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Childhood abuse may increase risk of MS in women
, according to the first prospective cohort study of its kind.
More research is needed to uncover underlying mechanisms of action, according to lead author Karine Eid, MD, a PhD candidate at Haukeland University Hospital, Bergen, Norway, and colleagues.
“Trauma and stressful life events have been associated with an increased risk of autoimmune disorders,” the investigators wrote in the Journal Of Neurology, Neurosurgery, & Psychiatry. “Whether adverse events in childhood can have an impact on MS susceptibility is not known.”
The present study recruited participants from the Norwegian Mother, Father and Child cohort, a population consisting of Norwegian women who were pregnant from 1999 to 2008. Of the 77,997 participating women, 14,477 reported emotional, sexual, and/or physical abuse in childhood, while the remaining 63,520 women reported no abuse. After a mean follow-up of 13 years, 300 women were diagnosed with MS, among whom 24% reported a history of childhood abuse, compared with 19% among women who did not develop MS.
To look for associations between childhood abuse and risk of MS, the investigators used a Cox model adjusted for confounders and mediators, including smoking, obesity, adult socioeconomic factors, and childhood social status. The model revealed that emotional abuse increased the risk of MS by 40% (hazard ratio [HR] 1.40; 95% confidence interval [CI], 1.03-1.90), and sexual abuse increased the risk of MS by 65% (HR 1.65; 95% CI, 1.13-2.39).
Although physical abuse alone did not significantly increase risk of MS (HR 1.31; 95% CI, 0.83-2.06), it did contribute to a dose-response relationship when women were exposed to more than one type of childhood abuse. Women exposed to two out of three abuse categories had a 66% increased risk of MS (HR 1.66; 95% CI, 1.04-2.67), whereas women exposed to all three types of abuse had the highest risk of MS, at 93% (HR 1.93; 95% CI, 1.02-3.67).
Dr. Eid and colleagues noted that their findings are supported by previous retrospective research, and discussed possible mechanisms of action.
“The increased risk of MS after exposure to childhood sexual and emotional abuse may have a biological explanation,” they wrote. “Childhood abuse can cause dysregulation of the hypothalamic-pituitary-adrenal axis, lead to oxidative stress, and induce a proinflammatory state decades into adulthood. Psychological stress has been shown to disrupt the blood-brain barrier and cause epigenetic changes that may increase the risk of neurodegenerative disorders, including MS.
“The underlying mechanisms behind this association should be investigated further,” they concluded.
Study findings should guide interventions
Commenting on the research, Ruth Ann Marrie, MD, PhD, professor of medicine and community health sciences and director of the multiple sclerosis clinic at Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, said that the present study “has several strengths compared to prior studies – including that it is prospective and the sample size.”
Dr. Marrie, who was not involved in the study, advised clinicians in the field to take note of the findings, as patients with a history of abuse may need unique interventions.
“Providers need to recognize the higher prevalence of childhood maltreatment in people with MS,” Dr. Marrie said in an interview. “These findings dovetail with others that suggest that adverse childhood experiences are associated with increased mental health concerns and pain catastrophizing in people with MS. Affected individuals may benefit from additional psychological supports and trauma-informed care.”
Tiffany Joy Braley, MD, associate professor of neurology, and Carri Polick, RN and PhD candidate at the school of nursing, University of Michigan, Ann Arbor, who published a case report last year highlighting the importance of evaluating stress exposure in MS, suggested that the findings should guide interventions at both a system and patient level.
“Although a cause-and-effect relationship cannot be established by the current study, these and related findings should be considered in the context of system level and policy interventions that address links between environment and health care disparities,” they said in a joint, written comment. “Given recent impetus to provide trauma-informed health care, these data could be particularly informative in neurological conditions which are associated with high mental health comorbidity. Traumatic stress screening practices could lead to referrals for appropriate support services and more personalized health care.”
While several mechanisms have been proposed to explain the link between traumatic stress and MS, more work is needed in this area, they added.
This knowledge gap was acknowledged by Dr. Marrie.
“Our understanding of the etiology of MS remains incomplete,” Dr. Marrie said. “We still need a better understanding of mechanisms by which adverse childhood experiences lead to MS, how they interact with other risk factors for MS (beyond smoking and obesity), and whether there are any interventions that can mitigate the risk of developing MS that is associated with adverse childhood experiences.”
The investigators disclosed relationships with Novartis, Biogen, Merck, and others. Dr. Marrie receives research support from the Canadian Institutes of Health Research, the National Multiple Sclerosis Society, MS Society of Canada, the Consortium of Multiple Sclerosis Centers, Crohn’s and Colitis Canada, Research Manitoba, and the Arthritis Society; she has no pharmaceutical support. Dr. Braley and Ms. Polick reported no conflicts of interest.
, according to the first prospective cohort study of its kind.
More research is needed to uncover underlying mechanisms of action, according to lead author Karine Eid, MD, a PhD candidate at Haukeland University Hospital, Bergen, Norway, and colleagues.
“Trauma and stressful life events have been associated with an increased risk of autoimmune disorders,” the investigators wrote in the Journal Of Neurology, Neurosurgery, & Psychiatry. “Whether adverse events in childhood can have an impact on MS susceptibility is not known.”
The present study recruited participants from the Norwegian Mother, Father and Child cohort, a population consisting of Norwegian women who were pregnant from 1999 to 2008. Of the 77,997 participating women, 14,477 reported emotional, sexual, and/or physical abuse in childhood, while the remaining 63,520 women reported no abuse. After a mean follow-up of 13 years, 300 women were diagnosed with MS, among whom 24% reported a history of childhood abuse, compared with 19% among women who did not develop MS.
To look for associations between childhood abuse and risk of MS, the investigators used a Cox model adjusted for confounders and mediators, including smoking, obesity, adult socioeconomic factors, and childhood social status. The model revealed that emotional abuse increased the risk of MS by 40% (hazard ratio [HR] 1.40; 95% confidence interval [CI], 1.03-1.90), and sexual abuse increased the risk of MS by 65% (HR 1.65; 95% CI, 1.13-2.39).
Although physical abuse alone did not significantly increase risk of MS (HR 1.31; 95% CI, 0.83-2.06), it did contribute to a dose-response relationship when women were exposed to more than one type of childhood abuse. Women exposed to two out of three abuse categories had a 66% increased risk of MS (HR 1.66; 95% CI, 1.04-2.67), whereas women exposed to all three types of abuse had the highest risk of MS, at 93% (HR 1.93; 95% CI, 1.02-3.67).
Dr. Eid and colleagues noted that their findings are supported by previous retrospective research, and discussed possible mechanisms of action.
“The increased risk of MS after exposure to childhood sexual and emotional abuse may have a biological explanation,” they wrote. “Childhood abuse can cause dysregulation of the hypothalamic-pituitary-adrenal axis, lead to oxidative stress, and induce a proinflammatory state decades into adulthood. Psychological stress has been shown to disrupt the blood-brain barrier and cause epigenetic changes that may increase the risk of neurodegenerative disorders, including MS.
“The underlying mechanisms behind this association should be investigated further,” they concluded.
Study findings should guide interventions
Commenting on the research, Ruth Ann Marrie, MD, PhD, professor of medicine and community health sciences and director of the multiple sclerosis clinic at Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, said that the present study “has several strengths compared to prior studies – including that it is prospective and the sample size.”
Dr. Marrie, who was not involved in the study, advised clinicians in the field to take note of the findings, as patients with a history of abuse may need unique interventions.
“Providers need to recognize the higher prevalence of childhood maltreatment in people with MS,” Dr. Marrie said in an interview. “These findings dovetail with others that suggest that adverse childhood experiences are associated with increased mental health concerns and pain catastrophizing in people with MS. Affected individuals may benefit from additional psychological supports and trauma-informed care.”
Tiffany Joy Braley, MD, associate professor of neurology, and Carri Polick, RN and PhD candidate at the school of nursing, University of Michigan, Ann Arbor, who published a case report last year highlighting the importance of evaluating stress exposure in MS, suggested that the findings should guide interventions at both a system and patient level.
“Although a cause-and-effect relationship cannot be established by the current study, these and related findings should be considered in the context of system level and policy interventions that address links between environment and health care disparities,” they said in a joint, written comment. “Given recent impetus to provide trauma-informed health care, these data could be particularly informative in neurological conditions which are associated with high mental health comorbidity. Traumatic stress screening practices could lead to referrals for appropriate support services and more personalized health care.”
While several mechanisms have been proposed to explain the link between traumatic stress and MS, more work is needed in this area, they added.
This knowledge gap was acknowledged by Dr. Marrie.
“Our understanding of the etiology of MS remains incomplete,” Dr. Marrie said. “We still need a better understanding of mechanisms by which adverse childhood experiences lead to MS, how they interact with other risk factors for MS (beyond smoking and obesity), and whether there are any interventions that can mitigate the risk of developing MS that is associated with adverse childhood experiences.”
The investigators disclosed relationships with Novartis, Biogen, Merck, and others. Dr. Marrie receives research support from the Canadian Institutes of Health Research, the National Multiple Sclerosis Society, MS Society of Canada, the Consortium of Multiple Sclerosis Centers, Crohn’s and Colitis Canada, Research Manitoba, and the Arthritis Society; she has no pharmaceutical support. Dr. Braley and Ms. Polick reported no conflicts of interest.
, according to the first prospective cohort study of its kind.
More research is needed to uncover underlying mechanisms of action, according to lead author Karine Eid, MD, a PhD candidate at Haukeland University Hospital, Bergen, Norway, and colleagues.
“Trauma and stressful life events have been associated with an increased risk of autoimmune disorders,” the investigators wrote in the Journal Of Neurology, Neurosurgery, & Psychiatry. “Whether adverse events in childhood can have an impact on MS susceptibility is not known.”
The present study recruited participants from the Norwegian Mother, Father and Child cohort, a population consisting of Norwegian women who were pregnant from 1999 to 2008. Of the 77,997 participating women, 14,477 reported emotional, sexual, and/or physical abuse in childhood, while the remaining 63,520 women reported no abuse. After a mean follow-up of 13 years, 300 women were diagnosed with MS, among whom 24% reported a history of childhood abuse, compared with 19% among women who did not develop MS.
To look for associations between childhood abuse and risk of MS, the investigators used a Cox model adjusted for confounders and mediators, including smoking, obesity, adult socioeconomic factors, and childhood social status. The model revealed that emotional abuse increased the risk of MS by 40% (hazard ratio [HR] 1.40; 95% confidence interval [CI], 1.03-1.90), and sexual abuse increased the risk of MS by 65% (HR 1.65; 95% CI, 1.13-2.39).
Although physical abuse alone did not significantly increase risk of MS (HR 1.31; 95% CI, 0.83-2.06), it did contribute to a dose-response relationship when women were exposed to more than one type of childhood abuse. Women exposed to two out of three abuse categories had a 66% increased risk of MS (HR 1.66; 95% CI, 1.04-2.67), whereas women exposed to all three types of abuse had the highest risk of MS, at 93% (HR 1.93; 95% CI, 1.02-3.67).
Dr. Eid and colleagues noted that their findings are supported by previous retrospective research, and discussed possible mechanisms of action.
“The increased risk of MS after exposure to childhood sexual and emotional abuse may have a biological explanation,” they wrote. “Childhood abuse can cause dysregulation of the hypothalamic-pituitary-adrenal axis, lead to oxidative stress, and induce a proinflammatory state decades into adulthood. Psychological stress has been shown to disrupt the blood-brain barrier and cause epigenetic changes that may increase the risk of neurodegenerative disorders, including MS.
“The underlying mechanisms behind this association should be investigated further,” they concluded.
Study findings should guide interventions
Commenting on the research, Ruth Ann Marrie, MD, PhD, professor of medicine and community health sciences and director of the multiple sclerosis clinic at Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, said that the present study “has several strengths compared to prior studies – including that it is prospective and the sample size.”
Dr. Marrie, who was not involved in the study, advised clinicians in the field to take note of the findings, as patients with a history of abuse may need unique interventions.
“Providers need to recognize the higher prevalence of childhood maltreatment in people with MS,” Dr. Marrie said in an interview. “These findings dovetail with others that suggest that adverse childhood experiences are associated with increased mental health concerns and pain catastrophizing in people with MS. Affected individuals may benefit from additional psychological supports and trauma-informed care.”
Tiffany Joy Braley, MD, associate professor of neurology, and Carri Polick, RN and PhD candidate at the school of nursing, University of Michigan, Ann Arbor, who published a case report last year highlighting the importance of evaluating stress exposure in MS, suggested that the findings should guide interventions at both a system and patient level.
“Although a cause-and-effect relationship cannot be established by the current study, these and related findings should be considered in the context of system level and policy interventions that address links between environment and health care disparities,” they said in a joint, written comment. “Given recent impetus to provide trauma-informed health care, these data could be particularly informative in neurological conditions which are associated with high mental health comorbidity. Traumatic stress screening practices could lead to referrals for appropriate support services and more personalized health care.”
While several mechanisms have been proposed to explain the link between traumatic stress and MS, more work is needed in this area, they added.
This knowledge gap was acknowledged by Dr. Marrie.
“Our understanding of the etiology of MS remains incomplete,” Dr. Marrie said. “We still need a better understanding of mechanisms by which adverse childhood experiences lead to MS, how they interact with other risk factors for MS (beyond smoking and obesity), and whether there are any interventions that can mitigate the risk of developing MS that is associated with adverse childhood experiences.”
The investigators disclosed relationships with Novartis, Biogen, Merck, and others. Dr. Marrie receives research support from the Canadian Institutes of Health Research, the National Multiple Sclerosis Society, MS Society of Canada, the Consortium of Multiple Sclerosis Centers, Crohn’s and Colitis Canada, Research Manitoba, and the Arthritis Society; she has no pharmaceutical support. Dr. Braley and Ms. Polick reported no conflicts of interest.
FROM THE JOURNAL OF NEUROLOGY, NEUROSURGERY, & PSYCHIATRY
Dr. Faith Fitzgerald was dedicated to her patients, students, and friends
Dr. Fitzgerald adopted this means of transportation to allow her to examine and talk to her patients, following a hip injury and surgery, which left her unable to do the amount of walking typically required to conduct rounds at a hospital.
Her colleague, Mark C. Henderson, MD, MACP, described Dr. Fitzgerald as being “extremely dedicated to each patient,” having taken care of many of them for decades. Her will to find a way to practice with severe physical limitations exemplified this dedication, said Dr. Henderson, who worked in the hospital alongside her, including handing over patients to her.
Dr. Fitzgerald died on Dec. 3, 2021, at 78 years, after working in a career spanning 6 decades, including actively practicing internal medicine at UC Davis Medical Center for 40 years.
Her career also included working as a medical educator, influencing several people interviewed for this story in that role, and advising the staff of Internal Medicine News for more than 3 decades.
“Faith Fitzgerald was an incredible teacher and mentor for so many people,” noted Robert H. Hopkins Jr., MD, who practices general internal medicine and med-peds at the University of Arkansans for Medical Sciences, Little Rock and is a member of the editorial advisory board of Internal Medicine News.
‘The patient and the next generation’ were always in mind
A contributor to Dr. Fitzgerald’s success as an educator was her dogged commitment to her patients, said Dr. Henderson, who is associate dean for admissions at the University of California, Davis, and professor and vice chair for education in the department of internal medicine. The latter of these positions was previously held by Dr. Fitzgerald.
“She always arrived early for hospital rounds, often waking up her patients,” he said. “She evolved this practice to be present before all the chaos of the day ensued and honestly to spend quality of time with patients.”
“She always had two things in mind: the patient and the next generation,” Dr. Henderson continued. “A lot of times, because she had seen the patients earlier in the morning, she knew where to focus the team she was training” and “she could show her students and residents all of these interesting findings.”
“It was a very efficient way of conducting bedside teaching,” he added.
