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A special part of the brain lights up when we see food
“We eat first with our eyes.”
The Roman foodie Apicius is thought to have uttered those words in the 1st century A.D. Now, some 2,000 years later, scientists may be proving him right.
Dubbed the “ventral food component,” this part resides in the brain’s visual cortex, in a region known to play a role in identifying faces, scenes, and words.
The study, published in the journal Current Biology, involved using artificial intelligence (AI) technology to build a computer model of this part of the brain. Similar models are emerging across fields of research to simulate and study complex systems of the body. A computer model of the digestive system was recently used to determine the best body position for taking a pill.
“The research is still cutting-edge,” says study author Meenakshi Khosla, PhD. “There’s a lot more to be done to understand whether this region is the same or different in different individuals, and how it is modulated by experience or familiarity with different kinds of foods.”
Pinpointing those differences could provide insights into how people choose what they eat, or even help us learn what drives eating disorders, Dr. Khosla says.
Part of what makes this study unique was the researchers’ approach, dubbed “hypothesis neutral.” Instead of setting out to prove or disprove a firm hypothesis, they simply started exploring the data to see what they could find. The goal: To go beyond “the idiosyncratic hypotheses scientists have already thought to test,” the paper says. So, they began sifting through a public database called the Natural Scenes Dataset, an inventory of brain scans from eight volunteers viewing 56,720 images.
As expected, the software analyzing the dataset spotted brain regions already known to be triggered by images of faces, bodies, words, and scenes. But to the researchers’ surprise, the analysis also revealed a previously unknown part of the brain that seemed to be responding to images of food.
“Our first reaction was, ‘That’s cute and all, but it can’t possibly be true,’ ” Dr. Khosla says.
To confirm their discovery, the researchers used the data to train a computer model of this part of the brain, a process that takes less than an hour. Then they fed the model more than 1.2 million new images.
Sure enough, the model lit up in response to food. Color didn’t matter – even black-and-white food images triggered it, though not as strongly as color ones. And the model could tell the difference between food and objects that looked like food: a banana versus a crescent moon, or a blueberry muffin versus a puppy with a muffin-like face.
From the human data, the researchers found that some people responded slightly more to processed foods like pizza than unprocessed foods like apples. They hope to explore how other things, such as liking or disliking a food, may affect a person’s response to that food.
This technology could open up other areas of research as well. Dr. Khosla hopes to use it to explore how the brain responds to social cues like body language and facial expressions.
For now, Dr. Khosla has already begun to verify the computer model in real people by scanning the brains of a new set of volunteers. “We collected pilot data in a few subjects recently and were able to localize this component,” she says.
A version of this article first appeared on Medscape.com.
“We eat first with our eyes.”
The Roman foodie Apicius is thought to have uttered those words in the 1st century A.D. Now, some 2,000 years later, scientists may be proving him right.
Dubbed the “ventral food component,” this part resides in the brain’s visual cortex, in a region known to play a role in identifying faces, scenes, and words.
The study, published in the journal Current Biology, involved using artificial intelligence (AI) technology to build a computer model of this part of the brain. Similar models are emerging across fields of research to simulate and study complex systems of the body. A computer model of the digestive system was recently used to determine the best body position for taking a pill.
“The research is still cutting-edge,” says study author Meenakshi Khosla, PhD. “There’s a lot more to be done to understand whether this region is the same or different in different individuals, and how it is modulated by experience or familiarity with different kinds of foods.”
Pinpointing those differences could provide insights into how people choose what they eat, or even help us learn what drives eating disorders, Dr. Khosla says.
Part of what makes this study unique was the researchers’ approach, dubbed “hypothesis neutral.” Instead of setting out to prove or disprove a firm hypothesis, they simply started exploring the data to see what they could find. The goal: To go beyond “the idiosyncratic hypotheses scientists have already thought to test,” the paper says. So, they began sifting through a public database called the Natural Scenes Dataset, an inventory of brain scans from eight volunteers viewing 56,720 images.
As expected, the software analyzing the dataset spotted brain regions already known to be triggered by images of faces, bodies, words, and scenes. But to the researchers’ surprise, the analysis also revealed a previously unknown part of the brain that seemed to be responding to images of food.
