Mixed Topics

The Food and Drug Administration issued warning letters to 12 companies selling over-the-counter (OTC) skin lightening products, the agency announced on April 19. All the products contain hydroquinone as the active ingredient, and don’t meet the requirements to be sold legally over the counter. The letters were dated April 13.

The 12 products with hydroquinone are “unapproved drugs and are not generally recognized as safe and effective” (abbreviated as GRASE), the FDA said.

Among the side effects associated with hydroquinone products reported to the FDA are skin rashes, facial swelling, and skin discoloration or ochronosis. The discoloration can be permanent, the FDA said. The lighteners are marketed for use on age or dark spots on the skin associated with melasma.

Tri-Luma, a prescription product for the treatment of moderate to severe melasma of the face, is the only FDA-approved drug containing hydroquinone, according to the FDA. It contains 4% hydroquinone and two other ingredients. It is meant to be used under the supervision of a health care professional. Tri-Luma is indicated for up to 8 weeks of treatment for moderate to severe melasma of the face. The OTC products contain up to 2%. (Generic versions of 4% hydroquinone are available by prescription, dermatologists said.)

“Hydroquinone is a very effective medication, and that’s exactly what it is, a medication,” said Lily Talakoub, MD, a dermatologist in McLean, Va., who supports the FDA action. “It’s very effective and very safe to use in the right hands, but when it is overused or used in the wrong situation, it can cause problems.” Those problems often occur, she said, when there is no health care professional overseeing the use of the OTC products, and when people use them over the long term.

The FDA action to ban the OTC products is “very appropriate,” said dermatologist Pooja Sodha, MD, assistant professor and director of the Center for Laser and Cosmetic Dermatology at George Washington University, Washington. “We know patients pick this up [an OTC product] and use it without physician oversight.” When patients use the products longer than is appropriate, which is also common, it can worsen the initial skin issue, she said.

The action follows reforms finalized under the CARES Act (Coronavirus Aid, Relief and Economic Security Act), which included not only COVID-19 response efforts but also updated the method in which certain OTC drugs are regulated. Manufacturers of the skin lightening products that don’t have FDA approval had been told to remove the products from the market by September 2020.

The recent letters were sent to a dozen companies still marketing their products without an FDA new drug approval. The agency asked the companies to take prompt action and respond with 15 days, stating what they have done to correct the violations.

The 12 companies are AMBI Enterprises, Clinical Formula, Elements Brands Inc., Genomma Lab USA, Intilight/Dr Thomas Balshi, M&M Beauty and Wellness, Neoteric Cosmetics/Scott’s Liquid Gold, Skin Authority, Skin Pro, Skin PS Brands, True Earth Health Products, and Ultimark Products.

Health care professionals and consumers can report adverse reactions associated with these products to the FDA’s MedWatch Adverse Event Reporting program.

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

The Food and Drug Administration issued warning letters to 12 companies selling over-the-counter (OTC) skin lightening products, the agency announced on April 19. All the products contain hydroquinone as the active ingredient, and don’t meet the requirements to be sold legally over the counter. The letters were dated April 13.

The 12 products with hydroquinone are “unapproved drugs and are not generally recognized as safe and effective” (abbreviated as GRASE), the FDA said.

Among the side effects associated with hydroquinone products reported to the FDA are skin rashes, facial swelling, and skin discoloration or ochronosis. The discoloration can be permanent, the FDA said. The lighteners are marketed for use on age or dark spots on the skin associated with melasma.

Tri-Luma, a prescription product for the treatment of moderate to severe melasma of the face, is the only FDA-approved drug containing hydroquinone, according to the FDA. It contains 4% hydroquinone and two other ingredients. It is meant to be used under the supervision of a health care professional. Tri-Luma is indicated for up to 8 weeks of treatment for moderate to severe melasma of the face. The OTC products contain up to 2%. (Generic versions of 4% hydroquinone are available by prescription, dermatologists said.)

“Hydroquinone is a very effective medication, and that’s exactly what it is, a medication,” said Lily Talakoub, MD, a dermatologist in McLean, Va., who supports the FDA action. “It’s very effective and very safe to use in the right hands, but when it is overused or used in the wrong situation, it can cause problems.” Those problems often occur, she said, when there is no health care professional overseeing the use of the OTC products, and when people use them over the long term.

The FDA action to ban the OTC products is “very appropriate,” said dermatologist Pooja Sodha, MD, assistant professor and director of the Center for Laser and Cosmetic Dermatology at George Washington University, Washington. “We know patients pick this up [an OTC product] and use it without physician oversight.” When patients use the products longer than is appropriate, which is also common, it can worsen the initial skin issue, she said.

The action follows reforms finalized under the CARES Act (Coronavirus Aid, Relief and Economic Security Act), which included not only COVID-19 response efforts but also updated the method in which certain OTC drugs are regulated. Manufacturers of the skin lightening products that don’t have FDA approval had been told to remove the products from the market by September 2020.

The recent letters were sent to a dozen companies still marketing their products without an FDA new drug approval. The agency asked the companies to take prompt action and respond with 15 days, stating what they have done to correct the violations.

The 12 companies are AMBI Enterprises, Clinical Formula, Elements Brands Inc., Genomma Lab USA, Intilight/Dr Thomas Balshi, M&M Beauty and Wellness, Neoteric Cosmetics/Scott’s Liquid Gold, Skin Authority, Skin Pro, Skin PS Brands, True Earth Health Products, and Ultimark Products.

Health care professionals and consumers can report adverse reactions associated with these products to the FDA’s MedWatch Adverse Event Reporting program.

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

The Food and Drug Administration issued warning letters to 12 companies selling over-the-counter (OTC) skin lightening products, the agency announced on April 19. All the products contain hydroquinone as the active ingredient, and don’t meet the requirements to be sold legally over the counter. The letters were dated April 13.

The 12 products with hydroquinone are “unapproved drugs and are not generally recognized as safe and effective” (abbreviated as GRASE), the FDA said.

Among the side effects associated with hydroquinone products reported to the FDA are skin rashes, facial swelling, and skin discoloration or ochronosis. The discoloration can be permanent, the FDA said. The lighteners are marketed for use on age or dark spots on the skin associated with melasma.

Tri-Luma, a prescription product for the treatment of moderate to severe melasma of the face, is the only FDA-approved drug containing hydroquinone, according to the FDA. It contains 4% hydroquinone and two other ingredients. It is meant to be used under the supervision of a health care professional. Tri-Luma is indicated for up to 8 weeks of treatment for moderate to severe melasma of the face. The OTC products contain up to 2%. (Generic versions of 4% hydroquinone are available by prescription, dermatologists said.)

“Hydroquinone is a very effective medication, and that’s exactly what it is, a medication,” said Lily Talakoub, MD, a dermatologist in McLean, Va., who supports the FDA action. “It’s very effective and very safe to use in the right hands, but when it is overused or used in the wrong situation, it can cause problems.” Those problems often occur, she said, when there is no health care professional overseeing the use of the OTC products, and when people use them over the long term.

The FDA action to ban the OTC products is “very appropriate,” said dermatologist Pooja Sodha, MD, assistant professor and director of the Center for Laser and Cosmetic Dermatology at George Washington University, Washington. “We know patients pick this up [an OTC product] and use it without physician oversight.” When patients use the products longer than is appropriate, which is also common, it can worsen the initial skin issue, she said.

The action follows reforms finalized under the CARES Act (Coronavirus Aid, Relief and Economic Security Act), which included not only COVID-19 response efforts but also updated the method in which certain OTC drugs are regulated. Manufacturers of the skin lightening products that don’t have FDA approval had been told to remove the products from the market by September 2020.

The recent letters were sent to a dozen companies still marketing their products without an FDA new drug approval. The agency asked the companies to take prompt action and respond with 15 days, stating what they have done to correct the violations.

The 12 companies are AMBI Enterprises, Clinical Formula, Elements Brands Inc., Genomma Lab USA, Intilight/Dr Thomas Balshi, M&M Beauty and Wellness, Neoteric Cosmetics/Scott’s Liquid Gold, Skin Authority, Skin Pro, Skin PS Brands, True Earth Health Products, and Ultimark Products.

Health care professionals and consumers can report adverse reactions associated with these products to the FDA’s MedWatch Adverse Event Reporting program.

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

Heartland virus (HRTV), an emerging infection first detected in lone star ticks in Missouri in 2009, has spread to lone star ticks in Georgia, a study published in Emerging Infectious Diseases reports.

HRTV disease is transmitted by the bite of an infected Amblyomma americanum tick, named “lone star” because of the silver-white spot on the female scutum (back).

“By … sampling … in an area with reported exposure to HRTV in wildlife and humans and testing for infection in thousands of ticks from multiple sites and physiologic stages, we confirmed the presence of HRTV in Georgia,” the authors write.

“This information about the expanding geographic range of lone star ticks, combined with increased human presence in tick-infested habitats, can be used to improve strategies for preventing tick bites and to alert physicians about this emerging tickborne virus infection,” a press release by the Centers for Disease Control and Prevention notes.
 

Persistent field and lab work led to HRTV discovery in Georgia

The search for infected lone star ticks began after a retroactive analysis confirmed that a person who died in Georgia in 2005 from an unidentified illness was infected with HRTV. A subsequent analysis of serum samples collected earlier from local white-tailed deer showed that the deer had been exposed to HRTV since at least 2001, according to a press release by Emory University.

These discoveries prompted local researchers to investigate whether lone star ticks in rural, woodsy central Georgia were carrying HRTV.

Lead study author Yamila Romer, MD, an infectious disease clinician and microbiologist in the department of environmental sciences at Emory University in Atlanta, and her colleagues collected samples of ticks in 2018 at 26 sites near the location of the patient who died and the seropositive deer. In 2019, they focused their collections on the two sites that had provided the most ticks in 2018.

From April to October in both years, the research team visited sites weekly to swish white flannel flags through underbrush. They picked off adult and nymph Amblyomma americanum ticks, placed them into vials, and transported them to their lab. They sorted 9,294 ticks by sex, life stage, and collection site. Then they crushed the ticks and extracted their RNA.

To confirm viral infection, the team tested RNA extracted from cell culture supernatants using a real-time polymerase chain reaction test specific for HRTV.

In the three pools of ticks that tested positive for HRTV, the researchers found a minimum infection rate of 0.46/1,000 ticks, suggesting that about 1 of every 2,000 ticks carried HRTV. They sequenced the genome of the three isolates and found that the genomes were similar to one another but were very different from the genomes from HRTV samples taken outside Georgia.

Catherine A. Hill, PhD, a professor of entomology and vector biology and the interim head of the department of entomology at Purdue University in West Lafayette, Ind., was impressed with the researchers’ discovery.

“Heartland virus is difficult to detect,” she said in an email. “The prevalence of human cases is low, and the virus appears to be present at very low levels in populations of lone star tick. The investigators went to some lengths to survey for the virus, collect, and process thousands of ticks – and they found the needle in the haystack.” Dr. Hill was not involved in the study.
 

Georgia data help researchers monitor HRTV spread

HRTV was first identified in 2009 in Missouri in two people hospitalized with fever, muscle pain, diarrhea, and low white blood cell and platelet counts. Researchers traced the infections to lone star ticks, and they found antibodies to the virus in blood samples from deer and other wild mammals.

According to the CDC, U.S. cases of tick-borne diseases more than doubled between 2004 and 2016. As of January 2021, more than 50 human cases of HRTV disease had been reported in 11 Midwestern and Southeastern states: Arkansas, Georgia, Illinois, Indiana, Iowa, Kansas, Kentucky, Missouri, North Carolina, Oklahoma, and Tennessee.
 

Precautions, signs, symptoms, testing, and treatment

“The lone star tick is aggressive and will actively seek out a human host to bite,” Dr. Hill noted.

She recommends that health care providers advise patients to avoid tick habitat, wear protective clothing, apply repellants, know the signs and symptoms of tick-borne disease, and seek immediate medical care if they become ill.

Common symptoms of HRTV disease include fatigue, fever, nausea, diarrhea, and anorexia. Treatment is supportive. Many patients have been hospitalized, and some with comorbidities have died.

HRTV infection is rarely tested for, and the disease burden is unknown. With no commercial tests available in the United States, the CDC performs molecular and serologic testing for HRTV infection. The agency advises doctors to contact their state health department if they suspect a patient may have HRTV disease.
 

Further research is needed

Samantha M. Wisely, PhD, a professor of wildlife ecology and the director of the Cervidae Health Research Initiative at the University of Florida in Gainesville, was not surprised by the study finding.

“The more we look for heartland virus, the more places we find it,” Dr. Wisely told this news organization in an email.

“Little is known about which wildlife play a role in maintaining the virus on the landscape,” said Dr. Wisely, who was not involved in the study. “White-tailed deer have been shown to produce antibodies, meaning they have been exposed to the virus, but no one has actually found the virus in a wildlife species.”

The whole-genome sequencing of the virus was particularly important, Dr. Wisely explained. “Whole-genome data allow researchers to better understand viral evolution, pathogenicity, and viral dynamics across space and time – how it is evolving.”

The study was supported by a grant from the Emory University Research Council. The authors, Dr. Wisely, and Dr. Hill have disclosed no relevant financial relationships.

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

Heartland virus (HRTV), an emerging infection first detected in lone star ticks in Missouri in 2009, has spread to lone star ticks in Georgia, a study published in Emerging Infectious Diseases reports.

HRTV disease is transmitted by the bite of an infected Amblyomma americanum tick, named “lone star” because of the silver-white spot on the female scutum (back).