Dr. Fitzgerald taught primarily in the department of internal medicine at UC Davis Health. She joined the faculty of that school in 1980. Her 38-year-long career there included serving as residency program director for nearly 20 years, chief of general medicine, vice chair for education, and the medical school’s first associate dean for humanities and bioethics.
Several people who knew Dr. Fitzgerald well also attributed her effectiveness as a teacher and a doctor to the kindness she showed all people no matter their background or station in life.
“Every patient she saw in clinic, she booked for an hour ‘til the day she left UC Davis,” noted Carmelina Raffetto, Dr. Fitzgerald’s closest friend and former administrative assistant, during UC Davis Health’s virtual memorial ceremony for Dr. Fitzgerald.
“Her patients all had her phone number, her pager. ... She loved teaching, she loved her patients, and she loved staff.
“She treated all of us equally. Whether you were in housekeeping or in the cafeteria, or if you were just walking down the hall, she had kind words and she never wanted anyone to feel that they weren’t’ special,” added Ms. Raffetto, who is currently executive director of the Northern California American College of Physicians chapter.
Throughout her career, she received over three dozen teaching awards, according to a statement from UC Davis. In 2002, for example, Dr. Fitzgerald received the Alpha Omega Alpha medical honor society’s Robert J. Glaser Award for providing medical students with an outstanding educational experience. Additional teaching awards included the American College of Physicians Distinguished Teacher Award, the California Medical Association Golden Apple Award and the UC San Francisco Gold Headed Cane.
She also received awards from UC Davis, including the Hibbard Williams Lifetime Achievement award, the Tupper Award for Excellence in Teaching and the UC Davis School of Medicine Golden Apple Award. She was also chosen as the UC Davis Senior Class Outstanding Clinical Teacher seven times and was named the Department of Medicine Distinguished Faculty Teacher on four separate occasions, the statement said.
Her early life and family
Dr. Fitzgerald was born in Boston on Sept. 24, 1943, and “knew from early childhood that she would be a physician,” according to her biography on Changing the Face of Medicine.
She completed undergraduate studies at the University of California, Santa Barbara. She graduated from the University of California, San Francisco, in 1969 and completed her residency in internal medicine at the same institution. In addition to teaching at UC Davis, Dr. Fitzgerald served as assistant professor of medicine at University of Michigan, Ann Arbor, for 2 years early in her career.
Dr. Fitzgerald is survived by her brother, Sean, and sister-in-law, Deborah Fitzgerald. Dr. Fitzgerald lived with and cared for her mother, Irene Fitzgerald – who passed away in 2005 – for more than a decade.
Dr. Fitzgerald asked for any donations in her memory to be used to establish scholarships for medical students with financial need, as she had been supported by scholarship money long ago while a student at the University of California. Donations to the Faith Fitzgerald, MD, Medical Student Scholarship Fund can be made here.
Dr. Fitzgerald adopted this means of transportation to allow her to examine and talk to her patients, following a hip injury and surgery, which left her unable to do the amount of walking typically required to conduct rounds at a hospital.
Her colleague, Mark C. Henderson, MD, MACP, described Dr. Fitzgerald as being “extremely dedicated to each patient,” having taken care of many of them for decades. Her will to find a way to practice with severe physical limitations exemplified this dedication, said Dr. Henderson, who worked in the hospital alongside her, including handing over patients to her.
Dr. Fitzgerald died on Dec. 3, 2021, at 78 years, after working in a career spanning 6 decades, including actively practicing internal medicine at UC Davis Medical Center for 40 years.
Her career also included working as a medical educator, influencing several people interviewed for this story in that role, and advising the staff of Internal Medicine News for more than 3 decades.
“Faith Fitzgerald was an incredible teacher and mentor for so many people,” noted Robert H. Hopkins Jr., MD, who practices general internal medicine and med-peds at the University of Arkansans for Medical Sciences, Little Rock and is a member of the editorial advisory board of Internal Medicine News.
‘The patient and the next generation’ were always in mind
A contributor to Dr. Fitzgerald’s success as an educator was her dogged commitment to her patients, said Dr. Henderson, who is associate dean for admissions at the University of California, Davis, and professor and vice chair for education in the department of internal medicine. The latter of these positions was previously held by Dr. Fitzgerald.
“She always arrived early for hospital rounds, often waking up her patients,” he said. “She evolved this practice to be present before all the chaos of the day ensued and honestly to spend quality of time with patients.”
“She always had two things in mind: the patient and the next generation,” Dr. Henderson continued. “A lot of times, because she had seen the patients earlier in the morning, she knew where to focus the team she was training” and “she could show her students and residents all of these interesting findings.”
“It was a very efficient way of conducting bedside teaching,” he added.
Dr. Fitzgerald taught primarily in the department of internal medicine at UC Davis Health. She joined the faculty of that school in 1980. Her 38-year-long career there included serving as residency program director for nearly 20 years, chief of general medicine, vice chair for education, and the medical school’s first associate dean for humanities and bioethics.
Several people who knew Dr. Fitzgerald well also attributed her effectiveness as a teacher and a doctor to the kindness she showed all people no matter their background or station in life.
“Every patient she saw in clinic, she booked for an hour ‘til the day she left UC Davis,” noted Carmelina Raffetto, Dr. Fitzgerald’s closest friend and former administrative assistant, during UC Davis Health’s virtual memorial ceremony for Dr. Fitzgerald.
“Her patients all had her phone number, her pager. ... She loved teaching, she loved her patients, and she loved staff.
“She treated all of us equally. Whether you were in housekeeping or in the cafeteria, or if you were just walking down the hall, she had kind words and she never wanted anyone to feel that they weren’t’ special,” added Ms. Raffetto, who is currently executive director of the Northern California American College of Physicians chapter.
Throughout her career, she received over three dozen teaching awards, according to a statement from UC Davis. In 2002, for example, Dr. Fitzgerald received the Alpha Omega Alpha medical honor society’s Robert J. Glaser Award for providing medical students with an outstanding educational experience. Additional teaching awards included the American College of Physicians Distinguished Teacher Award, the California Medical Association Golden Apple Award and the UC San Francisco Gold Headed Cane.
She also received awards from UC Davis, including the Hibbard Williams Lifetime Achievement award, the Tupper Award for Excellence in Teaching and the UC Davis School of Medicine Golden Apple Award. She was also chosen as the UC Davis Senior Class Outstanding Clinical Teacher seven times and was named the Department of Medicine Distinguished Faculty Teacher on four separate occasions, the statement said.
Her early life and family
Dr. Fitzgerald was born in Boston on Sept. 24, 1943, and “knew from early childhood that she would be a physician,” according to her biography on Changing the Face of Medicine.
She completed undergraduate studies at the University of California, Santa Barbara. She graduated from the University of California, San Francisco, in 1969 and completed her residency in internal medicine at the same institution. In addition to teaching at UC Davis, Dr. Fitzgerald served as assistant professor of medicine at University of Michigan, Ann Arbor, for 2 years early in her career.
Dr. Fitzgerald is survived by her brother, Sean, and sister-in-law, Deborah Fitzgerald. Dr. Fitzgerald lived with and cared for her mother, Irene Fitzgerald – who passed away in 2005 – for more than a decade.
Dr. Fitzgerald asked for any donations in her memory to be used to establish scholarships for medical students with financial need, as she had been supported by scholarship money long ago while a student at the University of California. Donations to the Faith Fitzgerald, MD, Medical Student Scholarship Fund can be made here.
Dr. Fitzgerald adopted this means of transportation to allow her to examine and talk to her patients, following a hip injury and surgery, which left her unable to do the amount of walking typically required to conduct rounds at a hospital.
Her colleague, Mark C. Henderson, MD, MACP, described Dr. Fitzgerald as being “extremely dedicated to each patient,” having taken care of many of them for decades. Her will to find a way to practice with severe physical limitations exemplified this dedication, said Dr. Henderson, who worked in the hospital alongside her, including handing over patients to her.
Dr. Fitzgerald died on Dec. 3, 2021, at 78 years, after working in a career spanning 6 decades, including actively practicing internal medicine at UC Davis Medical Center for 40 years.
Her career also included working as a medical educator, influencing several people interviewed for this story in that role, and advising the staff of Internal Medicine News for more than 3 decades.
“Faith Fitzgerald was an incredible teacher and mentor for so many people,” noted Robert H. Hopkins Jr., MD, who practices general internal medicine and med-peds at the University of Arkansans for Medical Sciences, Little Rock and is a member of the editorial advisory board of Internal Medicine News.
‘The patient and the next generation’ were always in mind
A contributor to Dr. Fitzgerald’s success as an educator was her dogged commitment to her patients, said Dr. Henderson, who is associate dean for admissions at the University of California, Davis, and professor and vice chair for education in the department of internal medicine. The latter of these positions was previously held by Dr. Fitzgerald.
“She always arrived early for hospital rounds, often waking up her patients,” he said. “She evolved this practice to be present before all the chaos of the day ensued and honestly to spend quality of time with patients.”
“She always had two things in mind: the patient and the next generation,” Dr. Henderson continued. “A lot of times, because she had seen the patients earlier in the morning, she knew where to focus the team she was training” and “she could show her students and residents all of these interesting findings.”
“It was a very efficient way of conducting bedside teaching,” he added.
Dr. Fitzgerald taught primarily in the department of internal medicine at UC Davis Health. She joined the faculty of that school in 1980. Her 38-year-long career there included serving as residency program director for nearly 20 years, chief of general medicine, vice chair for education, and the medical school’s first associate dean for humanities and bioethics.
Several people who knew Dr. Fitzgerald well also attributed her effectiveness as a teacher and a doctor to the kindness she showed all people no matter their background or station in life.
“Every patient she saw in clinic, she booked for an hour ‘til the day she left UC Davis,” noted Carmelina Raffetto, Dr. Fitzgerald’s closest friend and former administrative assistant, during UC Davis Health’s virtual memorial ceremony for Dr. Fitzgerald.
“Her patients all had her phone number, her pager. ... She loved teaching, she loved her patients, and she loved staff.
“She treated all of us equally. Whether you were in housekeeping or in the cafeteria, or if you were just walking down the hall, she had kind words and she never wanted anyone to feel that they weren’t’ special,” added Ms. Raffetto, who is currently executive director of the Northern California American College of Physicians chapter.
Throughout her career, she received over three dozen teaching awards, according to a statement from UC Davis. In 2002, for example, Dr. Fitzgerald received the Alpha Omega Alpha medical honor society’s Robert J. Glaser Award for providing medical students with an outstanding educational experience. Additional teaching awards included the American College of Physicians Distinguished Teacher Award, the California Medical Association Golden Apple Award and the UC San Francisco Gold Headed Cane.
She also received awards from UC Davis, including the Hibbard Williams Lifetime Achievement award, the Tupper Award for Excellence in Teaching and the UC Davis School of Medicine Golden Apple Award. She was also chosen as the UC Davis Senior Class Outstanding Clinical Teacher seven times and was named the Department of Medicine Distinguished Faculty Teacher on four separate occasions, the statement said.
Her early life and family
Dr. Fitzgerald was born in Boston on Sept. 24, 1943, and “knew from early childhood that she would be a physician,” according to her biography on Changing the Face of Medicine.
She completed undergraduate studies at the University of California, Santa Barbara. She graduated from the University of California, San Francisco, in 1969 and completed her residency in internal medicine at the same institution. In addition to teaching at UC Davis, Dr. Fitzgerald served as assistant professor of medicine at University of Michigan, Ann Arbor, for 2 years early in her career.
Dr. Fitzgerald is survived by her brother, Sean, and sister-in-law, Deborah Fitzgerald. Dr. Fitzgerald lived with and cared for her mother, Irene Fitzgerald – who passed away in 2005 – for more than a decade.
Dr. Fitzgerald asked for any donations in her memory to be used to establish scholarships for medical students with financial need, as she had been supported by scholarship money long ago while a student at the University of California. Donations to the Faith Fitzgerald, MD, Medical Student Scholarship Fund can be made here.
Cupping in dermatology
My inspiration to write about cupping this month stems from the perception that everyone seems to be talking about it, from a facialist who suggested it for me to a coworker who swears by cupping to treat her allergies. Cupping is by no means a novel procedure. Its use as a health therapy dates back thousands of years to ancient Egypt (1500 BCE), ancient Greece (described by Hippocrates), ancient Rome (described by the Greek physician Galen), China (during the Han dynasty, 206 BCE to 220 CE) and traditional Islamic culture.1 Over the past decade, the popularity of this ancient procedure has been increasing in the United States.1 Cupping has been applied as a remedy for various dermatologic and medical conditions, including herpes zoster, headaches, diminished appetite, maldigestion, abscess evacuation, narcolepsy, pain, fever, dysmenorrhea, and gout.1,2
Theories on the mechanism(s) of action
The practice of cupping is differentiated into dry and wet cupping.1,2 Traditionally, with dry cupping, a flame is applied to heat the air inside a thick glass cup (rather than the cup itself).1 The cup is placed on the skin surface, and negative pressure suctions the skin into the cup. Wet cupping differs mainly from dry cupping in that it involves blood-letting. Cups made of either silicone or glass of varying size and shapes are used. Modern adaptations to cupping include needle, herbal, and pulsatile cupping, as well as a “moving cupping” technique (vs. traditionally stationary cups).1
There are several theories, many of which are derived from the nondermatologic literature (that is, pain management), as to how cupping may deliver a clinical benefit. Some theories are based in scientific and medical principles, whereas other theories are more whimsical – specifically, that cupping draws out evil spirits.2 Studies of dry cupping have suggested that the procedure results in increased oxygenation of muscles via a local increase in oxygenated hemoglobin, which may help improve muscular activity and reduce pain.1 As theorized by Lowe in 2017, negative pressure exerted by dry cupping leads to stretching and dilation of capillaries, which increases blood flow.3 Wet cupping has been shown to increase heat shock protein 70 (HSP70) and beta-endorphin expression in rat models, which is thought to facilitate pain management.1 Removal of oxidants and reduction of reactive oxygen species in the blood is believed to be among the benefits of wet cupping.1
Cupping in general dermatology
While , as well as various inflammatory conditions.
Herpes zoster
In 2010, Cao et al. reported on their systematic review of wet cupping after completing searches of multiple databases (that is, PubMed, the Cochrane Library [Issue 3, 2008], China Network Knowledge Infrastructure, Chinese Scientific Journal Database, and Wan Fang Database). They identified eight randomized controlled trials involving 651 patients, with meta-analyses revealing that wet cupping performed better than medications in terms of the number of “cured” patients, number of patients with improved symptoms, and a lower incidence of postherpetic neuralgia. Wet cupping, in addition to medication, was also found to be superior to medication alone in multiple patients. The researchers concluded that wet cupping appears to effectively treat herpes zoster.4 However, the study failed to identify which medications were used to treat herpes zoster. In the United States, common medications for herpes zoster include acyclovir, valacyclovir, steroids, gabapentin, and other neuromodulators. Without knowing which medications were used, it is difficult to compare cupping to medication in terms of efficacy in treating herpes zoster.