“Our first reaction was, ‘That’s cute and all, but it can’t possibly be true,’ ” Dr. Khosla says.
To confirm their discovery, the researchers used the data to train a computer model of this part of the brain, a process that takes less than an hour. Then they fed the model more than 1.2 million new images.
Sure enough, the model lit up in response to food. Color didn’t matter – even black-and-white food images triggered it, though not as strongly as color ones. And the model could tell the difference between food and objects that looked like food: a banana versus a crescent moon, or a blueberry muffin versus a puppy with a muffin-like face.
From the human data, the researchers found that some people responded slightly more to processed foods like pizza than unprocessed foods like apples. They hope to explore how other things, such as liking or disliking a food, may affect a person’s response to that food.
This technology could open up other areas of research as well. Dr. Khosla hopes to use it to explore how the brain responds to social cues like body language and facial expressions.
For now, Dr. Khosla has already begun to verify the computer model in real people by scanning the brains of a new set of volunteers. “We collected pilot data in a few subjects recently and were able to localize this component,” she says.
A version of this article first appeared on Medscape.com.
“We eat first with our eyes.”
The Roman foodie Apicius is thought to have uttered those words in the 1st century A.D. Now, some 2,000 years later, scientists may be proving him right.
Dubbed the “ventral food component,” this part resides in the brain’s visual cortex, in a region known to play a role in identifying faces, scenes, and words.
The study, published in the journal Current Biology, involved using artificial intelligence (AI) technology to build a computer model of this part of the brain. Similar models are emerging across fields of research to simulate and study complex systems of the body. A computer model of the digestive system was recently used to determine the best body position for taking a pill.
“The research is still cutting-edge,” says study author Meenakshi Khosla, PhD. “There’s a lot more to be done to understand whether this region is the same or different in different individuals, and how it is modulated by experience or familiarity with different kinds of foods.”
Pinpointing those differences could provide insights into how people choose what they eat, or even help us learn what drives eating disorders, Dr. Khosla says.
Part of what makes this study unique was the researchers’ approach, dubbed “hypothesis neutral.” Instead of setting out to prove or disprove a firm hypothesis, they simply started exploring the data to see what they could find. The goal: To go beyond “the idiosyncratic hypotheses scientists have already thought to test,” the paper says. So, they began sifting through a public database called the Natural Scenes Dataset, an inventory of brain scans from eight volunteers viewing 56,720 images.
As expected, the software analyzing the dataset spotted brain regions already known to be triggered by images of faces, bodies, words, and scenes. But to the researchers’ surprise, the analysis also revealed a previously unknown part of the brain that seemed to be responding to images of food.
“Our first reaction was, ‘That’s cute and all, but it can’t possibly be true,’ ” Dr. Khosla says.
To confirm their discovery, the researchers used the data to train a computer model of this part of the brain, a process that takes less than an hour. Then they fed the model more than 1.2 million new images.
Sure enough, the model lit up in response to food. Color didn’t matter – even black-and-white food images triggered it, though not as strongly as color ones. And the model could tell the difference between food and objects that looked like food: a banana versus a crescent moon, or a blueberry muffin versus a puppy with a muffin-like face.
From the human data, the researchers found that some people responded slightly more to processed foods like pizza than unprocessed foods like apples. They hope to explore how other things, such as liking or disliking a food, may affect a person’s response to that food.
This technology could open up other areas of research as well. Dr. Khosla hopes to use it to explore how the brain responds to social cues like body language and facial expressions.
For now, Dr. Khosla has already begun to verify the computer model in real people by scanning the brains of a new set of volunteers. “We collected pilot data in a few subjects recently and were able to localize this component,” she says.
A version of this article first appeared on Medscape.com.
FROM CURRENT BIOLOGY
From Frankenstein to Lecter: Hollywood’s baddest docs
Masks can be scary on Halloween, but more so when they come with scrubs, scalpels, and God complexes. In March, Medscape readers chose their favorite characters and performers in the Hollywood health care system. from a deep bench (and no, Dr Evil didn’t go to medical school; neither did Dr No, for that matter). Before you see these folks who’d rather haunt than heal, we urge you to seek a second opinion.