“By … sampling … in an area with reported exposure to HRTV in wildlife and humans and testing for infection in thousands of ticks from multiple sites and physiologic stages, we confirmed the presence of HRTV in Georgia,” the authors write.

“This information about the expanding geographic range of lone star ticks, combined with increased human presence in tick-infested habitats, can be used to improve strategies for preventing tick bites and to alert physicians about this emerging tickborne virus infection,” a press release by the Centers for Disease Control and Prevention notes.
 

Persistent field and lab work led to HRTV discovery in Georgia

The search for infected lone star ticks began after a retroactive analysis confirmed that a person who died in Georgia in 2005 from an unidentified illness was infected with HRTV. A subsequent analysis of serum samples collected earlier from local white-tailed deer showed that the deer had been exposed to HRTV since at least 2001, according to a press release by Emory University.

These discoveries prompted local researchers to investigate whether lone star ticks in rural, woodsy central Georgia were carrying HRTV.

Lead study author Yamila Romer, MD, an infectious disease clinician and microbiologist in the department of environmental sciences at Emory University in Atlanta, and her colleagues collected samples of ticks in 2018 at 26 sites near the location of the patient who died and the seropositive deer. In 2019, they focused their collections on the two sites that had provided the most ticks in 2018.

From April to October in both years, the research team visited sites weekly to swish white flannel flags through underbrush. They picked off adult and nymph Amblyomma americanum ticks, placed them into vials, and transported them to their lab. They sorted 9,294 ticks by sex, life stage, and collection site. Then they crushed the ticks and extracted their RNA.

To confirm viral infection, the team tested RNA extracted from cell culture supernatants using a real-time polymerase chain reaction test specific for HRTV.

In the three pools of ticks that tested positive for HRTV, the researchers found a minimum infection rate of 0.46/1,000 ticks, suggesting that about 1 of every 2,000 ticks carried HRTV. They sequenced the genome of the three isolates and found that the genomes were similar to one another but were very different from the genomes from HRTV samples taken outside Georgia.

Catherine A. Hill, PhD, a professor of entomology and vector biology and the interim head of the department of entomology at Purdue University in West Lafayette, Ind., was impressed with the researchers’ discovery.

“Heartland virus is difficult to detect,” she said in an email. “The prevalence of human cases is low, and the virus appears to be present at very low levels in populations of lone star tick. The investigators went to some lengths to survey for the virus, collect, and process thousands of ticks – and they found the needle in the haystack.” Dr. Hill was not involved in the study.
 

Georgia data help researchers monitor HRTV spread

HRTV was first identified in 2009 in Missouri in two people hospitalized with fever, muscle pain, diarrhea, and low white blood cell and platelet counts. Researchers traced the infections to lone star ticks, and they found antibodies to the virus in blood samples from deer and other wild mammals.

According to the CDC, U.S. cases of tick-borne diseases more than doubled between 2004 and 2016. As of January 2021, more than 50 human cases of HRTV disease had been reported in 11 Midwestern and Southeastern states: Arkansas, Georgia, Illinois, Indiana, Iowa, Kansas, Kentucky, Missouri, North Carolina, Oklahoma, and Tennessee.
 

Precautions, signs, symptoms, testing, and treatment

“The lone star tick is aggressive and will actively seek out a human host to bite,” Dr. Hill noted.

She recommends that health care providers advise patients to avoid tick habitat, wear protective clothing, apply repellants, know the signs and symptoms of tick-borne disease, and seek immediate medical care if they become ill.

Common symptoms of HRTV disease include fatigue, fever, nausea, diarrhea, and anorexia. Treatment is supportive. Many patients have been hospitalized, and some with comorbidities have died.

HRTV infection is rarely tested for, and the disease burden is unknown. With no commercial tests available in the United States, the CDC performs molecular and serologic testing for HRTV infection. The agency advises doctors to contact their state health department if they suspect a patient may have HRTV disease.
 

Further research is needed

Samantha M. Wisely, PhD, a professor of wildlife ecology and the director of the Cervidae Health Research Initiative at the University of Florida in Gainesville, was not surprised by the study finding.

“The more we look for heartland virus, the more places we find it,” Dr. Wisely told this news organization in an email.

“Little is known about which wildlife play a role in maintaining the virus on the landscape,” said Dr. Wisely, who was not involved in the study. “White-tailed deer have been shown to produce antibodies, meaning they have been exposed to the virus, but no one has actually found the virus in a wildlife species.”

The whole-genome sequencing of the virus was particularly important, Dr. Wisely explained. “Whole-genome data allow researchers to better understand viral evolution, pathogenicity, and viral dynamics across space and time – how it is evolving.”

The study was supported by a grant from the Emory University Research Council. The authors, Dr. Wisely, and Dr. Hill have disclosed no relevant financial relationships.

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

Heartland virus (HRTV), an emerging infection first detected in lone star ticks in Missouri in 2009, has spread to lone star ticks in Georgia, a study published in Emerging Infectious Diseases reports.

HRTV disease is transmitted by the bite of an infected Amblyomma americanum tick, named “lone star” because of the silver-white spot on the female scutum (back).

“By … sampling … in an area with reported exposure to HRTV in wildlife and humans and testing for infection in thousands of ticks from multiple sites and physiologic stages, we confirmed the presence of HRTV in Georgia,” the authors write.

“This information about the expanding geographic range of lone star ticks, combined with increased human presence in tick-infested habitats, can be used to improve strategies for preventing tick bites and to alert physicians about this emerging tickborne virus infection,” a press release by the Centers for Disease Control and Prevention notes.
 

Persistent field and lab work led to HRTV discovery in Georgia

The search for infected lone star ticks began after a retroactive analysis confirmed that a person who died in Georgia in 2005 from an unidentified illness was infected with HRTV. A subsequent analysis of serum samples collected earlier from local white-tailed deer showed that the deer had been exposed to HRTV since at least 2001, according to a press release by Emory University.

These discoveries prompted local researchers to investigate whether lone star ticks in rural, woodsy central Georgia were carrying HRTV.

Lead study author Yamila Romer, MD, an infectious disease clinician and microbiologist in the department of environmental sciences at Emory University in Atlanta, and her colleagues collected samples of ticks in 2018 at 26 sites near the location of the patient who died and the seropositive deer. In 2019, they focused their collections on the two sites that had provided the most ticks in 2018.

From April to October in both years, the research team visited sites weekly to swish white flannel flags through underbrush. They picked off adult and nymph Amblyomma americanum ticks, placed them into vials, and transported them to their lab. They sorted 9,294 ticks by sex, life stage, and collection site. Then they crushed the ticks and extracted their RNA.

To confirm viral infection, the team tested RNA extracted from cell culture supernatants using a real-time polymerase chain reaction test specific for HRTV.

In the three pools of ticks that tested positive for HRTV, the researchers found a minimum infection rate of 0.46/1,000 ticks, suggesting that about 1 of every 2,000 ticks carried HRTV. They sequenced the genome of the three isolates and found that the genomes were similar to one another but were very different from the genomes from HRTV samples taken outside Georgia.

Catherine A. Hill, PhD, a professor of entomology and vector biology and the interim head of the department of entomology at Purdue University in West Lafayette, Ind., was impressed with the researchers’ discovery.

“Heartland virus is difficult to detect,” she said in an email. “The prevalence of human cases is low, and the virus appears to be present at very low levels in populations of lone star tick. The investigators went to some lengths to survey for the virus, collect, and process thousands of ticks – and they found the needle in the haystack.” Dr. Hill was not involved in the study.
 

Georgia data help researchers monitor HRTV spread

HRTV was first identified in 2009 in Missouri in two people hospitalized with fever, muscle pain, diarrhea, and low white blood cell and platelet counts. Researchers traced the infections to lone star ticks, and they found antibodies to the virus in blood samples from deer and other wild mammals.

According to the CDC, U.S. cases of tick-borne diseases more than doubled between 2004 and 2016. As of January 2021, more than 50 human cases of HRTV disease had been reported in 11 Midwestern and Southeastern states: Arkansas, Georgia, Illinois, Indiana, Iowa, Kansas, Kentucky, Missouri, North Carolina, Oklahoma, and Tennessee.
 

Precautions, signs, symptoms, testing, and treatment

“The lone star tick is aggressive and will actively seek out a human host to bite,” Dr. Hill noted.

She recommends that health care providers advise patients to avoid tick habitat, wear protective clothing, apply repellants, know the signs and symptoms of tick-borne disease, and seek immediate medical care if they become ill.

Common symptoms of HRTV disease include fatigue, fever, nausea, diarrhea, and anorexia. Treatment is supportive. Many patients have been hospitalized, and some with comorbidities have died.

HRTV infection is rarely tested for, and the disease burden is unknown. With no commercial tests available in the United States, the CDC performs molecular and serologic testing for HRTV infection. The agency advises doctors to contact their state health department if they suspect a patient may have HRTV disease.
 

Further research is needed

Samantha M. Wisely, PhD, a professor of wildlife ecology and the director of the Cervidae Health Research Initiative at the University of Florida in Gainesville, was not surprised by the study finding.

“The more we look for heartland virus, the more places we find it,” Dr. Wisely told this news organization in an email.

“Little is known about which wildlife play a role in maintaining the virus on the landscape,” said Dr. Wisely, who was not involved in the study. “White-tailed deer have been shown to produce antibodies, meaning they have been exposed to the virus, but no one has actually found the virus in a wildlife species.”

The whole-genome sequencing of the virus was particularly important, Dr. Wisely explained. “Whole-genome data allow researchers to better understand viral evolution, pathogenicity, and viral dynamics across space and time – how it is evolving.”

The study was supported by a grant from the Emory University Research Council. The authors, Dr. Wisely, and Dr. Hill have disclosed no relevant financial relationships.

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

Most health care providers are comfortable recommending palliative care (PC) for their patients with interstitial lung disease (ILD), but most do so at the time of disease progression, rather than diagnosis, as indicated on survey data from 128 clinicians.

ILD is associated with a high mortality rate and profound symptoms that contribute to poor quality of life, Rebecca A. Gersen, MD, of Johns Hopkins University, Baltimore, and colleagues wrote.

“Nevertheless, there is often a lack of preparedness for death by both patients and providers, contributing to increased distress,” they said. Clinician perspectives on the use of PC for ILD patients have not been well studied, although PC is not limited to end-of-life care and is recommended for ILD patients by professional organizations, including the American Thoracic Society. “PC is successful in improving breathlessness in chronic lung disease and can increase survival.”

In a study published in the journal CHEST^®, the researchers surveyed health care providers at 68 Pulmonary Fibrosis Foundation centers across the United States. The survey was sent and collected by email and a restricted social media platform. A total of 128 providers from 34 states completed the survey between October 2020 and January 2021. Of these, 61% were physicians, and 67% identified as White.

Overall, 95% of the respondents agreed or strongly agreed that addressing advance directives is important, but only 66% agreed or strongly agreed that they themselves addressed advance directives in the outpatient ILD clinic setting. A greater number (91%) agreed or strongly agreed that they had a high level of comfort in discussing prognosis, while 88% agreed or strongly agreed that they felt comfortable assessing a patient’s readiness for and acceptance of PC. Approximately two-thirds (67%) agreed or strongly agreed that they use PC services for ILD patients. There were no significant differences in responses from clinicians who had more than 10 years of experience and those who had less.

Of the providers who referred patients to PC, 54% did so at objective disease progression, and 80% did so at objective and/or symptomatic progress; 2% referred patients to PC at initial ILD diagnosis.

Lack of resources

Health care providers who reported that they rarely referred patients to palliative care were significantly more likely to cite a lack of local PC options (P < .01). Those who rarely referred patients for PC also were significantly less likely to feel comfortable discussing prognoses or advance directives in the ILD clinic (P = .03 and P = .02, respectively).

Among the 23% of responders who reported that they rarely referred patients, 66% said they did not have PC at their institution.

“In addition to understanding and addressing barriers to care, educational resources may be key to improving PC delivery to the ILD population,” the researchers wrote.

The study findings were limited by several factors, including voluntary participation, lack of a validated questionnaire, and use of self-reports, which may not reflect physicians’ actual practice, the researchers noted. Other limitations include the use of U.S. data only, which may not generalize to countries with different health care models.

However, the results were strengthened by the use of data from providers at a range of institutions across the United States and by the high overall survey response rate, the researchers said.

“While ILD providers reassuringly demonstrate knowledge and interest in PC involvement, no current system exists to facilitate and monitor response to referral,” they noted. “Future research is desperately needed to address barriers to the provision of PC in order to enhance access to a critical service in the management and care of patients with ILD.”

The study was supported by the National Heart, Lung, and Blood Institute. The researchers disclosed no relevant financial relationships.

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

Most health care providers are comfortable recommending palliative care (PC) for their patients with interstitial lung disease (ILD), but most do so at the time of disease progression, rather than diagnosis, as indicated on survey data from 128 clinicians.

ILD is associated with a high mortality rate and profound symptoms that contribute to poor quality of life, Rebecca A. Gersen, MD, of Johns Hopkins University, Baltimore, and colleagues wrote.

“Nevertheless, there is often a lack of preparedness for death by both patients and providers, contributing to increased distress,” they said. Clinician perspectives on the use of PC for ILD patients have not been well studied, although PC is not limited to end-of-life care and is recommended for ILD patients by professional organizations, including the American Thoracic Society. “PC is successful in improving breathlessness in chronic lung disease and can increase survival.”

In a study published in the journal CHEST^®, the researchers surveyed health care providers at 68 Pulmonary Fibrosis Foundation centers across the United States. The survey was sent and collected by email and a restricted social media platform. A total of 128 providers from 34 states completed the survey between October 2020 and January 2021. Of these, 61% were physicians, and 67% identified as White.