Urticaria
Urticaria (hives) is an inflammatory skin condition that can be very uncomfortable for patients but often resolves without intervention within several months after onset. In 2001, Li and Ding reported on the treatment with cupping of 40 patients with urticaria. The cure rate among the treatment group was cited as 55%, compared with 30% in the control group, who were treated with a traditional Chinese remedy and an unidentified first-generation antihistamine.1,5 In 2020, Xiao et al. conducted a systematic review and meta-analysis of cupping therapy for patients with chronic urticaria. They identified 13 comparisons from 12 randomized controlled trials involving 842 subjects. The investigators found no significant differences between wet cupping and medication usage. They also found that cupping combined with antihistamine treatment was superior to antihistamines alone, and cupping therapy with acupuncture was more effective than acupuncture alone. The investigators did call for caution, citing the poor quality of the studies reviewed.6
It is important to note that it is difficult to attribute resolution of urticaria to the use of cupping given the self-resolution often associated with this condition. Antihistamines are the mainstay of therapy for urticaria, but in my personal experience, patients are not entirely satisfied with the level of symptom control with antihistamines alone and often search for alternative therapies to control the pesky hives and associated itch. In 2014, omalizumab (Xolair) was approved for treating chronic idiopathic urticaria, which has helped patients control symptoms of chronic idiopathic urticaria without needing to take antihistamines. There was no indication that the studies reviewed by Xiao et al. compared cupping against this new effective treatment. Therefore, these studies comparing cupping to medical management are outdated.
Acne, eczema, and psoriasis
Soliman’s 2018 review of cupping in dermatology included a few studies on these common cutaneous conditions. For instance, a 2013 single-blind prospective study by Xu et al. reported on the results of patients with moderate acne who received wet cupping (in the form of prickling bloodletting) twice weekly for 6 weeks.7 They reported that patients demonstrated improvement in the global acne grading system (GAGS) score by the end of the trial.1,7 Unfortunately, cupping was not compared with standard acne treatments (that is, benzoyl peroxide, topical and oral antibiotics, isotretinoin, topical retinoids, spironolactone).
In evaluating cupping for acute eczema, wet cupping was compared with oral loratadine and topical ointments in a 2007 study by Yao and Li. They divided 88 cases into treatment and control groups, with the former group (n = 46) receiving bloodletting puncturing and cupping and the control group (n = 42) receiving oral loratadine and topical Pairuisong (an herbal ointment used in Chinese medicine). The investigators observed no significant difference in total effective rates but a superior difference in the rates of responses that were considered “cured” and “markedly effective” in favor of the cupping treatment.1,8 However, a case report by Hon et al. has indicated that cupping therapy may be associated with more harm than benefit when used as an eczema treatment.1,9
In addition, it is important to note that the past 5 years have been gamechanging in the management of chronic eczema in terms of the array of novel and effective therapies (e.g., dupilumab and JAK inhibitors) and chronic moderate-to-severe eczema has become very treatable. Similarly, acute eczema is often successfully managed with topical steroids, calcineurin inhibitors, and emollients. As such, there is no compelling reason to consider an unproven treatment such as cupping.
In 2020, Xing et al. reviewed 16 randomized controlled trials assessing the use of “moving cupping” for plaque psoriasis, with 1,164 patients meeting inclusion criteria. Moving cupping was found to be significantly more effective than “no-moving” cupping therapy, and moving cupping, combined with medications, performed better than medications alone.10 None of the trials evaluated in this study included randomized controlled trials that compared patients using any of the more modern psoriasis medications, specifically biologics. And, again, the studies evaluated were not of the highest quality.
The data that support cupping, as summarized above, are based mostly on case reports, and strong double-blind prospective studies are lacking. Additionally, most of the studies cited gauged the efficacy of cupping using qualitative endpoints, rather than standardized quantitative endpoints and scales. Moreover, spontaneous remission of various dermatoses can occur, or they can improve over time, including acute eczema, psoriasis, and, especially, urticaria.
Adverse effects of cupping
Often alternative therapies are seen as “benign” and without adverse effects. However, complications can result from cupping. Trauma can be induced from the cupping itself by damaging superficial blood vessels and causing bruising.1,11 Blistering can also occur secondary to the suction effect, and the epidermal and dermal layers of the skin can be separated.1,11 Further, burns and discoloration have also been noted secondary to heat, trauma, and post inflammatory pigmentary changes.1,11 Another risk of cupping is the Koebner phenomenon, which occurs with psoriasis, with new lesions appearing in traumatized skin.12 Other adverse outcomes that have been reported with cupping include reactivation of herpes simplex virus secondary to skin trauma, iron deficiency anemia (secondary to blood loss), panniculitis, infections, and residual marks mistaken for signs of child abuse.1,11
Cupping in aesthetic dermatology
Facial cupping, a distinct practice from body cupping used to treat general dermatology conditions described previously, is also increasing in popularity. This practice is usually conducted in association with a facial or facial acupuncture by an aesthetician or other licensed professional. It can also be performed using at-home kits. The marketing claims for facial cupping cite improved tightening and contouring of facial skin, increased facial microcirculation and collagen synthesis, and enhanced lymphatic flow to aid with facial puffiness or swelling. One supposed mechanism for these benefits is that cupping increases blood flow. Interestingly, there was a 2020 animal study in which photoacoustic imaging of a mouse ear revealed increased temporary blood flow in the cupping microenvironment.13 Currently, however, there is no evidence in the English scientific literature that supports facial cupping. The benefits attributed to facial cupping for aesthetic purposes have emerged only in personal anecdotes. The temporary increase in blood flow may induce inflammation and swelling that adds volume to the face and temporarily diminishes wrinkles. However, this temporary plumpness may be associated with adverse effects, such as local trauma, irritation, bruising, postinflammatory pigmentary alteration, or even herpes reactivation. In my opinion, the possible adverse effects of cupping outweigh any potential benefit, especially given the insufficient evidence supporting the utility of cupping for cosmetic enhancement.
Summary
There is increasing interest among patients to incorporate complementary and alternative medicine – including the ancient tradition of cupping – in managing medical dermatologic conditions. However, current evidence supporting cupping as an effective therapeutic strategy is not strong, with most studies to date appearing to be of poor quality or not sufficiently convincing to displace standard therapies. Our medical strategies for managing chronic dermatologic conditions, particularly inflammatory disorders, continue to improve from both a safety and a proven efficacy standpoint. Therefore, I would not forgo medical management in favor of cupping. While cupping can be used as an adjunct therapy, I would caution patients about possible adverse side effects. In the aesthetic world, cupping is also gaining popularity, but this trend is also not supported by current evidence or studies, at least in the Western literature.
Dr. Goldman is a dermatologist in private practice in Miami and specializes in cosmetic and general dermatology. She practices at Baumann Cosmetic & Research Institute and is also opening a general dermatology practice. Write to her at [email protected] or message her on Instragram @DrChloeGoldman. Dr. Goldman receives compensation to create social media content for Replenix, a skin care company. She has no other disclosures.
References
1. Soliman Y et al. Acta Dermatovenerol Alp Pannonica Adriat. 2018 Jun;27(2):103-7.
2. França K and Lotti T. Advances in Integrative Dermatology. John Wiley & Sons, 2019.
3. Lowe DT. Complement Ther Clin Pract. 2017 Nov;29:162-8.
4.Cao H et al. Altern Ther Health Med. 2010 Nov-Dec;16(6):48-54.
5. Li L and Ding J. J Tradit Chin Med. 2001 Mar;21(1):37-8.
6. Xiao XJ et al. J Integr Med. 2020 Jul;18(4):303-12.
7. Xu J et al. J Tradit Chin Med. 2013 Dec;33(6):752-6.
8. Yao J et al. Zhongguo Zhen Jiu. 2007; Jun;27(6):424-6.
9. Hon KL et al. Case Rep Pediatr. 2013;2013:605829.
10. Xing M et al. Medicine (Baltimore). 2020 Oct 9;99(41):e22539.
11. Kim TH et al. Eur J Integr Med. 2014 Aug 1;6(4):434-40.
12. Vender R and Vender R. J Cutan Med Surg. 2015 May-Jun;19(3):320-2.
13. Zhou Y et al. Biomed Opt Express. 2020 Apr 6;11(5):2394-401.
This article was updated 4/25/22.
My inspiration to write about cupping this month stems from the perception that everyone seems to be talking about it, from a facialist who suggested it for me to a coworker who swears by cupping to treat her allergies. Cupping is by no means a novel procedure. Its use as a health therapy dates back thousands of years to ancient Egypt (1500 BCE), ancient Greece (described by Hippocrates), ancient Rome (described by the Greek physician Galen), China (during the Han dynasty, 206 BCE to 220 CE) and traditional Islamic culture.1 Over the past decade, the popularity of this ancient procedure has been increasing in the United States.1 Cupping has been applied as a remedy for various dermatologic and medical conditions, including herpes zoster, headaches, diminished appetite, maldigestion, abscess evacuation, narcolepsy, pain, fever, dysmenorrhea, and gout.1,2
Theories on the mechanism(s) of action
The practice of cupping is differentiated into dry and wet cupping.1,2 Traditionally, with dry cupping, a flame is applied to heat the air inside a thick glass cup (rather than the cup itself).1 The cup is placed on the skin surface, and negative pressure suctions the skin into the cup. Wet cupping differs mainly from dry cupping in that it involves blood-letting. Cups made of either silicone or glass of varying size and shapes are used. Modern adaptations to cupping include needle, herbal, and pulsatile cupping, as well as a “moving cupping” technique (vs. traditionally stationary cups).1
There are several theories, many of which are derived from the nondermatologic literature (that is, pain management), as to how cupping may deliver a clinical benefit. Some theories are based in scientific and medical principles, whereas other theories are more whimsical – specifically, that cupping draws out evil spirits.2 Studies of dry cupping have suggested that the procedure results in increased oxygenation of muscles via a local increase in oxygenated hemoglobin, which may help improve muscular activity and reduce pain.1 As theorized by Lowe in 2017, negative pressure exerted by dry cupping leads to stretching and dilation of capillaries, which increases blood flow.3 Wet cupping has been shown to increase heat shock protein 70 (HSP70) and beta-endorphin expression in rat models, which is thought to facilitate pain management.1 Removal of oxidants and reduction of reactive oxygen species in the blood is believed to be among the benefits of wet cupping.1
Cupping in general dermatology
While , as well as various inflammatory conditions.
Herpes zoster
In 2010, Cao et al. reported on their systematic review of wet cupping after completing searches of multiple databases (that is, PubMed, the Cochrane Library [Issue 3, 2008], China Network Knowledge Infrastructure, Chinese Scientific Journal Database, and Wan Fang Database). They identified eight randomized controlled trials involving 651 patients, with meta-analyses revealing that wet cupping performed better than medications in terms of the number of “cured” patients, number of patients with improved symptoms, and a lower incidence of postherpetic neuralgia. Wet cupping, in addition to medication, was also found to be superior to medication alone in multiple patients. The researchers concluded that wet cupping appears to effectively treat herpes zoster.4 However, the study failed to identify which medications were used to treat herpes zoster. In the United States, common medications for herpes zoster include acyclovir, valacyclovir, steroids, gabapentin, and other neuromodulators. Without knowing which medications were used, it is difficult to compare cupping to medication in terms of efficacy in treating herpes zoster.
Urticaria
Urticaria (hives) is an inflammatory skin condition that can be very uncomfortable for patients but often resolves without intervention within several months after onset. In 2001, Li and Ding reported on the treatment with cupping of 40 patients with urticaria. The cure rate among the treatment group was cited as 55%, compared with 30% in the control group, who were treated with a traditional Chinese remedy and an unidentified first-generation antihistamine.1,5 In 2020, Xiao et al. conducted a systematic review and meta-analysis of cupping therapy for patients with chronic urticaria. They identified 13 comparisons from 12 randomized controlled trials involving 842 subjects. The investigators found no significant differences between wet cupping and medication usage. They also found that cupping combined with antihistamine treatment was superior to antihistamines alone, and cupping therapy with acupuncture was more effective than acupuncture alone. The investigators did call for caution, citing the poor quality of the studies reviewed.6
It is important to note that it is difficult to attribute resolution of urticaria to the use of cupping given the self-resolution often associated with this condition. Antihistamines are the mainstay of therapy for urticaria, but in my personal experience, patients are not entirely satisfied with the level of symptom control with antihistamines alone and often search for alternative therapies to control the pesky hives and associated itch. In 2014, omalizumab (Xolair) was approved for treating chronic idiopathic urticaria, which has helped patients control symptoms of chronic idiopathic urticaria without needing to take antihistamines. There was no indication that the studies reviewed by Xiao et al. compared cupping against this new effective treatment. Therefore, these studies comparing cupping to medical management are outdated.
Acne, eczema, and psoriasis
Soliman’s 2018 review of cupping in dermatology included a few studies on these common cutaneous conditions. For instance, a 2013 single-blind prospective study by Xu et al. reported on the results of patients with moderate acne who received wet cupping (in the form of prickling bloodletting) twice weekly for 6 weeks.7 They reported that patients demonstrated improvement in the global acne grading system (GAGS) score by the end of the trial.1,7 Unfortunately, cupping was not compared with standard acne treatments (that is, benzoyl peroxide, topical and oral antibiotics, isotretinoin, topical retinoids, spironolactone).
In evaluating cupping for acute eczema, wet cupping was compared with oral loratadine and topical ointments in a 2007 study by Yao and Li. They divided 88 cases into treatment and control groups, with the former group (n = 46) receiving bloodletting puncturing and cupping and the control group (n = 42) receiving oral loratadine and topical Pairuisong (an herbal ointment used in Chinese medicine). The investigators observed no significant difference in total effective rates but a superior difference in the rates of responses that were considered “cured” and “markedly effective” in favor of the cupping treatment.1,8 However, a case report by Hon et al. has indicated that cupping therapy may be associated with more harm than benefit when used as an eczema treatment.1,9
In addition, it is important to note that the past 5 years have been gamechanging in the management of chronic eczema in terms of the array of novel and effective therapies (e.g., dupilumab and JAK inhibitors) and chronic moderate-to-severe eczema has become very treatable. Similarly, acute eczema is often successfully managed with topical steroids, calcineurin inhibitors, and emollients. As such, there is no compelling reason to consider an unproven treatment such as cupping.
In 2020, Xing et al. reviewed 16 randomized controlled trials assessing the use of “moving cupping” for plaque psoriasis, with 1,164 patients meeting inclusion criteria. Moving cupping was found to be significantly more effective than “no-moving” cupping therapy, and moving cupping, combined with medications, performed better than medications alone.10 None of the trials evaluated in this study included randomized controlled trials that compared patients using any of the more modern psoriasis medications, specifically biologics. And, again, the studies evaluated were not of the highest quality.
The data that support cupping, as summarized above, are based mostly on case reports, and strong double-blind prospective studies are lacking. Additionally, most of the studies cited gauged the efficacy of cupping using qualitative endpoints, rather than standardized quantitative endpoints and scales. Moreover, spontaneous remission of various dermatoses can occur, or they can improve over time, including acute eczema, psoriasis, and, especially, urticaria.
Adverse effects of cupping
Often alternative therapies are seen as “benign” and without adverse effects. However, complications can result from cupping. Trauma can be induced from the cupping itself by damaging superficial blood vessels and causing bruising.1,11 Blistering can also occur secondary to the suction effect, and the epidermal and dermal layers of the skin can be separated.1,11 Further, burns and discoloration have also been noted secondary to heat, trauma, and post inflammatory pigmentary changes.1,11 Another risk of cupping is the Koebner phenomenon, which occurs with psoriasis, with new lesions appearing in traumatized skin.12 Other adverse outcomes that have been reported with cupping include reactivation of herpes simplex virus secondary to skin trauma, iron deficiency anemia (secondary to blood loss), panniculitis, infections, and residual marks mistaken for signs of child abuse.1,11
Cupping in aesthetic dermatology
Facial cupping, a distinct practice from body cupping used to treat general dermatology conditions described previously, is also increasing in popularity. This practice is usually conducted in association with a facial or facial acupuncture by an aesthetician or other licensed professional. It can also be performed using at-home kits. The marketing claims for facial cupping cite improved tightening and contouring of facial skin, increased facial microcirculation and collagen synthesis, and enhanced lymphatic flow to aid with facial puffiness or swelling. One supposed mechanism for these benefits is that cupping increases blood flow. Interestingly, there was a 2020 animal study in which photoacoustic imaging of a mouse ear revealed increased temporary blood flow in the cupping microenvironment.13 Currently, however, there is no evidence in the English scientific literature that supports facial cupping. The benefits attributed to facial cupping for aesthetic purposes have emerged only in personal anecdotes. The temporary increase in blood flow may induce inflammation and swelling that adds volume to the face and temporarily diminishes wrinkles. However, this temporary plumpness may be associated with adverse effects, such as local trauma, irritation, bruising, postinflammatory pigmentary alteration, or even herpes reactivation. In my opinion, the possible adverse effects of cupping outweigh any potential benefit, especially given the insufficient evidence supporting the utility of cupping for cosmetic enhancement.