George Harris (Richard Widmark, “Coma,” 1978)
“Medicine is now a great social force,” says Dr. George Harris (Richard Widmark), chief of surgery at Boston Memorial. Because the public trusts doctors, “we’ll make the hard decisions” – like choosing which young, healthy patients to put into an irreversible coma to harvest their organs. Harris’ audience of one here is Dr. Susan Wheeler (Genevieve Bujold), the upstart who has uncovered his plot, and whom Harris has just drugged to prepare her as his next unintentional donor. “Coma” was based on a bestseller by Robin Cook and directed by Michael Crichton, who left Harvard Medical School for a career in popular books and films, including “The Andromeda Strain” and “Jurassic Park.” Although Dr. Harris starts out as a reassuring friend and mentor to Dr. Wheeler, older moviegoers won’t forget that he launched to stardom by tossing a woman in a wheelchair down the stairs in 1947’s “Kiss of Death.”
Christian Szell (Laurence Olivier, “Marathon Man,” 1976)
He may look harmless, but Christian Szell (Laurence Olivier) is a sadist with a secret, a stash, and throat-slitting skills. Szell, a dentist known as the White Angel of Auschwitz for his war crimes, stops at nothing to protect the diamonds he stole from his victims in the camps. In one of Hollywood’s most infamous torture scenes, Szell tries to extract information from Babe Levy (Dustin Hoffman), an innocent grad student, plying the tools of his trade. When Szell asks, “Is it safe?” he’s not curious about whether Babe’s insurance covers anesthesia.
Orin Scrivello (Steve Martin, “Little Shop of Horrors,” 1986)
Sticking with deranged dentists, Orin Scrivello, DDS, (Steve Martin) sings and dances his way into your nightmares buoyed by copious helpings of nitrous oxide. Orin’s too-encouraging momma told him to parlay his sadistic tendencies into a career “where people will pay you to be inhumane.” Sonny listened. Moviegoers were treated to screeching sound effects of a tooth getting yanked during an Elvis-like musical number shot in part from inside a patient’s mouth. Martin makes a creepy scene more fun than a long, slow root canal.
Henry Frankenstein (Colin Clive, “Frankenstein,” 1931)
His alarming need for fresh corpses forced Henry Frankenstein (Colin Clive) to leave medical school and experiment solo in a castle. He insists to his betrothed that he hasn’t gone mad when she arrives as he is bringing a dead body back to life during a raging lightning storm. When she and Henry’s mentor, Dr Waldman, witness him succeed, Waldman warns Henry that the former owner of the purloined brain was a notorious criminal. When Henry exclaims: “It’s alive, it’s alive !” little did he know that he created the face (Boris Karloff) that would launch a thousand sequels, a spectacular satire, and untold Halloween masks.
Dr. Gogol (Peter Lorre, “Mad Love,” 1935)
A few years after playing doctor Frankenstein, Colin Clive became the patient of a mad medic himself. A concert pianist whose hands have been mangled in a train wreck, Clive’s wife turns to Dr. Gogol (Peter Lorre, in his Hollywood debut), who promises to surgically reattach the musician’s hands. Unfortunately, Gogol is so obsessed with the wife, a star of gory stage shows, that he has created a wax figure of her. He schemes to win her in the flesh by attaching a murderer’s hands to Clive, then frame him for committing murder with those hands. Gogol utters the madman’s lament: “I have conquered science. Why can’t I conquer love?” A modern remake would surely have him asking, “Why do they swipe left?
Hannibal Lecter (Anthony Hopkins, “Silence of the Lambs,” 1991)
The FBI, hunting for a serial killer, sends trainee Clarice Starling (Jodie Foster) to seek insight into the murderer from the imprisoned Dr. Hannibal Lecter (Anthony Hopkins), a brilliant psychiatrist with a penchant for murder — and a taste for the flesh of his victims. Lecter proves to be a menace from their first meeting; the bars and glass surrounding his cell offer Clarice no protection from his gaze and ability to read her mind. In his own way, the urbane, pathologically charming Lecter takes a shine to Clarice, helping with the case while embarking on another murderous spree against men who recently wronged her. When he escapes, his plans do not include dinner with – or of – Clarice, but others, well, they’re not so lucky.
