that occurs after acute pancreatitis, according to a new report.

The benefits of statins depended on the consistency of usage, with regular users having a lower risk of developing postpancreatitis diabetes than irregular users. The results were similar with low, moderate, and high statin doses, as well as in cases of both mild and severe acute pancreatitis.

“About 15% of patients with acute pancreatitis will develop diabetes mellitus in the next 5 years, and although we can monitor for it, we can’t do anything to prevent it,” Nikhil Thiruvengadam, MD, the lead study author and a gastroenterologist at Loma Linda (Calif.) University, told this news organization.

iStock/ThinkStock

“This could push you as a clinician to prescribe [a statin if you have a reason to] because it could provide two benefits instead of just one,” he said.

The study was published online in Clinical Gastroenterology and Hepatology.
 

Steady use mattered, not dose

Patients with acute pancreatitis face at least a twofold increased risk of developing postpancreatitis diabetes, the study authors write. Although previous studies have shown that statins can lower the incidence and severity of acute pancreatitis, they haven’t been studied for the prevention of postpancreatitis diabetes.

In a collaborative study with several other universities, Dr. Thiruvengadam and colleagues examined commercial insurance claims from the Optum Clinformatics database to assess the impact of statins on 118,479 patients without preexisting diabetes admitted for a first episode of acute pancreatitis between 2008 and 2020.

They compared patients who consistently used statins with irregular users and nonusers. Regular statin usage was defined as patients who had statin prescriptions filled for at least 80% of the year prior to their acute pancreatitis diagnosis. The analysis included 9,048 patients (7.6%) who used statins regularly, 27,272 (23%) who used statins irregularly, and 82,159 (69.3%) nonusers.

With a median follow-up of 3.5 years, the 5-year cumulative incidence of postpancreatitis diabetes was 7.5% among regular statin users and 12.7% among nonusers. Regular statin users had a 42% lower risk of developing postpancreatitis diabetes, compared with nonusers. Irregular statin users had a 15% lower risk of postpancreatitis diabetes.

In addition, the 5-year cumulative incidence of insulin-dependent postpancreatitis diabetes was 2.4% among regular statin users and 6.6% among nonusers. Regular statin users had a 52% lower risk of developing insulin-dependent diabetes as compared with nonusers.

Daily dosage didn’t demonstrate a linear dose-response relationship. That means high-dose statins may not be more effective in preventing diabetes as compared with lower doses, the study authors write.

Statin usage was effective across additional analyses, including sex, etiologies of pancreatitis, and in both mild and severe acute pancreatitis. According to the study authors, this suggests that a broad population of these patients may benefit from statins.

“We were pleasantly surprised by the variety of findings,” Dr. Thiruvengadam said. “We’re seeing strong signals, especially with consistency of usage.”
 

Ongoing studies

The results may seem paradoxical, the study authors write, given an epidemiologic association with a slight increase in new-onset diabetes with statin initiation. But, as other researchers have reported, postpancreatitis diabetes and type 2 diabetes have different clinical features and underlying pathophysiology. For example, patients with postpancreatitis diabetes have much higher rates of requiring insulin, hospitalization, and all-cause mortality, the study authors write.

In fact, postpancreatitis diabetes is thought to be driven by chronic low-grade inflammation attributable to interleukin-6 and tumor necrosis factor–alpha. Statins have been shown to reduce tumor necrosis factor–alpha secretion and the production of C-reactive protein in response to circulating interleukin-6 in hepatocytes, they write.

The results should inform long-term prospective studies of acute pancreatitis, the study authors write, as well as randomized controlled trials of statins.

In the meantime, gastroenterologists and primary care physicians who see outpatients after hospitalization for acute pancreatitis may consider using statins, particularly in those who may have another possible indication for statin therapy, such as mild hyperlipidemia.

“There appears to be a low-dose benefit, which is another reason why providers may consider using statins, though it’s not for everyone with pancreatitis,” Dr. Thiruvengadam said. “This could be an exploratory pathway and suggested for use in the right setting.”

The Type 1 Diabetes in Acute Pancreatitis Consortium, sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases, is conducting an observational cohort study at more than a dozen locations across the country to investigate the incidence, etiology, and pathophysiology of diabetes after acute pancreatitis.

“Diabetes is surprisingly common after even a single attack of acute pancreatitis,” Chris Forsmark, MD, professor of medicine and chief of the division of gastroenterology, hepatology, and nutrition at the University of Florida, Gainesville, told this news organization.

Dr. Forsmark, who wasn’t involved with this study, is a member of T1DAPC and one of the principal investigators in Florida.

“The reduction of risk by 42% is quite substantial,” he said. “Like all such studies, there is risk of bias and confounding in determining the actual risk. Nonetheless, the results provide a strong reason for confirmation in other datasets and for further study.”

The study didn’t report funding support. Dr. Thiruvengadam and Dr. Forsmark report no relevant financial relationships.

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

Some medications are safer and more effective than others for treating spine-related pain in older patients, a new comprehensive literature review suggests.

Investigators assessed the evidence for medications used for this indication in older adults by reviewing 138 double-blind, placebo-controlled trials.

Among their key findings and recommendations: Acetaminophen has a favorable safety profile for spine-related pain but nonsteroidal anti-inflammatory drugs (NSAIDs) have greater efficacy.

However, NSAIDs should be used in lower doses in the short term, with gastrointestinal precaution, the researchers note.

Corticosteroids have the least evidence for treating nonspecific back pain, they add.

“Most older people experience neck or low back pain at some point, bothersome enough to see their doctor,” coinvestigator Michael Perloff, MD, PhD, department of neurology, Boston University, said in a news release.

“Our findings provide a helpful medication guide for physicians to use for spine pain in an older population that can have a complex medical history,” Dr. Perloff added.

The results were published online in Drugs and Aging.
 

Recommendations, warnings

With the graying of the U.S. population, spine-related pain is increasingly common, the investigators note.

Medications play an important role in pain management, but their use has limitations in the elderly, owing to reduced liver and renal function, comorbid medical problems, and polypharmacy.

Other key findings from the literature review include that, although the nerve pain medications gabapentin and pregabalin may cause dizziness or difficulty walking, they also have some demonstrated benefit for neck and back nerve pain, such as sciatica, in older adults.

These agents should be used in lower doses with smaller dose adjustments, the researchers note.

They caution that the muscle relaxants carisoprodol, chlorzoxazone, cyclobenzaprine, metaxalone, methocarbamol, and orphenadrine should be avoided in older adults because of their association with risk for sedation and falls.
 

‘Rational therapeutic choices’

Three other muscle relaxants – tizanidine, baclofen, and dantrolene – may be helpful for neck and back pain. The most evidence favors tizanidine and baclofen. These should be used in reduced doses. Tizanidine should be avoided in patients with liver disease, and for patients with kidney disease, the dosing of baclofen should be reduced, the investigators write.

Other findings include the following:

• Older tricyclic antidepressants should typically be avoided in this population because of their side effects, but nortriptyline and desipramine may be better tolerated for neck and back nerve pain at lower doses.
• Newer antidepressants, particularly the selective serotonin-norepinephrine reuptake inhibitor duloxetine, have a better safety profile and good efficacy for spine-related nerve pain.
• Traditional opioids are typically avoided in the treatment of spine-related pain in older adults, owing to their associated risks.

However, low-dose opioid therapy may be helpful for severe refractory pain, with close monitoring of patients, the researchers note.

Weaker opioids, such as tramadol, may be better tolerated by older patients. They work well when combined with acetaminophen, but they carry the risk for sedation, upset stomach, and constipation.

“Medications used at the correct dose, for the correct diagnosis, adjusting for preexisting medical problems can result in better use of treatments for spine pain,” coinvestigator Jonathan Fu, MD, also with the department of neurology, Boston University, said in the release.

“Rational therapeutic choices should be targeted to spine pain diagnosis, such as NSAIDs and acetaminophen for arthritic and myofascial-based complaints, gabapentinoids or duloxetine for neuropathic and radicular symptoms, antispastic agents for myofascial-based pain, and combination therapy for mixed etiologies,” the investigators write.

They also emphasize that medications should be coupled with physical therapy and exercise programs, as well as treatment of the underlying degenerative disease process and medical illness, while keeping in mind the need for possible interventions and/or corrective surgery.

The research had no specific funding. The investigators have reported no relevant financial relationships.

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

Some medications are safer and more effective than others for treating spine-related pain in older patients, a new comprehensive literature review suggests.

Investigators assessed the evidence for medications used for this indication in older adults by reviewing 138 double-blind, placebo-controlled trials.

Among their key findings and recommendations: Acetaminophen has a favorable safety profile for spine-related pain but nonsteroidal anti-inflammatory drugs (NSAIDs) have greater efficacy.

However, NSAIDs should be used in lower doses in the short term, with gastrointestinal precaution, the researchers note.

Corticosteroids have the least evidence for treating nonspecific back pain, they add.

“Most older people experience neck or low back pain at some point, bothersome enough to see their doctor,” coinvestigator Michael Perloff, MD, PhD, department of neurology, Boston University, said in a news release.

“Our findings provide a helpful medication guide for physicians to use for spine pain in an older population that can have a complex medical history,” Dr. Perloff added.

The results were published online in Drugs and Aging.
 

Recommendations, warnings

With the graying of the U.S. population, spine-related pain is increasingly common, the investigators note.

Medications play an important role in pain management, but their use has limitations in the elderly, owing to reduced liver and renal function, comorbid medical problems, and polypharmacy.

Other key findings from the literature review include that, although the nerve pain medications gabapentin and pregabalin may cause dizziness or difficulty walking, they also have some demonstrated benefit for neck and back nerve pain, such as sciatica, in older adults.

These agents should be used in lower doses with smaller dose adjustments, the researchers note.

They caution that the muscle relaxants carisoprodol, chlorzoxazone, cyclobenzaprine, metaxalone, methocarbamol, and orphenadrine should be avoided in older adults because of their association with risk for sedation and falls.
 

‘Rational therapeutic choices’

Three other muscle relaxants – tizanidine, baclofen, and dantrolene – may be helpful for neck and back pain. The most evidence favors tizanidine and baclofen. These should be used in reduced doses. Tizanidine should be avoided in patients with liver disease, and for patients with kidney disease, the dosing of baclofen should be reduced, the investigators write.

Other findings include the following:

• Older tricyclic antidepressants should typically be avoided in this population because of their side effects, but nortriptyline and desipramine may be better tolerated for neck and back nerve pain at lower doses.
• Newer antidepressants, particularly the selective serotonin-norepinephrine reuptake inhibitor duloxetine, have a better safety profile and good efficacy for spine-related nerve pain.
• Traditional opioids are typically avoided in the treatment of spine-related pain in older adults, owing to their associated risks.

However, low-dose opioid therapy may be helpful for severe refractory pain, with close monitoring of patients, the researchers note.

Weaker opioids, such as tramadol, may be better tolerated by older patients. They work well when combined with acetaminophen, but they carry the risk for sedation, upset stomach, and constipation.

“Medications used at the correct dose, for the correct diagnosis, adjusting for preexisting medical problems can result in better use of treatments for spine pain,” coinvestigator Jonathan Fu, MD, also with the department of neurology, Boston University, said in the release.

“Rational therapeutic choices should be targeted to spine pain diagnosis, such as NSAIDs and acetaminophen for arthritic and myofascial-based complaints, gabapentinoids or duloxetine for neuropathic and radicular symptoms, antispastic agents for myofascial-based pain, and combination therapy for mixed etiologies,” the investigators write.

They also emphasize that medications should be coupled with physical therapy and exercise programs, as well as treatment of the underlying degenerative disease process and medical illness, while keeping in mind the need for possible interventions and/or corrective surgery.

The research had no specific funding. The investigators have reported no relevant financial relationships.

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

Some medications are safer and more effective than others for treating spine-related pain in older patients, a new comprehensive literature review suggests.

Investigators assessed the evidence for medications used for this indication in older adults by reviewing 138 double-blind, placebo-controlled trials.

Among their key findings and recommendations: Acetaminophen has a favorable safety profile for spine-related pain but nonsteroidal anti-inflammatory drugs (NSAIDs) have greater efficacy.

However, NSAIDs should be used in lower doses in the short term, with gastrointestinal precaution, the researchers note.

Corticosteroids have the least evidence for treating nonspecific back pain, they add.

“Most older people experience neck or low back pain at some point, bothersome enough to see their doctor,” coinvestigator Michael Perloff, MD, PhD, department of neurology, Boston University, said in a news release.

“Our findings provide a helpful medication guide for physicians to use for spine pain in an older population that can have a complex medical history,” Dr. Perloff added.

The results were published online in Drugs and Aging.
 

Recommendations, warnings

With the graying of the U.S. population, spine-related pain is increasingly common, the investigators note.