Overall, 95% of the respondents agreed or strongly agreed that addressing advance directives is important, but only 66% agreed or strongly agreed that they themselves addressed advance directives in the outpatient ILD clinic setting. A greater number (91%) agreed or strongly agreed that they had a high level of comfort in discussing prognosis, while 88% agreed or strongly agreed that they felt comfortable assessing a patient’s readiness for and acceptance of PC. Approximately two-thirds (67%) agreed or strongly agreed that they use PC services for ILD patients. There were no significant differences in responses from clinicians who had more than 10 years of experience and those who had less.

Of the providers who referred patients to PC, 54% did so at objective disease progression, and 80% did so at objective and/or symptomatic progress; 2% referred patients to PC at initial ILD diagnosis.

Lack of resources

Health care providers who reported that they rarely referred patients to palliative care were significantly more likely to cite a lack of local PC options (P < .01). Those who rarely referred patients for PC also were significantly less likely to feel comfortable discussing prognoses or advance directives in the ILD clinic (P = .03 and P = .02, respectively).

Among the 23% of responders who reported that they rarely referred patients, 66% said they did not have PC at their institution.

“In addition to understanding and addressing barriers to care, educational resources may be key to improving PC delivery to the ILD population,” the researchers wrote.

The study findings were limited by several factors, including voluntary participation, lack of a validated questionnaire, and use of self-reports, which may not reflect physicians’ actual practice, the researchers noted. Other limitations include the use of U.S. data only, which may not generalize to countries with different health care models.

However, the results were strengthened by the use of data from providers at a range of institutions across the United States and by the high overall survey response rate, the researchers said.

“While ILD providers reassuringly demonstrate knowledge and interest in PC involvement, no current system exists to facilitate and monitor response to referral,” they noted. “Future research is desperately needed to address barriers to the provision of PC in order to enhance access to a critical service in the management and care of patients with ILD.”

The study was supported by the National Heart, Lung, and Blood Institute. The researchers disclosed no relevant financial relationships.

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

Most health care providers are comfortable recommending palliative care (PC) for their patients with interstitial lung disease (ILD), but most do so at the time of disease progression, rather than diagnosis, as indicated on survey data from 128 clinicians.

ILD is associated with a high mortality rate and profound symptoms that contribute to poor quality of life, Rebecca A. Gersen, MD, of Johns Hopkins University, Baltimore, and colleagues wrote.

“Nevertheless, there is often a lack of preparedness for death by both patients and providers, contributing to increased distress,” they said. Clinician perspectives on the use of PC for ILD patients have not been well studied, although PC is not limited to end-of-life care and is recommended for ILD patients by professional organizations, including the American Thoracic Society. “PC is successful in improving breathlessness in chronic lung disease and can increase survival.”

In a study published in the journal CHEST^®, the researchers surveyed health care providers at 68 Pulmonary Fibrosis Foundation centers across the United States. The survey was sent and collected by email and a restricted social media platform. A total of 128 providers from 34 states completed the survey between October 2020 and January 2021. Of these, 61% were physicians, and 67% identified as White.

Overall, 95% of the respondents agreed or strongly agreed that addressing advance directives is important, but only 66% agreed or strongly agreed that they themselves addressed advance directives in the outpatient ILD clinic setting. A greater number (91%) agreed or strongly agreed that they had a high level of comfort in discussing prognosis, while 88% agreed or strongly agreed that they felt comfortable assessing a patient’s readiness for and acceptance of PC. Approximately two-thirds (67%) agreed or strongly agreed that they use PC services for ILD patients. There were no significant differences in responses from clinicians who had more than 10 years of experience and those who had less.

Of the providers who referred patients to PC, 54% did so at objective disease progression, and 80% did so at objective and/or symptomatic progress; 2% referred patients to PC at initial ILD diagnosis.

Lack of resources

Health care providers who reported that they rarely referred patients to palliative care were significantly more likely to cite a lack of local PC options (P < .01). Those who rarely referred patients for PC also were significantly less likely to feel comfortable discussing prognoses or advance directives in the ILD clinic (P = .03 and P = .02, respectively).

Among the 23% of responders who reported that they rarely referred patients, 66% said they did not have PC at their institution.

“In addition to understanding and addressing barriers to care, educational resources may be key to improving PC delivery to the ILD population,” the researchers wrote.

The study findings were limited by several factors, including voluntary participation, lack of a validated questionnaire, and use of self-reports, which may not reflect physicians’ actual practice, the researchers noted. Other limitations include the use of U.S. data only, which may not generalize to countries with different health care models.

However, the results were strengthened by the use of data from providers at a range of institutions across the United States and by the high overall survey response rate, the researchers said.

“While ILD providers reassuringly demonstrate knowledge and interest in PC involvement, no current system exists to facilitate and monitor response to referral,” they noted. “Future research is desperately needed to address barriers to the provision of PC in order to enhance access to a critical service in the management and care of patients with ILD.”

The study was supported by the National Heart, Lung, and Blood Institute. The researchers disclosed no relevant financial relationships.

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

A pair of new studies offers more evidence for the value of vegetables and the risk of red meat on the cancer prevention front. Researchers report that high consumption of vegetables – especially lettuce, legumes, and cruciferous varieties – appears to lower the risk of liver cancer/liver disease. A separate team suggests that high consumption of red meat, organ meats, and processed meats boosts the risk of gastric cancer.

The findings of the latter study “reinforce the idea that avoidance of red meat and processed meat is probably good beyond [the prevention of] colorectal cancer,” said corresponding author and epidemiologist Paolo Boffetta, MD, MPH, of Stony Brook University Cancer Center, New York, in an interview. “The possible carcinogenic effect may extend beyond the colon.”

Both studies were released at the annual meeting of the American Association for Cancer Research.

For the red meat study, researchers examined statistics from the Golestan cohort study, which is prospectively tracking 50,045 people aged 40-75 from northeastern Iran. The study focuses on esophageal cancer due to the region’s high rate of the disease.

Red meat consumption is fairly rare in the region, where residents typically prefer chicken, said study lead author Giulia Collatuzzo, MD, a resident physician in occupational medicine at the University of Bologna, Italy, in an interview. On average, participants reported eating 18.4 grams daily of red meat and 72.1 grams daily of white meat.

The researchers tracked study participants for a median 12-year follow-up, during which 369 developed esophageal cancer and 368 developed gastric cancer. Red meat was only linked to more esophageal cancer in women (hazard ratio, 1.13, 95% confidence interval, 1.00-1.18, for each quintile increase in consumption).

Overall red meat consumption (including red meat, organ meat, and processed meat) was linked to higher rates of gastric cancer (HR, 1.08, 95% CI, 1.00-1.17) for each quartile increase in consumption, as was consumption of the red meat subtype alone (HR, 1.09, 95% CI, 1.00-1.18).

According to Dr. Collatuzzo, the findings suggest that those in the highest quartile of overall red meat consumption may have around a 25% increase in risk, compared with the lowest quartile.

Overall, she said, the study findings aren’t surprising. The lack of a connection between red meat consumption and esophageal cancer may be due to the fact that meat only temporarily transits through the esophagus, she said.

For the liver cancer/liver disease study, researchers examined the medical records of 470,653 subjects in the NIH-AARP Diet and Health Study. They were recruited in 1995-1996 when they were 50-71 years old. Over a median follow-up of 15.5 years, 899 developed liver cancer, and 934 died of chronic liver disease.

The median intakes of vegetables in quintile 5 (highest) and quintile 1 (lowest) were 3.7 cups daily and 1.0 cups daily, respectively, said study lead author Long-Gang Zhao, MS, a graduate student at Harvard University.

After adjusting for possible cofounders, those in the highest quintile of vegetable consumption were a third less likely to develop liver cancer, compared with the lowest quintile (HR, 0.66, 95% CI, 0.53-0.82, P < 0.01). Several types of vegetables appeared to be the strongest cancer fighters: cruciferous (broccoli, cauliflower), lettuce, legumes, and carrots. These kinds of vegetables were also linked to lower rates of chronic liver disease mortality (all P < 0.01), as was total vegetable intake for the top quintile versus the lowest quintile (HR, 0.60, 95% CI, 0.49-0.74, P = < 0.01).

“A one-cup increase (8 oz or 225 g) in vegetable intake was associated with about 20% decreased risk of liver cancer incidence and chronic liver mortality,” Zhao said.

There was no statistically significant link between fruit consumption and liver cancer or chronic liver disease mortality.

The findings provide more insight into diet and liver disease, Zhao said. “Chronic liver disease, which predisposes to liver cancer, is the tenth cause of death worldwide, causing two million deaths each year. It shares some etiological processes with liver cancer. Therefore, examining both chronic liver disease mortality and liver cancer incidence in our study may provide a more general picture for the prevention of liver diseases.”

As for limitations, both studies are based on self-reports about food consumption, which can be unreliable, and the subjects in the fruit/vegetable analysis were mainly of European origin.

The authors of both studies report no relevant disclosures. No funding is reported for either study.

A pair of new studies offers more evidence for the value of vegetables and the risk of red meat on the cancer prevention front. Researchers report that high consumption of vegetables – especially lettuce, legumes, and cruciferous varieties – appears to lower the risk of liver cancer/liver disease. A separate team suggests that high consumption of red meat, organ meats, and processed meats boosts the risk of gastric cancer.

The findings of the latter study “reinforce the idea that avoidance of red meat and processed meat is probably good beyond [the prevention of] colorectal cancer,” said corresponding author and epidemiologist Paolo Boffetta, MD, MPH, of Stony Brook University Cancer Center, New York, in an interview. “The possible carcinogenic effect may extend beyond the colon.”

Both studies were released at the annual meeting of the American Association for Cancer Research.

For the red meat study, researchers examined statistics from the Golestan cohort study, which is prospectively tracking 50,045 people aged 40-75 from northeastern Iran. The study focuses on esophageal cancer due to the region’s high rate of the disease.

Red meat consumption is fairly rare in the region, where residents typically prefer chicken, said study lead author Giulia Collatuzzo, MD, a resident physician in occupational medicine at the University of Bologna, Italy, in an interview. On average, participants reported eating 18.4 grams daily of red meat and 72.1 grams daily of white meat.

The researchers tracked study participants for a median 12-year follow-up, during which 369 developed esophageal cancer and 368 developed gastric cancer. Red meat was only linked to more esophageal cancer in women (hazard ratio, 1.13, 95% confidence interval, 1.00-1.18, for each quintile increase in consumption).

Overall red meat consumption (including red meat, organ meat, and processed meat) was linked to higher rates of gastric cancer (HR, 1.08, 95% CI, 1.00-1.17) for each quartile increase in consumption, as was consumption of the red meat subtype alone (HR, 1.09, 95% CI, 1.00-1.18).

According to Dr. Collatuzzo, the findings suggest that those in the highest quartile of overall red meat consumption may have around a 25% increase in risk, compared with the lowest quartile.

Overall, she said, the study findings aren’t surprising. The lack of a connection between red meat consumption and esophageal cancer may be due to the fact that meat only temporarily transits through the esophagus, she said.

For the liver cancer/liver disease study, researchers examined the medical records of 470,653 subjects in the NIH-AARP Diet and Health Study. They were recruited in 1995-1996 when they were 50-71 years old. Over a median follow-up of 15.5 years, 899 developed liver cancer, and 934 died of chronic liver disease.

The median intakes of vegetables in quintile 5 (highest) and quintile 1 (lowest) were 3.7 cups daily and 1.0 cups daily, respectively, said study lead author Long-Gang Zhao, MS, a graduate student at Harvard University.

After adjusting for possible cofounders, those in the highest quintile of vegetable consumption were a third less likely to develop liver cancer, compared with the lowest quintile (HR, 0.66, 95% CI, 0.53-0.82, P < 0.01). Several types of vegetables appeared to be the strongest cancer fighters: cruciferous (broccoli, cauliflower), lettuce, legumes, and carrots. These kinds of vegetables were also linked to lower rates of chronic liver disease mortality (all P < 0.01), as was total vegetable intake for the top quintile versus the lowest quintile (HR, 0.60, 95% CI, 0.49-0.74, P = < 0.01).

“A one-cup increase (8 oz or 225 g) in vegetable intake was associated with about 20% decreased risk of liver cancer incidence and chronic liver mortality,” Zhao said.

There was no statistically significant link between fruit consumption and liver cancer or chronic liver disease mortality.

The findings provide more insight into diet and liver disease, Zhao said. “Chronic liver disease, which predisposes to liver cancer, is the tenth cause of death worldwide, causing two million deaths each year. It shares some etiological processes with liver cancer. Therefore, examining both chronic liver disease mortality and liver cancer incidence in our study may provide a more general picture for the prevention of liver diseases.”

As for limitations, both studies are based on self-reports about food consumption, which can be unreliable, and the subjects in the fruit/vegetable analysis were mainly of European origin.

The authors of both studies report no relevant disclosures. No funding is reported for either study.

A pair of new studies offers more evidence for the value of vegetables and the risk of red meat on the cancer prevention front. Researchers report that high consumption of vegetables – especially lettuce, legumes, and cruciferous varieties – appears to lower the risk of liver cancer/liver disease. A separate team suggests that high consumption of red meat, organ meats, and processed meats boosts the risk of gastric cancer.

The findings of the latter study “reinforce the idea that avoidance of red meat and processed meat is probably good beyond [the prevention of] colorectal cancer,” said corresponding author and epidemiologist Paolo Boffetta, MD, MPH, of Stony Brook University Cancer Center, New York, in an interview. “The possible carcinogenic effect may extend beyond the colon.”