Henry Jekyll (Fredric March, “Dr. Jekyll and Mr. Hyde,” 1931)
Henry Jekyll (Fredric March) is a jumble of personalities. By day, he’s a kindly doctor in Victorian London with an American accent. But he is so determined to split good and evil personalities that he devises a potion to outsource his id. As he watches himself morph into Mr. Hyde – a hairy, cone-headed dude in serious need of an orthodontist – he exclaims, “Free! Free at last!” Free, that is, for his simian side to engage in debauchery, abuse, self-hatred, intimations of rape, and ultimately murder – all of which are explored in this pre-Code film, the first talkie version of Robert Louis Stevenson’s story.
Dr. Moreau (Charles Laughton, “Island of Lost Souls,” 1932)
“Strange-looking natives you have here,” shipwreck victim Edward Parker (Richard Arlen) tells his host, the white-suited, whip-wielding Dr Moreau. Before long, we learn that Moreau’s evil veterinary talents have created an island population of human/beast hybrids who are forced to follow his laws – especially one forbidding them from eating meat or walking on all fours. Lawbreakers get taken to the House of Pain, a medical setting which, as its name suggests, lacks adequate analgesia. Burt Lancaster and Marlon Brando took on the Moreau role in later versions, but Laughton is the creepiest when he asks, “Do you know what it means to feel like God?” The film was banned for years in Britain, and H.G. Wells despised this take on his antivivisection tale.
Charles Nichols (Jeroen Krabbé, “The Fugitive,” 1993)
Richard Kimble, a Chicago vascular surgeon, arrives home to find that a man just brutally murdered his loving wife. The killer escapes, and Kimble falls into the frame-up. Convicted for the murder and headed to prison, Kimble breaks free in an epic escape scene. He spends the rest of the movie all but giving his right arm to find the murderer, while being pursued by a dogged U.S. Marshal played with gusto by Tommy Lee Jones. Kimble eventually discovers that his colleague, Dr. Charles Nichols (Jeroen Krabbé), is not quite the best friend a man could have – or the most ethical of clinical investigators.
Elliot and Beverly Mantle (Jeremy Irons, “Dead Ringers,” 1988)
“You’ve got to try the movie star,” fertility specialist Elliot Mantle (Jeremy Irons) implores to his identical but meek twin brother, Beverly (also Jeremy Irons), talking about an actress-patient (Genevieve Bujold) as if she were a menu item. Beverly shares a practice with Elliot, along with a soul and an easily satisfied drug addiction. Beverly is unaware that Elliot seduces patients before passing them off to his brother, including the actress. Beverly is in love with the actress, which upsets the equilibrium of their shared soul. He aims to fix this, but not without some trauma involving freakish and unsanitary operating implements.
Dean Armitage (Bradley Whitford, “Get Out,” 2017)
Neurosurgeon Dean Armitage (Bradley Whitford) was such a fan of President Obama that he would have voted for him a third time if he could. At least, that’s how he portrays himself to Chris (Daniel Kaluuya), an African American photographer and the new boyfriend of Armitage’s White daughter. The Armitage estate has plenty of people of color – on staff, anyway – but Chris finds them odd and distant. It turns out that a gathering of rich White people is in fact an auction for his eyesight. Horror ensues. The main message from this film is not unlike that of Russian operatives who fall out of favor with the Kremlin: Don’t drink the tea.
A version of this article first appeared on Medscape.com.
Masks can be scary on Halloween, but more so when they come with scrubs, scalpels, and God complexes. In March, Medscape readers chose their favorite characters and performers in the Hollywood health care system. from a deep bench (and no, Dr Evil didn’t go to medical school; neither did Dr No, for that matter). Before you see these folks who’d rather haunt than heal, we urge you to seek a second opinion.