Summary
There is increasing interest among patients to incorporate complementary and alternative medicine – including the ancient tradition of cupping – in managing medical dermatologic conditions. However, current evidence supporting cupping as an effective therapeutic strategy is not strong, with most studies to date appearing to be of poor quality or not sufficiently convincing to displace standard therapies. Our medical strategies for managing chronic dermatologic conditions, particularly inflammatory disorders, continue to improve from both a safety and a proven efficacy standpoint. Therefore, I would not forgo medical management in favor of cupping. While cupping can be used as an adjunct therapy, I would caution patients about possible adverse side effects. In the aesthetic world, cupping is also gaining popularity, but this trend is also not supported by current evidence or studies, at least in the Western literature.
Dr. Goldman is a dermatologist in private practice in Miami and specializes in cosmetic and general dermatology. She practices at Baumann Cosmetic & Research Institute and is also opening a general dermatology practice. Write to her at [email protected] or message her on Instragram @DrChloeGoldman. Dr. Goldman receives compensation to create social media content for Replenix, a skin care company. She has no other disclosures.
References
1. Soliman Y et al. Acta Dermatovenerol Alp Pannonica Adriat. 2018 Jun;27(2):103-7.
2. França K and Lotti T. Advances in Integrative Dermatology. John Wiley & Sons, 2019.
3. Lowe DT. Complement Ther Clin Pract. 2017 Nov;29:162-8.
4.Cao H et al. Altern Ther Health Med. 2010 Nov-Dec;16(6):48-54.
5. Li L and Ding J. J Tradit Chin Med. 2001 Mar;21(1):37-8.
6. Xiao XJ et al. J Integr Med. 2020 Jul;18(4):303-12.
7. Xu J et al. J Tradit Chin Med. 2013 Dec;33(6):752-6.
8. Yao J et al. Zhongguo Zhen Jiu. 2007; Jun;27(6):424-6.
9. Hon KL et al. Case Rep Pediatr. 2013;2013:605829.
10. Xing M et al. Medicine (Baltimore). 2020 Oct 9;99(41):e22539.
11. Kim TH et al. Eur J Integr Med. 2014 Aug 1;6(4):434-40.
12. Vender R and Vender R. J Cutan Med Surg. 2015 May-Jun;19(3):320-2.
13. Zhou Y et al. Biomed Opt Express. 2020 Apr 6;11(5):2394-401.
This article was updated 4/25/22.
My inspiration to write about cupping this month stems from the perception that everyone seems to be talking about it, from a facialist who suggested it for me to a coworker who swears by cupping to treat her allergies. Cupping is by no means a novel procedure. Its use as a health therapy dates back thousands of years to ancient Egypt (1500 BCE), ancient Greece (described by Hippocrates), ancient Rome (described by the Greek physician Galen), China (during the Han dynasty, 206 BCE to 220 CE) and traditional Islamic culture.1 Over the past decade, the popularity of this ancient procedure has been increasing in the United States.1 Cupping has been applied as a remedy for various dermatologic and medical conditions, including herpes zoster, headaches, diminished appetite, maldigestion, abscess evacuation, narcolepsy, pain, fever, dysmenorrhea, and gout.1,2
Theories on the mechanism(s) of action
The practice of cupping is differentiated into dry and wet cupping.1,2 Traditionally, with dry cupping, a flame is applied to heat the air inside a thick glass cup (rather than the cup itself).1 The cup is placed on the skin surface, and negative pressure suctions the skin into the cup. Wet cupping differs mainly from dry cupping in that it involves blood-letting. Cups made of either silicone or glass of varying size and shapes are used. Modern adaptations to cupping include needle, herbal, and pulsatile cupping, as well as a “moving cupping” technique (vs. traditionally stationary cups).1
There are several theories, many of which are derived from the nondermatologic literature (that is, pain management), as to how cupping may deliver a clinical benefit. Some theories are based in scientific and medical principles, whereas other theories are more whimsical – specifically, that cupping draws out evil spirits.2 Studies of dry cupping have suggested that the procedure results in increased oxygenation of muscles via a local increase in oxygenated hemoglobin, which may help improve muscular activity and reduce pain.1 As theorized by Lowe in 2017, negative pressure exerted by dry cupping leads to stretching and dilation of capillaries, which increases blood flow.3 Wet cupping has been shown to increase heat shock protein 70 (HSP70) and beta-endorphin expression in rat models, which is thought to facilitate pain management.1 Removal of oxidants and reduction of reactive oxygen species in the blood is believed to be among the benefits of wet cupping.1
Cupping in general dermatology
While , as well as various inflammatory conditions.
Herpes zoster
In 2010, Cao et al. reported on their systematic review of wet cupping after completing searches of multiple databases (that is, PubMed, the Cochrane Library [Issue 3, 2008], China Network Knowledge Infrastructure, Chinese Scientific Journal Database, and Wan Fang Database). They identified eight randomized controlled trials involving 651 patients, with meta-analyses revealing that wet cupping performed better than medications in terms of the number of “cured” patients, number of patients with improved symptoms, and a lower incidence of postherpetic neuralgia. Wet cupping, in addition to medication, was also found to be superior to medication alone in multiple patients. The researchers concluded that wet cupping appears to effectively treat herpes zoster.4 However, the study failed to identify which medications were used to treat herpes zoster. In the United States, common medications for herpes zoster include acyclovir, valacyclovir, steroids, gabapentin, and other neuromodulators. Without knowing which medications were used, it is difficult to compare cupping to medication in terms of efficacy in treating herpes zoster.
Urticaria
Urticaria (hives) is an inflammatory skin condition that can be very uncomfortable for patients but often resolves without intervention within several months after onset. In 2001, Li and Ding reported on the treatment with cupping of 40 patients with urticaria. The cure rate among the treatment group was cited as 55%, compared with 30% in the control group, who were treated with a traditional Chinese remedy and an unidentified first-generation antihistamine.1,5 In 2020, Xiao et al. conducted a systematic review and meta-analysis of cupping therapy for patients with chronic urticaria. They identified 13 comparisons from 12 randomized controlled trials involving 842 subjects. The investigators found no significant differences between wet cupping and medication usage. They also found that cupping combined with antihistamine treatment was superior to antihistamines alone, and cupping therapy with acupuncture was more effective than acupuncture alone. The investigators did call for caution, citing the poor quality of the studies reviewed.6
It is important to note that it is difficult to attribute resolution of urticaria to the use of cupping given the self-resolution often associated with this condition. Antihistamines are the mainstay of therapy for urticaria, but in my personal experience, patients are not entirely satisfied with the level of symptom control with antihistamines alone and often search for alternative therapies to control the pesky hives and associated itch. In 2014, omalizumab (Xolair) was approved for treating chronic idiopathic urticaria, which has helped patients control symptoms of chronic idiopathic urticaria without needing to take antihistamines. There was no indication that the studies reviewed by Xiao et al. compared cupping against this new effective treatment. Therefore, these studies comparing cupping to medical management are outdated.
Acne, eczema, and psoriasis
Soliman’s 2018 review of cupping in dermatology included a few studies on these common cutaneous conditions. For instance, a 2013 single-blind prospective study by Xu et al. reported on the results of patients with moderate acne who received wet cupping (in the form of prickling bloodletting) twice weekly for 6 weeks.7 They reported that patients demonstrated improvement in the global acne grading system (GAGS) score by the end of the trial.1,7 Unfortunately, cupping was not compared with standard acne treatments (that is, benzoyl peroxide, topical and oral antibiotics, isotretinoin, topical retinoids, spironolactone).
In evaluating cupping for acute eczema, wet cupping was compared with oral loratadine and topical ointments in a 2007 study by Yao and Li. They divided 88 cases into treatment and control groups, with the former group (n = 46) receiving bloodletting puncturing and cupping and the control group (n = 42) receiving oral loratadine and topical Pairuisong (an herbal ointment used in Chinese medicine). The investigators observed no significant difference in total effective rates but a superior difference in the rates of responses that were considered “cured” and “markedly effective” in favor of the cupping treatment.1,8 However, a case report by Hon et al. has indicated that cupping therapy may be associated with more harm than benefit when used as an eczema treatment.1,9
In addition, it is important to note that the past 5 years have been gamechanging in the management of chronic eczema in terms of the array of novel and effective therapies (e.g., dupilumab and JAK inhibitors) and chronic moderate-to-severe eczema has become very treatable. Similarly, acute eczema is often successfully managed with topical steroids, calcineurin inhibitors, and emollients. As such, there is no compelling reason to consider an unproven treatment such as cupping.
In 2020, Xing et al. reviewed 16 randomized controlled trials assessing the use of “moving cupping” for plaque psoriasis, with 1,164 patients meeting inclusion criteria. Moving cupping was found to be significantly more effective than “no-moving” cupping therapy, and moving cupping, combined with medications, performed better than medications alone.10 None of the trials evaluated in this study included randomized controlled trials that compared patients using any of the more modern psoriasis medications, specifically biologics. And, again, the studies evaluated were not of the highest quality.
The data that support cupping, as summarized above, are based mostly on case reports, and strong double-blind prospective studies are lacking. Additionally, most of the studies cited gauged the efficacy of cupping using qualitative endpoints, rather than standardized quantitative endpoints and scales. Moreover, spontaneous remission of various dermatoses can occur, or they can improve over time, including acute eczema, psoriasis, and, especially, urticaria.
Adverse effects of cupping
Often alternative therapies are seen as “benign” and without adverse effects. However, complications can result from cupping. Trauma can be induced from the cupping itself by damaging superficial blood vessels and causing bruising.1,11 Blistering can also occur secondary to the suction effect, and the epidermal and dermal layers of the skin can be separated.1,11 Further, burns and discoloration have also been noted secondary to heat, trauma, and post inflammatory pigmentary changes.1,11 Another risk of cupping is the Koebner phenomenon, which occurs with psoriasis, with new lesions appearing in traumatized skin.12 Other adverse outcomes that have been reported with cupping include reactivation of herpes simplex virus secondary to skin trauma, iron deficiency anemia (secondary to blood loss), panniculitis, infections, and residual marks mistaken for signs of child abuse.1,11
Cupping in aesthetic dermatology
Facial cupping, a distinct practice from body cupping used to treat general dermatology conditions described previously, is also increasing in popularity. This practice is usually conducted in association with a facial or facial acupuncture by an aesthetician or other licensed professional. It can also be performed using at-home kits. The marketing claims for facial cupping cite improved tightening and contouring of facial skin, increased facial microcirculation and collagen synthesis, and enhanced lymphatic flow to aid with facial puffiness or swelling. One supposed mechanism for these benefits is that cupping increases blood flow. Interestingly, there was a 2020 animal study in which photoacoustic imaging of a mouse ear revealed increased temporary blood flow in the cupping microenvironment.13 Currently, however, there is no evidence in the English scientific literature that supports facial cupping. The benefits attributed to facial cupping for aesthetic purposes have emerged only in personal anecdotes. The temporary increase in blood flow may induce inflammation and swelling that adds volume to the face and temporarily diminishes wrinkles. However, this temporary plumpness may be associated with adverse effects, such as local trauma, irritation, bruising, postinflammatory pigmentary alteration, or even herpes reactivation. In my opinion, the possible adverse effects of cupping outweigh any potential benefit, especially given the insufficient evidence supporting the utility of cupping for cosmetic enhancement.
Summary
There is increasing interest among patients to incorporate complementary and alternative medicine – including the ancient tradition of cupping – in managing medical dermatologic conditions. However, current evidence supporting cupping as an effective therapeutic strategy is not strong, with most studies to date appearing to be of poor quality or not sufficiently convincing to displace standard therapies. Our medical strategies for managing chronic dermatologic conditions, particularly inflammatory disorders, continue to improve from both a safety and a proven efficacy standpoint. Therefore, I would not forgo medical management in favor of cupping. While cupping can be used as an adjunct therapy, I would caution patients about possible adverse side effects. In the aesthetic world, cupping is also gaining popularity, but this trend is also not supported by current evidence or studies, at least in the Western literature.
Dr. Goldman is a dermatologist in private practice in Miami and specializes in cosmetic and general dermatology. She practices at Baumann Cosmetic & Research Institute and is also opening a general dermatology practice. Write to her at [email protected] or message her on Instragram @DrChloeGoldman. Dr. Goldman receives compensation to create social media content for Replenix, a skin care company. She has no other disclosures.
References
1. Soliman Y et al. Acta Dermatovenerol Alp Pannonica Adriat. 2018 Jun;27(2):103-7.
2. França K and Lotti T. Advances in Integrative Dermatology. John Wiley & Sons, 2019.
3. Lowe DT. Complement Ther Clin Pract. 2017 Nov;29:162-8.
4.Cao H et al. Altern Ther Health Med. 2010 Nov-Dec;16(6):48-54.
5. Li L and Ding J. J Tradit Chin Med. 2001 Mar;21(1):37-8.
6. Xiao XJ et al. J Integr Med. 2020 Jul;18(4):303-12.
7. Xu J et al. J Tradit Chin Med. 2013 Dec;33(6):752-6.
8. Yao J et al. Zhongguo Zhen Jiu. 2007; Jun;27(6):424-6.
9. Hon KL et al. Case Rep Pediatr. 2013;2013:605829.
10. Xing M et al. Medicine (Baltimore). 2020 Oct 9;99(41):e22539.
11. Kim TH et al. Eur J Integr Med. 2014 Aug 1;6(4):434-40.
12. Vender R and Vender R. J Cutan Med Surg. 2015 May-Jun;19(3):320-2.
13. Zhou Y et al. Biomed Opt Express. 2020 Apr 6;11(5):2394-401.
This article was updated 4/25/22.
What’s the most likely cause of this man’s severe headaches?
He reports that these started 3 days ago. His headache is worse when he stands, and resolves when he lies down. Valsalva maneuver makes the headache much worse. The headaches are present in the occipital region. He also has noticed the onset of tinnitus. A physical exam reveals that his blood pressure is 110/70 mm Hg, his pulse is 60 beats per minute, and his temperature is 36.4° C. His standing BP is 105/60 mm Hg and standing pulse is 66 bpm. Both his neurologic exam and noncontrast head CT scan are normal.
Which of the following is the most likely diagnosis?
A) Subarachnoid hemorrhage
B) POTS (Postural orthostatic tachycardia syndrome)
C) Hypnic headache
D) Spontaneous intracranial hypotension (SIH)
E) Acoustic neuroma
The most likely cause for this patient’s headaches given his set of symptoms is spontaneous intracranial hypotension. Orthostatic headaches are common with POTS, but the absence of tachycardia with standing makes this diagnosis unlikely.
Spontaneous intracranial hypotension has symptoms that we are all familiar with in the post–lumbar puncture patient. In patients with post-LP headache, the positional nature makes it easy to diagnose. Patients who have had a lumbar puncture have a clear reason they have a cerebrospinal fluid (CSF) leak, leading to intracranial hypotension. Those with SIH do not.
Related research
Schievink summarized a lot of useful information in a review of patients with spontaneous intracranial hypotension.1 The incidence is about 5/100,000, with the most common age around 40 years old. The most common symptom is orthostatic headache. The headache usually occurs within 15 minutes upon standing, and many patients have the onset of headache rapidly upon standing.