Medications play an important role in pain management, but their use has limitations in the elderly, owing to reduced liver and renal function, comorbid medical problems, and polypharmacy.

Other key findings from the literature review include that, although the nerve pain medications gabapentin and pregabalin may cause dizziness or difficulty walking, they also have some demonstrated benefit for neck and back nerve pain, such as sciatica, in older adults.

These agents should be used in lower doses with smaller dose adjustments, the researchers note.

They caution that the muscle relaxants carisoprodol, chlorzoxazone, cyclobenzaprine, metaxalone, methocarbamol, and orphenadrine should be avoided in older adults because of their association with risk for sedation and falls.
 

‘Rational therapeutic choices’

Three other muscle relaxants – tizanidine, baclofen, and dantrolene – may be helpful for neck and back pain. The most evidence favors tizanidine and baclofen. These should be used in reduced doses. Tizanidine should be avoided in patients with liver disease, and for patients with kidney disease, the dosing of baclofen should be reduced, the investigators write.

Other findings include the following:

• Older tricyclic antidepressants should typically be avoided in this population because of their side effects, but nortriptyline and desipramine may be better tolerated for neck and back nerve pain at lower doses.
• Newer antidepressants, particularly the selective serotonin-norepinephrine reuptake inhibitor duloxetine, have a better safety profile and good efficacy for spine-related nerve pain.
• Traditional opioids are typically avoided in the treatment of spine-related pain in older adults, owing to their associated risks.

However, low-dose opioid therapy may be helpful for severe refractory pain, with close monitoring of patients, the researchers note.

Weaker opioids, such as tramadol, may be better tolerated by older patients. They work well when combined with acetaminophen, but they carry the risk for sedation, upset stomach, and constipation.

“Medications used at the correct dose, for the correct diagnosis, adjusting for preexisting medical problems can result in better use of treatments for spine pain,” coinvestigator Jonathan Fu, MD, also with the department of neurology, Boston University, said in the release.

“Rational therapeutic choices should be targeted to spine pain diagnosis, such as NSAIDs and acetaminophen for arthritic and myofascial-based complaints, gabapentinoids or duloxetine for neuropathic and radicular symptoms, antispastic agents for myofascial-based pain, and combination therapy for mixed etiologies,” the investigators write.

They also emphasize that medications should be coupled with physical therapy and exercise programs, as well as treatment of the underlying degenerative disease process and medical illness, while keeping in mind the need for possible interventions and/or corrective surgery.

The research had no specific funding. The investigators have reported no relevant financial relationships.

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

Avocados are a rich source of fiber and healthy fat, but eating one a day for 6 months did not shrink waist size or belly fat, according to the findings of a new study.

But it did improve diet quality and led to modest lowering of total cholesterol.

More than 1,000 adults with overweight or obesity and a large waist – at least 35 inches in women and 40 inches in men – took part in this U.S. study, called the Habitual Diet and Avocado Trial (HAT).

tookapic/Pixabay

The people in the study were divided into two groups: usual diet plus one large avocado every day and usual diet with two avocados at most per month (control group).

Those in the avocado-a-day group were given a regular supply of fresh avocados along with written instructions for how to ripen and prepare them.

They had MRI scans to measure belly fat and fat around other organs at the beginning of the study and after 6 months.

After 6 months, the people who ate an avocado a day did not have less fat around their middles – the main trial outcome – compared with people in the control group.

But at 6 months, those in the avocado-a-day group had:

• No weight gain. People’s weight remained stable in both groups.
• Improved diet quality by 8 points on a 100-point scale
• A 2.9-mg/dL decrease in total cholesterol
• A 2.5-mg/dL decrease in LDL cholesterol

The study was done by researchers at Penn State University; Tufts University; Loma Linda University; and the University of California, Los Angeles, with coordinating support from Wake Forest University.

It was published in the Journal of the American Heart Association.

“While the avocados did not affect belly fat or weight gain, the study still provides evidence that avocados can be a beneficial addition to a well-balanced diet,” Penny M. Kris-Etherton, PhD, one of the researchers and a professor of nutritional sciences at Penn State University, University Park, said in a news release.

“Incorporating an avocado per day in this study did not cause weight gain and also caused a slight decrease in LDL cholesterol, which are all important findings for better health,” she said.

Similarly, study researcher Joan Sabaté, MD, a professor at Loma Linda (Calif.) University, said: “While one avocado a day did not lead to clinically significant improvements in abdominal fat and other cardiometabolic risk factors, consuming one avocado a day did not result in body weight gain.”

“This is positive,” he said, “because eating extra calories from avocados doesn’t impact body weight or abdominal fat, and it slightly decreases total and LDL cholesterol.”

Kristina S. Petersen, PhD, another of the researchers and an assistant professor of nutritional sciences at Texas Tech University, Lubbock, pointed out that people are generally poor at adhering to the Dietary Guidelines for Americans.

This study suggests that an avocado a day can improve diet quality, she noted, which “ is important because we know a higher diet quality is associated with lower risk of several diseases, including heart disease, type 2 diabetes, and some cancers.”

But the researchers also stressed that it is important to consider the diet as a whole.

“Consistent with prior observations, a change in dietary patterns rather than a single food or nutrient may be necessary to achieve clinically significant improvements” in belly fat and other risk factors for heart attack, stroke, and diabetes, they wrote. 

HAT was funded by the Hass Avocado Board, which also supplied the avocados.

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

Avocados are a rich source of fiber and healthy fat, but eating one a day for 6 months did not shrink waist size or belly fat, according to the findings of a new study.

But it did improve diet quality and led to modest lowering of total cholesterol.

More than 1,000 adults with overweight or obesity and a large waist – at least 35 inches in women and 40 inches in men – took part in this U.S. study, called the Habitual Diet and Avocado Trial (HAT).

tookapic/Pixabay

The people in the study were divided into two groups: usual diet plus one large avocado every day and usual diet with two avocados at most per month (control group).

Those in the avocado-a-day group were given a regular supply of fresh avocados along with written instructions for how to ripen and prepare them.

They had MRI scans to measure belly fat and fat around other organs at the beginning of the study and after 6 months.

After 6 months, the people who ate an avocado a day did not have less fat around their middles – the main trial outcome – compared with people in the control group.

But at 6 months, those in the avocado-a-day group had:

• No weight gain. People’s weight remained stable in both groups.
• Improved diet quality by 8 points on a 100-point scale
• A 2.9-mg/dL decrease in total cholesterol
• A 2.5-mg/dL decrease in LDL cholesterol

The study was done by researchers at Penn State University; Tufts University; Loma Linda University; and the University of California, Los Angeles, with coordinating support from Wake Forest University.

It was published in the Journal of the American Heart Association.

“While the avocados did not affect belly fat or weight gain, the study still provides evidence that avocados can be a beneficial addition to a well-balanced diet,” Penny M. Kris-Etherton, PhD, one of the researchers and a professor of nutritional sciences at Penn State University, University Park, said in a news release.

“Incorporating an avocado per day in this study did not cause weight gain and also caused a slight decrease in LDL cholesterol, which are all important findings for better health,” she said.

Similarly, study researcher Joan Sabaté, MD, a professor at Loma Linda (Calif.) University, said: “While one avocado a day did not lead to clinically significant improvements in abdominal fat and other cardiometabolic risk factors, consuming one avocado a day did not result in body weight gain.”

“This is positive,” he said, “because eating extra calories from avocados doesn’t impact body weight or abdominal fat, and it slightly decreases total and LDL cholesterol.”

Kristina S. Petersen, PhD, another of the researchers and an assistant professor of nutritional sciences at Texas Tech University, Lubbock, pointed out that people are generally poor at adhering to the Dietary Guidelines for Americans.

This study suggests that an avocado a day can improve diet quality, she noted, which “ is important because we know a higher diet quality is associated with lower risk of several diseases, including heart disease, type 2 diabetes, and some cancers.”

But the researchers also stressed that it is important to consider the diet as a whole.

“Consistent with prior observations, a change in dietary patterns rather than a single food or nutrient may be necessary to achieve clinically significant improvements” in belly fat and other risk factors for heart attack, stroke, and diabetes, they wrote. 

HAT was funded by the Hass Avocado Board, which also supplied the avocados.

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

Avocados are a rich source of fiber and healthy fat, but eating one a day for 6 months did not shrink waist size or belly fat, according to the findings of a new study.

But it did improve diet quality and led to modest lowering of total cholesterol.

More than 1,000 adults with overweight or obesity and a large waist – at least 35 inches in women and 40 inches in men – took part in this U.S. study, called the Habitual Diet and Avocado Trial (HAT).

tookapic/Pixabay

The people in the study were divided into two groups: usual diet plus one large avocado every day and usual diet with two avocados at most per month (control group).

Those in the avocado-a-day group were given a regular supply of fresh avocados along with written instructions for how to ripen and prepare them.

They had MRI scans to measure belly fat and fat around other organs at the beginning of the study and after 6 months.

After 6 months, the people who ate an avocado a day did not have less fat around their middles – the main trial outcome – compared with people in the control group.

But at 6 months, those in the avocado-a-day group had:

• No weight gain. People’s weight remained stable in both groups.
• Improved diet quality by 8 points on a 100-point scale
• A 2.9-mg/dL decrease in total cholesterol
• A 2.5-mg/dL decrease in LDL cholesterol

The study was done by researchers at Penn State University; Tufts University; Loma Linda University; and the University of California, Los Angeles, with coordinating support from Wake Forest University.

It was published in the Journal of the American Heart Association.

“While the avocados did not affect belly fat or weight gain, the study still provides evidence that avocados can be a beneficial addition to a well-balanced diet,” Penny M. Kris-Etherton, PhD, one of the researchers and a professor of nutritional sciences at Penn State University, University Park, said in a news release.

“Incorporating an avocado per day in this study did not cause weight gain and also caused a slight decrease in LDL cholesterol, which are all important findings for better health,” she said.

Similarly, study researcher Joan Sabaté, MD, a professor at Loma Linda (Calif.) University, said: “While one avocado a day did not lead to clinically significant improvements in abdominal fat and other cardiometabolic risk factors, consuming one avocado a day did not result in body weight gain.”

“This is positive,” he said, “because eating extra calories from avocados doesn’t impact body weight or abdominal fat, and it slightly decreases total and LDL cholesterol.”

Kristina S. Petersen, PhD, another of the researchers and an assistant professor of nutritional sciences at Texas Tech University, Lubbock, pointed out that people are generally poor at adhering to the Dietary Guidelines for Americans.

This study suggests that an avocado a day can improve diet quality, she noted, which “ is important because we know a higher diet quality is associated with lower risk of several diseases, including heart disease, type 2 diabetes, and some cancers.”

But the researchers also stressed that it is important to consider the diet as a whole.

“Consistent with prior observations, a change in dietary patterns rather than a single food or nutrient may be necessary to achieve clinically significant improvements” in belly fat and other risk factors for heart attack, stroke, and diabetes, they wrote. 

HAT was funded by the Hass Avocado Board, which also supplied the avocados.

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

The number of overdose deaths involving methadone decreased after the implementation of an early-pandemic policy that allowed some patients with opioid use disorder (OUD) to take methadone at home, new research shows.

Overdose deaths both with and without methadone rose sharply in March 2020, when the policy was announced. Of note, methadone-related deaths decreased in the following months, whereas deaths not involving methadone continued to increase.

“Coupled with research demonstrating improved patient satisfaction, treatment access, and engagement from these policies, these findings can inform decisions about permanently expanding take-home methadone,” the investigators wrote.

The study was published online in JAMA Psychiatry.
 

An essential tool

Before the pandemic, patients seeking methadone treatment for OUD in the United States had to visit a federally certified opioid treatment clinic every day to receive the medication.

In response to the pandemic, the Substance Abuse and Mental Health Services Administration instituted a new policy that allowed states to request exceptions to provide take-home methadone for up to 4 weeks for stable patients and up to 2 weeks for those who were less stable.

To determine the effect of this policy change on overdose death rates, researchers analyzed data on overdose deaths from January 2019 to August 2021.

Overall, the percentage of deaths involving methadone decreased from 4.5% in 2019 to 3.2% in 2021.

The investigators found a sharp increase in all overdose deaths in March 2020. Deaths that did not involve methadone increased by an average of 78.12 more each month before March 2020, increased by an average of 1,078.27 during March 2020, and then continued to increase by an average of 69.07 more each month after March 2020.

Overdose deaths involving methadone increased by a similar amount in March 2020, stabilized, and then decreased 0.05% per month.

Researchers attributed the increase in methadone-related deaths in March 2020 with the rise in overall drug overdose deaths driven by illicitly made fentanyl in the early months of the COVID-19 pandemic.

A study published in JAMA Network Open in March 2022 showed that methadone and other medications to treat OUD are widely underutilized.