George Harris (Richard Widmark, “Coma,” 1978)
“Medicine is now a great social force,” says Dr. George Harris (Richard Widmark), chief of surgery at Boston Memorial. Because the public trusts doctors, “we’ll make the hard decisions” – like choosing which young, healthy patients to put into an irreversible coma to harvest their organs. Harris’ audience of one here is Dr. Susan Wheeler (Genevieve Bujold), the upstart who has uncovered his plot, and whom Harris has just drugged to prepare her as his next unintentional donor. “Coma” was based on a bestseller by Robin Cook and directed by Michael Crichton, who left Harvard Medical School for a career in popular books and films, including “The Andromeda Strain” and “Jurassic Park.” Although Dr. Harris starts out as a reassuring friend and mentor to Dr. Wheeler, older moviegoers won’t forget that he launched to stardom by tossing a woman in a wheelchair down the stairs in 1947’s “Kiss of Death.”
Christian Szell (Laurence Olivier, “Marathon Man,” 1976)
He may look harmless, but Christian Szell (Laurence Olivier) is a sadist with a secret, a stash, and throat-slitting skills. Szell, a dentist known as the White Angel of Auschwitz for his war crimes, stops at nothing to protect the diamonds he stole from his victims in the camps. In one of Hollywood’s most infamous torture scenes, Szell tries to extract information from Babe Levy (Dustin Hoffman), an innocent grad student, plying the tools of his trade. When Szell asks, “Is it safe?” he’s not curious about whether Babe’s insurance covers anesthesia.
Orin Scrivello (Steve Martin, “Little Shop of Horrors,” 1986)
Sticking with deranged dentists, Orin Scrivello, DDS, (Steve Martin) sings and dances his way into your nightmares buoyed by copious helpings of nitrous oxide. Orin’s too-encouraging momma told him to parlay his sadistic tendencies into a career “where people will pay you to be inhumane.” Sonny listened. Moviegoers were treated to screeching sound effects of a tooth getting yanked during an Elvis-like musical number shot in part from inside a patient’s mouth. Martin makes a creepy scene more fun than a long, slow root canal.
Henry Frankenstein (Colin Clive, “Frankenstein,” 1931)
His alarming need for fresh corpses forced Henry Frankenstein (Colin Clive) to leave medical school and experiment solo in a castle. He insists to his betrothed that he hasn’t gone mad when she arrives as he is bringing a dead body back to life during a raging lightning storm. When she and Henry’s mentor, Dr Waldman, witness him succeed, Waldman warns Henry that the former owner of the purloined brain was a notorious criminal. When Henry exclaims: “It’s alive, it’s alive !” little did he know that he created the face (Boris Karloff) that would launch a thousand sequels, a spectacular satire, and untold Halloween masks.
Dr. Gogol (Peter Lorre, “Mad Love,” 1935)
A few years after playing doctor Frankenstein, Colin Clive became the patient of a mad medic himself. A concert pianist whose hands have been mangled in a train wreck, Clive’s wife turns to Dr. Gogol (Peter Lorre, in his Hollywood debut), who promises to surgically reattach the musician’s hands. Unfortunately, Gogol is so obsessed with the wife, a star of gory stage shows, that he has created a wax figure of her. He schemes to win her in the flesh by attaching a murderer’s hands to Clive, then frame him for committing murder with those hands. Gogol utters the madman’s lament: “I have conquered science. Why can’t I conquer love?” A modern remake would surely have him asking, “Why do they swipe left?
Hannibal Lecter (Anthony Hopkins, “Silence of the Lambs,” 1991)
The FBI, hunting for a serial killer, sends trainee Clarice Starling (Jodie Foster) to seek insight into the murderer from the imprisoned Dr. Hannibal Lecter (Anthony Hopkins), a brilliant psychiatrist with a penchant for murder — and a taste for the flesh of his victims. Lecter proves to be a menace from their first meeting; the bars and glass surrounding his cell offer Clarice no protection from his gaze and ability to read her mind. In his own way, the urbane, pathologically charming Lecter takes a shine to Clarice, helping with the case while embarking on another murderous spree against men who recently wronged her. When he escapes, his plans do not include dinner with – or of – Clarice, but others, well, they’re not so lucky.