Usually the headache improves with lying down, and it is often brought on with Valsalva maneuver. Many patients report headaches that are worse in the second half of the day.
Orthostatic headache occurs in almost all patients with spontaneous intracranial hypotension, but in one series it occurred only in 77% of patients with SIH.2 The patients who did not have typical headaches are more likely to have auditory symptoms such as tinnitus and muffled hearing.3
When you suspect SIH, appropriate workup is to start with brain MR imaging with contrast. Krantz and colleagues found dural enhancement was present in 83% of cases of SIH, venous distention sign in 75%, and brain sagging in 61%.4
About 10% of patients with SIH have normal brain imaging, so if the clinical features strongly suggest the diagnosis, moving on to spinal imaging with CT myelography or spinal MR are appropriate next steps.5
The causes of SIH are meningeal diverticula (usually in the thoracic or upper lumbar regions), ventral dural tears (usually from osteophytes), and cerebrospinal fluid–venous fistulas. Treatment of SIH has traditionally included a conservative approach of bed rest, oral hydration, and caffeine. The effectiveness of this is unknown, and, in one small series, 61% had headache symptoms at 6 months.6
Epidural blood patches are likely more rapidly effective than conservative therapy. In one study comparing the two treatments, Chung and colleagues found that 77% of the patients who received an epidural blood patch had complete headache relief at 4 weeks, compared with 40% of those who received conservative measures (P < .05).7
Clinical pearls
- Strongly consider SIH in patients with positional headache.
- Brain MR should be the first diagnostic test.
Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and serves as 3rd-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact him at [email protected].
References
1. Schievink WI. Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension. JAMA. 2006;295:2286-96.
2. Mea E et al. Headache attributed to spontaneous intracranial hypotension. Neurol Sci. 2008;29:164-65.
3. Krantz PG et al. Spontaneous Intracranial Hypotension: 10 Myths and Misperceptions. Headache. 2018;58:948-59.
4. Krantz PG et. al. Imaging signs in spontaneous intracranial hypotension: prevalence and relationship to CSF pressure. AJNR Am J Neuroradiol. 2016;37:1374-8.
5. Krantz PG et al. Spontaneous intracranial hypotension: Pathogenesis, diagnosis, and treatment. Neuroimaging Clin N Am. 2019;29:581-94.
6. Kong D-S et. al. Clinical features and long-term results of spontaneous intracranial hypotension. Neurosurgery. 2005;57:91-6.
7. Chung SJ et al. Short- and long-term outcomes of spontaneous CSF hypovolemia. Eur Neurol. 2005;54:63-7.
He reports that these started 3 days ago. His headache is worse when he stands, and resolves when he lies down. Valsalva maneuver makes the headache much worse. The headaches are present in the occipital region. He also has noticed the onset of tinnitus. A physical exam reveals that his blood pressure is 110/70 mm Hg, his pulse is 60 beats per minute, and his temperature is 36.4° C. His standing BP is 105/60 mm Hg and standing pulse is 66 bpm. Both his neurologic exam and noncontrast head CT scan are normal.
Which of the following is the most likely diagnosis?
A) Subarachnoid hemorrhage
B) POTS (Postural orthostatic tachycardia syndrome)
C) Hypnic headache
D) Spontaneous intracranial hypotension (SIH)
E) Acoustic neuroma
The most likely cause for this patient’s headaches given his set of symptoms is spontaneous intracranial hypotension. Orthostatic headaches are common with POTS, but the absence of tachycardia with standing makes this diagnosis unlikely.
Spontaneous intracranial hypotension has symptoms that we are all familiar with in the post–lumbar puncture patient. In patients with post-LP headache, the positional nature makes it easy to diagnose. Patients who have had a lumbar puncture have a clear reason they have a cerebrospinal fluid (CSF) leak, leading to intracranial hypotension. Those with SIH do not.
Related research
Schievink summarized a lot of useful information in a review of patients with spontaneous intracranial hypotension.1 The incidence is about 5/100,000, with the most common age around 40 years old. The most common symptom is orthostatic headache. The headache usually occurs within 15 minutes upon standing, and many patients have the onset of headache rapidly upon standing.
Usually the headache improves with lying down, and it is often brought on with Valsalva maneuver. Many patients report headaches that are worse in the second half of the day.
Orthostatic headache occurs in almost all patients with spontaneous intracranial hypotension, but in one series it occurred only in 77% of patients with SIH.2 The patients who did not have typical headaches are more likely to have auditory symptoms such as tinnitus and muffled hearing.3
When you suspect SIH, appropriate workup is to start with brain MR imaging with contrast. Krantz and colleagues found dural enhancement was present in 83% of cases of SIH, venous distention sign in 75%, and brain sagging in 61%.4
About 10% of patients with SIH have normal brain imaging, so if the clinical features strongly suggest the diagnosis, moving on to spinal imaging with CT myelography or spinal MR are appropriate next steps.5
The causes of SIH are meningeal diverticula (usually in the thoracic or upper lumbar regions), ventral dural tears (usually from osteophytes), and cerebrospinal fluid–venous fistulas. Treatment of SIH has traditionally included a conservative approach of bed rest, oral hydration, and caffeine. The effectiveness of this is unknown, and, in one small series, 61% had headache symptoms at 6 months.6
Epidural blood patches are likely more rapidly effective than conservative therapy. In one study comparing the two treatments, Chung and colleagues found that 77% of the patients who received an epidural blood patch had complete headache relief at 4 weeks, compared with 40% of those who received conservative measures (P < .05).7
Clinical pearls
- Strongly consider SIH in patients with positional headache.
- Brain MR should be the first diagnostic test.
Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and serves as 3rd-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact him at [email protected].
References
1. Schievink WI. Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension. JAMA. 2006;295:2286-96.
2. Mea E et al. Headache attributed to spontaneous intracranial hypotension. Neurol Sci. 2008;29:164-65.
3. Krantz PG et al. Spontaneous Intracranial Hypotension: 10 Myths and Misperceptions. Headache. 2018;58:948-59.
4. Krantz PG et. al. Imaging signs in spontaneous intracranial hypotension: prevalence and relationship to CSF pressure. AJNR Am J Neuroradiol. 2016;37:1374-8.
5. Krantz PG et al. Spontaneous intracranial hypotension: Pathogenesis, diagnosis, and treatment. Neuroimaging Clin N Am. 2019;29:581-94.
6. Kong D-S et. al. Clinical features and long-term results of spontaneous intracranial hypotension. Neurosurgery. 2005;57:91-6.
7. Chung SJ et al. Short- and long-term outcomes of spontaneous CSF hypovolemia. Eur Neurol. 2005;54:63-7.
He reports that these started 3 days ago. His headache is worse when he stands, and resolves when he lies down. Valsalva maneuver makes the headache much worse. The headaches are present in the occipital region. He also has noticed the onset of tinnitus. A physical exam reveals that his blood pressure is 110/70 mm Hg, his pulse is 60 beats per minute, and his temperature is 36.4° C. His standing BP is 105/60 mm Hg and standing pulse is 66 bpm. Both his neurologic exam and noncontrast head CT scan are normal.
Which of the following is the most likely diagnosis?
A) Subarachnoid hemorrhage
B) POTS (Postural orthostatic tachycardia syndrome)
C) Hypnic headache
D) Spontaneous intracranial hypotension (SIH)
E) Acoustic neuroma
The most likely cause for this patient’s headaches given his set of symptoms is spontaneous intracranial hypotension. Orthostatic headaches are common with POTS, but the absence of tachycardia with standing makes this diagnosis unlikely.
Spontaneous intracranial hypotension has symptoms that we are all familiar with in the post–lumbar puncture patient. In patients with post-LP headache, the positional nature makes it easy to diagnose. Patients who have had a lumbar puncture have a clear reason they have a cerebrospinal fluid (CSF) leak, leading to intracranial hypotension. Those with SIH do not.
Related research
Schievink summarized a lot of useful information in a review of patients with spontaneous intracranial hypotension.1 The incidence is about 5/100,000, with the most common age around 40 years old. The most common symptom is orthostatic headache. The headache usually occurs within 15 minutes upon standing, and many patients have the onset of headache rapidly upon standing.
Usually the headache improves with lying down, and it is often brought on with Valsalva maneuver. Many patients report headaches that are worse in the second half of the day.
Orthostatic headache occurs in almost all patients with spontaneous intracranial hypotension, but in one series it occurred only in 77% of patients with SIH.2 The patients who did not have typical headaches are more likely to have auditory symptoms such as tinnitus and muffled hearing.3
When you suspect SIH, appropriate workup is to start with brain MR imaging with contrast. Krantz and colleagues found dural enhancement was present in 83% of cases of SIH, venous distention sign in 75%, and brain sagging in 61%.4
About 10% of patients with SIH have normal brain imaging, so if the clinical features strongly suggest the diagnosis, moving on to spinal imaging with CT myelography or spinal MR are appropriate next steps.5
The causes of SIH are meningeal diverticula (usually in the thoracic or upper lumbar regions), ventral dural tears (usually from osteophytes), and cerebrospinal fluid–venous fistulas. Treatment of SIH has traditionally included a conservative approach of bed rest, oral hydration, and caffeine. The effectiveness of this is unknown, and, in one small series, 61% had headache symptoms at 6 months.6
Epidural blood patches are likely more rapidly effective than conservative therapy. In one study comparing the two treatments, Chung and colleagues found that 77% of the patients who received an epidural blood patch had complete headache relief at 4 weeks, compared with 40% of those who received conservative measures (P < .05).7
Clinical pearls
- Strongly consider SIH in patients with positional headache.
- Brain MR should be the first diagnostic test.
Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and serves as 3rd-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact him at [email protected].
References
1. Schievink WI. Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension. JAMA. 2006;295:2286-96.
2. Mea E et al. Headache attributed to spontaneous intracranial hypotension. Neurol Sci. 2008;29:164-65.
3. Krantz PG et al. Spontaneous Intracranial Hypotension: 10 Myths and Misperceptions. Headache. 2018;58:948-59.
4. Krantz PG et. al. Imaging signs in spontaneous intracranial hypotension: prevalence and relationship to CSF pressure. AJNR Am J Neuroradiol. 2016;37:1374-8.
5. Krantz PG et al. Spontaneous intracranial hypotension: Pathogenesis, diagnosis, and treatment. Neuroimaging Clin N Am. 2019;29:581-94.
6. Kong D-S et. al. Clinical features and long-term results of spontaneous intracranial hypotension. Neurosurgery. 2005;57:91-6.
7. Chung SJ et al. Short- and long-term outcomes of spontaneous CSF hypovolemia. Eur Neurol. 2005;54:63-7.
The work after work
Across the country, taxes unite us. Not that we all share the same, rather that we all have to do them. It was recently tax weekend in our house: The Saturday and Sunday that cap off weeks of hunting and gathering faded receipts and sorting through reams of credit card bills to find all the dollars we spent on work. The task is more tedious than all the Wednesdays of taking out trash bins combined, and equally as exciting. But wait, that’s not all.
This weekend I’ve been chatting with bots from a solar company trying to solve our drop in energy production and sat on terminal hold with apparently one person who answers the phone for Amazon. There’s also an homeowner’s association meeting to prepare for and research to be done on ceiling fans.
“Life admin” is a crisp phrase coined by Elizabeth Emens, JD, PhD, that captures the never-ending to-do list that comes with running a household. An accomplished law professor at Columbia University, New York, Dr. Emens noticed the negative impact this life admin has on our quality of life. Reading her book, “Life Admin: How I Learned to Do Less, Do Better, and Live More” (New York: HarperOne, 2019), your eyes widen as she magically makes salient all this hidden work that is stealing our time. Life admin, kidmin, mom and dadmin, just rattling them off feels like donning x-ray glasses allowing us to see how much work we do outside of our work. As doctors, I would add “family house calls,” as a contributing factor: Random family and friends who want to talk for a minute about their knee replacement or what drug the ICU should give Uncle Larry who is fighting COVID. (I only know ivermectin, but it would only help if he just had scabies).
By all accounts, the amount of life admin is growing insidiously, worsened by the great pandemic. There are events to plan and reply to, more DIY customer service to fix your own problems, more work to find a VRBO for a weekend getaway at the beach. (There are none on the entire coast of California this summer, so I just saved you time there. You’re welcome.)
There is no good time to do this work and combined with the heavy burden of our responsibilities as physicians, it can feel like fuel feeding the burnout fire.
Dr. Emens has some top tips to help. First up, know your admin type. Are you a super doer, reluctant doer, admin denier, or admin avoider? I’m mostly in the avoider quadrant, dropping into reluctant doer when consequences loom. Next, choose strategies that fit you. Instead of avoiding, there are some things I might deflect. For example, When your aunt in Peoria asks where she can get a COVID test, you can use LMGTFY.com to generate a link that will show them how to use Google to help with their question. Dr. Emens is joking, but the point rang true. We can lighten the load a bit if we delegate or push back the excessive or undue requests. For some tasks, we’d be better off paying someone to take it over. Last tip here, try doing life admin with a partner, be it spouse, friend, or colleague. This is particularly useful when your partner is a super doer, as mine is. Not only can they make the work lighter, but also less dreary.
We physicians are focused on fixing physician burnout. Maybe we should also be looking at what happens in the “second shift” at home. Tax season is over, but will be back soon.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected]
Across the country, taxes unite us. Not that we all share the same, rather that we all have to do them. It was recently tax weekend in our house: The Saturday and Sunday that cap off weeks of hunting and gathering faded receipts and sorting through reams of credit card bills to find all the dollars we spent on work. The task is more tedious than all the Wednesdays of taking out trash bins combined, and equally as exciting. But wait, that’s not all.
This weekend I’ve been chatting with bots from a solar company trying to solve our drop in energy production and sat on terminal hold with apparently one person who answers the phone for Amazon. There’s also an homeowner’s association meeting to prepare for and research to be done on ceiling fans.
“Life admin” is a crisp phrase coined by Elizabeth Emens, JD, PhD, that captures the never-ending to-do list that comes with running a household. An accomplished law professor at Columbia University, New York, Dr. Emens noticed the negative impact this life admin has on our quality of life. Reading her book, “Life Admin: How I Learned to Do Less, Do Better, and Live More” (New York: HarperOne, 2019), your eyes widen as she magically makes salient all this hidden work that is stealing our time. Life admin, kidmin, mom and dadmin, just rattling them off feels like donning x-ray glasses allowing us to see how much work we do outside of our work. As doctors, I would add “family house calls,” as a contributing factor: Random family and friends who want to talk for a minute about their knee replacement or what drug the ICU should give Uncle Larry who is fighting COVID. (I only know ivermectin, but it would only help if he just had scabies).
By all accounts, the amount of life admin is growing insidiously, worsened by the great pandemic. There are events to plan and reply to, more DIY customer service to fix your own problems, more work to find a VRBO for a weekend getaway at the beach. (There are none on the entire coast of California this summer, so I just saved you time there. You’re welcome.)
There is no good time to do this work and combined with the heavy burden of our responsibilities as physicians, it can feel like fuel feeding the burnout fire.
Dr. Emens has some top tips to help. First up, know your admin type. Are you a super doer, reluctant doer, admin denier, or admin avoider? I’m mostly in the avoider quadrant, dropping into reluctant doer when consequences loom. Next, choose strategies that fit you. Instead of avoiding, there are some things I might deflect. For example, When your aunt in Peoria asks where she can get a COVID test, you can use LMGTFY.com to generate a link that will show them how to use Google to help with their question. Dr. Emens is joking, but the point rang true. We can lighten the load a bit if we delegate or push back the excessive or undue requests. For some tasks, we’d be better off paying someone to take it over. Last tip here, try doing life admin with a partner, be it spouse, friend, or colleague. This is particularly useful when your partner is a super doer, as mine is. Not only can they make the work lighter, but also less dreary.