That research cited concern over misuse as a key reason for clinicians’ reluctance to prescribe the drugs. The researchers of the current study hope that these new findings lay some of these fears to rest.

“Treatment is an essential tool to stop the addiction and overdose crises, but it is vastly underused,” Nora Volkow, MD, coinvestigator, and director of the National Institute on Drug Abuse, said in a press release. “This evidence adds significant weight to the argument that effective treatment for substance use disorders should be offered in an accessible and practical way that works for people who need it.”

The study was funded by the Centers for Disease Control and Prevention and the National Institutes of Health. The authors reported no relevant disclosures related to the study.

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

The number of overdose deaths involving methadone decreased after the implementation of an early-pandemic policy that allowed some patients with opioid use disorder (OUD) to take methadone at home, new research shows.

Overdose deaths both with and without methadone rose sharply in March 2020, when the policy was announced. Of note, methadone-related deaths decreased in the following months, whereas deaths not involving methadone continued to increase.

“Coupled with research demonstrating improved patient satisfaction, treatment access, and engagement from these policies, these findings can inform decisions about permanently expanding take-home methadone,” the investigators wrote.

The study was published online in JAMA Psychiatry.
 

An essential tool

Before the pandemic, patients seeking methadone treatment for OUD in the United States had to visit a federally certified opioid treatment clinic every day to receive the medication.

In response to the pandemic, the Substance Abuse and Mental Health Services Administration instituted a new policy that allowed states to request exceptions to provide take-home methadone for up to 4 weeks for stable patients and up to 2 weeks for those who were less stable.

To determine the effect of this policy change on overdose death rates, researchers analyzed data on overdose deaths from January 2019 to August 2021.

Overall, the percentage of deaths involving methadone decreased from 4.5% in 2019 to 3.2% in 2021.

The investigators found a sharp increase in all overdose deaths in March 2020. Deaths that did not involve methadone increased by an average of 78.12 more each month before March 2020, increased by an average of 1,078.27 during March 2020, and then continued to increase by an average of 69.07 more each month after March 2020.

Overdose deaths involving methadone increased by a similar amount in March 2020, stabilized, and then decreased 0.05% per month.

Researchers attributed the increase in methadone-related deaths in March 2020 with the rise in overall drug overdose deaths driven by illicitly made fentanyl in the early months of the COVID-19 pandemic.

A study published in JAMA Network Open in March 2022 showed that methadone and other medications to treat OUD are widely underutilized.

That research cited concern over misuse as a key reason for clinicians’ reluctance to prescribe the drugs. The researchers of the current study hope that these new findings lay some of these fears to rest.

“Treatment is an essential tool to stop the addiction and overdose crises, but it is vastly underused,” Nora Volkow, MD, coinvestigator, and director of the National Institute on Drug Abuse, said in a press release. “This evidence adds significant weight to the argument that effective treatment for substance use disorders should be offered in an accessible and practical way that works for people who need it.”

The study was funded by the Centers for Disease Control and Prevention and the National Institutes of Health. The authors reported no relevant disclosures related to the study.

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

The number of overdose deaths involving methadone decreased after the implementation of an early-pandemic policy that allowed some patients with opioid use disorder (OUD) to take methadone at home, new research shows.

Overdose deaths both with and without methadone rose sharply in March 2020, when the policy was announced. Of note, methadone-related deaths decreased in the following months, whereas deaths not involving methadone continued to increase.

“Coupled with research demonstrating improved patient satisfaction, treatment access, and engagement from these policies, these findings can inform decisions about permanently expanding take-home methadone,” the investigators wrote.

The study was published online in JAMA Psychiatry.
 

An essential tool

Before the pandemic, patients seeking methadone treatment for OUD in the United States had to visit a federally certified opioid treatment clinic every day to receive the medication.

In response to the pandemic, the Substance Abuse and Mental Health Services Administration instituted a new policy that allowed states to request exceptions to provide take-home methadone for up to 4 weeks for stable patients and up to 2 weeks for those who were less stable.

To determine the effect of this policy change on overdose death rates, researchers analyzed data on overdose deaths from January 2019 to August 2021.

Overall, the percentage of deaths involving methadone decreased from 4.5% in 2019 to 3.2% in 2021.

The investigators found a sharp increase in all overdose deaths in March 2020. Deaths that did not involve methadone increased by an average of 78.12 more each month before March 2020, increased by an average of 1,078.27 during March 2020, and then continued to increase by an average of 69.07 more each month after March 2020.

Overdose deaths involving methadone increased by a similar amount in March 2020, stabilized, and then decreased 0.05% per month.

Researchers attributed the increase in methadone-related deaths in March 2020 with the rise in overall drug overdose deaths driven by illicitly made fentanyl in the early months of the COVID-19 pandemic.

A study published in JAMA Network Open in March 2022 showed that methadone and other medications to treat OUD are widely underutilized.

That research cited concern over misuse as a key reason for clinicians’ reluctance to prescribe the drugs. The researchers of the current study hope that these new findings lay some of these fears to rest.

“Treatment is an essential tool to stop the addiction and overdose crises, but it is vastly underused,” Nora Volkow, MD, coinvestigator, and director of the National Institute on Drug Abuse, said in a press release. “This evidence adds significant weight to the argument that effective treatment for substance use disorders should be offered in an accessible and practical way that works for people who need it.”

The study was funded by the Centers for Disease Control and Prevention and the National Institutes of Health. The authors reported no relevant disclosures related to the study.

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

The potentially fatal parechovirus is now circulating in multiple states, causing fevers, seizures, and sepsis-like symptoms, including confusion and extreme pain, according to the CDC.

Human parechoviruses are common in children and most have been infected before they start kindergarten, the CDC said. Between 6 months and 5 years of age, symptoms include an upper respiratory tract infection, fever, and rash.

But infants younger than 3 months may have more serious, and possibly fatal, infections. They may get “sepsis-like illness, seizures, and meningitis or meningoencephalitis, particularly in infants younger than 1 month,” the CDC said. At least one newborn has reportedly died from the infection.

Parechovirus can spread like other common germs, from feces that are later ingested – likely due to poor handwashing – and through droplets sent airborne by coughing or sneezing. It can be transmitted by people both with and without symptoms of the infection.

The microbe can reproduce for 1-3 weeks in the upper respiratory tract and up to 6 months in the gastrointestinal tract, the CDC said.

Kristina Angel Bryant, MD, a pediatric infectious disease specialist at the University of Louisville Hospital, says parechoviruses often cause rashes on the hands and feet, which some experts refer to as “mittens and booties.”

The CDC is urging doctors to test for parechovirus if they recognize these symptoms in infants if there is no other explanation for what might be distressing them.

There is no specific treatment for parechovirus. And with no standard testing system in place, experts are unsure if the number of parechovirus cases is higher in 2022 than in previous years.

The message for parents, Dr. Bryant says, is: Don’t panic. “This is not a new virus.”

“One of the most common symptoms is fever, and in some kids, that is the only symptom,” she says. “Older infants and toddlers may have only cold symptoms, and some kids have no symptoms at all.”

Parents can take the usual steps to protect their child from the viral illness, including diligent handwashing and having less contact with people who are sick, Dr. Bryant says.

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

The potentially fatal parechovirus is now circulating in multiple states, causing fevers, seizures, and sepsis-like symptoms, including confusion and extreme pain, according to the CDC.

Human parechoviruses are common in children and most have been infected before they start kindergarten, the CDC said. Between 6 months and 5 years of age, symptoms include an upper respiratory tract infection, fever, and rash.

But infants younger than 3 months may have more serious, and possibly fatal, infections. They may get “sepsis-like illness, seizures, and meningitis or meningoencephalitis, particularly in infants younger than 1 month,” the CDC said. At least one newborn has reportedly died from the infection.

Parechovirus can spread like other common germs, from feces that are later ingested – likely due to poor handwashing – and through droplets sent airborne by coughing or sneezing. It can be transmitted by people both with and without symptoms of the infection.

The microbe can reproduce for 1-3 weeks in the upper respiratory tract and up to 6 months in the gastrointestinal tract, the CDC said.

Kristina Angel Bryant, MD, a pediatric infectious disease specialist at the University of Louisville Hospital, says parechoviruses often cause rashes on the hands and feet, which some experts refer to as “mittens and booties.”

The CDC is urging doctors to test for parechovirus if they recognize these symptoms in infants if there is no other explanation for what might be distressing them.

There is no specific treatment for parechovirus. And with no standard testing system in place, experts are unsure if the number of parechovirus cases is higher in 2022 than in previous years.

The message for parents, Dr. Bryant says, is: Don’t panic. “This is not a new virus.”

“One of the most common symptoms is fever, and in some kids, that is the only symptom,” she says. “Older infants and toddlers may have only cold symptoms, and some kids have no symptoms at all.”

Parents can take the usual steps to protect their child from the viral illness, including diligent handwashing and having less contact with people who are sick, Dr. Bryant says.

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

The potentially fatal parechovirus is now circulating in multiple states, causing fevers, seizures, and sepsis-like symptoms, including confusion and extreme pain, according to the CDC.

Human parechoviruses are common in children and most have been infected before they start kindergarten, the CDC said. Between 6 months and 5 years of age, symptoms include an upper respiratory tract infection, fever, and rash.

But infants younger than 3 months may have more serious, and possibly fatal, infections. They may get “sepsis-like illness, seizures, and meningitis or meningoencephalitis, particularly in infants younger than 1 month,” the CDC said. At least one newborn has reportedly died from the infection.

Parechovirus can spread like other common germs, from feces that are later ingested – likely due to poor handwashing – and through droplets sent airborne by coughing or sneezing. It can be transmitted by people both with and without symptoms of the infection.

The microbe can reproduce for 1-3 weeks in the upper respiratory tract and up to 6 months in the gastrointestinal tract, the CDC said.

Kristina Angel Bryant, MD, a pediatric infectious disease specialist at the University of Louisville Hospital, says parechoviruses often cause rashes on the hands and feet, which some experts refer to as “mittens and booties.”

The CDC is urging doctors to test for parechovirus if they recognize these symptoms in infants if there is no other explanation for what might be distressing them.

There is no specific treatment for parechovirus. And with no standard testing system in place, experts are unsure if the number of parechovirus cases is higher in 2022 than in previous years.

The message for parents, Dr. Bryant says, is: Don’t panic. “This is not a new virus.”

“One of the most common symptoms is fever, and in some kids, that is the only symptom,” she says. “Older infants and toddlers may have only cold symptoms, and some kids have no symptoms at all.”

Parents can take the usual steps to protect their child from the viral illness, including diligent handwashing and having less contact with people who are sick, Dr. Bryant says.

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

As a field, radiation oncology is perhaps one of medicine’s best kept secrets. Sometimes, even our own colleagues don’t know where our department exists in the hospital or exactly what we do.

As two radiation oncologists who are, in fact, the children of radiation oncologists, we will admit that it’s possible we are a tiny bit biased. We cannot lie, though: Our field is a hidden gem.

What is well known is that radiation oncologists have a symbiotic relationship with our treatment technology. The evolution of treatment machines and radiation precision allows us to deliver patient-tailored treatment down to the millimeter. What may get lost in the discussions of isodose lines and penumbra, however, is that we’ve also got cutting-edge research and personalized patient care within a specialized team in the depths of the hospital.

Because the inner workings of what happens to patients as they come in and out of our office remains a mystery, we hope to use this space to clarify the top five things most physicians don’t know about radiation oncology.
 

1. Nobody knows what goes on in the basement.

Misconceptions about our subspecialty are common, even among other oncologists. A frequent misconception is that a radiation oncologist’s involvement in patient care is limited, and radiation is delivered in a standardized manner. This essentially renders radiation oncologists technicians of expensive machines.

In reality however, radiation oncologists touch every aspect of a patient’s care, and customized radiation therapy may be indicated for virtually every cancer site in both curative and palliative settings. We strive to deliver precision medicine and practice truly patient-centered care.

To cure cancer, radiation may be used in the neoadjuvant (prior to local surgical resection), definitive (as the primary local therapy), and adjuvant (postsurgical) setting. In palliative cases, radiation can be used to treat areas of metastatic spread as well as primary unresectable tumors to alleviate obstruction and/or bleeding symptoms. Referral to radiation oncology, therefore, can be appropriate at many different points of time on the continuum of cancer care.

For many treating radiation oncologists, the close personal connections that we form with our patients is one of the primary reasons we went into this field. Not only are we making patient-centered clinical decisions during every step of the treatment plan evaluation and optimization but we also see our patients weekly for clinical visits and then ongoing in visits that may span many years of survivorship.

Our deep commitment to addressing patient needs as they are receiving treatment and responsibility for late radiation effects is absolutely an integral part of our training and lifelong practice.
 

2. We get down in the details.

The workflow from consultation to radiation delivery can be confusing for anyone outside our specialized field.