Both studies were released at the annual meeting of the American Association for Cancer Research.

For the red meat study, researchers examined statistics from the Golestan cohort study, which is prospectively tracking 50,045 people aged 40-75 from northeastern Iran. The study focuses on esophageal cancer due to the region’s high rate of the disease.

Red meat consumption is fairly rare in the region, where residents typically prefer chicken, said study lead author Giulia Collatuzzo, MD, a resident physician in occupational medicine at the University of Bologna, Italy, in an interview. On average, participants reported eating 18.4 grams daily of red meat and 72.1 grams daily of white meat.

The researchers tracked study participants for a median 12-year follow-up, during which 369 developed esophageal cancer and 368 developed gastric cancer. Red meat was only linked to more esophageal cancer in women (hazard ratio, 1.13, 95% confidence interval, 1.00-1.18, for each quintile increase in consumption).

Overall red meat consumption (including red meat, organ meat, and processed meat) was linked to higher rates of gastric cancer (HR, 1.08, 95% CI, 1.00-1.17) for each quartile increase in consumption, as was consumption of the red meat subtype alone (HR, 1.09, 95% CI, 1.00-1.18).

According to Dr. Collatuzzo, the findings suggest that those in the highest quartile of overall red meat consumption may have around a 25% increase in risk, compared with the lowest quartile.

Overall, she said, the study findings aren’t surprising. The lack of a connection between red meat consumption and esophageal cancer may be due to the fact that meat only temporarily transits through the esophagus, she said.

For the liver cancer/liver disease study, researchers examined the medical records of 470,653 subjects in the NIH-AARP Diet and Health Study. They were recruited in 1995-1996 when they were 50-71 years old. Over a median follow-up of 15.5 years, 899 developed liver cancer, and 934 died of chronic liver disease.

The median intakes of vegetables in quintile 5 (highest) and quintile 1 (lowest) were 3.7 cups daily and 1.0 cups daily, respectively, said study lead author Long-Gang Zhao, MS, a graduate student at Harvard University.

After adjusting for possible cofounders, those in the highest quintile of vegetable consumption were a third less likely to develop liver cancer, compared with the lowest quintile (HR, 0.66, 95% CI, 0.53-0.82, P < 0.01). Several types of vegetables appeared to be the strongest cancer fighters: cruciferous (broccoli, cauliflower), lettuce, legumes, and carrots. These kinds of vegetables were also linked to lower rates of chronic liver disease mortality (all P < 0.01), as was total vegetable intake for the top quintile versus the lowest quintile (HR, 0.60, 95% CI, 0.49-0.74, P = < 0.01).

“A one-cup increase (8 oz or 225 g) in vegetable intake was associated with about 20% decreased risk of liver cancer incidence and chronic liver mortality,” Zhao said.

There was no statistically significant link between fruit consumption and liver cancer or chronic liver disease mortality.

The findings provide more insight into diet and liver disease, Zhao said. “Chronic liver disease, which predisposes to liver cancer, is the tenth cause of death worldwide, causing two million deaths each year. It shares some etiological processes with liver cancer. Therefore, examining both chronic liver disease mortality and liver cancer incidence in our study may provide a more general picture for the prevention of liver diseases.”

As for limitations, both studies are based on self-reports about food consumption, which can be unreliable, and the subjects in the fruit/vegetable analysis were mainly of European origin.

The authors of both studies report no relevant disclosures. No funding is reported for either study.

The average life expectancy in the United States is expected to drop by 2.26 years from 2019 to 2021, the sharpest decrease during that time among high-income nations, according to a new study.

The study, published in medRxiv, said U.S. life expectancy went from 78.86 years in 2019 to 76.99 years in 2020, during the thick of the global COVID-19 pandemic. Though vaccines were widely available in 2021, the U.S. life expectancy was expected to keep going down, to 76.60 years.

In “peer countries” – Austria, Belgium, Denmark, England and Wales, Finland, France, Germany, Israel, Italy, the Netherlands, New Zealand, Northern Ireland, Norway, Portugal, Scotland, South Korea, Spain, Sweden, and Switzerland – life expectancy went down only 0.57 years from 2019 to 2020 and increased by 0.28 years in 2021, the study said. The peer countries now have a life expectancy that’s 5 years longer than in the United States.

“The fact the U.S. lost so many more lives than other high-income countries speaks not only to how we managed the pandemic, but also to more deeply rooted problems that predated the pandemic,” said Steven H. Woolf, MD, one of the study authors and a professor of family medicine and population health at Virginia Commonwealth University, Richmond, according to Reuters.

“U.S. life expectancy has been falling behind other countries since the 1980s, and the gap has widened over time, especially in the last decade.”

Lack of universal health care, income and educational inequality, and less-healthy physical and social environments helped lead to the decline in American life expectancy, according to Dr. Woolf.

The life expectancy drop from 2019 to 2020 hit Black and Hispanic people hardest, according to the study. But the drop from 2020 to 2021 affected White people the most, with average life expectancy among them going down about a third of a year.

Researchers looked at death data from the National Center for Health Statistics, the Human Mortality Database, and overseas statistical agencies. Life expectancy for 2021 was estimated “using a previously validated modeling method,” the study said.

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

The average life expectancy in the United States is expected to drop by 2.26 years from 2019 to 2021, the sharpest decrease during that time among high-income nations, according to a new study.

The study, published in medRxiv, said U.S. life expectancy went from 78.86 years in 2019 to 76.99 years in 2020, during the thick of the global COVID-19 pandemic. Though vaccines were widely available in 2021, the U.S. life expectancy was expected to keep going down, to 76.60 years.

In “peer countries” – Austria, Belgium, Denmark, England and Wales, Finland, France, Germany, Israel, Italy, the Netherlands, New Zealand, Northern Ireland, Norway, Portugal, Scotland, South Korea, Spain, Sweden, and Switzerland – life expectancy went down only 0.57 years from 2019 to 2020 and increased by 0.28 years in 2021, the study said. The peer countries now have a life expectancy that’s 5 years longer than in the United States.

“The fact the U.S. lost so many more lives than other high-income countries speaks not only to how we managed the pandemic, but also to more deeply rooted problems that predated the pandemic,” said Steven H. Woolf, MD, one of the study authors and a professor of family medicine and population health at Virginia Commonwealth University, Richmond, according to Reuters.

“U.S. life expectancy has been falling behind other countries since the 1980s, and the gap has widened over time, especially in the last decade.”

Lack of universal health care, income and educational inequality, and less-healthy physical and social environments helped lead to the decline in American life expectancy, according to Dr. Woolf.

The life expectancy drop from 2019 to 2020 hit Black and Hispanic people hardest, according to the study. But the drop from 2020 to 2021 affected White people the most, with average life expectancy among them going down about a third of a year.

Researchers looked at death data from the National Center for Health Statistics, the Human Mortality Database, and overseas statistical agencies. Life expectancy for 2021 was estimated “using a previously validated modeling method,” the study said.

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

The average life expectancy in the United States is expected to drop by 2.26 years from 2019 to 2021, the sharpest decrease during that time among high-income nations, according to a new study.

The study, published in medRxiv, said U.S. life expectancy went from 78.86 years in 2019 to 76.99 years in 2020, during the thick of the global COVID-19 pandemic. Though vaccines were widely available in 2021, the U.S. life expectancy was expected to keep going down, to 76.60 years.

In “peer countries” – Austria, Belgium, Denmark, England and Wales, Finland, France, Germany, Israel, Italy, the Netherlands, New Zealand, Northern Ireland, Norway, Portugal, Scotland, South Korea, Spain, Sweden, and Switzerland – life expectancy went down only 0.57 years from 2019 to 2020 and increased by 0.28 years in 2021, the study said. The peer countries now have a life expectancy that’s 5 years longer than in the United States.

“The fact the U.S. lost so many more lives than other high-income countries speaks not only to how we managed the pandemic, but also to more deeply rooted problems that predated the pandemic,” said Steven H. Woolf, MD, one of the study authors and a professor of family medicine and population health at Virginia Commonwealth University, Richmond, according to Reuters.

“U.S. life expectancy has been falling behind other countries since the 1980s, and the gap has widened over time, especially in the last decade.”

Lack of universal health care, income and educational inequality, and less-healthy physical and social environments helped lead to the decline in American life expectancy, according to Dr. Woolf.

The life expectancy drop from 2019 to 2020 hit Black and Hispanic people hardest, according to the study. But the drop from 2020 to 2021 affected White people the most, with average life expectancy among them going down about a third of a year.

Researchers looked at death data from the National Center for Health Statistics, the Human Mortality Database, and overseas statistical agencies. Life expectancy for 2021 was estimated “using a previously validated modeling method,” the study said.

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

What are the most common organisms that cause chorioamnionitis and puerperal endometritis?

Continue to the answer...

Chorioamnionitis and puerperal endometritis are polymicrobial, mixed aerobic-anaerobic infections. The dominant organisms are anaerobic gram-negative bacilli (Bacteroides and Prevotella species); anaerobic gram-positive cocci (Peptococcus species and Peptostreptococcus species); aerobic gram-negative bacilli (principally, Escherichia coli, Klebsiella pneumoniae, and Proteus species); and aerobic gram-positive cocci (enterococci, staphylococci, and group B streptococci).

What are the most common organisms that cause chorioamnionitis and puerperal endometritis?

Continue to the answer...

Chorioamnionitis and puerperal endometritis are polymicrobial, mixed aerobic-anaerobic infections. The dominant organisms are anaerobic gram-negative bacilli (Bacteroides and Prevotella species); anaerobic gram-positive cocci (Peptococcus species and Peptostreptococcus species); aerobic gram-negative bacilli (principally, Escherichia coli, Klebsiella pneumoniae, and Proteus species); and aerobic gram-positive cocci (enterococci, staphylococci, and group B streptococci).

What are the most common organisms that cause chorioamnionitis and puerperal endometritis?

Continue to the answer...

Chorioamnionitis and puerperal endometritis are polymicrobial, mixed aerobic-anaerobic infections. The dominant organisms are anaerobic gram-negative bacilli (Bacteroides and Prevotella species); anaerobic gram-positive cocci (Peptococcus species and Peptostreptococcus species); aerobic gram-negative bacilli (principally, Escherichia coli, Klebsiella pneumoniae, and Proteus species); and aerobic gram-positive cocci (enterococci, staphylococci, and group B streptococci).

Heart rate variability (HRV), as assessed during a deep breathing test, may lead to improved diagnosis of post-traumatic stress disorder, according to a study published in Frontiers in Psychiatry.

It is estimated that between 8% and 15% of clinically recognized pregnancies and up to 30% of all pregnancies result in miscarriage – a loss that can be devastating for everyone. There are limited data on the strength of the association between perinatal loss and subsequent common mental health disorders, such as anxiety, depression, and PTSD. The prevalence of PTSD among this group is still unknown, and one of the factors that contribute to the absence of data is that diagnostic evaluation is subjective.

To address this issue, researchers from Anhembi Morumbi University (UAM) in São José dos Campos, Brazil, along with teams in the United States and United Arab Emirates (UAE), investigated biomarkers for the severity of PTSD. The hope is that the research will enable psychiatrists to assess women who experience pregnancy loss more objectively. Study author Ovidiu Constantin Baltatu, MD, PhD, a professor at Brazil’s UAM and the UAE’s Khalifa University, spoke to this news organization about the study.

Under the guidance of Dr. Baltatu, psychologist Cláudia de Faria Cardoso carried out the research as part of her studies in biomedical engineering at UAM. Fifty-three women were recruited; the average age of the cohort was 33 years. All participants had a history of at least one perinatal loss. Pregnancy loss intervals ranged from less than 40 days to more than 6 months.

Participants completed a clinical interview and a questionnaire; PTSD symptoms were assessed on the basis of criteria in the DSM-5. The instrument used for the assessment was the Brazilian version of the Post-traumatic Stress Disorder Checklist (PCL-5). In addition, to evaluate general autonomic dysfunction, patients completed the Composite Autonomic Symptom Score 31 (COMPASS-31) questionnaire.

HRV was assessed during a deep breathing test using an HRV scanner system with wireless electrocardiography that enabled real-time data analysis and visualization. The investigators examined the following HRV measures: standard deviation (SD) of normal R-R wave intervals (SDNN), square root of the mean of the sum of the squares of differences between adjacent normal R wave intervals, and the number of all R-R intervals in which the change in consecutive normal sinus intervals exceeds 50 ms divided by the total number of R-R intervals measured.

Of the 53 participants, 25 had been diagnosed with pregnancy loss–induced PTSD. The results indicated a significant association between PCL-5 scores and HRV indices. The SDNN index effectively distinguished between patients with PTSD and those without.

To Dr. Baltatu, HRV indices reflect dysfunction of the autonomic nervous system (ANS), one of the major neural pathways activated by stress.

Although the deep breathing test has been around for a long time, it’s not widely used in current clinical practice, he said. According to him, maximum and minimum heart rates during breathing at six cycles per minute can typically be used to calculate the inspiratory-to-expiratory ratio, thus providing an indication of ANS function. “Our group introduced the study of HRV during deep breathing test, which is a step forward,” he said.

The methodology used by the team was well received by the participants. “With the deep breathing test, the women were able to look at a screen and see real-time graphics displaying the stress that they were experiencing after having suffered trauma. This visualization of objective measures was perceived as an improved care,” said Dr. Baltatu.