We physicians are focused on fixing physician burnout. Maybe we should also be looking at what happens in the “second shift” at home. Tax season is over, but will be back soon.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected]
Across the country, taxes unite us. Not that we all share the same, rather that we all have to do them. It was recently tax weekend in our house: The Saturday and Sunday that cap off weeks of hunting and gathering faded receipts and sorting through reams of credit card bills to find all the dollars we spent on work. The task is more tedious than all the Wednesdays of taking out trash bins combined, and equally as exciting. But wait, that’s not all.
This weekend I’ve been chatting with bots from a solar company trying to solve our drop in energy production and sat on terminal hold with apparently one person who answers the phone for Amazon. There’s also an homeowner’s association meeting to prepare for and research to be done on ceiling fans.
“Life admin” is a crisp phrase coined by Elizabeth Emens, JD, PhD, that captures the never-ending to-do list that comes with running a household. An accomplished law professor at Columbia University, New York, Dr. Emens noticed the negative impact this life admin has on our quality of life. Reading her book, “Life Admin: How I Learned to Do Less, Do Better, and Live More” (New York: HarperOne, 2019), your eyes widen as she magically makes salient all this hidden work that is stealing our time. Life admin, kidmin, mom and dadmin, just rattling them off feels like donning x-ray glasses allowing us to see how much work we do outside of our work. As doctors, I would add “family house calls,” as a contributing factor: Random family and friends who want to talk for a minute about their knee replacement or what drug the ICU should give Uncle Larry who is fighting COVID. (I only know ivermectin, but it would only help if he just had scabies).
By all accounts, the amount of life admin is growing insidiously, worsened by the great pandemic. There are events to plan and reply to, more DIY customer service to fix your own problems, more work to find a VRBO for a weekend getaway at the beach. (There are none on the entire coast of California this summer, so I just saved you time there. You’re welcome.)
There is no good time to do this work and combined with the heavy burden of our responsibilities as physicians, it can feel like fuel feeding the burnout fire.
Dr. Emens has some top tips to help. First up, know your admin type. Are you a super doer, reluctant doer, admin denier, or admin avoider? I’m mostly in the avoider quadrant, dropping into reluctant doer when consequences loom. Next, choose strategies that fit you. Instead of avoiding, there are some things I might deflect. For example, When your aunt in Peoria asks where she can get a COVID test, you can use LMGTFY.com to generate a link that will show them how to use Google to help with their question. Dr. Emens is joking, but the point rang true. We can lighten the load a bit if we delegate or push back the excessive or undue requests. For some tasks, we’d be better off paying someone to take it over. Last tip here, try doing life admin with a partner, be it spouse, friend, or colleague. This is particularly useful when your partner is a super doer, as mine is. Not only can they make the work lighter, but also less dreary.
We physicians are focused on fixing physician burnout. Maybe we should also be looking at what happens in the “second shift” at home. Tax season is over, but will be back soon.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected]
The unseen benefit of an MRI
Mrs. Smith came in for neck pain.
This isn’t a new issue, her last flare was 4 or 5 years ago. I’d done an MRI back then, which just showed reassuringly typical arthritic changes, and she did great with a few sessions of physical therapy.
She’d woke one morning a few months ago with a stiff and aching neck, similar to how this started last time. A couple weeks of rest and NSAIDs hadn’t helped. There were no radiating symptoms and her exam was the same as it’s been since I met her back in 2010.
I wrote her an order for physical therapy and found the address and phone number of the place she’d gone to for it a few years ago. She looked at my order, then set it on my desk and said “Doctor, I’d really like an MRI.”
I went back to her chart and reread my note for her last flare of neck pain. Identical symptoms, identical exam. I pulled up the previous MRI report and went over it. Then I explained to her that there really was no indication for an MRI at this point. I suggested we go ahead with physical therapy, and if that didn’t help I would then re-check the study.
She wasn’t going to budge. A friend of hers had recently needed urgent surgery for a cervical myelopathy and was in rehab. Mrs. Smith’s husband’s health was getting worse, and if her neck had something seriously wrong she wouldn’t be able to take care of him if it went unchecked.
So I backed down and ordered a cervical spine MRI, which was pretty much unchanged from the previous MRI. After it came back she was willing to do therapy.
I’m sure some out there will accuse me, the doctor, of letting the patient call the shots. To some degree you’re correct. But it’s not like the request was insanely unreasonable. Obviously, there were other factors going on, too. She was scared and needed reassurance that there wasn’t anything therapy wouldn’t help and that she would be able to keep caring for her ailing husband during his cancer treatments.
There are doctors out there with a more paternalistic view of patient care than mine. They’re probably thinking I should have taken a hardball approach of “you don’t need an MRI. You can do therapy, or you can find another doctor.” But that’s not me. I can’t do that to a nice older lady, especially one who’s been coming to me for various ailments over the last 12 years.
Not only that, but such an approach seemed doomed to fail in this case. It might have gotten her to go to therapy, but I suspect she wouldn’t have gotten better. Her fears about a serious neck issue would increase over time, until she (or the therapist) finally called, said she wasn’t getting better, and could I order an MRI now?
In that way, maybe the MRI helped guarantee that she’d have a good response to therapy.
I can’t say that what I did was the right thing. But it was right for Mrs. Smith.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Mrs. Smith came in for neck pain.
This isn’t a new issue, her last flare was 4 or 5 years ago. I’d done an MRI back then, which just showed reassuringly typical arthritic changes, and she did great with a few sessions of physical therapy.
She’d woke one morning a few months ago with a stiff and aching neck, similar to how this started last time. A couple weeks of rest and NSAIDs hadn’t helped. There were no radiating symptoms and her exam was the same as it’s been since I met her back in 2010.
I wrote her an order for physical therapy and found the address and phone number of the place she’d gone to for it a few years ago. She looked at my order, then set it on my desk and said “Doctor, I’d really like an MRI.”
I went back to her chart and reread my note for her last flare of neck pain. Identical symptoms, identical exam. I pulled up the previous MRI report and went over it. Then I explained to her that there really was no indication for an MRI at this point. I suggested we go ahead with physical therapy, and if that didn’t help I would then re-check the study.
She wasn’t going to budge. A friend of hers had recently needed urgent surgery for a cervical myelopathy and was in rehab. Mrs. Smith’s husband’s health was getting worse, and if her neck had something seriously wrong she wouldn’t be able to take care of him if it went unchecked.
So I backed down and ordered a cervical spine MRI, which was pretty much unchanged from the previous MRI. After it came back she was willing to do therapy.
I’m sure some out there will accuse me, the doctor, of letting the patient call the shots. To some degree you’re correct. But it’s not like the request was insanely unreasonable. Obviously, there were other factors going on, too. She was scared and needed reassurance that there wasn’t anything therapy wouldn’t help and that she would be able to keep caring for her ailing husband during his cancer treatments.
There are doctors out there with a more paternalistic view of patient care than mine. They’re probably thinking I should have taken a hardball approach of “you don’t need an MRI. You can do therapy, or you can find another doctor.” But that’s not me. I can’t do that to a nice older lady, especially one who’s been coming to me for various ailments over the last 12 years.
Not only that, but such an approach seemed doomed to fail in this case. It might have gotten her to go to therapy, but I suspect she wouldn’t have gotten better. Her fears about a serious neck issue would increase over time, until she (or the therapist) finally called, said she wasn’t getting better, and could I order an MRI now?
In that way, maybe the MRI helped guarantee that she’d have a good response to therapy.
I can’t say that what I did was the right thing. But it was right for Mrs. Smith.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Mrs. Smith came in for neck pain.
This isn’t a new issue, her last flare was 4 or 5 years ago. I’d done an MRI back then, which just showed reassuringly typical arthritic changes, and she did great with a few sessions of physical therapy.
She’d woke one morning a few months ago with a stiff and aching neck, similar to how this started last time. A couple weeks of rest and NSAIDs hadn’t helped. There were no radiating symptoms and her exam was the same as it’s been since I met her back in 2010.
I wrote her an order for physical therapy and found the address and phone number of the place she’d gone to for it a few years ago. She looked at my order, then set it on my desk and said “Doctor, I’d really like an MRI.”
I went back to her chart and reread my note for her last flare of neck pain. Identical symptoms, identical exam. I pulled up the previous MRI report and went over it. Then I explained to her that there really was no indication for an MRI at this point. I suggested we go ahead with physical therapy, and if that didn’t help I would then re-check the study.
She wasn’t going to budge. A friend of hers had recently needed urgent surgery for a cervical myelopathy and was in rehab. Mrs. Smith’s husband’s health was getting worse, and if her neck had something seriously wrong she wouldn’t be able to take care of him if it went unchecked.
So I backed down and ordered a cervical spine MRI, which was pretty much unchanged from the previous MRI. After it came back she was willing to do therapy.
I’m sure some out there will accuse me, the doctor, of letting the patient call the shots. To some degree you’re correct. But it’s not like the request was insanely unreasonable. Obviously, there were other factors going on, too. She was scared and needed reassurance that there wasn’t anything therapy wouldn’t help and that she would be able to keep caring for her ailing husband during his cancer treatments.
There are doctors out there with a more paternalistic view of patient care than mine. They’re probably thinking I should have taken a hardball approach of “you don’t need an MRI. You can do therapy, or you can find another doctor.” But that’s not me. I can’t do that to a nice older lady, especially one who’s been coming to me for various ailments over the last 12 years.
Not only that, but such an approach seemed doomed to fail in this case. It might have gotten her to go to therapy, but I suspect she wouldn’t have gotten better. Her fears about a serious neck issue would increase over time, until she (or the therapist) finally called, said she wasn’t getting better, and could I order an MRI now?
In that way, maybe the MRI helped guarantee that she’d have a good response to therapy.
I can’t say that what I did was the right thing. But it was right for Mrs. Smith.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Surgery shows no survival, morbidity benefit for mild hyperparathyroidism
Patients who receive parathyroidectomy for mild primary hyperparathyroidism show no benefits in survival or morbidity, including fractures, cancer, or cardiovascular outcomes over more than 10 years, compared with those not receiving the surgery, results from a randomized, prospective trial show.
“In contrast to existing data showing increased mortality and cardiovascular morbidity in mild primary hyperparathyroidism, we did not find any treatment effect of parathyroidectomy on these important clinical endpoints,” report the authors of the study, published in the Annals of Internal Medicine.
Reason to evaluate and revise current recommendations?
With mild primary hyperparathyroidism becoming the predominant form of hyperparathyroidism, the results suggest rethinking the current recommendations for the condition, the study authors note.
“Over the years, more active management of mild primary hyperparathyroidism has been recommended, with a widening of criteria for parathyroidectomy,” they write.
“With the low number of kidney stones (n = 5) and no effect of parathyroidectomy on fractures, there may be a need to evaluate and potentially revise the current recommendations.”
The authors of an accompanying editorial agree that “the [results] provide a strong rationale for nonoperative management of patients with mild primary hyperparathyroidism.”
“The findings suggest that most patients can be managed nonoperatively, with monitoring of serum calcium levels every 1 to 2 years or if symptoms occur,” write the editorial authors, Mark J. Bolland, PhD, and Andrew Grey, MD, of the department of medicine, University of Auckland, New Zealand.
Although parathyroidectomy is recommended for the treatment in patients with hyperparathyroidism with severe hypercalcemia or overt symptoms, there has been debate on the long-term benefits of surgery among those with milder cases.
Most previous studies that have shown benefits, such as reductions in the risk of fracture with parathyroidectomy, have importantly not distinguished between mild and more severe primary hyperparathyroidism, the authors note.
No significant differences in mortality between surgery, nonsurgery groups
For the Scandinavian Investigation of Primary Hyperparathyroidism (SIPH) trial, first author Mikkel Pretorius, MD, Oslo University Hospital and Faculty of Medicine, University of Oslo, and colleagues enrolled 191 patients between 1998 and 2005 in Sweden, Norway, and Denmark, who were aged 50-80 years and had mild primary hyperparathyroidism, defined as serum calcium levels of 10.42-11.22 mg/dL.
Participants were randomized to receive surgery (n = 95) or nonoperative observation without intervention (n = 96).
After a 10-year follow-up, 129 patients had completed the final visit. The overall death rate was 7.6%, and, with eight deaths in the surgery group and seven in the nonsurgery group, there were no significant differences between groups in terms of mortality (HR, 1.17; P = .76).
During an extended observation period that lasted until 2018, mortality rates increased by 23%, but with a relatively even distribution of 24 deaths in the surgery group and 20 among those with no surgery.
Chronic hypercalcemia related to primary hyperparathyroidism has been debated as being associated with an increased risk of cardiovascular disease or cancer, however, “the absolute numbers for these and the other disease-specific causes of death were nearly identical between groups,” the authors write, with 17 deaths from cardiovascular disease, eight from cancer, and eight from cerebrovascular disease.
In terms of morbidity, including cardiovascular events, cerebrovascular events, cancer, peripheral fractures, and renal stones, there were 101 events overall, with 52 in the parathyroidectomy group and 49 in the nonsurgery group, which again, was not a significant difference.
Sixteen vertebral fractures occurred overall in 14 patients, which were evenly split at seven patients in each group.
The authors note that “the incidence of peripheral fractures for women in our study was around 2,900 per 100,000 person-years, in the same range as for 70-year-old women in a study in Gothenburg, Sweden (about 2,600 per 100,000 person-years).”
There were no between-group differences in terms of time to death or first morbidity event for any of the prespecified events.
Of the 96 patients originally assigned to the nonsurgery group, 17 (18%) had surgery during follow-up, including three for serious hypercalcemia, three by their own choice, two for decreasing bone density, one for kidney stones, and the others for unclear or unrelated reasons.
Study limitations include that only 26 men (13 in each group) were included, and only 16 completed the study. “The external validity for men based on this study is therefore limited,” the authors note.
And although most people with primary hyperparathyroidism are adults, the older age of participants suggests the results should not be generalized to younger patients with benign parathyroid tumors.
The editorialists note that age should be one of the few factors that may, indeed, suggest appropriate candidates for parathyroidectomy.
“Younger patients (aged < 50 years) may have more aggressive disease,” they explain.
In addition, “patients with serum calcium levels above 3 mmol/L (> 12 mg/dL) are at greater risk for symptomatic hypercalcemia, and patients with a recent history of kidney stones may have fewer future stones after surgical cure.”
“Yet, such patients are a small minority of those with primary hyperparathyroidism,” they note.
The study authors underscore that “our data add evidence to guide the decisionmaking process in deliberative dialogue between clinicians and patients.”
The study received funding from Swedish government grants, the Norwegian Research Council, and the South-Eastern Norway Regional Health Authority.
A version of this article first appeared on Medscape.com.
Patients who receive parathyroidectomy for mild primary hyperparathyroidism show no benefits in survival or morbidity, including fractures, cancer, or cardiovascular outcomes over more than 10 years, compared with those not receiving the surgery, results from a randomized, prospective trial show.
“In contrast to existing data showing increased mortality and cardiovascular morbidity in mild primary hyperparathyroidism, we did not find any treatment effect of parathyroidectomy on these important clinical endpoints,” report the authors of the study, published in the Annals of Internal Medicine.
Reason to evaluate and revise current recommendations?
With mild primary hyperparathyroidism becoming the predominant form of hyperparathyroidism, the results suggest rethinking the current recommendations for the condition, the study authors note.
“Over the years, more active management of mild primary hyperparathyroidism has been recommended, with a widening of criteria for parathyroidectomy,” they write.
“With the low number of kidney stones (n = 5) and no effect of parathyroidectomy on fractures, there may be a need to evaluate and potentially revise the current recommendations.”
The authors of an accompanying editorial agree that “the [results] provide a strong rationale for nonoperative management of patients with mild primary hyperparathyroidism.”