Once seen in consult and considered a good candidate for radiation, patients will enter the essential next step: the treatment planning imaging – or “simulation.”

The simulation scan – mostly CT, although occasionally fused MRI or PET – involves a separate appointment and another hour or so of arranging and scanning patients in the exact position that they will be treated. Given the precision of modern radiation, the simulation often includes making a customized mold so patients have minimal movement during treatment. These simulation images allow the radiation oncology team to create a treatment plan that is customized to each patient and precisely reproducible during their course of radiation treatments – what’s known as fractions.

Creating a treatment plan involves a radiation oncologist literally drawing – or contouring – on pictures of the patient’s internal anatomy in three dimensions. Radiation oncologists contour exactly where the cancer is – or where it was if the treatment is given postoperatively – and identify the surrounding organs so that the doses can be preferentially directed to the cancer target and minimize risk to nearby organs. This precision is within millimeters and accounts for microscopic disease, organ motion, and patient setup. Ultimately, we create colorful heat gradient volumes of the anticipated radiation dose delivery and optimize these to reflect our planning priorities.

We use advanced technologies to shape the beams of radiation to treat the tumor and avoid delivering high doses to the neighboring tissues with techniques such as intensity modulated radiation therapy (IMRT), stereotactic ablative radiation therapy (SABR or SBRT), and stereotactic radiosurgery. We can also take advantage of the unique properties of different modalities, such as proton therapy and electron therapy, to achieve these same goals if indicated. Radiation oncologists live for precision medicine in every aspect of their workflow.
 

3. We roll deep.

Radiation oncology is exemplary of “the art of medicine.” We fuse anatomy-based treatment design with advanced technology and orchestrate the daily functions of a large medical team.

But, the treatment plan and delivery would not be possible without the input and care given within a large multi- and intradisciplinary team of oncologists, medical physicists, dosimetrists, radiation therapists, nurses, social workers, and other support staff. Radiation oncologists participate in regular tumor boards with surgeons, medical oncologists, pathologists, and radiologists to optimize interdisciplinary management of complex patients, providing a thoughtful tumor localization and treatment plan, as well as to better understand an individual’s ongoing symptoms and well-being as a whole. Considering all aspects of what a patient may need involves communication with fellow physicians, nurse navigators, and social workers.

Within our own department, treatment plan creation and quality checking or verification can sometimes take over 2 weeks, with detailed input from dosimetrists and medical physicists. The actual treatment delivery involves daily communication with the radiation therapists who are dedicated to each treatment machine – like the linear accelerator – and symptom management with clinic nurses and supportive staff, such as physical therapists and registered dietitians.

This massive team effort is required to get each patient through daily radiation treatments that can last 7 weeks and may require rapid replanning if the tumor shrinks or the patient loses weight.

As part of this team, radiation oncologists are uniquely positioned to quarterback each play and guide the entire game strategy.
 

4. Radiation therapy takes a lot of heat.

Radiation therapy is often blamed for issues unrelated to the treatment. Irradiating the pelvis for prostate cancer, for instance, does not cause a headache or heartburn during or after treatment.

Other than fatigue, associated side effects are localized and related to the total radiation dose and fraction size – how much and how fast – that reaches the surrounding tissues.

Our colleagues often swap stories of the bizarre things radiation therapy has been blamed for, including dental problems in someone receiving vaginal cylinder treatment, heart dysfunction in someone treated for rectal cancer, and hip fracture in someone treated for breast cancer because the radiation “destroyed” their bones. At best, these are humorous stories, but at worst, they can delay diagnosis and treatment of what is truly causing someone’s symptoms.
 

5. We truly believe that less is more.

One of the most fundamental aspects of radiation oncology is our drive to optimize treatment delivery and continually improve patient care – sometimes at our own field’s economic detriment. We’re dedicated to showing that patients may get the same benefit from less and less radiation.

In the past 2 decades, the evolution and adoption of photon IMRT and proton therapy has allowed radiation plans to successfully spare surrounding tissue while improving our targeting. This evolution is coupled with technological and imaging advances that allow us to delivery of doses to certain tumors via SABR/SBRT in one to five total fractions.

A prime example: Treatment to eradicate lung or gastrointestinal tumors, which used to span up to 6 weeks, can now potentially be delivered in as little as 1 week.

For other common cancers, hypofractionation – slightly higher radiation doses per fraction at fewer total fractions overall – has revolutionized patient care, providing less radiation without impacting survival or increasing treatment toxicity.

Take breast cancer care: 50 years ago, virtually all patients with breast cancer received a mastectomy and lymph node dissections. Today, surgical techniques for lumpectomy paired with radiation therapy to the whole breast now allows us to preserve disease-free survival for those who elected to keep their breasts.

Over the past 20 years, the standards of care have shifted from 6-7 weeks of treatment to 3-4 weeks using a hypofractionated model that involves daily whole-breast radiation. The most recent clinical trials have shown that whole-breast radiation can be delivered safely and effectively for select women in as few as five fractions with either whole or partial breast targeting. Additional research driven by the idea of “right sizing” radiation treatment has even shown that certain women may not need radiation at all.

This evolution in radiation therapy illustrates how our subspecialty is constantly working to improve survival and patient well-being, form deep connections with our patients, and push the boundaries of medical innovations.

We are proud to be radiation oncologists and happy to share more. Want to know more about what goes on in the basement? Come on down, we’re happy to show you around.

Dr. Giap is a resident in the department of radiation oncology at the University of Florida, Gainesville. Dr. Chino is an assistant attending in the department of radiation oncology at Memorial Sloan Kettering Cancer Center, New York. Neither reported any relevant conflicts of interest.

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

As a field, radiation oncology is perhaps one of medicine’s best kept secrets. Sometimes, even our own colleagues don’t know where our department exists in the hospital or exactly what we do.

As two radiation oncologists who are, in fact, the children of radiation oncologists, we will admit that it’s possible we are a tiny bit biased. We cannot lie, though: Our field is a hidden gem.

What is well known is that radiation oncologists have a symbiotic relationship with our treatment technology. The evolution of treatment machines and radiation precision allows us to deliver patient-tailored treatment down to the millimeter. What may get lost in the discussions of isodose lines and penumbra, however, is that we’ve also got cutting-edge research and personalized patient care within a specialized team in the depths of the hospital.

Because the inner workings of what happens to patients as they come in and out of our office remains a mystery, we hope to use this space to clarify the top five things most physicians don’t know about radiation oncology.
 

1. Nobody knows what goes on in the basement.

Misconceptions about our subspecialty are common, even among other oncologists. A frequent misconception is that a radiation oncologist’s involvement in patient care is limited, and radiation is delivered in a standardized manner. This essentially renders radiation oncologists technicians of expensive machines.

In reality however, radiation oncologists touch every aspect of a patient’s care, and customized radiation therapy may be indicated for virtually every cancer site in both curative and palliative settings. We strive to deliver precision medicine and practice truly patient-centered care.

To cure cancer, radiation may be used in the neoadjuvant (prior to local surgical resection), definitive (as the primary local therapy), and adjuvant (postsurgical) setting. In palliative cases, radiation can be used to treat areas of metastatic spread as well as primary unresectable tumors to alleviate obstruction and/or bleeding symptoms. Referral to radiation oncology, therefore, can be appropriate at many different points of time on the continuum of cancer care.

For many treating radiation oncologists, the close personal connections that we form with our patients is one of the primary reasons we went into this field. Not only are we making patient-centered clinical decisions during every step of the treatment plan evaluation and optimization but we also see our patients weekly for clinical visits and then ongoing in visits that may span many years of survivorship.

Our deep commitment to addressing patient needs as they are receiving treatment and responsibility for late radiation effects is absolutely an integral part of our training and lifelong practice.
 

2. We get down in the details.

The workflow from consultation to radiation delivery can be confusing for anyone outside our specialized field.

Once seen in consult and considered a good candidate for radiation, patients will enter the essential next step: the treatment planning imaging – or “simulation.”

The simulation scan – mostly CT, although occasionally fused MRI or PET – involves a separate appointment and another hour or so of arranging and scanning patients in the exact position that they will be treated. Given the precision of modern radiation, the simulation often includes making a customized mold so patients have minimal movement during treatment. These simulation images allow the radiation oncology team to create a treatment plan that is customized to each patient and precisely reproducible during their course of radiation treatments – what’s known as fractions.

Creating a treatment plan involves a radiation oncologist literally drawing – or contouring – on pictures of the patient’s internal anatomy in three dimensions. Radiation oncologists contour exactly where the cancer is – or where it was if the treatment is given postoperatively – and identify the surrounding organs so that the doses can be preferentially directed to the cancer target and minimize risk to nearby organs. This precision is within millimeters and accounts for microscopic disease, organ motion, and patient setup. Ultimately, we create colorful heat gradient volumes of the anticipated radiation dose delivery and optimize these to reflect our planning priorities.

We use advanced technologies to shape the beams of radiation to treat the tumor and avoid delivering high doses to the neighboring tissues with techniques such as intensity modulated radiation therapy (IMRT), stereotactic ablative radiation therapy (SABR or SBRT), and stereotactic radiosurgery. We can also take advantage of the unique properties of different modalities, such as proton therapy and electron therapy, to achieve these same goals if indicated. Radiation oncologists live for precision medicine in every aspect of their workflow.
 

3. We roll deep.

Radiation oncology is exemplary of “the art of medicine.” We fuse anatomy-based treatment design with advanced technology and orchestrate the daily functions of a large medical team.

But, the treatment plan and delivery would not be possible without the input and care given within a large multi- and intradisciplinary team of oncologists, medical physicists, dosimetrists, radiation therapists, nurses, social workers, and other support staff. Radiation oncologists participate in regular tumor boards with surgeons, medical oncologists, pathologists, and radiologists to optimize interdisciplinary management of complex patients, providing a thoughtful tumor localization and treatment plan, as well as to better understand an individual’s ongoing symptoms and well-being as a whole. Considering all aspects of what a patient may need involves communication with fellow physicians, nurse navigators, and social workers.

Within our own department, treatment plan creation and quality checking or verification can sometimes take over 2 weeks, with detailed input from dosimetrists and medical physicists. The actual treatment delivery involves daily communication with the radiation therapists who are dedicated to each treatment machine – like the linear accelerator – and symptom management with clinic nurses and supportive staff, such as physical therapists and registered dietitians.

This massive team effort is required to get each patient through daily radiation treatments that can last 7 weeks and may require rapid replanning if the tumor shrinks or the patient loses weight.

As part of this team, radiation oncologists are uniquely positioned to quarterback each play and guide the entire game strategy.
 

4. Radiation therapy takes a lot of heat.

Radiation therapy is often blamed for issues unrelated to the treatment. Irradiating the pelvis for prostate cancer, for instance, does not cause a headache or heartburn during or after treatment.

Other than fatigue, associated side effects are localized and related to the total radiation dose and fraction size – how much and how fast – that reaches the surrounding tissues.

Our colleagues often swap stories of the bizarre things radiation therapy has been blamed for, including dental problems in someone receiving vaginal cylinder treatment, heart dysfunction in someone treated for rectal cancer, and hip fracture in someone treated for breast cancer because the radiation “destroyed” their bones. At best, these are humorous stories, but at worst, they can delay diagnosis and treatment of what is truly causing someone’s symptoms.
 

5. We truly believe that less is more.

One of the most fundamental aspects of radiation oncology is our drive to optimize treatment delivery and continually improve patient care – sometimes at our own field’s economic detriment. We’re dedicated to showing that patients may get the same benefit from less and less radiation.

In the past 2 decades, the evolution and adoption of photon IMRT and proton therapy has allowed radiation plans to successfully spare surrounding tissue while improving our targeting. This evolution is coupled with technological and imaging advances that allow us to delivery of doses to certain tumors via SABR/SBRT in one to five total fractions.

A prime example: Treatment to eradicate lung or gastrointestinal tumors, which used to span up to 6 weeks, can now potentially be delivered in as little as 1 week.

For other common cancers, hypofractionation – slightly higher radiation doses per fraction at fewer total fractions overall – has revolutionized patient care, providing less radiation without impacting survival or increasing treatment toxicity.

Take breast cancer care: 50 years ago, virtually all patients with breast cancer received a mastectomy and lymph node dissections. Today, surgical techniques for lumpectomy paired with radiation therapy to the whole breast now allows us to preserve disease-free survival for those who elected to keep their breasts.

Over the past 20 years, the standards of care have shifted from 6-7 weeks of treatment to 3-4 weeks using a hypofractionated model that involves daily whole-breast radiation. The most recent clinical trials have shown that whole-breast radiation can be delivered safely and effectively for select women in as few as five fractions with either whole or partial breast targeting. Additional research driven by the idea of “right sizing” radiation treatment has even shown that certain women may not need radiation at all.