In general, HRV provides a more objective means of diagnosing PTSD. “Normally, PTSD is assessed through a questionnaire and an interview with psychologists,” said Dr. Baltatu. The subjectivity of the assessment is one of the main factors associated with the underdiagnosis of this condition, he explained.

It is important to remember that other factors, such as a lack of awareness about the problem, also hinder the diagnosis of PTSD in this population, Dr. Baltatu added. Women who have had a miscarriage often don’t think that their symptoms may result from PTSD. This fact highlights why it is so important that hospitals have a clinical psychologist on staff. In addition, Dr. Baltatu pointed out that a woman who experiences a pregnancy loss usually has negative memories of the hospital and is therefore reluctant to reach out for professional help. “In our study, all psychological care and assessments took place outside of a hospital setting, which the participants seemed to appreciate,” he emphasized.

Dr. Baltatu and his team are conducting follow-up research. The preliminary results indicate that the biomarkers identified in the study are promising in the assessment of patients’ clinical progress. This finding may reflect the fact that the HRV indices have proven useful not only in diagnosing but also in monitoring women in treatment, because they are able to identify which patients are responding better to treatment.

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

Heart rate variability (HRV), as assessed during a deep breathing test, may lead to improved diagnosis of post-traumatic stress disorder, according to a study published in Frontiers in Psychiatry.

It is estimated that between 8% and 15% of clinically recognized pregnancies and up to 30% of all pregnancies result in miscarriage – a loss that can be devastating for everyone. There are limited data on the strength of the association between perinatal loss and subsequent common mental health disorders, such as anxiety, depression, and PTSD. The prevalence of PTSD among this group is still unknown, and one of the factors that contribute to the absence of data is that diagnostic evaluation is subjective.

To address this issue, researchers from Anhembi Morumbi University (UAM) in São José dos Campos, Brazil, along with teams in the United States and United Arab Emirates (UAE), investigated biomarkers for the severity of PTSD. The hope is that the research will enable psychiatrists to assess women who experience pregnancy loss more objectively. Study author Ovidiu Constantin Baltatu, MD, PhD, a professor at Brazil’s UAM and the UAE’s Khalifa University, spoke to this news organization about the study.

Under the guidance of Dr. Baltatu, psychologist Cláudia de Faria Cardoso carried out the research as part of her studies in biomedical engineering at UAM. Fifty-three women were recruited; the average age of the cohort was 33 years. All participants had a history of at least one perinatal loss. Pregnancy loss intervals ranged from less than 40 days to more than 6 months.

Participants completed a clinical interview and a questionnaire; PTSD symptoms were assessed on the basis of criteria in the DSM-5. The instrument used for the assessment was the Brazilian version of the Post-traumatic Stress Disorder Checklist (PCL-5). In addition, to evaluate general autonomic dysfunction, patients completed the Composite Autonomic Symptom Score 31 (COMPASS-31) questionnaire.

HRV was assessed during a deep breathing test using an HRV scanner system with wireless electrocardiography that enabled real-time data analysis and visualization. The investigators examined the following HRV measures: standard deviation (SD) of normal R-R wave intervals (SDNN), square root of the mean of the sum of the squares of differences between adjacent normal R wave intervals, and the number of all R-R intervals in which the change in consecutive normal sinus intervals exceeds 50 ms divided by the total number of R-R intervals measured.

Of the 53 participants, 25 had been diagnosed with pregnancy loss–induced PTSD. The results indicated a significant association between PCL-5 scores and HRV indices. The SDNN index effectively distinguished between patients with PTSD and those without.

To Dr. Baltatu, HRV indices reflect dysfunction of the autonomic nervous system (ANS), one of the major neural pathways activated by stress.

Although the deep breathing test has been around for a long time, it’s not widely used in current clinical practice, he said. According to him, maximum and minimum heart rates during breathing at six cycles per minute can typically be used to calculate the inspiratory-to-expiratory ratio, thus providing an indication of ANS function. “Our group introduced the study of HRV during deep breathing test, which is a step forward,” he said.

The methodology used by the team was well received by the participants. “With the deep breathing test, the women were able to look at a screen and see real-time graphics displaying the stress that they were experiencing after having suffered trauma. This visualization of objective measures was perceived as an improved care,” said Dr. Baltatu.

In general, HRV provides a more objective means of diagnosing PTSD. “Normally, PTSD is assessed through a questionnaire and an interview with psychologists,” said Dr. Baltatu. The subjectivity of the assessment is one of the main factors associated with the underdiagnosis of this condition, he explained.

It is important to remember that other factors, such as a lack of awareness about the problem, also hinder the diagnosis of PTSD in this population, Dr. Baltatu added. Women who have had a miscarriage often don’t think that their symptoms may result from PTSD. This fact highlights why it is so important that hospitals have a clinical psychologist on staff. In addition, Dr. Baltatu pointed out that a woman who experiences a pregnancy loss usually has negative memories of the hospital and is therefore reluctant to reach out for professional help. “In our study, all psychological care and assessments took place outside of a hospital setting, which the participants seemed to appreciate,” he emphasized.

Dr. Baltatu and his team are conducting follow-up research. The preliminary results indicate that the biomarkers identified in the study are promising in the assessment of patients’ clinical progress. This finding may reflect the fact that the HRV indices have proven useful not only in diagnosing but also in monitoring women in treatment, because they are able to identify which patients are responding better to treatment.

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

Heart rate variability (HRV), as assessed during a deep breathing test, may lead to improved diagnosis of post-traumatic stress disorder, according to a study published in Frontiers in Psychiatry.

It is estimated that between 8% and 15% of clinically recognized pregnancies and up to 30% of all pregnancies result in miscarriage – a loss that can be devastating for everyone. There are limited data on the strength of the association between perinatal loss and subsequent common mental health disorders, such as anxiety, depression, and PTSD. The prevalence of PTSD among this group is still unknown, and one of the factors that contribute to the absence of data is that diagnostic evaluation is subjective.

To address this issue, researchers from Anhembi Morumbi University (UAM) in São José dos Campos, Brazil, along with teams in the United States and United Arab Emirates (UAE), investigated biomarkers for the severity of PTSD. The hope is that the research will enable psychiatrists to assess women who experience pregnancy loss more objectively. Study author Ovidiu Constantin Baltatu, MD, PhD, a professor at Brazil’s UAM and the UAE’s Khalifa University, spoke to this news organization about the study.

Under the guidance of Dr. Baltatu, psychologist Cláudia de Faria Cardoso carried out the research as part of her studies in biomedical engineering at UAM. Fifty-three women were recruited; the average age of the cohort was 33 years. All participants had a history of at least one perinatal loss. Pregnancy loss intervals ranged from less than 40 days to more than 6 months.

Participants completed a clinical interview and a questionnaire; PTSD symptoms were assessed on the basis of criteria in the DSM-5. The instrument used for the assessment was the Brazilian version of the Post-traumatic Stress Disorder Checklist (PCL-5). In addition, to evaluate general autonomic dysfunction, patients completed the Composite Autonomic Symptom Score 31 (COMPASS-31) questionnaire.

HRV was assessed during a deep breathing test using an HRV scanner system with wireless electrocardiography that enabled real-time data analysis and visualization. The investigators examined the following HRV measures: standard deviation (SD) of normal R-R wave intervals (SDNN), square root of the mean of the sum of the squares of differences between adjacent normal R wave intervals, and the number of all R-R intervals in which the change in consecutive normal sinus intervals exceeds 50 ms divided by the total number of R-R intervals measured.

Of the 53 participants, 25 had been diagnosed with pregnancy loss–induced PTSD. The results indicated a significant association between PCL-5 scores and HRV indices. The SDNN index effectively distinguished between patients with PTSD and those without.

To Dr. Baltatu, HRV indices reflect dysfunction of the autonomic nervous system (ANS), one of the major neural pathways activated by stress.

Although the deep breathing test has been around for a long time, it’s not widely used in current clinical practice, he said. According to him, maximum and minimum heart rates during breathing at six cycles per minute can typically be used to calculate the inspiratory-to-expiratory ratio, thus providing an indication of ANS function. “Our group introduced the study of HRV during deep breathing test, which is a step forward,” he said.

The methodology used by the team was well received by the participants. “With the deep breathing test, the women were able to look at a screen and see real-time graphics displaying the stress that they were experiencing after having suffered trauma. This visualization of objective measures was perceived as an improved care,” said Dr. Baltatu.

In general, HRV provides a more objective means of diagnosing PTSD. “Normally, PTSD is assessed through a questionnaire and an interview with psychologists,” said Dr. Baltatu. The subjectivity of the assessment is one of the main factors associated with the underdiagnosis of this condition, he explained.

It is important to remember that other factors, such as a lack of awareness about the problem, also hinder the diagnosis of PTSD in this population, Dr. Baltatu added. Women who have had a miscarriage often don’t think that their symptoms may result from PTSD. This fact highlights why it is so important that hospitals have a clinical psychologist on staff. In addition, Dr. Baltatu pointed out that a woman who experiences a pregnancy loss usually has negative memories of the hospital and is therefore reluctant to reach out for professional help. “In our study, all psychological care and assessments took place outside of a hospital setting, which the participants seemed to appreciate,” he emphasized.

Dr. Baltatu and his team are conducting follow-up research. The preliminary results indicate that the biomarkers identified in the study are promising in the assessment of patients’ clinical progress. This finding may reflect the fact that the HRV indices have proven useful not only in diagnosing but also in monitoring women in treatment, because they are able to identify which patients are responding better to treatment.

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

In a recent article published in JAMA Psychiatry, Joshua E. J. Buckman and coauthors described the results of a large research study which concludes that depression is harder to treat in those who are homeless or unemployed.

It is always good to get more data and this article adds to the literature about the social determinants of depression. A frustrating aspect is that this is no surprise at all, not least for anyone in the mental health field. We have known that intuitively for decades.

Again, data is always good to bolster intuition with science. But what are the actionable items to take from the paper?

Homelessness and unemployment are things very hard to fix and the millions of homeless in one of the richest countries of the world illustrate the many complexities. However, there are a few policy and clinical points I would like to make, reflecting some of the chapters in a recently published book – edited by me and my colleague Maria D. Llorente – “Clinical Management of the Homeless Patient: Social Medical and Psychiatric Issues” (New York: Springer, May 2021).

The first is, if you really tackle homelessness, with a combination of federal, state, and local resources, you can make a difference. The Department of Veterans Affairs, under the leadership of former VA Secretary Eric Shinseki and others, has been markedly successful. Note, for instance, the Health Care for Homeless Veterans program , which conducts outreach to vulnerable veterans not currently receiving services and engages them in treatment and rehabilitative programs.

Secondly, there is a marked absence of shelters that can care for the homeless with medical problems. This leads to extended and extensive hospital stays. This is especially frustrating during the COVID era, when hospital beds are in such short supply. Having a safe place to discharge patients who still need wound or diabetes care would save money for the overall health care system and be best for the patient.

Third, it may be best to modify discharge regimens for those patients who are unhoused. For example, metformin, taken by mouth once a day, is more practical for unhoused patients with diabetes than insulin, which needs to be refrigerated and injected multiple times a day. While one can argue whether care for the homeless should differ from those who are housed, in practical terms, simplifying regimens is more likely to promote compliance.

My last take-home point is check the Feet. So many of our homeless patients who end up on hospital wards have been wearing ill-fitting or no shoes while they are out on the street. Their toenails may be long and thick. They may have cellulitis or ulcers. Or gangrene. Unfortunately, these medical issues can also cause surgical amputations of the lower extremities.

Back to the article by Buckman and colleagues. The data they provide is good to have. But we need more action to provide appropriate and compassionate care for those who are unhoused and ill – care that is good for them, good for the nation’s finances, and good for our moral standing in the world.

Dr. Ritchie is chair of psychiatry at Medstar Washington (D.C.) Hospital Center. She is a member of the Clinical Psychiatry News editorial advisory board, and has no conflicts of interest.

In a recent article published in JAMA Psychiatry, Joshua E. J. Buckman and coauthors described the results of a large research study which concludes that depression is harder to treat in those who are homeless or unemployed.

It is always good to get more data and this article adds to the literature about the social determinants of depression. A frustrating aspect is that this is no surprise at all, not least for anyone in the mental health field. We have known that intuitively for decades.

Again, data is always good to bolster intuition with science. But what are the actionable items to take from the paper?

Homelessness and unemployment are things very hard to fix and the millions of homeless in one of the richest countries of the world illustrate the many complexities. However, there are a few policy and clinical points I would like to make, reflecting some of the chapters in a recently published book – edited by me and my colleague Maria D. Llorente – “Clinical Management of the Homeless Patient: Social Medical and Psychiatric Issues” (New York: Springer, May 2021).

The first is, if you really tackle homelessness, with a combination of federal, state, and local resources, you can make a difference. The Department of Veterans Affairs, under the leadership of former VA Secretary Eric Shinseki and others, has been markedly successful. Note, for instance, the Health Care for Homeless Veterans program , which conducts outreach to vulnerable veterans not currently receiving services and engages them in treatment and rehabilitative programs.

Secondly, there is a marked absence of shelters that can care for the homeless with medical problems. This leads to extended and extensive hospital stays. This is especially frustrating during the COVID era, when hospital beds are in such short supply. Having a safe place to discharge patients who still need wound or diabetes care would save money for the overall health care system and be best for the patient.

Third, it may be best to modify discharge regimens for those patients who are unhoused. For example, metformin, taken by mouth once a day, is more practical for unhoused patients with diabetes than insulin, which needs to be refrigerated and injected multiple times a day. While one can argue whether care for the homeless should differ from those who are housed, in practical terms, simplifying regimens is more likely to promote compliance.