“The findings suggest that most patients can be managed nonoperatively, with monitoring of serum calcium levels every 1 to 2 years or if symptoms occur,” write the editorial authors, Mark J. Bolland, PhD, and Andrew Grey, MD, of the department of medicine, University of Auckland, New Zealand.
Although parathyroidectomy is recommended for the treatment in patients with hyperparathyroidism with severe hypercalcemia or overt symptoms, there has been debate on the long-term benefits of surgery among those with milder cases.
Most previous studies that have shown benefits, such as reductions in the risk of fracture with parathyroidectomy, have importantly not distinguished between mild and more severe primary hyperparathyroidism, the authors note.
No significant differences in mortality between surgery, nonsurgery groups
For the Scandinavian Investigation of Primary Hyperparathyroidism (SIPH) trial, first author Mikkel Pretorius, MD, Oslo University Hospital and Faculty of Medicine, University of Oslo, and colleagues enrolled 191 patients between 1998 and 2005 in Sweden, Norway, and Denmark, who were aged 50-80 years and had mild primary hyperparathyroidism, defined as serum calcium levels of 10.42-11.22 mg/dL.
Participants were randomized to receive surgery (n = 95) or nonoperative observation without intervention (n = 96).
After a 10-year follow-up, 129 patients had completed the final visit. The overall death rate was 7.6%, and, with eight deaths in the surgery group and seven in the nonsurgery group, there were no significant differences between groups in terms of mortality (HR, 1.17; P = .76).
During an extended observation period that lasted until 2018, mortality rates increased by 23%, but with a relatively even distribution of 24 deaths in the surgery group and 20 among those with no surgery.
Chronic hypercalcemia related to primary hyperparathyroidism has been debated as being associated with an increased risk of cardiovascular disease or cancer, however, “the absolute numbers for these and the other disease-specific causes of death were nearly identical between groups,” the authors write, with 17 deaths from cardiovascular disease, eight from cancer, and eight from cerebrovascular disease.
In terms of morbidity, including cardiovascular events, cerebrovascular events, cancer, peripheral fractures, and renal stones, there were 101 events overall, with 52 in the parathyroidectomy group and 49 in the nonsurgery group, which again, was not a significant difference.
Sixteen vertebral fractures occurred overall in 14 patients, which were evenly split at seven patients in each group.
The authors note that “the incidence of peripheral fractures for women in our study was around 2,900 per 100,000 person-years, in the same range as for 70-year-old women in a study in Gothenburg, Sweden (about 2,600 per 100,000 person-years).”
There were no between-group differences in terms of time to death or first morbidity event for any of the prespecified events.
Of the 96 patients originally assigned to the nonsurgery group, 17 (18%) had surgery during follow-up, including three for serious hypercalcemia, three by their own choice, two for decreasing bone density, one for kidney stones, and the others for unclear or unrelated reasons.
Study limitations include that only 26 men (13 in each group) were included, and only 16 completed the study. “The external validity for men based on this study is therefore limited,” the authors note.
And although most people with primary hyperparathyroidism are adults, the older age of participants suggests the results should not be generalized to younger patients with benign parathyroid tumors.
The editorialists note that age should be one of the few factors that may, indeed, suggest appropriate candidates for parathyroidectomy.
“Younger patients (aged < 50 years) may have more aggressive disease,” they explain.
In addition, “patients with serum calcium levels above 3 mmol/L (> 12 mg/dL) are at greater risk for symptomatic hypercalcemia, and patients with a recent history of kidney stones may have fewer future stones after surgical cure.”
“Yet, such patients are a small minority of those with primary hyperparathyroidism,” they note.
The study authors underscore that “our data add evidence to guide the decisionmaking process in deliberative dialogue between clinicians and patients.”
The study received funding from Swedish government grants, the Norwegian Research Council, and the South-Eastern Norway Regional Health Authority.
A version of this article first appeared on Medscape.com.
Patients who receive parathyroidectomy for mild primary hyperparathyroidism show no benefits in survival or morbidity, including fractures, cancer, or cardiovascular outcomes over more than 10 years, compared with those not receiving the surgery, results from a randomized, prospective trial show.
“In contrast to existing data showing increased mortality and cardiovascular morbidity in mild primary hyperparathyroidism, we did not find any treatment effect of parathyroidectomy on these important clinical endpoints,” report the authors of the study, published in the Annals of Internal Medicine.
Reason to evaluate and revise current recommendations?
With mild primary hyperparathyroidism becoming the predominant form of hyperparathyroidism, the results suggest rethinking the current recommendations for the condition, the study authors note.
“Over the years, more active management of mild primary hyperparathyroidism has been recommended, with a widening of criteria for parathyroidectomy,” they write.
“With the low number of kidney stones (n = 5) and no effect of parathyroidectomy on fractures, there may be a need to evaluate and potentially revise the current recommendations.”
The authors of an accompanying editorial agree that “the [results] provide a strong rationale for nonoperative management of patients with mild primary hyperparathyroidism.”
“The findings suggest that most patients can be managed nonoperatively, with monitoring of serum calcium levels every 1 to 2 years or if symptoms occur,” write the editorial authors, Mark J. Bolland, PhD, and Andrew Grey, MD, of the department of medicine, University of Auckland, New Zealand.
Although parathyroidectomy is recommended for the treatment in patients with hyperparathyroidism with severe hypercalcemia or overt symptoms, there has been debate on the long-term benefits of surgery among those with milder cases.
Most previous studies that have shown benefits, such as reductions in the risk of fracture with parathyroidectomy, have importantly not distinguished between mild and more severe primary hyperparathyroidism, the authors note.
No significant differences in mortality between surgery, nonsurgery groups
For the Scandinavian Investigation of Primary Hyperparathyroidism (SIPH) trial, first author Mikkel Pretorius, MD, Oslo University Hospital and Faculty of Medicine, University of Oslo, and colleagues enrolled 191 patients between 1998 and 2005 in Sweden, Norway, and Denmark, who were aged 50-80 years and had mild primary hyperparathyroidism, defined as serum calcium levels of 10.42-11.22 mg/dL.
Participants were randomized to receive surgery (n = 95) or nonoperative observation without intervention (n = 96).
After a 10-year follow-up, 129 patients had completed the final visit. The overall death rate was 7.6%, and, with eight deaths in the surgery group and seven in the nonsurgery group, there were no significant differences between groups in terms of mortality (HR, 1.17; P = .76).
During an extended observation period that lasted until 2018, mortality rates increased by 23%, but with a relatively even distribution of 24 deaths in the surgery group and 20 among those with no surgery.
Chronic hypercalcemia related to primary hyperparathyroidism has been debated as being associated with an increased risk of cardiovascular disease or cancer, however, “the absolute numbers for these and the other disease-specific causes of death were nearly identical between groups,” the authors write, with 17 deaths from cardiovascular disease, eight from cancer, and eight from cerebrovascular disease.
In terms of morbidity, including cardiovascular events, cerebrovascular events, cancer, peripheral fractures, and renal stones, there were 101 events overall, with 52 in the parathyroidectomy group and 49 in the nonsurgery group, which again, was not a significant difference.
Sixteen vertebral fractures occurred overall in 14 patients, which were evenly split at seven patients in each group.
The authors note that “the incidence of peripheral fractures for women in our study was around 2,900 per 100,000 person-years, in the same range as for 70-year-old women in a study in Gothenburg, Sweden (about 2,600 per 100,000 person-years).”
There were no between-group differences in terms of time to death or first morbidity event for any of the prespecified events.
Of the 96 patients originally assigned to the nonsurgery group, 17 (18%) had surgery during follow-up, including three for serious hypercalcemia, three by their own choice, two for decreasing bone density, one for kidney stones, and the others for unclear or unrelated reasons.
Study limitations include that only 26 men (13 in each group) were included, and only 16 completed the study. “The external validity for men based on this study is therefore limited,” the authors note.
And although most people with primary hyperparathyroidism are adults, the older age of participants suggests the results should not be generalized to younger patients with benign parathyroid tumors.
The editorialists note that age should be one of the few factors that may, indeed, suggest appropriate candidates for parathyroidectomy.
“Younger patients (aged < 50 years) may have more aggressive disease,” they explain.
In addition, “patients with serum calcium levels above 3 mmol/L (> 12 mg/dL) are at greater risk for symptomatic hypercalcemia, and patients with a recent history of kidney stones may have fewer future stones after surgical cure.”
“Yet, such patients are a small minority of those with primary hyperparathyroidism,” they note.
The study authors underscore that “our data add evidence to guide the decisionmaking process in deliberative dialogue between clinicians and patients.”
The study received funding from Swedish government grants, the Norwegian Research Council, and the South-Eastern Norway Regional Health Authority.
A version of this article first appeared on Medscape.com.
FROM ANNALS OF INTERNAL MEDICINE
24-year-old female presents with a 3-month history of nonpruritic rash
, typically characterized by symmetrical, nonblanching, purpuric, telangiectatic, and atrophic patches with a predilection for the lower extremities and buttocks.
Plaques are usually 1-3 cm in diameter and annular with punctate telangiectasias and cayenne pepper petechiae in the border. The annular patches may form concentric rings. It is most commonly seen in children and young females.
The etiology of Majocchi’s disease is largely unknown and idiopathic.
Triggers are not always detected but may be associated with viral infections, chronic comorbidities, and medications. Levofloxacin and isotretinoin have been described in as reports as causing PATM. Other medications reported to cause PPD include sedatives, stimulants, antibiotics, NSAIDS, and cardiovascular drugs.
Diagnosis of PATM is clinical and histopathologic. Direct immunofluorescence (DIF) may show fibrinogen, IgM, and/or C3 deposition in superficial dermal vessels. Histopathologic findings show lymphocytic infiltrate involving the superficial small vessels, extravasated red blood cells, and hemosiderin-laden macrophages.
There is no consensus regarding treatment with variable responses to proposed treatment based on reports and case studies. The first line of treatment is topical corticosteroids and compression hose. Additional treatments, including narrowband UVB phototherapy (NBUVB), griseofulvin, pentoxifylline, cyclosporine, colchicine, rutoside with ascorbic acid, and methotrexate, have been used with varying success.
In this patient, a punch biopsy was performed, which revealed lymphocytes and extravasated erythrocytes and siderophages in the dermis. She was treated with topical steroids with improvement. She started NBUVB, a short course of griseofulvin, and vitamin C supplements.
This case and the photos were photo submitted by Ms. Xu, of the University of California, San Diego, and Dr. Sateesh, of San Diego Family Dermatology. Dr. Donna Bilu Martin edited the column.
Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to [email protected].
References
1. Garcez A et al. An Bras Dermatol. Sep-Oct 2020;95(5):664-6. doi: 10.1016/j.abd.2020.02.007.
2. Asadbeigi S, Momtahen S. Pigmented purpuric dermatosis. PathologyOutlines.com website.
3. Martínez P et al. Actas Dermosifiliogr (Engl Ed). 2020 Apr;111(3):196-204. doi: 10.1016/j.ad.2019.02.013.
4. Hoesly FJ et al. Int J Dermatol. 2009 Oct;48(10):1129-33. doi: 10.1111/j.1365-4632.2009.04160.x.
, typically characterized by symmetrical, nonblanching, purpuric, telangiectatic, and atrophic patches with a predilection for the lower extremities and buttocks.
Plaques are usually 1-3 cm in diameter and annular with punctate telangiectasias and cayenne pepper petechiae in the border. The annular patches may form concentric rings. It is most commonly seen in children and young females.
The etiology of Majocchi’s disease is largely unknown and idiopathic.
Triggers are not always detected but may be associated with viral infections, chronic comorbidities, and medications. Levofloxacin and isotretinoin have been described in as reports as causing PATM. Other medications reported to cause PPD include sedatives, stimulants, antibiotics, NSAIDS, and cardiovascular drugs.
Diagnosis of PATM is clinical and histopathologic. Direct immunofluorescence (DIF) may show fibrinogen, IgM, and/or C3 deposition in superficial dermal vessels. Histopathologic findings show lymphocytic infiltrate involving the superficial small vessels, extravasated red blood cells, and hemosiderin-laden macrophages.
There is no consensus regarding treatment with variable responses to proposed treatment based on reports and case studies. The first line of treatment is topical corticosteroids and compression hose. Additional treatments, including narrowband UVB phototherapy (NBUVB), griseofulvin, pentoxifylline, cyclosporine, colchicine, rutoside with ascorbic acid, and methotrexate, have been used with varying success.
In this patient, a punch biopsy was performed, which revealed lymphocytes and extravasated erythrocytes and siderophages in the dermis. She was treated with topical steroids with improvement. She started NBUVB, a short course of griseofulvin, and vitamin C supplements.
This case and the photos were photo submitted by Ms. Xu, of the University of California, San Diego, and Dr. Sateesh, of San Diego Family Dermatology. Dr. Donna Bilu Martin edited the column.
Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to [email protected].
References
1. Garcez A et al. An Bras Dermatol. Sep-Oct 2020;95(5):664-6. doi: 10.1016/j.abd.2020.02.007.
2. Asadbeigi S, Momtahen S. Pigmented purpuric dermatosis. PathologyOutlines.com website.
3. Martínez P et al. Actas Dermosifiliogr (Engl Ed). 2020 Apr;111(3):196-204. doi: 10.1016/j.ad.2019.02.013.
4. Hoesly FJ et al. Int J Dermatol. 2009 Oct;48(10):1129-33. doi: 10.1111/j.1365-4632.2009.04160.x.
, typically characterized by symmetrical, nonblanching, purpuric, telangiectatic, and atrophic patches with a predilection for the lower extremities and buttocks.
Plaques are usually 1-3 cm in diameter and annular with punctate telangiectasias and cayenne pepper petechiae in the border. The annular patches may form concentric rings. It is most commonly seen in children and young females.
The etiology of Majocchi’s disease is largely unknown and idiopathic.
Triggers are not always detected but may be associated with viral infections, chronic comorbidities, and medications. Levofloxacin and isotretinoin have been described in as reports as causing PATM. Other medications reported to cause PPD include sedatives, stimulants, antibiotics, NSAIDS, and cardiovascular drugs.
Diagnosis of PATM is clinical and histopathologic. Direct immunofluorescence (DIF) may show fibrinogen, IgM, and/or C3 deposition in superficial dermal vessels. Histopathologic findings show lymphocytic infiltrate involving the superficial small vessels, extravasated red blood cells, and hemosiderin-laden macrophages.
There is no consensus regarding treatment with variable responses to proposed treatment based on reports and case studies. The first line of treatment is topical corticosteroids and compression hose. Additional treatments, including narrowband UVB phototherapy (NBUVB), griseofulvin, pentoxifylline, cyclosporine, colchicine, rutoside with ascorbic acid, and methotrexate, have been used with varying success.
In this patient, a punch biopsy was performed, which revealed lymphocytes and extravasated erythrocytes and siderophages in the dermis. She was treated with topical steroids with improvement. She started NBUVB, a short course of griseofulvin, and vitamin C supplements.
This case and the photos were photo submitted by Ms. Xu, of the University of California, San Diego, and Dr. Sateesh, of San Diego Family Dermatology. Dr. Donna Bilu Martin edited the column.
Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to [email protected].
References
1. Garcez A et al. An Bras Dermatol. Sep-Oct 2020;95(5):664-6. doi: 10.1016/j.abd.2020.02.007.
2. Asadbeigi S, Momtahen S. Pigmented purpuric dermatosis. PathologyOutlines.com website.
3. Martínez P et al. Actas Dermosifiliogr (Engl Ed). 2020 Apr;111(3):196-204. doi: 10.1016/j.ad.2019.02.013.
4. Hoesly FJ et al. Int J Dermatol. 2009 Oct;48(10):1129-33. doi: 10.1111/j.1365-4632.2009.04160.x.
ILD progression, not diagnosis, triggers palliative care
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.