This evolution in radiation therapy illustrates how our subspecialty is constantly working to improve survival and patient well-being, form deep connections with our patients, and push the boundaries of medical innovations.

We are proud to be radiation oncologists and happy to share more. Want to know more about what goes on in the basement? Come on down, we’re happy to show you around.

Dr. Giap is a resident in the department of radiation oncology at the University of Florida, Gainesville. Dr. Chino is an assistant attending in the department of radiation oncology at Memorial Sloan Kettering Cancer Center, New York. Neither reported any relevant conflicts of interest.

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

As a field, radiation oncology is perhaps one of medicine’s best kept secrets. Sometimes, even our own colleagues don’t know where our department exists in the hospital or exactly what we do.

As two radiation oncologists who are, in fact, the children of radiation oncologists, we will admit that it’s possible we are a tiny bit biased. We cannot lie, though: Our field is a hidden gem.

What is well known is that radiation oncologists have a symbiotic relationship with our treatment technology. The evolution of treatment machines and radiation precision allows us to deliver patient-tailored treatment down to the millimeter. What may get lost in the discussions of isodose lines and penumbra, however, is that we’ve also got cutting-edge research and personalized patient care within a specialized team in the depths of the hospital.

Because the inner workings of what happens to patients as they come in and out of our office remains a mystery, we hope to use this space to clarify the top five things most physicians don’t know about radiation oncology.
 

1. Nobody knows what goes on in the basement.

Misconceptions about our subspecialty are common, even among other oncologists. A frequent misconception is that a radiation oncologist’s involvement in patient care is limited, and radiation is delivered in a standardized manner. This essentially renders radiation oncologists technicians of expensive machines.

In reality however, radiation oncologists touch every aspect of a patient’s care, and customized radiation therapy may be indicated for virtually every cancer site in both curative and palliative settings. We strive to deliver precision medicine and practice truly patient-centered care.

To cure cancer, radiation may be used in the neoadjuvant (prior to local surgical resection), definitive (as the primary local therapy), and adjuvant (postsurgical) setting. In palliative cases, radiation can be used to treat areas of metastatic spread as well as primary unresectable tumors to alleviate obstruction and/or bleeding symptoms. Referral to radiation oncology, therefore, can be appropriate at many different points of time on the continuum of cancer care.

For many treating radiation oncologists, the close personal connections that we form with our patients is one of the primary reasons we went into this field. Not only are we making patient-centered clinical decisions during every step of the treatment plan evaluation and optimization but we also see our patients weekly for clinical visits and then ongoing in visits that may span many years of survivorship.

Our deep commitment to addressing patient needs as they are receiving treatment and responsibility for late radiation effects is absolutely an integral part of our training and lifelong practice.
 

2. We get down in the details.

The workflow from consultation to radiation delivery can be confusing for anyone outside our specialized field.

Once seen in consult and considered a good candidate for radiation, patients will enter the essential next step: the treatment planning imaging – or “simulation.”

The simulation scan – mostly CT, although occasionally fused MRI or PET – involves a separate appointment and another hour or so of arranging and scanning patients in the exact position that they will be treated. Given the precision of modern radiation, the simulation often includes making a customized mold so patients have minimal movement during treatment. These simulation images allow the radiation oncology team to create a treatment plan that is customized to each patient and precisely reproducible during their course of radiation treatments – what’s known as fractions.

Creating a treatment plan involves a radiation oncologist literally drawing – or contouring – on pictures of the patient’s internal anatomy in three dimensions. Radiation oncologists contour exactly where the cancer is – or where it was if the treatment is given postoperatively – and identify the surrounding organs so that the doses can be preferentially directed to the cancer target and minimize risk to nearby organs. This precision is within millimeters and accounts for microscopic disease, organ motion, and patient setup. Ultimately, we create colorful heat gradient volumes of the anticipated radiation dose delivery and optimize these to reflect our planning priorities.

We use advanced technologies to shape the beams of radiation to treat the tumor and avoid delivering high doses to the neighboring tissues with techniques such as intensity modulated radiation therapy (IMRT), stereotactic ablative radiation therapy (SABR or SBRT), and stereotactic radiosurgery. We can also take advantage of the unique properties of different modalities, such as proton therapy and electron therapy, to achieve these same goals if indicated. Radiation oncologists live for precision medicine in every aspect of their workflow.
 

3. We roll deep.

Radiation oncology is exemplary of “the art of medicine.” We fuse anatomy-based treatment design with advanced technology and orchestrate the daily functions of a large medical team.

But, the treatment plan and delivery would not be possible without the input and care given within a large multi- and intradisciplinary team of oncologists, medical physicists, dosimetrists, radiation therapists, nurses, social workers, and other support staff. Radiation oncologists participate in regular tumor boards with surgeons, medical oncologists, pathologists, and radiologists to optimize interdisciplinary management of complex patients, providing a thoughtful tumor localization and treatment plan, as well as to better understand an individual’s ongoing symptoms and well-being as a whole. Considering all aspects of what a patient may need involves communication with fellow physicians, nurse navigators, and social workers.

Within our own department, treatment plan creation and quality checking or verification can sometimes take over 2 weeks, with detailed input from dosimetrists and medical physicists. The actual treatment delivery involves daily communication with the radiation therapists who are dedicated to each treatment machine – like the linear accelerator – and symptom management with clinic nurses and supportive staff, such as physical therapists and registered dietitians.

This massive team effort is required to get each patient through daily radiation treatments that can last 7 weeks and may require rapid replanning if the tumor shrinks or the patient loses weight.

As part of this team, radiation oncologists are uniquely positioned to quarterback each play and guide the entire game strategy.
 

4. Radiation therapy takes a lot of heat.

Radiation therapy is often blamed for issues unrelated to the treatment. Irradiating the pelvis for prostate cancer, for instance, does not cause a headache or heartburn during or after treatment.

Other than fatigue, associated side effects are localized and related to the total radiation dose and fraction size – how much and how fast – that reaches the surrounding tissues.

Our colleagues often swap stories of the bizarre things radiation therapy has been blamed for, including dental problems in someone receiving vaginal cylinder treatment, heart dysfunction in someone treated for rectal cancer, and hip fracture in someone treated for breast cancer because the radiation “destroyed” their bones. At best, these are humorous stories, but at worst, they can delay diagnosis and treatment of what is truly causing someone’s symptoms.
 

5. We truly believe that less is more.

One of the most fundamental aspects of radiation oncology is our drive to optimize treatment delivery and continually improve patient care – sometimes at our own field’s economic detriment. We’re dedicated to showing that patients may get the same benefit from less and less radiation.

In the past 2 decades, the evolution and adoption of photon IMRT and proton therapy has allowed radiation plans to successfully spare surrounding tissue while improving our targeting. This evolution is coupled with technological and imaging advances that allow us to delivery of doses to certain tumors via SABR/SBRT in one to five total fractions.

A prime example: Treatment to eradicate lung or gastrointestinal tumors, which used to span up to 6 weeks, can now potentially be delivered in as little as 1 week.

For other common cancers, hypofractionation – slightly higher radiation doses per fraction at fewer total fractions overall – has revolutionized patient care, providing less radiation without impacting survival or increasing treatment toxicity.

Take breast cancer care: 50 years ago, virtually all patients with breast cancer received a mastectomy and lymph node dissections. Today, surgical techniques for lumpectomy paired with radiation therapy to the whole breast now allows us to preserve disease-free survival for those who elected to keep their breasts.

Over the past 20 years, the standards of care have shifted from 6-7 weeks of treatment to 3-4 weeks using a hypofractionated model that involves daily whole-breast radiation. The most recent clinical trials have shown that whole-breast radiation can be delivered safely and effectively for select women in as few as five fractions with either whole or partial breast targeting. Additional research driven by the idea of “right sizing” radiation treatment has even shown that certain women may not need radiation at all.

This evolution in radiation therapy illustrates how our subspecialty is constantly working to improve survival and patient well-being, form deep connections with our patients, and push the boundaries of medical innovations.

We are proud to be radiation oncologists and happy to share more. Want to know more about what goes on in the basement? Come on down, we’re happy to show you around.

Dr. Giap is a resident in the department of radiation oncology at the University of Florida, Gainesville. Dr. Chino is an assistant attending in the department of radiation oncology at Memorial Sloan Kettering Cancer Center, New York. Neither reported any relevant conflicts of interest.

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

Walking 10,000 steps per day may reduce the risk of death for those who have trouble regulating their blood sugar, according to the findings from a study of almost 1,700 American adults with prediabetes or diabetes.

Researchers from the University of Seville, Spain, evaluated U.S. adults with prediabetes and diabetes using data from the Centers for Disease Control and Prevention’s National Health and Nutrition Examination Survey, collected between 2005 and 2006.

The findings were published this month in Diabetes Care.

Ariel Skelley/Getty Images

Of the total, 1,194 adults had prediabetes, and 493 had diabetes. People with diabetes in the study were diagnosed by a doctor or had a fasting blood glucose level higher than 126 mg/dL. People with prediabetes in the study were also diagnosed by a doctor or had a fasting glucose level from 100 to 125 mg/dL.

Over half (56%) of prediabetic adults were male (average age 55 years), and they took an average of 8,500 steps per day. Half (51%) of the diabetic adults were also male (average age 61 years), and they took fewer steps per day – about 6,300.

The people in the study wore an accelerometer on their waist to count their steps for 7 consecutive days. The researchers adjusted for age, sex, ethnicity, smoking, alcohol use, diet, and use of diabetes medications.

Over 9 years, 200 people with prediabetes and 138 with diabetes died. Based on those who survived after follow-up, walking nearly 10,000 steps per day was best for reducing the risk of death from any cause for people with prediabetes and diabetes.

But about 20% of people in the study were removed from the analysis because they had invalid accelerometry data. Adults who are healthy enough to walk 10,000 steps may have different rates of death from those who aren’t, according to the study authors, who called for more research to compare these two groups.

If 10,000 steps seem like a daunting task, talking to a doctor about finding a routine that works for your physical ability could be helpful, the study authors suggest.

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

Walking 10,000 steps per day may reduce the risk of death for those who have trouble regulating their blood sugar, according to the findings from a study of almost 1,700 American adults with prediabetes or diabetes.

Researchers from the University of Seville, Spain, evaluated U.S. adults with prediabetes and diabetes using data from the Centers for Disease Control and Prevention’s National Health and Nutrition Examination Survey, collected between 2005 and 2006.

The findings were published this month in Diabetes Care.

Ariel Skelley/Getty Images

Of the total, 1,194 adults had prediabetes, and 493 had diabetes. People with diabetes in the study were diagnosed by a doctor or had a fasting blood glucose level higher than 126 mg/dL. People with prediabetes in the study were also diagnosed by a doctor or had a fasting glucose level from 100 to 125 mg/dL.

Over half (56%) of prediabetic adults were male (average age 55 years), and they took an average of 8,500 steps per day. Half (51%) of the diabetic adults were also male (average age 61 years), and they took fewer steps per day – about 6,300.

The people in the study wore an accelerometer on their waist to count their steps for 7 consecutive days. The researchers adjusted for age, sex, ethnicity, smoking, alcohol use, diet, and use of diabetes medications.

Over 9 years, 200 people with prediabetes and 138 with diabetes died. Based on those who survived after follow-up, walking nearly 10,000 steps per day was best for reducing the risk of death from any cause for people with prediabetes and diabetes.

But about 20% of people in the study were removed from the analysis because they had invalid accelerometry data. Adults who are healthy enough to walk 10,000 steps may have different rates of death from those who aren’t, according to the study authors, who called for more research to compare these two groups.

If 10,000 steps seem like a daunting task, talking to a doctor about finding a routine that works for your physical ability could be helpful, the study authors suggest.

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

Walking 10,000 steps per day may reduce the risk of death for those who have trouble regulating their blood sugar, according to the findings from a study of almost 1,700 American adults with prediabetes or diabetes.

Researchers from the University of Seville, Spain, evaluated U.S. adults with prediabetes and diabetes using data from the Centers for Disease Control and Prevention’s National Health and Nutrition Examination Survey, collected between 2005 and 2006.

The findings were published this month in Diabetes Care.

Ariel Skelley/Getty Images

Of the total, 1,194 adults had prediabetes, and 493 had diabetes. People with diabetes in the study were diagnosed by a doctor or had a fasting blood glucose level higher than 126 mg/dL. People with prediabetes in the study were also diagnosed by a doctor or had a fasting glucose level from 100 to 125 mg/dL.

Over half (56%) of prediabetic adults were male (average age 55 years), and they took an average of 8,500 steps per day. Half (51%) of the diabetic adults were also male (average age 61 years), and they took fewer steps per day – about 6,300.