My last take-home point is check the Feet. So many of our homeless patients who end up on hospital wards have been wearing ill-fitting or no shoes while they are out on the street. Their toenails may be long and thick. They may have cellulitis or ulcers. Or gangrene. Unfortunately, these medical issues can also cause surgical amputations of the lower extremities.

Back to the article by Buckman and colleagues. The data they provide is good to have. But we need more action to provide appropriate and compassionate care for those who are unhoused and ill – care that is good for them, good for the nation’s finances, and good for our moral standing in the world.

Dr. Ritchie is chair of psychiatry at Medstar Washington (D.C.) Hospital Center. She is a member of the Clinical Psychiatry News editorial advisory board, and has no conflicts of interest.

In a recent article published in JAMA Psychiatry, Joshua E. J. Buckman and coauthors described the results of a large research study which concludes that depression is harder to treat in those who are homeless or unemployed.

It is always good to get more data and this article adds to the literature about the social determinants of depression. A frustrating aspect is that this is no surprise at all, not least for anyone in the mental health field. We have known that intuitively for decades.

Again, data is always good to bolster intuition with science. But what are the actionable items to take from the paper?

Homelessness and unemployment are things very hard to fix and the millions of homeless in one of the richest countries of the world illustrate the many complexities. However, there are a few policy and clinical points I would like to make, reflecting some of the chapters in a recently published book – edited by me and my colleague Maria D. Llorente – “Clinical Management of the Homeless Patient: Social Medical and Psychiatric Issues” (New York: Springer, May 2021).

The first is, if you really tackle homelessness, with a combination of federal, state, and local resources, you can make a difference. The Department of Veterans Affairs, under the leadership of former VA Secretary Eric Shinseki and others, has been markedly successful. Note, for instance, the Health Care for Homeless Veterans program , which conducts outreach to vulnerable veterans not currently receiving services and engages them in treatment and rehabilitative programs.

Secondly, there is a marked absence of shelters that can care for the homeless with medical problems. This leads to extended and extensive hospital stays. This is especially frustrating during the COVID era, when hospital beds are in such short supply. Having a safe place to discharge patients who still need wound or diabetes care would save money for the overall health care system and be best for the patient.

Third, it may be best to modify discharge regimens for those patients who are unhoused. For example, metformin, taken by mouth once a day, is more practical for unhoused patients with diabetes than insulin, which needs to be refrigerated and injected multiple times a day. While one can argue whether care for the homeless should differ from those who are housed, in practical terms, simplifying regimens is more likely to promote compliance.

My last take-home point is check the Feet. So many of our homeless patients who end up on hospital wards have been wearing ill-fitting or no shoes while they are out on the street. Their toenails may be long and thick. They may have cellulitis or ulcers. Or gangrene. Unfortunately, these medical issues can also cause surgical amputations of the lower extremities.

Back to the article by Buckman and colleagues. The data they provide is good to have. But we need more action to provide appropriate and compassionate care for those who are unhoused and ill – care that is good for them, good for the nation’s finances, and good for our moral standing in the world.

Dr. Ritchie is chair of psychiatry at Medstar Washington (D.C.) Hospital Center. She is a member of the Clinical Psychiatry News editorial advisory board, and has no conflicts of interest.

At least one in four adults worldwide is thought to have nonalcoholic fatty liver disease, a major risk factor for cardiovascular disease (CVD), which is the leading cause of death in NAFLD, but the condition is widely underdiagnosed, according to a new American Heart Association scientific statement on NAFLD and cardiovascular risks.

The statement, published in Arteriosclerosis, Thrombosis, and Vascular Biology, aims to increase awareness of NAFLD among cardiologists and other clinicians treating vulnerable patients. It pulls together the existing evidence for using imaging to diagnose NAFLD as well as the role of current and emerging treatments for managing the disease.

“NAFLD is common, but most patients are undiagnosed,” statement writing committee chair P. Barton Duell, MD, said in an interview. “The identification of normal liver enzyme levels does not exclude the diagnosis of NAFLD. Early diagnosis and treatment are necessary to improve the health of patients with established NAFLD, as well as preventing the development of NAFLD in patients who are at risk for the condition.”

Dr. Duell is a professor at the Knight Cardiovascular Institute and division of endocrinology, diabetes and clinical nutrition at Oregon Health & Science University, Portland.

This is the AHA’s first scientific statement on NAFLD. In 2021, the association issued a statement on obesity and CVD). Also in 2021, a multiorganization group headed by the American Gastroenterological Association published a “Call to Action” on nonalcoholic steatohepatitis (NASH) , a form of NAFLD that’s characterized by inflammation and scarring of the liver, and typically requires a liver biopsy for diagnosis.

Key take-homes

The AHA statement on NAFLD is sweeping. Among its key take-home messages:

• Calling into question the effectiveness of AST and ALT testing for diagnosing NAFLD and NASH.
• Providing context to the role of insulin resistance – either with or without diabetes – as well as obesity (particularly visceral adiposity), metabolic syndrome, and dyslipidemia in NAFLD.
• Advocating for lifestyle interventions – diet, exercise, weight loss and alcohol avoidance – as the key therapeutic intervention for NAFLD.
• Asserting that glucagonlike peptide–1 receptor agonists may modestly improve NAFLD.

The statement also tackles the differences in terminology different organizations use to describe NAFLD. “The terminology section is important to ensure everyone is using the right terminology in assessing patients, as well as choosing appropriate treatment interventions,” Dr. Duell said.

The statement also explores genetic factors that can predispose people to NAFLD, Dr. Duell pointed out, and it goes into detail about strategies for screening NAFLD and NASH. “It is not possible to diagnose NAFLD without understanding the pros and cons of various screening modalities, as well as the lack of sensitivity of some tests for detection of NAFLD We hope this information will increase success in screening for and early identification of NAFLD.”

Dr. Duell explained the rationale for issuing the statement. “Rates of NAFLD are increasing worldwide in association with rising rates of elevated body mass index and the metabolic syndrome, but the condition is commonly undiagnosed,” he said. “This allows patients to experience progression of disease, leading to hepatic and cardiovascular complications.” 

Avoiding NAFLD risk factors along with early diagnosis and treatment “may have the potential to mitigate long-term complications from NAFLD,” Dr. Duell said.

“This is one of first times where we really look at cardiovascular risks associated with NAFLD and pinpoint the risk factors, the imaging tools that can be used for diagnosing fatty liver disease, and ultimately what potential treatments we can consider,” Tiffany M. Powell-Wiley, MD, MPH, author of the AHA statement on obesity and CV risk, said in an interview.

“NAFLD has not been at the forefront of  cardiologists’ minds, but this statement highlights the importance of liver fat as a fat depot,” said Dr. Powell-Wiley, chief of the Social Determinants of Obesity and Cardiovascular Risk Laboratory at the National Heart, Lung, and Blood Institute in Bethesda, Md.

“It does provide greater clarity for us as cardiologists, especially when thinking about what is required for diagnosis and ultimately how this relates to cardiovascular disease for people with fatty liver disease,” she said.

Dr. Duell and Dr. Powell-Wiley have no relevant relationships to disclose.


 

At least one in four adults worldwide is thought to have nonalcoholic fatty liver disease, a major risk factor for cardiovascular disease (CVD), which is the leading cause of death in NAFLD, but the condition is widely underdiagnosed, according to a new American Heart Association scientific statement on NAFLD and cardiovascular risks.

The statement, published in Arteriosclerosis, Thrombosis, and Vascular Biology, aims to increase awareness of NAFLD among cardiologists and other clinicians treating vulnerable patients. It pulls together the existing evidence for using imaging to diagnose NAFLD as well as the role of current and emerging treatments for managing the disease.

“NAFLD is common, but most patients are undiagnosed,” statement writing committee chair P. Barton Duell, MD, said in an interview. “The identification of normal liver enzyme levels does not exclude the diagnosis of NAFLD. Early diagnosis and treatment are necessary to improve the health of patients with established NAFLD, as well as preventing the development of NAFLD in patients who are at risk for the condition.”

Dr. Duell is a professor at the Knight Cardiovascular Institute and division of endocrinology, diabetes and clinical nutrition at Oregon Health & Science University, Portland.

This is the AHA’s first scientific statement on NAFLD. In 2021, the association issued a statement on obesity and CVD). Also in 2021, a multiorganization group headed by the American Gastroenterological Association published a “Call to Action” on nonalcoholic steatohepatitis (NASH) , a form of NAFLD that’s characterized by inflammation and scarring of the liver, and typically requires a liver biopsy for diagnosis.

Key take-homes

The AHA statement on NAFLD is sweeping. Among its key take-home messages:

• Calling into question the effectiveness of AST and ALT testing for diagnosing NAFLD and NASH.
• Providing context to the role of insulin resistance – either with or without diabetes – as well as obesity (particularly visceral adiposity), metabolic syndrome, and dyslipidemia in NAFLD.
• Advocating for lifestyle interventions – diet, exercise, weight loss and alcohol avoidance – as the key therapeutic intervention for NAFLD.
• Asserting that glucagonlike peptide–1 receptor agonists may modestly improve NAFLD.

The statement also tackles the differences in terminology different organizations use to describe NAFLD. “The terminology section is important to ensure everyone is using the right terminology in assessing patients, as well as choosing appropriate treatment interventions,” Dr. Duell said.

The statement also explores genetic factors that can predispose people to NAFLD, Dr. Duell pointed out, and it goes into detail about strategies for screening NAFLD and NASH. “It is not possible to diagnose NAFLD without understanding the pros and cons of various screening modalities, as well as the lack of sensitivity of some tests for detection of NAFLD We hope this information will increase success in screening for and early identification of NAFLD.”

Dr. Duell explained the rationale for issuing the statement. “Rates of NAFLD are increasing worldwide in association with rising rates of elevated body mass index and the metabolic syndrome, but the condition is commonly undiagnosed,” he said. “This allows patients to experience progression of disease, leading to hepatic and cardiovascular complications.” 

Avoiding NAFLD risk factors along with early diagnosis and treatment “may have the potential to mitigate long-term complications from NAFLD,” Dr. Duell said.

“This is one of first times where we really look at cardiovascular risks associated with NAFLD and pinpoint the risk factors, the imaging tools that can be used for diagnosing fatty liver disease, and ultimately what potential treatments we can consider,” Tiffany M. Powell-Wiley, MD, MPH, author of the AHA statement on obesity and CV risk, said in an interview.

“NAFLD has not been at the forefront of  cardiologists’ minds, but this statement highlights the importance of liver fat as a fat depot,” said Dr. Powell-Wiley, chief of the Social Determinants of Obesity and Cardiovascular Risk Laboratory at the National Heart, Lung, and Blood Institute in Bethesda, Md.

“It does provide greater clarity for us as cardiologists, especially when thinking about what is required for diagnosis and ultimately how this relates to cardiovascular disease for people with fatty liver disease,” she said.

Dr. Duell and Dr. Powell-Wiley have no relevant relationships to disclose.


 

At least one in four adults worldwide is thought to have nonalcoholic fatty liver disease, a major risk factor for cardiovascular disease (CVD), which is the leading cause of death in NAFLD, but the condition is widely underdiagnosed, according to a new American Heart Association scientific statement on NAFLD and cardiovascular risks.

The statement, published in Arteriosclerosis, Thrombosis, and Vascular Biology, aims to increase awareness of NAFLD among cardiologists and other clinicians treating vulnerable patients. It pulls together the existing evidence for using imaging to diagnose NAFLD as well as the role of current and emerging treatments for managing the disease.

“NAFLD is common, but most patients are undiagnosed,” statement writing committee chair P. Barton Duell, MD, said in an interview. “The identification of normal liver enzyme levels does not exclude the diagnosis of NAFLD. Early diagnosis and treatment are necessary to improve the health of patients with established NAFLD, as well as preventing the development of NAFLD in patients who are at risk for the condition.”

Dr. Duell is a professor at the Knight Cardiovascular Institute and division of endocrinology, diabetes and clinical nutrition at Oregon Health & Science University, Portland.

This is the AHA’s first scientific statement on NAFLD. In 2021, the association issued a statement on obesity and CVD). Also in 2021, a multiorganization group headed by the American Gastroenterological Association published a “Call to Action” on nonalcoholic steatohepatitis (NASH) , a form of NAFLD that’s characterized by inflammation and scarring of the liver, and typically requires a liver biopsy for diagnosis.

Key take-homes

The AHA statement on NAFLD is sweeping. Among its key take-home messages:

• Calling into question the effectiveness of AST and ALT testing for diagnosing NAFLD and NASH.
• Providing context to the role of insulin resistance – either with or without diabetes – as well as obesity (particularly visceral adiposity), metabolic syndrome, and dyslipidemia in NAFLD.
• Advocating for lifestyle interventions – diet, exercise, weight loss and alcohol avoidance – as the key therapeutic intervention for NAFLD.
• Asserting that glucagonlike peptide–1 receptor agonists may modestly improve NAFLD.

The statement also tackles the differences in terminology different organizations use to describe NAFLD. “The terminology section is important to ensure everyone is using the right terminology in assessing patients, as well as choosing appropriate treatment interventions,” Dr. Duell said.

The statement also explores genetic factors that can predispose people to NAFLD, Dr. Duell pointed out, and it goes into detail about strategies for screening NAFLD and NASH. “It is not possible to diagnose NAFLD without understanding the pros and cons of various screening modalities, as well as the lack of sensitivity of some tests for detection of NAFLD We hope this information will increase success in screening for and early identification of NAFLD.”