FROM THE JOURNAL CHEST®
Inadequate pain relief in OA, high opioid use before TKA
Inadequate pain relief was recorded in 68.8% of a sample of people with hip or knee OA who participated in the population-based EpiReumaPt study, researchers reported at the OARSI 2022 World Congress.
“This can be explained by a lack of effectiveness of current management strategies, low uptake of recommended interventions by health care professionals, and also by low adherence by patients to medication and lifestyle interventions,” said Daniela Sofia Albino Costa, MSc, a PhD student at NOVA University Lisbon.
In addition to looking at the prevalence of inadequate pain relief – defined as a score of 5 or higher on the Numeric Pain Rating Scale (NPRS) – the study she presented at the congress, which was sponsored by the Osteoarthritis Research Society International, looked at the predictors for inadequate pain control.
It was found that being female, obesity, and having multimorbidity doubled the risk of inadequate versus adequate pain control, with respective odds ratios of 2.32 (P < .001), 2.26 (P = .006), and 2.07 (P = .001). Overweight was also associated with an increased odds ratio for poor pain control (OR, 1.84; P = .0035).
“We found that patients with inadequate pain relief also have a low performance on activities of daily living and a low quality of life,” Ms. Costa said.
Nearly one-third (29%) of patients in the inadequate pain relief group (n = 765) took medication, versus 15% of patients in the adequate pain relief group (n = 270). This was mostly NSAIDs, but also included analgesics and antipyretics, and in a few cases (4.8% vs. 1.3%), simple opioids.
“We know that current care is not concordant with recommendations,” said Ms. Costa, noting that medication being used as first-line treatment and core nonpharmacologic interventions are being offered to less than half of patients who are eligible.
In addition, the rate for total joint replacement has increased globally, and pain is an important predictor for this.
“So, we need to evaluate pain control and current management offered to people with hip or knee arthritis to identify to identify areas for improvement,” Ms. Costa said.
High rates of prescription opioid use before TKA
In a separate study also presented at the congress, Daniel Rhon, DPT, DSc, director of musculoskeletal research in primary care at Brooke Army Medical Center in San Antonio, gave a worrying glimpse of high rates of opioid use in the 4 years before total knee arthroplasty (TKA).
Using data from the U.S. Military Health System, the records of all individuals who had a knee replacement procedure between January 2017 and December 2018 were studied, to identify and characterize the use of prescription opioids.
Of the 46,362 individuals, 52.9% had prior opioid use, despite the fact that “opioids are not recommended for the management of knee OA,” said Dr. Rhon.
He also reported that as many as 40% of those who had at least one prescription for opioids had received a high-potency drug, such as fentanyl or oxycodone. The mean age of participants overall was 65 years, with a higher mean for those receiving opioids than those who did not (68 vs. 61.5 years). Data on sex and ethnicity were not available in time for presentation at the congress.
“Most of these individuals are getting these opioid prescriptions probably within 6 months, which maybe aligns with escalation of pain and maybe the decision to have that knee replacement,” Dr. Rhon said. Individuals that used opioids filled their most recent prescription a median of 146 days before TKA to surgery, with a mean of 317 days.
“You can’t always link the reason for the opioid prescription, that’s not really clear in the database,” he admitted; however, an analysis was performed to check if other surgeries had been performed that may have warranted the opioid treatment. The results revealed that very few of the opioid users (4%-7%) had undergone another type of surgical procedure.
“So, we feel a little bit better, that these findings weren’t for other surgical procedures,” said Dr. Rhon. He added that future qualitative research was needed to understand why health care professionals were prescribing opioids, and why patients felt like they needed them.
“That’s bad,” Haxby Abbott, PhD, DPT, a research professor at the University of Otago, Dunedin, New Zealand, commented on Twitter.
Dr. Abbott, who was not involved in the study, added: “We’ve done a similar study of the whole NZ population [currently under review] – similar to Australia and not nearly as bad as you found. That needs urgent attention.”
Sharp rise in opioid use 2 years before TKA
Lower rates of opioid use before TKA were seen in two European cohorts, at 43% in England and 33% in Sweden, as reported by Clara Hellberg, PhD, MD, of Lund (Sweden) University. However, rates had increased over a 10-year study period from a respective 23% and 16%, with a sharp increase in use in the 2 years before knee replacement.
The analysis was based on 49,043 patients from the English national database Clinical Practice Research Datalink, and 5,955 patients from the Swedish Skåne Healthcare register who had undergone total knee replacement between 2015 and 2019 and were matched by age, sex and general practice to individuals not undergoing knee replacement.
The prevalence ratio for using opioids over a 10-year period increased from 1.6 to 2.7 in England, and from 1.6 to 2.6 in Sweden.
“While the overall prevalence of opioid use was higher in England, the majority of both cases and controls were using weak opioids,” Dr. Hellberg said.
“Codeine was classified as a weak opioid, whereas morphine was classified as a strong opioid,” she added.
In contrast, the proportion of people using strong opioids in Sweden was greater than in England, she said.
The high opioid use found in the study highlights “the need for better opioid stewardship, and the availability of acceptable, effective alternatives,” Dr. Hellberg and associates concluded in their abstract.
The study presented by Ms. Costa was funded by the Portuguese national funding agency for science, research and technology and by an independent research grant from Pfizer. Dr. Rhon acknowledged grant funding from the National Institutes of Health and the U.S. Department of Defense. Dr. Hellberg had no conflicts of interest to disclose.
Inadequate pain relief was recorded in 68.8% of a sample of people with hip or knee OA who participated in the population-based EpiReumaPt study, researchers reported at the OARSI 2022 World Congress.
“This can be explained by a lack of effectiveness of current management strategies, low uptake of recommended interventions by health care professionals, and also by low adherence by patients to medication and lifestyle interventions,” said Daniela Sofia Albino Costa, MSc, a PhD student at NOVA University Lisbon.
In addition to looking at the prevalence of inadequate pain relief – defined as a score of 5 or higher on the Numeric Pain Rating Scale (NPRS) – the study she presented at the congress, which was sponsored by the Osteoarthritis Research Society International, looked at the predictors for inadequate pain control.
It was found that being female, obesity, and having multimorbidity doubled the risk of inadequate versus adequate pain control, with respective odds ratios of 2.32 (P < .001), 2.26 (P = .006), and 2.07 (P = .001). Overweight was also associated with an increased odds ratio for poor pain control (OR, 1.84; P = .0035).
“We found that patients with inadequate pain relief also have a low performance on activities of daily living and a low quality of life,” Ms. Costa said.
Nearly one-third (29%) of patients in the inadequate pain relief group (n = 765) took medication, versus 15% of patients in the adequate pain relief group (n = 270). This was mostly NSAIDs, but also included analgesics and antipyretics, and in a few cases (4.8% vs. 1.3%), simple opioids.
“We know that current care is not concordant with recommendations,” said Ms. Costa, noting that medication being used as first-line treatment and core nonpharmacologic interventions are being offered to less than half of patients who are eligible.
In addition, the rate for total joint replacement has increased globally, and pain is an important predictor for this.
“So, we need to evaluate pain control and current management offered to people with hip or knee arthritis to identify to identify areas for improvement,” Ms. Costa said.
High rates of prescription opioid use before TKA
In a separate study also presented at the congress, Daniel Rhon, DPT, DSc, director of musculoskeletal research in primary care at Brooke Army Medical Center in San Antonio, gave a worrying glimpse of high rates of opioid use in the 4 years before total knee arthroplasty (TKA).
Using data from the U.S. Military Health System, the records of all individuals who had a knee replacement procedure between January 2017 and December 2018 were studied, to identify and characterize the use of prescription opioids.
Of the 46,362 individuals, 52.9% had prior opioid use, despite the fact that “opioids are not recommended for the management of knee OA,” said Dr. Rhon.
He also reported that as many as 40% of those who had at least one prescription for opioids had received a high-potency drug, such as fentanyl or oxycodone. The mean age of participants overall was 65 years, with a higher mean for those receiving opioids than those who did not (68 vs. 61.5 years). Data on sex and ethnicity were not available in time for presentation at the congress.
“Most of these individuals are getting these opioid prescriptions probably within 6 months, which maybe aligns with escalation of pain and maybe the decision to have that knee replacement,” Dr. Rhon said. Individuals that used opioids filled their most recent prescription a median of 146 days before TKA to surgery, with a mean of 317 days.
“You can’t always link the reason for the opioid prescription, that’s not really clear in the database,” he admitted; however, an analysis was performed to check if other surgeries had been performed that may have warranted the opioid treatment. The results revealed that very few of the opioid users (4%-7%) had undergone another type of surgical procedure.
“So, we feel a little bit better, that these findings weren’t for other surgical procedures,” said Dr. Rhon. He added that future qualitative research was needed to understand why health care professionals were prescribing opioids, and why patients felt like they needed them.
“That’s bad,” Haxby Abbott, PhD, DPT, a research professor at the University of Otago, Dunedin, New Zealand, commented on Twitter.
Dr. Abbott, who was not involved in the study, added: “We’ve done a similar study of the whole NZ population [currently under review] – similar to Australia and not nearly as bad as you found. That needs urgent attention.”
Sharp rise in opioid use 2 years before TKA
Lower rates of opioid use before TKA were seen in two European cohorts, at 43% in England and 33% in Sweden, as reported by Clara Hellberg, PhD, MD, of Lund (Sweden) University. However, rates had increased over a 10-year study period from a respective 23% and 16%, with a sharp increase in use in the 2 years before knee replacement.
The analysis was based on 49,043 patients from the English national database Clinical Practice Research Datalink, and 5,955 patients from the Swedish Skåne Healthcare register who had undergone total knee replacement between 2015 and 2019 and were matched by age, sex and general practice to individuals not undergoing knee replacement.
The prevalence ratio for using opioids over a 10-year period increased from 1.6 to 2.7 in England, and from 1.6 to 2.6 in Sweden.
“While the overall prevalence of opioid use was higher in England, the majority of both cases and controls were using weak opioids,” Dr. Hellberg said.
“Codeine was classified as a weak opioid, whereas morphine was classified as a strong opioid,” she added.
In contrast, the proportion of people using strong opioids in Sweden was greater than in England, she said.
The high opioid use found in the study highlights “the need for better opioid stewardship, and the availability of acceptable, effective alternatives,” Dr. Hellberg and associates concluded in their abstract.
The study presented by Ms. Costa was funded by the Portuguese national funding agency for science, research and technology and by an independent research grant from Pfizer. Dr. Rhon acknowledged grant funding from the National Institutes of Health and the U.S. Department of Defense. Dr. Hellberg had no conflicts of interest to disclose.
Inadequate pain relief was recorded in 68.8% of a sample of people with hip or knee OA who participated in the population-based EpiReumaPt study, researchers reported at the OARSI 2022 World Congress.
“This can be explained by a lack of effectiveness of current management strategies, low uptake of recommended interventions by health care professionals, and also by low adherence by patients to medication and lifestyle interventions,” said Daniela Sofia Albino Costa, MSc, a PhD student at NOVA University Lisbon.
In addition to looking at the prevalence of inadequate pain relief – defined as a score of 5 or higher on the Numeric Pain Rating Scale (NPRS) – the study she presented at the congress, which was sponsored by the Osteoarthritis Research Society International, looked at the predictors for inadequate pain control.
It was found that being female, obesity, and having multimorbidity doubled the risk of inadequate versus adequate pain control, with respective odds ratios of 2.32 (P < .001), 2.26 (P = .006), and 2.07 (P = .001). Overweight was also associated with an increased odds ratio for poor pain control (OR, 1.84; P = .0035).
“We found that patients with inadequate pain relief also have a low performance on activities of daily living and a low quality of life,” Ms. Costa said.
Nearly one-third (29%) of patients in the inadequate pain relief group (n = 765) took medication, versus 15% of patients in the adequate pain relief group (n = 270). This was mostly NSAIDs, but also included analgesics and antipyretics, and in a few cases (4.8% vs. 1.3%), simple opioids.
“We know that current care is not concordant with recommendations,” said Ms. Costa, noting that medication being used as first-line treatment and core nonpharmacologic interventions are being offered to less than half of patients who are eligible.
In addition, the rate for total joint replacement has increased globally, and pain is an important predictor for this.
“So, we need to evaluate pain control and current management offered to people with hip or knee arthritis to identify to identify areas for improvement,” Ms. Costa said.
High rates of prescription opioid use before TKA
In a separate study also presented at the congress, Daniel Rhon, DPT, DSc, director of musculoskeletal research in primary care at Brooke Army Medical Center in San Antonio, gave a worrying glimpse of high rates of opioid use in the 4 years before total knee arthroplasty (TKA).
Using data from the U.S. Military Health System, the records of all individuals who had a knee replacement procedure between January 2017 and December 2018 were studied, to identify and characterize the use of prescription opioids.
Of the 46,362 individuals, 52.9% had prior opioid use, despite the fact that “opioids are not recommended for the management of knee OA,” said Dr. Rhon.
He also reported that as many as 40% of those who had at least one prescription for opioids had received a high-potency drug, such as fentanyl or oxycodone. The mean age of participants overall was 65 years, with a higher mean for those receiving opioids than those who did not (68 vs. 61.5 years). Data on sex and ethnicity were not available in time for presentation at the congress.
“Most of these individuals are getting these opioid prescriptions probably within 6 months, which maybe aligns with escalation of pain and maybe the decision to have that knee replacement,” Dr. Rhon said. Individuals that used opioids filled their most recent prescription a median of 146 days before TKA to surgery, with a mean of 317 days.
“You can’t always link the reason for the opioid prescription, that’s not really clear in the database,” he admitted; however, an analysis was performed to check if other surgeries had been performed that may have warranted the opioid treatment. The results revealed that very few of the opioid users (4%-7%) had undergone another type of surgical procedure.
“So, we feel a little bit better, that these findings weren’t for other surgical procedures,” said Dr. Rhon. He added that future qualitative research was needed to understand why health care professionals were prescribing opioids, and why patients felt like they needed them.
“That’s bad,” Haxby Abbott, PhD, DPT, a research professor at the University of Otago, Dunedin, New Zealand, commented on Twitter.
Dr. Abbott, who was not involved in the study, added: “We’ve done a similar study of the whole NZ population [currently under review] – similar to Australia and not nearly as bad as you found. That needs urgent attention.”
Sharp rise in opioid use 2 years before TKA
Lower rates of opioid use before TKA were seen in two European cohorts, at 43% in England and 33% in Sweden, as reported by Clara Hellberg, PhD, MD, of Lund (Sweden) University. However, rates had increased over a 10-year study period from a respective 23% and 16%, with a sharp increase in use in the 2 years before knee replacement.
The analysis was based on 49,043 patients from the English national database Clinical Practice Research Datalink, and 5,955 patients from the Swedish Skåne Healthcare register who had undergone total knee replacement between 2015 and 2019 and were matched by age, sex and general practice to individuals not undergoing knee replacement.
The prevalence ratio for using opioids over a 10-year period increased from 1.6 to 2.7 in England, and from 1.6 to 2.6 in Sweden.
“While the overall prevalence of opioid use was higher in England, the majority of both cases and controls were using weak opioids,” Dr. Hellberg said.
“Codeine was classified as a weak opioid, whereas morphine was classified as a strong opioid,” she added.
In contrast, the proportion of people using strong opioids in Sweden was greater than in England, she said.
The high opioid use found in the study highlights “the need for better opioid stewardship, and the availability of acceptable, effective alternatives,” Dr. Hellberg and associates concluded in their abstract.
The study presented by Ms. Costa was funded by the Portuguese national funding agency for science, research and technology and by an independent research grant from Pfizer. Dr. Rhon acknowledged grant funding from the National Institutes of Health and the U.S. Department of Defense. Dr. Hellberg had no conflicts of interest to disclose.
FROM OARSI 2022