The people in the study wore an accelerometer on their waist to count their steps for 7 consecutive days. The researchers adjusted for age, sex, ethnicity, smoking, alcohol use, diet, and use of diabetes medications.

Over 9 years, 200 people with prediabetes and 138 with diabetes died. Based on those who survived after follow-up, walking nearly 10,000 steps per day was best for reducing the risk of death from any cause for people with prediabetes and diabetes.

But about 20% of people in the study were removed from the analysis because they had invalid accelerometry data. Adults who are healthy enough to walk 10,000 steps may have different rates of death from those who aren’t, according to the study authors, who called for more research to compare these two groups.

If 10,000 steps seem like a daunting task, talking to a doctor about finding a routine that works for your physical ability could be helpful, the study authors suggest.

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

MUSCATINE, IOWA – Bailee Tordai, who was 33 weeks into her pregnancy, barely made it to the prenatal checkup. Her clunky old Jeep couldn’t complete the 2-mile trip from her house to the University of Iowa’s outreach clinic in her southeastern Iowa hometown. It was a hot June day, and a wiring problem made the Jeep conk out in the street.

A passerby helped Ms.Tordai, 22, push her stricken vehicle off the road and into a parking lot. Then she called her stepdad for a ride to the clinic.

Jaclyn Roman, a nurse-midwife, walked into the exam room. “I heard your car broke down.”

“Yup. You want to buy it? Five bucks!” Ms. Tordai joked.

Her lack of reliable transportation won’t be a laughing matter in August, when her baby is due. She will need to arrange for someone to drive her about 40 miles northwest to the University of Iowa Hospitals and Clinics in Iowa City. She can’t give birth at Muscatine’s hospital because it shuttered its birthing unit in 2020.

Ms. Roman is part of an unusual effort to minimize the harm caused by such closures. She’s one of 11 certified nurse-midwives from the University of Iowa who travel regularly to Muscatine and Washington, another southeastern Iowa town where the local hospital closed its birthing unit. The university’s pilot project, which is supported by a federal grant, doesn’t aim to reopen shuttered birthing units. Instead, the midwife team helps ensure area women receive related services. Last year, it served more than 500 patients in Muscatine and Washington.

Muscatine is one of hundreds of rural areas in the United States where hospitals have dropped birthing services during the past 2 decades, often because they lack obstetricians and other specialized staff members.

Hospital industry leaders say birthing units also tend to lose money, largely because of low payments from Medicaid, the public health insurance program that covers more than 40% of births in the United States and an even greater share in many rural areas.

The loss of labor-and-delivery services hits especially hard for women who lack resources and time to travel for care.

Muscatine, which is on the Mississippi River, has more than 23,000 residents, making it a relatively large town by Iowa standards. But its hospital is one of 41 Iowa facilities that have closed their birthing units since 2000, according to the Iowa Department of Public Health. Most were in rural areas. Just one has reopened, and only 56 Iowa hospitals now have birthing units.

The nurse-midwife team’s work includes crucial prenatal checkups. Most pregnant people are supposed to have a dozen or more such appointments before giving birth. Health care providers use the checkups to track how a pregnancy is progressing and to watch for signs of high blood pressure and other problems that can lead to premature births, stillbirths, or even maternal deaths. The midwives also advise women on how to keep themselves and their babies healthy after birth.

Karen Jefferson, DM, director of midwifery practice for the American College of Nurse-Midwives, said the University of Iowa team’s approach is an innovative way to address needs in rural areas that have lost hospital birthing units. “How wonderful would it be to see a provider in your town, instead of driving 40 miles for your prenatal visits – especially toward the end of pregnancy, when you’re going every week,” said Dr. Jefferson, who lives in rural New York.

Midwives can provide many other types of care for women and for babies. In theory, they could even open rural birthing centers outside of hospitals, Dr. Jefferson said. But they would need to overcome concerns about financing and about the availability of surgeons to do emergency cesarean sections, which she said are rarely needed in low-risk births.

The University of Iowa midwives focus on low-risk pregnancies, referring patients with significant health issues to physician specialists in Iowa City. Often, those specialists can visit with the patients and the midwives via video conference in the small-town clinics.

The loss of a hospital obstetrics unit can make finding local maternity care harder for rural families.

Ms. Tordai can attest that if patients must travel far for prenatal appointments, they’re less likely to get to them all. If she had to go to Iowa City for each of hers, repeatedly taking 3 hours off from her job managing a pizza restaurant would be tough, she said. On that June day her Jeep broke down, she would have canceled her appointment.

Instead, she wound up on an exam table at the Muscatine clinic listening to her baby’s heartbeat on a monitor and watching as Ms. Roman measured her belly.

“Nice job being perfect,” the midwife told her during the checkup.

Ms. Roman asked Ms. Tordai to describe her baby’s movements. “Constant,” she replied with a smile.

Ms. Roman asked whether she planned to breastfeed. Ms. Tordai said she didn’t have much luck with her first daughter, Aspen, now 4.

“Have you thought about a breastfeeding class?” the midwife asked.

“I don’t have time for that,” Ms. Tordai replied. Ms. Roman continued to coax her, noting where a breastfeeding class is available online.

Near the end of the appointment, Ms. Tordai asked Ms. Roman whether she could schedule an induced birth at the University of Iowa hospital. The midwife told her that, in general, letting labor begin on its own is better than artificially starting it.

But there was the matter of unreliable transportation. Ms. Tordai explained that scheduling the birth would help her arrange to have her mother drive her to the hospital in Iowa City. Ms. Roman agreed that transportation is a legitimate reason and arranged for an induced labor on Aug. 10.

The University of Iowa midwife team started offering services in 2020 in a clinic about 2 miles from Trinity Muscatine hospital. The hospital is owned by UnityPoint Health, a large nonprofit hospital system that blamed a lack of available obstetricians for the closure of the Muscatine birthing unit. At the time, UnityPoint leaders said they hoped to reopen the unit if they could recruit new obstetricians to the area.

Kristy Phillipson, a UnityPoint Health spokesperson, told KHN in June that the company has continued to try to recruit physicians, including for the Muscatine hospital. Although it has not reopened the birthing unit, the company regularly sends an obstetrician and other staff members to provide prenatal care and related services, she said.

Most pregnant patients from the area who choose UnityPoint for their care wind up giving birth at the system’s hospital in Bettendorf, a 45-minute drive to the east.

The University of Iowa midwife team has no plans to open its own birthing centers, but it hopes to expand its rural clinic service to other underserved towns. To do so, the university would need to hire more nurse-midwives, which could be a challenge. According to the Iowa Board of Nursing, 120 licensed nurse-midwives live in the state of 3 million people.

The University of Iowa plans to address that by starting the state’s first nurse-midwife training program in 2023. The master’s degree program, which will emphasize rural service, will train registered nurses to become nurse-midwives. It eventually could graduate eight people per year, said Amber Goodrich, a University of Iowa midwife helping lead the effort.

Those graduates could fill gaps throughout rural areas, where even more hospitals may shutter their birthing units in the coming years.

“This crisis is going nowhere fast,” Ms. Goodrich said.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

MUSCATINE, IOWA – Bailee Tordai, who was 33 weeks into her pregnancy, barely made it to the prenatal checkup. Her clunky old Jeep couldn’t complete the 2-mile trip from her house to the University of Iowa’s outreach clinic in her southeastern Iowa hometown. It was a hot June day, and a wiring problem made the Jeep conk out in the street.

A passerby helped Ms.Tordai, 22, push her stricken vehicle off the road and into a parking lot. Then she called her stepdad for a ride to the clinic.

Jaclyn Roman, a nurse-midwife, walked into the exam room. “I heard your car broke down.”

“Yup. You want to buy it? Five bucks!” Ms. Tordai joked.

Her lack of reliable transportation won’t be a laughing matter in August, when her baby is due. She will need to arrange for someone to drive her about 40 miles northwest to the University of Iowa Hospitals and Clinics in Iowa City. She can’t give birth at Muscatine’s hospital because it shuttered its birthing unit in 2020.

Ms. Roman is part of an unusual effort to minimize the harm caused by such closures. She’s one of 11 certified nurse-midwives from the University of Iowa who travel regularly to Muscatine and Washington, another southeastern Iowa town where the local hospital closed its birthing unit. The university’s pilot project, which is supported by a federal grant, doesn’t aim to reopen shuttered birthing units. Instead, the midwife team helps ensure area women receive related services. Last year, it served more than 500 patients in Muscatine and Washington.

Muscatine is one of hundreds of rural areas in the United States where hospitals have dropped birthing services during the past 2 decades, often because they lack obstetricians and other specialized staff members.

Hospital industry leaders say birthing units also tend to lose money, largely because of low payments from Medicaid, the public health insurance program that covers more than 40% of births in the United States and an even greater share in many rural areas.

The loss of labor-and-delivery services hits especially hard for women who lack resources and time to travel for care.

Muscatine, which is on the Mississippi River, has more than 23,000 residents, making it a relatively large town by Iowa standards. But its hospital is one of 41 Iowa facilities that have closed their birthing units since 2000, according to the Iowa Department of Public Health. Most were in rural areas. Just one has reopened, and only 56 Iowa hospitals now have birthing units.

The nurse-midwife team’s work includes crucial prenatal checkups. Most pregnant people are supposed to have a dozen or more such appointments before giving birth. Health care providers use the checkups to track how a pregnancy is progressing and to watch for signs of high blood pressure and other problems that can lead to premature births, stillbirths, or even maternal deaths. The midwives also advise women on how to keep themselves and their babies healthy after birth.

Karen Jefferson, DM, director of midwifery practice for the American College of Nurse-Midwives, said the University of Iowa team’s approach is an innovative way to address needs in rural areas that have lost hospital birthing units. “How wonderful would it be to see a provider in your town, instead of driving 40 miles for your prenatal visits – especially toward the end of pregnancy, when you’re going every week,” said Dr. Jefferson, who lives in rural New York.

Midwives can provide many other types of care for women and for babies. In theory, they could even open rural birthing centers outside of hospitals, Dr. Jefferson said. But they would need to overcome concerns about financing and about the availability of surgeons to do emergency cesarean sections, which she said are rarely needed in low-risk births.

The University of Iowa midwives focus on low-risk pregnancies, referring patients with significant health issues to physician specialists in Iowa City. Often, those specialists can visit with the patients and the midwives via video conference in the small-town clinics.

The loss of a hospital obstetrics unit can make finding local maternity care harder for rural families.

Ms. Tordai can attest that if patients must travel far for prenatal appointments, they’re less likely to get to them all. If she had to go to Iowa City for each of hers, repeatedly taking 3 hours off from her job managing a pizza restaurant would be tough, she said. On that June day her Jeep broke down, she would have canceled her appointment.

Instead, she wound up on an exam table at the Muscatine clinic listening to her baby’s heartbeat on a monitor and watching as Ms. Roman measured her belly.

“Nice job being perfect,” the midwife told her during the checkup.

Ms. Roman asked Ms. Tordai to describe her baby’s movements. “Constant,” she replied with a smile.

Ms. Roman asked whether she planned to breastfeed. Ms. Tordai said she didn’t have much luck with her first daughter, Aspen, now 4.

“Have you thought about a breastfeeding class?” the midwife asked.

“I don’t have time for that,” Ms. Tordai replied. Ms. Roman continued to coax her, noting where a breastfeeding class is available online.

Near the end of the appointment, Ms. Tordai asked Ms. Roman whether she could schedule an induced birth at the University of Iowa hospital. The midwife told her that, in general, letting labor begin on its own is better than artificially starting it.

But there was the matter of unreliable transportation. Ms. Tordai explained that scheduling the birth would help her arrange to have her mother drive her to the hospital in Iowa City. Ms. Roman agreed that transportation is a legitimate reason and arranged for an induced labor on Aug. 10.

The University of Iowa midwife team started offering services in 2020 in a clinic about 2 miles from Trinity Muscatine hospital. The hospital is owned by UnityPoint Health, a large nonprofit hospital system that blamed a lack of available obstetricians for the closure of the Muscatine birthing unit. At the time, UnityPoint leaders said they hoped to reopen the unit if they could recruit new obstetricians to the area.

Kristy Phillipson, a UnityPoint Health spokesperson, told KHN in June that the company has continued to try to recruit physicians, including for the Muscatine hospital. Although it has not reopened the birthing unit, the company regularly sends an obstetrician and other staff members to provide prenatal care and related services, she said.

Most pregnant patients from the area who choose UnityPoint for their care wind up giving birth at the system’s hospital in Bettendorf, a 45-minute drive to the east.

The University of Iowa midwife team has no plans to open its own birthing centers, but it hopes to expand its rural clinic service to other underserved towns. To do so, the university would need to hire more nurse-midwives, which could be a challenge. According to the Iowa Board of Nursing, 120 licensed nurse-midwives live in the state of 3 million people.