Dr. Duell explained the rationale for issuing the statement. “Rates of NAFLD are increasing worldwide in association with rising rates of elevated body mass index and the metabolic syndrome, but the condition is commonly undiagnosed,” he said. “This allows patients to experience progression of disease, leading to hepatic and cardiovascular complications.” 

Avoiding NAFLD risk factors along with early diagnosis and treatment “may have the potential to mitigate long-term complications from NAFLD,” Dr. Duell said.

“This is one of first times where we really look at cardiovascular risks associated with NAFLD and pinpoint the risk factors, the imaging tools that can be used for diagnosing fatty liver disease, and ultimately what potential treatments we can consider,” Tiffany M. Powell-Wiley, MD, MPH, author of the AHA statement on obesity and CV risk, said in an interview.

“NAFLD has not been at the forefront of  cardiologists’ minds, but this statement highlights the importance of liver fat as a fat depot,” said Dr. Powell-Wiley, chief of the Social Determinants of Obesity and Cardiovascular Risk Laboratory at the National Heart, Lung, and Blood Institute in Bethesda, Md.

“It does provide greater clarity for us as cardiologists, especially when thinking about what is required for diagnosis and ultimately how this relates to cardiovascular disease for people with fatty liver disease,” she said.

Dr. Duell and Dr. Powell-Wiley have no relevant relationships to disclose.


 

It is a great honor and privilege to care for the men and women who have bravely served our country, and to give a hero’s Final Salute in recognition of the veteran’s service and sacrifices. US Department of Veterans Affairs (VA) and other non-VA health care facilities caring for veterans find meaning and take pride in providing a Final Salute to veterans who spend their last days of life at their facilities. The Final Salute aligns with the mission of the VA: To fulfill President Lincoln’s promise “To care for him who shall have borne the battle, and for his widow, and his orphan” by serving and honoring the people who are America’s veterans.¹ As health care professionals, we feel and grieve the loss when a veteran dies within our facilities. While some VA and community health care facilities honor veterans at the time of death, others have yet to implement a Final Salute program.² How can we ensure that veterans at the time of death receive a hero’s Final Salute?

There are 26 million veterans alive today, representing about 8% of the total US adult population.³ Yet more than 1800 veterans die every day, representing about a quarter of all US deaths.^4,5 Most veterans die in the community; only 4% of veteran deaths occur in VA facilities.^5,6 This article highlights the unique tradition that a few VA and community health care facilities have launched to honor veterans whose journeys end under their care. This article also is a call to action to raise awareness of the importance of instituting the Final Salute program that is part of the end-of-life protocol for veterans.

A Final Salute ceremony (also called Honors Escort or Honor Walk) takes place when a veteran who dies in the hospital or nursing home is transported on the gurney from the location of their passing to the funeral home vehicle or the morgue. Staff, family members, visitors, and other veterans silently line the hallways from the veteran’s room to the health care facility exit and pay their respects to the deceased veteran. A Final Salute is a quiet, yet profound and powerful way for care teams to ensure that the deceased veteran does not leave alone.

VA-Based Ceremonies

There are many acts of remembrance at the bedside from the time of death to the time when the veteran’s body approaches the funeral home vehicle or the doors of the morgue. Tonya Ross, social worker and Honors Escort program manager at the Robert J. Dole VA Medical Center (VAMC) in Wichita, Kansas, reported that following the death of a veteran, there is a bedside remembrance that begins with a flag ceremony. Afterward, the veteran’s gurney is draped with the American flag, and as the procession moves through the medical center, the veterans salute, and all others place their hands over their hearts

Chaplain Michael Halyard at the Ozarks VAMC in Fayetteville, Arkansas, reported that following the death of a veteran, the chaplain greets family members with condolences and allows them to grieve and reflect on their life with the deceased veteran. On arrival of the funeral home team, an announcement for an Honor Walk is made. Staff, visitors, and family are lined up on the first floor of the hospital waiting to pay their final respects to the veteran. A slow processional of the veteran covered by a handmade quilt is escorted by a VA police officer and the chaplain. The processional stops in the middle and the chaplain announces, “Let us pause for a moment of silence as we honor one of our own US Army veterans who has completed the journey of life.”

The Final Salute at the VA Wilkes-Barre Community Living Center (CLC) in Pennsylvania begins with a bedside flag ceremony. Afterward, the veteran’s gurney is draped with the flag, and as the procession moves through the CLC, all who are standing along the route offer their respects. Throughout the ceremony, a team member remains with the family of the deceased, providing comfort and support. Once the ceremony is completed, the team member remains with the family to ensure all issues are addressed and all questions or concerns are answered.

Residents of the Philadelphia VAMC CLC in Pennsylvania have found a way to say a last goodbye to fellow veterans in a unique and dignified manner. Bettyanne Corkery, nurse manager for the Heroes’ Crossing hospice and palliative care unit explains, “Our Honor Guard evolved from our residents’ requests. We used to drape a flag over the body of veterans leaving us for the last time, but our residents came to us and said they wanted to do more.” CLC residents wanted to form an Honor Guard and say goodbye with dignity and grace. Gerry Donlon, a US Army Vietnam veteran and president of the residents council and chief program coordinator, explained that Honor Guard members are called to the deceased’s room and stand guard until the hearse comes. Donlon adds, “We proceed forward, along with the family, and the speaker system for the hospital plays patriotic songs, including Taps. When we get to the lobby, we stop, and I say a prayer. We fold the flag military style and hand it over to the family members, we render a Final Salute, and then the veteran is taken to the hearse.”⁷

Community Cermeonies

Texas Health Arlington Memorial Hospital (THAM) has honored 531 veterans with Final Salutes since 2015. Before the official procession begins, designated employees drape the patient’s body with the flag. Physicians, nurses, and volunteers escort the body in a silent procession along with the family. On leaving, the veteran’s family receives the flag in honor of their loved one. A specially designed medallion has been placed in the lobby floor at the location where the Final Salute is rendered. Christi Evans, RN, BSN, ACM, manager for care
coordination at AnMed Health, Anderson, South Carolina, witnessed a Final Salute at THAM for a relative and took the idea to Mike Johnston, Director of Spiritual Care to establish the program at AnMed Health, which has provided 118 Final Salutes since 2018.

Central Maine Healthcare (CMH), which operates 3 hospitals, provides 2 ceremonies. The Final Salute occurs prior to the veteran’s passing and the Honor Walk gathers hospital personnel outside the patient’s room as they are moved. During the Final Salute, with the approval of a veteran’s family, a veteran employed by CMF presents the veteran with a folded flag and certificate and thanks them for their service and hospital employee salute. After the veteran dies, staff members gather in the hallway for the Honor Walk. Ascension Sacred Heart (ASH), Florida, where on average 260 veterans look for treatment every month, has taken the Final Salute to all 4 of their hospitals. Sabrina Granese, BSN, RN, Military Service Line Director at ASH explains, “Patients that are active duty or veterans are identified at the time of admission. When a veteran passes away, with the approval of a veteran’s family, ‘Code veteran’ will be heard over the hospital intercom. Staff members will have 5 minutes to make their way to the main hospital entrance for the Honor Walk.” Similarly, the skilled nursing facilities operated by Bethesda Health Group, St. Louis, Missouri, have implemented the Veteran Escort Ceremony. Employees, volunteers, family members, and residents line the hallways during the procession to salute and honor the passing of the veteran’s body.

Closure For Families

Simple yet magnificent, a Final Salute shows that a veteran is “gone but not forgotten” and also shows families they are not alone as they too made sacrifices to allow their loved ones to serve in the Armed Forces; it signals the hope of healing and closure.⁸ “The staff came to pay their respects,” recalled Cindy Roberts, a social worker at the VA Bay Pines, when her relative died at the Ozarks VAMC. She explained, I wasn’t expecting as much because it was 2 AM. I have never in my life had an experience like that. I wish there were words to describe it; I wish every VAMC in the country did that.”

Hope Danishanko, social worker at the VA Wilkes-Barre CLC, said veterans are appreciative of the program. “I have had many CLC residents tell me that the Honors Escort allows them to have closure. They also feel it provides respect to the veteran who has passed.”

Bettyanne Corkery noted that the Philadelphia CLC Honor Guard program is unique because it is veteran driven. “They have sessions in which they talk about what works and what doesn’t, and they recruit new volunteers themselves,” she said. “It has evolved into the most beautiful ceremony, and they are constantly tweaking it.” According to Gerry Donlon, “When you see all 8 members of the Honor Guard get a call at 2 AM, and everyone shows up, you know there’s personal satisfaction. I’d like to see every CLC [throughout VA] do this. I really would.”⁷

“Family members tell us they feel blessed and honored to be a part of the program. They are so grateful for the way we pay tribute to their veteran loved one,” says Leslie Schaeffer, support services manager and bereavement coordinator and coordinator of the Veteran Escort Ceremony at Bethesda Health Group communities.

Privileged and humbled—that is how staff and family members describe feeling after participating in a Final Salute. Its impact on the families has been amazing. Between the tears, there are thanks for the recognition of the sacrifices their loved ones made. When one family was informed of the ceremony by Reverend Tricia Lytle, Manager of Spiritual Care at AnMed Health, the “whole family responded by explaining how much that meant at such a difficult time. They began sharing stories about his service and how proud he was to be a veteran,” she reported. “As I [Rev. Lytle] leaned over to present the flag at the bedside, the wife reached up and took hold as she tearfully accepted it and embraced it close to her heart. The staff in the hallway looked on respectfully also in tears.”

Conclusions

The Final Salute is a brief ceremonial procession demonstrating that the mission to care for America’s veterans does not end at the bedside. It ensures that no veteran’s body is alone when led out of the health facility room to the exit. With these Final Salute practices, I hope that the rest of VA and community health facilities caring for veterans will implement a Final Salute program to better honor veterans who depart in their care.

Acknowledgments
The author would like to express gratitude to everyone who so openly shared their stories—your insight, advice, and encouragement are inspiring and invaluable. Thank you to all the facilities that consented to be featured in this article.

It is a great honor and privilege to care for the men and women who have bravely served our country, and to give a hero’s Final Salute in recognition of the veteran’s service and sacrifices. US Department of Veterans Affairs (VA) and other non-VA health care facilities caring for veterans find meaning and take pride in providing a Final Salute to veterans who spend their last days of life at their facilities. The Final Salute aligns with the mission of the VA: To fulfill President Lincoln’s promise “To care for him who shall have borne the battle, and for his widow, and his orphan” by serving and honoring the people who are America’s veterans.¹ As health care professionals, we feel and grieve the loss when a veteran dies within our facilities. While some VA and community health care facilities honor veterans at the time of death, others have yet to implement a Final Salute program.² How can we ensure that veterans at the time of death receive a hero’s Final Salute?

There are 26 million veterans alive today, representing about 8% of the total US adult population.³ Yet more than 1800 veterans die every day, representing about a quarter of all US deaths.^4,5 Most veterans die in the community; only 4% of veteran deaths occur in VA facilities.^5,6 This article highlights the unique tradition that a few VA and community health care facilities have launched to honor veterans whose journeys end under their care. This article also is a call to action to raise awareness of the importance of instituting the Final Salute program that is part of the end-of-life protocol for veterans.

A Final Salute ceremony (also called Honors Escort or Honor Walk) takes place when a veteran who dies in the hospital or nursing home is transported on the gurney from the location of their passing to the funeral home vehicle or the morgue. Staff, family members, visitors, and other veterans silently line the hallways from the veteran’s room to the health care facility exit and pay their respects to the deceased veteran. A Final Salute is a quiet, yet profound and powerful way for care teams to ensure that the deceased veteran does not leave alone.

VA-Based Ceremonies

There are many acts of remembrance at the bedside from the time of death to the time when the veteran’s body approaches the funeral home vehicle or the doors of the morgue. Tonya Ross, social worker and Honors Escort program manager at the Robert J. Dole VA Medical Center (VAMC) in Wichita, Kansas, reported that following the death of a veteran, there is a bedside remembrance that begins with a flag ceremony. Afterward, the veteran’s gurney is draped with the American flag, and as the procession moves through the medical center, the veterans salute, and all others place their hands over their hearts

Chaplain Michael Halyard at the Ozarks VAMC in Fayetteville, Arkansas, reported that following the death of a veteran, the chaplain greets family members with condolences and allows them to grieve and reflect on their life with the deceased veteran. On arrival of the funeral home team, an announcement for an Honor Walk is made. Staff, visitors, and family are lined up on the first floor of the hospital waiting to pay their final respects to the veteran. A slow processional of the veteran covered by a handmade quilt is escorted by a VA police officer and the chaplain. The processional stops in the middle and the chaplain announces, “Let us pause for a moment of silence as we honor one of our own US Army veterans who has completed the journey of life.”

The Final Salute at the VA Wilkes-Barre Community Living Center (CLC) in Pennsylvania begins with a bedside flag ceremony. Afterward, the veteran’s gurney is draped with the flag, and as the procession moves through the CLC, all who are standing along the route offer their respects. Throughout the ceremony, a team member remains with the family of the deceased, providing comfort and support. Once the ceremony is completed, the team member remains with the family to ensure all issues are addressed and all questions or concerns are answered.