The University of Iowa plans to address that by starting the state’s first nurse-midwife training program in 2023. The master’s degree program, which will emphasize rural service, will train registered nurses to become nurse-midwives. It eventually could graduate eight people per year, said Amber Goodrich, a University of Iowa midwife helping lead the effort.

Those graduates could fill gaps throughout rural areas, where even more hospitals may shutter their birthing units in the coming years.

“This crisis is going nowhere fast,” Ms. Goodrich said.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

MUSCATINE, IOWA – Bailee Tordai, who was 33 weeks into her pregnancy, barely made it to the prenatal checkup. Her clunky old Jeep couldn’t complete the 2-mile trip from her house to the University of Iowa’s outreach clinic in her southeastern Iowa hometown. It was a hot June day, and a wiring problem made the Jeep conk out in the street.

A passerby helped Ms.Tordai, 22, push her stricken vehicle off the road and into a parking lot. Then she called her stepdad for a ride to the clinic.

Jaclyn Roman, a nurse-midwife, walked into the exam room. “I heard your car broke down.”

“Yup. You want to buy it? Five bucks!” Ms. Tordai joked.

Her lack of reliable transportation won’t be a laughing matter in August, when her baby is due. She will need to arrange for someone to drive her about 40 miles northwest to the University of Iowa Hospitals and Clinics in Iowa City. She can’t give birth at Muscatine’s hospital because it shuttered its birthing unit in 2020.

Ms. Roman is part of an unusual effort to minimize the harm caused by such closures. She’s one of 11 certified nurse-midwives from the University of Iowa who travel regularly to Muscatine and Washington, another southeastern Iowa town where the local hospital closed its birthing unit. The university’s pilot project, which is supported by a federal grant, doesn’t aim to reopen shuttered birthing units. Instead, the midwife team helps ensure area women receive related services. Last year, it served more than 500 patients in Muscatine and Washington.

Muscatine is one of hundreds of rural areas in the United States where hospitals have dropped birthing services during the past 2 decades, often because they lack obstetricians and other specialized staff members.

Hospital industry leaders say birthing units also tend to lose money, largely because of low payments from Medicaid, the public health insurance program that covers more than 40% of births in the United States and an even greater share in many rural areas.

The loss of labor-and-delivery services hits especially hard for women who lack resources and time to travel for care.

Muscatine, which is on the Mississippi River, has more than 23,000 residents, making it a relatively large town by Iowa standards. But its hospital is one of 41 Iowa facilities that have closed their birthing units since 2000, according to the Iowa Department of Public Health. Most were in rural areas. Just one has reopened, and only 56 Iowa hospitals now have birthing units.

The nurse-midwife team’s work includes crucial prenatal checkups. Most pregnant people are supposed to have a dozen or more such appointments before giving birth. Health care providers use the checkups to track how a pregnancy is progressing and to watch for signs of high blood pressure and other problems that can lead to premature births, stillbirths, or even maternal deaths. The midwives also advise women on how to keep themselves and their babies healthy after birth.

Karen Jefferson, DM, director of midwifery practice for the American College of Nurse-Midwives, said the University of Iowa team’s approach is an innovative way to address needs in rural areas that have lost hospital birthing units. “How wonderful would it be to see a provider in your town, instead of driving 40 miles for your prenatal visits – especially toward the end of pregnancy, when you’re going every week,” said Dr. Jefferson, who lives in rural New York.

Midwives can provide many other types of care for women and for babies. In theory, they could even open rural birthing centers outside of hospitals, Dr. Jefferson said. But they would need to overcome concerns about financing and about the availability of surgeons to do emergency cesarean sections, which she said are rarely needed in low-risk births.

The University of Iowa midwives focus on low-risk pregnancies, referring patients with significant health issues to physician specialists in Iowa City. Often, those specialists can visit with the patients and the midwives via video conference in the small-town clinics.

The loss of a hospital obstetrics unit can make finding local maternity care harder for rural families.

Ms. Tordai can attest that if patients must travel far for prenatal appointments, they’re less likely to get to them all. If she had to go to Iowa City for each of hers, repeatedly taking 3 hours off from her job managing a pizza restaurant would be tough, she said. On that June day her Jeep broke down, she would have canceled her appointment.

Instead, she wound up on an exam table at the Muscatine clinic listening to her baby’s heartbeat on a monitor and watching as Ms. Roman measured her belly.

“Nice job being perfect,” the midwife told her during the checkup.

Ms. Roman asked Ms. Tordai to describe her baby’s movements. “Constant,” she replied with a smile.

Ms. Roman asked whether she planned to breastfeed. Ms. Tordai said she didn’t have much luck with her first daughter, Aspen, now 4.

“Have you thought about a breastfeeding class?” the midwife asked.

“I don’t have time for that,” Ms. Tordai replied. Ms. Roman continued to coax her, noting where a breastfeeding class is available online.

Near the end of the appointment, Ms. Tordai asked Ms. Roman whether she could schedule an induced birth at the University of Iowa hospital. The midwife told her that, in general, letting labor begin on its own is better than artificially starting it.

But there was the matter of unreliable transportation. Ms. Tordai explained that scheduling the birth would help her arrange to have her mother drive her to the hospital in Iowa City. Ms. Roman agreed that transportation is a legitimate reason and arranged for an induced labor on Aug. 10.

The University of Iowa midwife team started offering services in 2020 in a clinic about 2 miles from Trinity Muscatine hospital. The hospital is owned by UnityPoint Health, a large nonprofit hospital system that blamed a lack of available obstetricians for the closure of the Muscatine birthing unit. At the time, UnityPoint leaders said they hoped to reopen the unit if they could recruit new obstetricians to the area.

Kristy Phillipson, a UnityPoint Health spokesperson, told KHN in June that the company has continued to try to recruit physicians, including for the Muscatine hospital. Although it has not reopened the birthing unit, the company regularly sends an obstetrician and other staff members to provide prenatal care and related services, she said.

Most pregnant patients from the area who choose UnityPoint for their care wind up giving birth at the system’s hospital in Bettendorf, a 45-minute drive to the east.

The University of Iowa midwife team has no plans to open its own birthing centers, but it hopes to expand its rural clinic service to other underserved towns. To do so, the university would need to hire more nurse-midwives, which could be a challenge. According to the Iowa Board of Nursing, 120 licensed nurse-midwives live in the state of 3 million people.

The University of Iowa plans to address that by starting the state’s first nurse-midwife training program in 2023. The master’s degree program, which will emphasize rural service, will train registered nurses to become nurse-midwives. It eventually could graduate eight people per year, said Amber Goodrich, a University of Iowa midwife helping lead the effort.

Those graduates could fill gaps throughout rural areas, where even more hospitals may shutter their birthing units in the coming years.

“This crisis is going nowhere fast,” Ms. Goodrich said.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

The addition of social determinants of health (SDOH) to machine-learning risk-prediction models improved forecasts of in-hospital mortality in Black adults hospitalized for heart failure (HF) but didn’t show similar ability in non-Black patients, in a study based in part on the American Heart Association–sponsored Get with the Guidelines in Heart Failure (GWTG-HF) registry.

The novel risk-prediction tool bolstered by SDOH at the zip-code level – including household income, number of adults without a high-school degree, poverty and unemployment rates, and other factors – stratified risk more sharply in Black patients than more standard models, including some based on multivariable logistic regression.

“Traditional risk models that exist for heart failure assign lower risks to Black individuals if everything else is held constant,” Ambarish Pandey, MD, MSCS, University of Texas Southwestern Medical Center, Dallas, told this news organization.

“I think that is problematic, because if Black patients are considered lower risk, they may not get appropriate risk-based therapies that are being provided. We wanted to move away from this approach and use a more race-agnostic approach,” said Dr. Pandey, who is senior author on the study published  in JAMA Cardiology, with lead author Matthew W. Segar, MD, Texas Heart Institute, Houston.

The training dataset for the prediction model consisted of 123,634 patients hospitalized with HF (mean age, 71 years), of whom 47% were women, enrolled in the GWTG-HF registry from 2010 through 2020.

The machine-learning models showed “excellent performance” when applied to an internal subset cohort of 82,420 patients, with a C statistic of 0.81 for Black patients and 0.82 for non-Black patients, the authors report, and in a real-world cohort of 553,506 patients, with C statistics of 0.74 and 0.75, respectively. The models performed similarly well, they write, in an external validation cohort derived from the ARIC registry, with C statistics of 0.79 and 0.80, respectively.

The machine-learning models’ performance surpassed that of the GWTG-HF risk-score model, C statistics 0.69 for both Black and non-Black patients, and other logistic regression models in which race was a covariate, the authors state.

“We also observed significant race-specific differences in the population-attributable risk of in-hospital mortality associated with the SDOH, with a significantly greater contribution of these parameters to the overall in-hospital mortality risk in Black patients versus non-Black patients,” they write.

For Black patients, five of the SDOH parameters were among the top 20 covariate predictors of in-hospital mortality: mean income level, vacancy and unemployment rates, proportion of the population without a high school degree, and proportion older than 65 years. Together they accounted for 11.6% of population-attributable risk for in-hospital death.

Only one SDOH parameter – percentage of population older than 65 years – made the top 20 for non-Black patients, with a population-attributable risk of 0.5%, the group reports.

“I hope our work spurs future investigations to better understand how social determinants contribute to risk and how they can be incorporated in management of these patients,” Dr. Pandey said.

“I commend the authors for attempting to address SDOH as a potential contributor to some of the differences in outcomes among patients with heart failure,” writes Eldrin F. Lewis, MD, MPH, Stanford University School of Medicine, Palo Alto, Calif., in an accompanying editorial.

“It is imperative that we use these newer techniques to go beyond simply predicting which groups are at heightened risk and leverage the data to create solutions that will reduce those risks for the individual patient,” Dr. Lewis states.

“We should use these tools to reduce racial and ethnic differences in the operations of health care systems, potential bias in management decisions, and inactivity due to the difficulty in getting guideline-directed medical therapy into the hands of people who may have limited resources with minimal out-of-pocket costs,” he writes.

The models assessed in the current report “set a new bar for risk prediction: Integration of a comprehensive set of demographics, comorbidities, and social determinants with machine learning obviates race and ethnicity in risk prediction,” contend JAMA Cardiology deputy editor Clyde W. Yancy, MD, and associate editor Sadiya S. Khan, MD, both from Northwestern University Feinberg School of Medicine, Chicago, in an accompanying editor’s note.

“This more careful incorporation of individual-level, neighborhood-level, and hospital-level social factors,” they conclude, “is now a candidate template for future risk models.”

Dr. Pandey discloses grant funding from Applied Therapeutics and Gilead Sciences; consulting for or serving as an advisor to Tricog Health, Eli Lilly, Rivus, and Roche Diagnostics; receiving nonfinancial support from Pfizer and Merck; and research support from the Texas Health Resources Clinical Scholarship, the Gilead Sciences Research Scholar Program, the National Institute on Aging GEMSSTAR Grant, and Applied Therapeutics. Dr. Segar discloses receiving nonfinancial support from Pfizer and Merck. Other disclosures are in the report. Dr. Lewis reported no disclosures. Dr. Yancy and Dr. Khan had no relevant disclosures.

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

The addition of social determinants of health (SDOH) to machine-learning risk-prediction models improved forecasts of in-hospital mortality in Black adults hospitalized for heart failure (HF) but didn’t show similar ability in non-Black patients, in a study based in part on the American Heart Association–sponsored Get with the Guidelines in Heart Failure (GWTG-HF) registry.

The novel risk-prediction tool bolstered by SDOH at the zip-code level – including household income, number of adults without a high-school degree, poverty and unemployment rates, and other factors – stratified risk more sharply in Black patients than more standard models, including some based on multivariable logistic regression.

“Traditional risk models that exist for heart failure assign lower risks to Black individuals if everything else is held constant,” Ambarish Pandey, MD, MSCS, University of Texas Southwestern Medical Center, Dallas, told this news organization.

“I think that is problematic, because if Black patients are considered lower risk, they may not get appropriate risk-based therapies that are being provided. We wanted to move away from this approach and use a more race-agnostic approach,” said Dr. Pandey, who is senior author on the study published  in JAMA Cardiology, with lead author Matthew W. Segar, MD, Texas Heart Institute, Houston.

The training dataset for the prediction model consisted of 123,634 patients hospitalized with HF (mean age, 71 years), of whom 47% were women, enrolled in the GWTG-HF registry from 2010 through 2020.

The machine-learning models showed “excellent performance” when applied to an internal subset cohort of 82,420 patients, with a C statistic of 0.81 for Black patients and 0.82 for non-Black patients, the authors report, and in a real-world cohort of 553,506 patients, with C statistics of 0.74 and 0.75, respectively. The models performed similarly well, they write, in an external validation cohort derived from the ARIC registry, with C statistics of 0.79 and 0.80, respectively.

The machine-learning models’ performance surpassed that of the GWTG-HF risk-score model, C statistics 0.69 for both Black and non-Black patients, and other logistic regression models in which race was a covariate, the authors state.

“We also observed significant race-specific differences in the population-attributable risk of in-hospital mortality associated with the SDOH, with a significantly greater contribution of these parameters to the overall in-hospital mortality risk in Black patients versus non-Black patients,” they write.

For Black patients, five of the SDOH parameters were among the top 20 covariate predictors of in-hospital mortality: mean income level, vacancy and unemployment rates, proportion of the population without a high school degree, and proportion older than 65 years. Together they accounted for 11.6% of population-attributable risk for in-hospital death.

Only one SDOH parameter – percentage of population older than 65 years – made the top 20 for non-Black patients, with a population-attributable risk of 0.5%, the group reports.

“I hope our work spurs future investigations to better understand how social determinants contribute to risk and how they can be incorporated in management of these patients,” Dr. Pandey said.

“I commend the authors for attempting to address SDOH as a potential contributor to some of the differences in outcomes among patients with heart failure,” writes Eldrin F. Lewis, MD, MPH, Stanford University School of Medicine, Palo Alto, Calif., in an accompanying editorial.

“It is imperative that we use these newer techniques to go beyond simply predicting which groups are at heightened risk and leverage the data to create solutions that will reduce those risks for the individual patient,” Dr. Lewis states.

“We should use these tools to reduce racial and ethnic differences in the operations of health care systems, potential bias in management decisions, and inactivity due to the difficulty in getting guideline-directed medical therapy into the hands of people who may have limited resources with minimal out-of-pocket costs,” he writes.

The models assessed in the current report “set a new bar for risk prediction: Integration of a comprehensive set of demographics, comorbidities, and social determinants with machine learning obviates race and ethnicity in risk prediction,” contend JAMA Cardiology deputy editor Clyde W. Yancy, MD, and associate editor Sadiya S. Khan, MD, both from Northwestern University Feinberg School of Medicine, Chicago, in an accompanying editor’s note.

“This more careful incorporation of individual-level, neighborhood-level, and hospital-level social factors,” they conclude, “is now a candidate template for future risk models.”

Dr. Pandey discloses grant funding from Applied Therapeutics and Gilead Sciences; consulting for or serving as an advisor to Tricog Health, Eli Lilly, Rivus, and Roche Diagnostics; receiving nonfinancial support from Pfizer and Merck; and research support from the Texas Health Resources Clinical Scholarship, the Gilead Sciences Research Scholar Program, the National Institute on Aging GEMSSTAR Grant, and Applied Therapeutics. Dr. Segar discloses receiving nonfinancial support from Pfizer and Merck. Other disclosures are in the report. Dr. Lewis reported no disclosures. Dr. Yancy and Dr. Khan had no relevant disclosures.

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

The addition of social determinants of health (SDOH) to machine-learning risk-prediction models improved forecasts of in-hospital mortality in Black adults hospitalized for heart failure (HF) but didn’t show similar ability in non-Black patients, in a study based in part on the American Heart Association–sponsored Get with the Guidelines in Heart Failure (GWTG-HF) registry.

The novel risk-prediction tool bolstered by SDOH at the zip-code level – including household income, number of adults without a high-school degree, poverty and unemployment rates, and other factors – stratified risk more sharply in Black patients than more standard models, including some based on multivariable logistic regression.

“Traditional risk models that exist for heart failure assign lower risks to Black individuals if everything else is held constant,” Ambarish Pandey, MD, MSCS, University of Texas Southwestern Medical Center, Dallas, told this news organization.

“I think that is problematic, because if Black patients are considered lower risk, they may not get appropriate risk-based therapies that are being provided. We wanted to move away from this approach and use a more race-agnostic approach,” said Dr. Pandey, who is senior author on the study published  in JAMA Cardiology, with lead author Matthew W. Segar, MD, Texas Heart Institute, Houston.

The training dataset for the prediction model consisted of 123,634 patients hospitalized with HF (mean age, 71 years), of whom 47% were women, enrolled in the GWTG-HF registry from 2010 through 2020.

The machine-learning models showed “excellent performance” when applied to an internal subset cohort of 82,420 patients, with a C statistic of 0.81 for Black patients and 0.82 for non-Black patients, the authors report, and in a real-world cohort of 553,506 patients, with C statistics of 0.74 and 0.75, respectively. The models performed similarly well, they write, in an external validation cohort derived from the ARIC registry, with C statistics of 0.79 and 0.80, respectively.

The machine-learning models’ performance surpassed that of the GWTG-HF risk-score model, C statistics 0.69 for both Black and non-Black patients, and other logistic regression models in which race was a covariate, the authors state.

“We also observed significant race-specific differences in the population-attributable risk of in-hospital mortality associated with the SDOH, with a significantly greater contribution of these parameters to the overall in-hospital mortality risk in Black patients versus non-Black patients,” they write.

For Black patients, five of the SDOH parameters were among the top 20 covariate predictors of in-hospital mortality: mean income level, vacancy and unemployment rates, proportion of the population without a high school degree, and proportion older than 65 years. Together they accounted for 11.6% of population-attributable risk for in-hospital death.

Only one SDOH parameter – percentage of population older than 65 years – made the top 20 for non-Black patients, with a population-attributable risk of 0.5%, the group reports.

“I hope our work spurs future investigations to better understand how social determinants contribute to risk and how they can be incorporated in management of these patients,” Dr. Pandey said.

“I commend the authors for attempting to address SDOH as a potential contributor to some of the differences in outcomes among patients with heart failure,” writes Eldrin F. Lewis, MD, MPH, Stanford University School of Medicine, Palo Alto, Calif., in an accompanying editorial.

“It is imperative that we use these newer techniques to go beyond simply predicting which groups are at heightened risk and leverage the data to create solutions that will reduce those risks for the individual patient,” Dr. Lewis states.

“We should use these tools to reduce racial and ethnic differences in the operations of health care systems, potential bias in management decisions, and inactivity due to the difficulty in getting guideline-directed medical therapy into the hands of people who may have limited resources with minimal out-of-pocket costs,” he writes.

The models assessed in the current report “set a new bar for risk prediction: Integration of a comprehensive set of demographics, comorbidities, and social determinants with machine learning obviates race and ethnicity in risk prediction,” contend JAMA Cardiology deputy editor Clyde W. Yancy, MD, and associate editor Sadiya S. Khan, MD, both from Northwestern University Feinberg School of Medicine, Chicago, in an accompanying editor’s note.

“This more careful incorporation of individual-level, neighborhood-level, and hospital-level social factors,” they conclude, “is now a candidate template for future risk models.”

Dr. Pandey discloses grant funding from Applied Therapeutics and Gilead Sciences; consulting for or serving as an advisor to Tricog Health, Eli Lilly, Rivus, and Roche Diagnostics; receiving nonfinancial support from Pfizer and Merck; and research support from the Texas Health Resources Clinical Scholarship, the Gilead Sciences Research Scholar Program, the National Institute on Aging GEMSSTAR Grant, and Applied Therapeutics. Dr. Segar discloses receiving nonfinancial support from Pfizer and Merck. Other disclosures are in the report. Dr. Lewis reported no disclosures. Dr. Yancy and Dr. Khan had no relevant disclosures.

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

Medically reviewed by Jennifer Casarella, MD

Dan Miller has parked his Nissan Altima on the side of the road near a field outside Chicago and is holding a gun to his head. 

Haunted for years by the compounded trauma of tours of duty in the Middle East and his work as a police officer in Chicago, at that moment, Dr. Miller saw no reason to live. And there were troubles at home with his wife and children, who had grown fearful of his behavior.

“My whole world was falling apart,” he says of that dark night in 2014. “It left a hole I didn’t know how to fill.”

He chose not to pull the trigger after a brochure on the passenger seat of his car gave him an unexpected perspective – and launched him on a path to help others in his situation.

Had Mr. Miller taken his life that night, he would have joined thousands of other veterans who died by suicide. About 17 U.S. veterans lose their lives this way each day, on average, according to the Department of Veterans Affairs. In 2019, the last year for which records are available, 6,261 veterans took their own lives – and the suicide rate for veterans was 52% higher than for nonveterans, the agency’s records show. 

The problem has become so severe that the Veterans Health Administration now uses artificial intelligence (AI) to help identify veterans at the highest risk of suicide – and reach out to them before a crisis strikes.

But that wasn’t available when Dan Miller’s life was unraveling.

In the years leading up to his near-suicide, his wife had pushed him to get help. “She said, ‘You’re not the same person you were when you left. The kids are scared of you. The pets are scared of you,” he recalls.

He resisted, even when his wife threatened divorce. Rising through the ranks of the Marines, Mr. Miller had become more emotionally isolated. He feared losing his job and the respect of others if he let anyone know what he was going through.

Finally, he gave the VHA a chance. He went in for an initial consultation in 2010 and didn’t find it helpful. He didn’t like being told what to do. So he stopped. He turned to obsessive exercise and excessive drinking.

That day in 2014, Mr. Miller’s wife told him she was taking the kids out for a playdate. After she left, he was served with divorce papers. Less than an hour later, he was parked in his car with his gun, ready to end his life.

But if it all had happened just a few years later, things might never have gotten to that point.
 

Scanning for suicide risk

In 2017, the VHA piloted its AI program, called REACH VET, that aims to help prevent veterans from dying by suicide.

Every month, a computer scans the electronic health records of all VHA patients who’ve had a health care visit for any reason in the last 2 years. It checks more than 140 variables and weights them to estimate someone’s overall suicide risk at that moment in time.

To build the risk algorithm, a computer combed through the medical records of 6,360 veterans confirmed to have died by suicide between 2009 and 2011. (The VHA continually updates the list of variables from the health records of VHA patients, including those who have died by suicide since then and others.)

Some variables are things you’d expect:

• A past suicide attempt.
• A diagnosis of depression or other mental illness.
• A diagnosis of a terminal illness.

Others are more surprising. For example, a diagnosis of arthritis or diabetes adds weight.

REACH VET flags the riskiest cases – the top 0.1% – for a mental health or primary care provider to review. They reach out to the patient to tell them how and why their record was flagged, discuss any recommended treatment changes, and ask them to come in for a visit.

“It’s an opportunity to talk about their risk factors, which is designed to lead to a conversation about safety planning,” says clinical psychologist Matthew Miller, PhD, national director of the U.S. Department of Veterans Affairs’ Suicide Prevention Program. He’s not related to Dan Miller.

Making a suicide safety plan

A safety plan is a document that outlines how a person can help prevent their own suicide in a crisis. 

The plan may include:

• A list of personal triggers or warning signs.
• What’s helped them in the past.
• Names of people or organizations who can support them.
• Plans to remove means of suicide, such as guns, from their environment.
• Their reasons for living.

In people at risk for suicide, research shows that having a safety plan reduces suicidal thoughts and attempts, lowers rates of depression and hopelessness, and boosts veterans’ engagement with the health care system. It may also help people manage things that trigger their suicidal thoughts.
 

Getting the call

What if REACH VET had been around when Dan Miller was in crisis – and he’d gotten a call from the VHA?

“It absolutely, positively would have helped because one of the biggest things on that day when I got served was feeling completely alone and that I had no one to turn to,” Mr. Miller says. He’s now a speaker for the Wounded Warrior Project, a nonprofit that serves veterans and active-duty service people.

Vets’ reactions to the unexpected VHA phone call, psychologist Dr. Miller says, “run the gamut from ‘Thank you for contacting me. Let’s talk,’ to ‘What are you talking about? Leave me alone!’ ”

Nothing stops all suicides. But REACH VET is having an impact. In a clinical trial, vets contacted through REACH VET had more doctor visits, were more likely to have a written suicide prevention safety plan, and had fewer hospital admissions for mental health, ER visits, and suicide attempts.
 

An assist from AI

Even simple outreach can make a big difference. And there’s research to prove it.

One study included 4,730 veterans recently discharged from psychiatric care at the VHA, a group considered at high risk for suicide. 

Half of them got 13 caring emails from hospital staff in the weeks after leaving the hospital. The emails mentioned personal things the patient had shared, like a love of hiking, and wished them well. The other veterans got routine follow-up but no emails.

Two years later, those who got the caring emails were less likely to have died by suicide than the other vets. The study was published in 2014 in Contemporary Clinical Trials.

Researchers have done studies like this many times: with handwritten notes from the primary care doctor, postcards from the ER, and so forth. The results never vary: The notes reduce suicide risk.

“If we could use AI to identify people to receive notes or phone calls, it would be a very effective and inexpensive way to guide follow-up care,” says Rebecca Bernert, PhD, director and founder of the Suicide Prevention Research Laboratory at Stanford (Calif.) University.