Residents of the Philadelphia VAMC CLC in Pennsylvania have found a way to say a last goodbye to fellow veterans in a unique and dignified manner. Bettyanne Corkery, nurse manager for the Heroes’ Crossing hospice and palliative care unit explains, “Our Honor Guard evolved from our residents’ requests. We used to drape a flag over the body of veterans leaving us for the last time, but our residents came to us and said they wanted to do more.” CLC residents wanted to form an Honor Guard and say goodbye with dignity and grace. Gerry Donlon, a US Army Vietnam veteran and president of the residents council and chief program coordinator, explained that Honor Guard members are called to the deceased’s room and stand guard until the hearse comes. Donlon adds, “We proceed forward, along with the family, and the speaker system for the hospital plays patriotic songs, including Taps. When we get to the lobby, we stop, and I say a prayer. We fold the flag military style and hand it over to the family members, we render a Final Salute, and then the veteran is taken to the hearse.”⁷

Community Cermeonies

Texas Health Arlington Memorial Hospital (THAM) has honored 531 veterans with Final Salutes since 2015. Before the official procession begins, designated employees drape the patient’s body with the flag. Physicians, nurses, and volunteers escort the body in a silent procession along with the family. On leaving, the veteran’s family receives the flag in honor of their loved one. A specially designed medallion has been placed in the lobby floor at the location where the Final Salute is rendered. Christi Evans, RN, BSN, ACM, manager for care
coordination at AnMed Health, Anderson, South Carolina, witnessed a Final Salute at THAM for a relative and took the idea to Mike Johnston, Director of Spiritual Care to establish the program at AnMed Health, which has provided 118 Final Salutes since 2018.

Central Maine Healthcare (CMH), which operates 3 hospitals, provides 2 ceremonies. The Final Salute occurs prior to the veteran’s passing and the Honor Walk gathers hospital personnel outside the patient’s room as they are moved. During the Final Salute, with the approval of a veteran’s family, a veteran employed by CMF presents the veteran with a folded flag and certificate and thanks them for their service and hospital employee salute. After the veteran dies, staff members gather in the hallway for the Honor Walk. Ascension Sacred Heart (ASH), Florida, where on average 260 veterans look for treatment every month, has taken the Final Salute to all 4 of their hospitals. Sabrina Granese, BSN, RN, Military Service Line Director at ASH explains, “Patients that are active duty or veterans are identified at the time of admission. When a veteran passes away, with the approval of a veteran’s family, ‘Code veteran’ will be heard over the hospital intercom. Staff members will have 5 minutes to make their way to the main hospital entrance for the Honor Walk.” Similarly, the skilled nursing facilities operated by Bethesda Health Group, St. Louis, Missouri, have implemented the Veteran Escort Ceremony. Employees, volunteers, family members, and residents line the hallways during the procession to salute and honor the passing of the veteran’s body.

Closure For Families

Simple yet magnificent, a Final Salute shows that a veteran is “gone but not forgotten” and also shows families they are not alone as they too made sacrifices to allow their loved ones to serve in the Armed Forces; it signals the hope of healing and closure.⁸ “The staff came to pay their respects,” recalled Cindy Roberts, a social worker at the VA Bay Pines, when her relative died at the Ozarks VAMC. She explained, I wasn’t expecting as much because it was 2 AM. I have never in my life had an experience like that. I wish there were words to describe it; I wish every VAMC in the country did that.”

Hope Danishanko, social worker at the VA Wilkes-Barre CLC, said veterans are appreciative of the program. “I have had many CLC residents tell me that the Honors Escort allows them to have closure. They also feel it provides respect to the veteran who has passed.”

Bettyanne Corkery noted that the Philadelphia CLC Honor Guard program is unique because it is veteran driven. “They have sessions in which they talk about what works and what doesn’t, and they recruit new volunteers themselves,” she said. “It has evolved into the most beautiful ceremony, and they are constantly tweaking it.” According to Gerry Donlon, “When you see all 8 members of the Honor Guard get a call at 2 AM, and everyone shows up, you know there’s personal satisfaction. I’d like to see every CLC [throughout VA] do this. I really would.”⁷

“Family members tell us they feel blessed and honored to be a part of the program. They are so grateful for the way we pay tribute to their veteran loved one,” says Leslie Schaeffer, support services manager and bereavement coordinator and coordinator of the Veteran Escort Ceremony at Bethesda Health Group communities.

Privileged and humbled—that is how staff and family members describe feeling after participating in a Final Salute. Its impact on the families has been amazing. Between the tears, there are thanks for the recognition of the sacrifices their loved ones made. When one family was informed of the ceremony by Reverend Tricia Lytle, Manager of Spiritual Care at AnMed Health, the “whole family responded by explaining how much that meant at such a difficult time. They began sharing stories about his service and how proud he was to be a veteran,” she reported. “As I [Rev. Lytle] leaned over to present the flag at the bedside, the wife reached up and took hold as she tearfully accepted it and embraced it close to her heart. The staff in the hallway looked on respectfully also in tears.”

Conclusions

The Final Salute is a brief ceremonial procession demonstrating that the mission to care for America’s veterans does not end at the bedside. It ensures that no veteran’s body is alone when led out of the health facility room to the exit. With these Final Salute practices, I hope that the rest of VA and community health facilities caring for veterans will implement a Final Salute program to better honor veterans who depart in their care.

Acknowledgments
The author would like to express gratitude to everyone who so openly shared their stories—your insight, advice, and encouragement are inspiring and invaluable. Thank you to all the facilities that consented to be featured in this article.

It is a great honor and privilege to care for the men and women who have bravely served our country, and to give a hero’s Final Salute in recognition of the veteran’s service and sacrifices. US Department of Veterans Affairs (VA) and other non-VA health care facilities caring for veterans find meaning and take pride in providing a Final Salute to veterans who spend their last days of life at their facilities. The Final Salute aligns with the mission of the VA: To fulfill President Lincoln’s promise “To care for him who shall have borne the battle, and for his widow, and his orphan” by serving and honoring the people who are America’s veterans.¹ As health care professionals, we feel and grieve the loss when a veteran dies within our facilities. While some VA and community health care facilities honor veterans at the time of death, others have yet to implement a Final Salute program.² How can we ensure that veterans at the time of death receive a hero’s Final Salute?

There are 26 million veterans alive today, representing about 8% of the total US adult population.³ Yet more than 1800 veterans die every day, representing about a quarter of all US deaths.^4,5 Most veterans die in the community; only 4% of veteran deaths occur in VA facilities.^5,6 This article highlights the unique tradition that a few VA and community health care facilities have launched to honor veterans whose journeys end under their care. This article also is a call to action to raise awareness of the importance of instituting the Final Salute program that is part of the end-of-life protocol for veterans.

A Final Salute ceremony (also called Honors Escort or Honor Walk) takes place when a veteran who dies in the hospital or nursing home is transported on the gurney from the location of their passing to the funeral home vehicle or the morgue. Staff, family members, visitors, and other veterans silently line the hallways from the veteran’s room to the health care facility exit and pay their respects to the deceased veteran. A Final Salute is a quiet, yet profound and powerful way for care teams to ensure that the deceased veteran does not leave alone.

VA-Based Ceremonies

There are many acts of remembrance at the bedside from the time of death to the time when the veteran’s body approaches the funeral home vehicle or the doors of the morgue. Tonya Ross, social worker and Honors Escort program manager at the Robert J. Dole VA Medical Center (VAMC) in Wichita, Kansas, reported that following the death of a veteran, there is a bedside remembrance that begins with a flag ceremony. Afterward, the veteran’s gurney is draped with the American flag, and as the procession moves through the medical center, the veterans salute, and all others place their hands over their hearts

Chaplain Michael Halyard at the Ozarks VAMC in Fayetteville, Arkansas, reported that following the death of a veteran, the chaplain greets family members with condolences and allows them to grieve and reflect on their life with the deceased veteran. On arrival of the funeral home team, an announcement for an Honor Walk is made. Staff, visitors, and family are lined up on the first floor of the hospital waiting to pay their final respects to the veteran. A slow processional of the veteran covered by a handmade quilt is escorted by a VA police officer and the chaplain. The processional stops in the middle and the chaplain announces, “Let us pause for a moment of silence as we honor one of our own US Army veterans who has completed the journey of life.”

The Final Salute at the VA Wilkes-Barre Community Living Center (CLC) in Pennsylvania begins with a bedside flag ceremony. Afterward, the veteran’s gurney is draped with the flag, and as the procession moves through the CLC, all who are standing along the route offer their respects. Throughout the ceremony, a team member remains with the family of the deceased, providing comfort and support. Once the ceremony is completed, the team member remains with the family to ensure all issues are addressed and all questions or concerns are answered.

Residents of the Philadelphia VAMC CLC in Pennsylvania have found a way to say a last goodbye to fellow veterans in a unique and dignified manner. Bettyanne Corkery, nurse manager for the Heroes’ Crossing hospice and palliative care unit explains, “Our Honor Guard evolved from our residents’ requests. We used to drape a flag over the body of veterans leaving us for the last time, but our residents came to us and said they wanted to do more.” CLC residents wanted to form an Honor Guard and say goodbye with dignity and grace. Gerry Donlon, a US Army Vietnam veteran and president of the residents council and chief program coordinator, explained that Honor Guard members are called to the deceased’s room and stand guard until the hearse comes. Donlon adds, “We proceed forward, along with the family, and the speaker system for the hospital plays patriotic songs, including Taps. When we get to the lobby, we stop, and I say a prayer. We fold the flag military style and hand it over to the family members, we render a Final Salute, and then the veteran is taken to the hearse.”⁷

Community Cermeonies

Texas Health Arlington Memorial Hospital (THAM) has honored 531 veterans with Final Salutes since 2015. Before the official procession begins, designated employees drape the patient’s body with the flag. Physicians, nurses, and volunteers escort the body in a silent procession along with the family. On leaving, the veteran’s family receives the flag in honor of their loved one. A specially designed medallion has been placed in the lobby floor at the location where the Final Salute is rendered. Christi Evans, RN, BSN, ACM, manager for care
coordination at AnMed Health, Anderson, South Carolina, witnessed a Final Salute at THAM for a relative and took the idea to Mike Johnston, Director of Spiritual Care to establish the program at AnMed Health, which has provided 118 Final Salutes since 2018.

Central Maine Healthcare (CMH), which operates 3 hospitals, provides 2 ceremonies. The Final Salute occurs prior to the veteran’s passing and the Honor Walk gathers hospital personnel outside the patient’s room as they are moved. During the Final Salute, with the approval of a veteran’s family, a veteran employed by CMF presents the veteran with a folded flag and certificate and thanks them for their service and hospital employee salute. After the veteran dies, staff members gather in the hallway for the Honor Walk. Ascension Sacred Heart (ASH), Florida, where on average 260 veterans look for treatment every month, has taken the Final Salute to all 4 of their hospitals. Sabrina Granese, BSN, RN, Military Service Line Director at ASH explains, “Patients that are active duty or veterans are identified at the time of admission. When a veteran passes away, with the approval of a veteran’s family, ‘Code veteran’ will be heard over the hospital intercom. Staff members will have 5 minutes to make their way to the main hospital entrance for the Honor Walk.” Similarly, the skilled nursing facilities operated by Bethesda Health Group, St. Louis, Missouri, have implemented the Veteran Escort Ceremony. Employees, volunteers, family members, and residents line the hallways during the procession to salute and honor the passing of the veteran’s body.

Closure For Families

Simple yet magnificent, a Final Salute shows that a veteran is “gone but not forgotten” and also shows families they are not alone as they too made sacrifices to allow their loved ones to serve in the Armed Forces; it signals the hope of healing and closure.⁸ “The staff came to pay their respects,” recalled Cindy Roberts, a social worker at the VA Bay Pines, when her relative died at the Ozarks VAMC. She explained, I wasn’t expecting as much because it was 2 AM. I have never in my life had an experience like that. I wish there were words to describe it; I wish every VAMC in the country did that.”

Hope Danishanko, social worker at the VA Wilkes-Barre CLC, said veterans are appreciative of the program. “I have had many CLC residents tell me that the Honors Escort allows them to have closure. They also feel it provides respect to the veteran who has passed.”

Bettyanne Corkery noted that the Philadelphia CLC Honor Guard program is unique because it is veteran driven. “They have sessions in which they talk about what works and what doesn’t, and they recruit new volunteers themselves,” she said. “It has evolved into the most beautiful ceremony, and they are constantly tweaking it.” According to Gerry Donlon, “When you see all 8 members of the Honor Guard get a call at 2 AM, and everyone shows up, you know there’s personal satisfaction. I’d like to see every CLC [throughout VA] do this. I really would.”⁷

“Family members tell us they feel blessed and honored to be a part of the program. They are so grateful for the way we pay tribute to their veteran loved one,” says Leslie Schaeffer, support services manager and bereavement coordinator and coordinator of the Veteran Escort Ceremony at Bethesda Health Group communities.

Privileged and humbled—that is how staff and family members describe feeling after participating in a Final Salute. Its impact on the families has been amazing. Between the tears, there are thanks for the recognition of the sacrifices their loved ones made. When one family was informed of the ceremony by Reverend Tricia Lytle, Manager of Spiritual Care at AnMed Health, the “whole family responded by explaining how much that meant at such a difficult time. They began sharing stories about his service and how proud he was to be a veteran,” she reported. “As I [Rev. Lytle] leaned over to present the flag at the bedside, the wife reached up and took hold as she tearfully accepted it and embraced it close to her heart. The staff in the hallway looked on respectfully also in tears.”

Conclusions

The Final Salute is a brief ceremonial procession demonstrating that the mission to care for America’s veterans does not end at the bedside. It ensures that no veteran’s body is alone when led out of the health facility room to the exit. With these Final Salute practices, I hope that the rest of VA and community health facilities caring for veterans will implement a Final Salute program to better honor veterans who depart in their care.

Acknowledgments
The author would like to express gratitude to everyone who so openly shared their stories—your insight, advice, and encouragement are inspiring and invaluable. Thank you to all the facilities that consented to be featured in this article.