Henry Jekyll (Fredric March, “Dr. Jekyll and Mr. Hyde,” 1931)
Henry Jekyll (Fredric March) is a jumble of personalities. By day, he’s a kindly doctor in Victorian London with an American accent. But he is so determined to split good and evil personalities that he devises a potion to outsource his id. As he watches himself morph into Mr. Hyde – a hairy, cone-headed dude in serious need of an orthodontist – he exclaims, “Free! Free at last!” Free, that is, for his simian side to engage in debauchery, abuse, self-hatred, intimations of rape, and ultimately murder – all of which are explored in this pre-Code film, the first talkie version of Robert Louis Stevenson’s story.
Dr. Moreau (Charles Laughton, “Island of Lost Souls,” 1932)
“Strange-looking natives you have here,” shipwreck victim Edward Parker (Richard Arlen) tells his host, the white-suited, whip-wielding Dr Moreau. Before long, we learn that Moreau’s evil veterinary talents have created an island population of human/beast hybrids who are forced to follow his laws – especially one forbidding them from eating meat or walking on all fours. Lawbreakers get taken to the House of Pain, a medical setting which, as its name suggests, lacks adequate analgesia. Burt Lancaster and Marlon Brando took on the Moreau role in later versions, but Laughton is the creepiest when he asks, “Do you know what it means to feel like God?” The film was banned for years in Britain, and H.G. Wells despised this take on his antivivisection tale.
Charles Nichols (Jeroen Krabbé, “The Fugitive,” 1993)
Richard Kimble, a Chicago vascular surgeon, arrives home to find that a man just brutally murdered his loving wife. The killer escapes, and Kimble falls into the frame-up. Convicted for the murder and headed to prison, Kimble breaks free in an epic escape scene. He spends the rest of the movie all but giving his right arm to find the murderer, while being pursued by a dogged U.S. Marshal played with gusto by Tommy Lee Jones. Kimble eventually discovers that his colleague, Dr. Charles Nichols (Jeroen Krabbé), is not quite the best friend a man could have – or the most ethical of clinical investigators.
Elliot and Beverly Mantle (Jeremy Irons, “Dead Ringers,” 1988)
“You’ve got to try the movie star,” fertility specialist Elliot Mantle (Jeremy Irons) implores to his identical but meek twin brother, Beverly (also Jeremy Irons), talking about an actress-patient (Genevieve Bujold) as if she were a menu item. Beverly shares a practice with Elliot, along with a soul and an easily satisfied drug addiction. Beverly is unaware that Elliot seduces patients before passing them off to his brother, including the actress. Beverly is in love with the actress, which upsets the equilibrium of their shared soul. He aims to fix this, but not without some trauma involving freakish and unsanitary operating implements.
Dean Armitage (Bradley Whitford, “Get Out,” 2017)
Neurosurgeon Dean Armitage (Bradley Whitford) was such a fan of President Obama that he would have voted for him a third time if he could. At least, that’s how he portrays himself to Chris (Daniel Kaluuya), an African American photographer and the new boyfriend of Armitage’s White daughter. The Armitage estate has plenty of people of color – on staff, anyway – but Chris finds them odd and distant. It turns out that a gathering of rich White people is in fact an auction for his eyesight. Horror ensues. The main message from this film is not unlike that of Russian operatives who fall out of favor with the Kremlin: Don’t drink the tea.
A version of this article first appeared on Medscape.com.
Masks can be scary on Halloween, but more so when they come with scrubs, scalpels, and God complexes. In March, Medscape readers chose their favorite characters and performers in the Hollywood health care system. from a deep bench (and no, Dr Evil didn’t go to medical school; neither did Dr No, for that matter). Before you see these folks who’d rather haunt than heal, we urge you to seek a second opinion.
George Harris (Richard Widmark, “Coma,” 1978)
“Medicine is now a great social force,” says Dr. George Harris (Richard Widmark), chief of surgery at Boston Memorial. Because the public trusts doctors, “we’ll make the hard decisions” – like choosing which young, healthy patients to put into an irreversible coma to harvest their organs. Harris’ audience of one here is Dr. Susan Wheeler (Genevieve Bujold), the upstart who has uncovered his plot, and whom Harris has just drugged to prepare her as his next unintentional donor. “Coma” was based on a bestseller by Robin Cook and directed by Michael Crichton, who left Harvard Medical School for a career in popular books and films, including “The Andromeda Strain” and “Jurassic Park.” Although Dr. Harris starts out as a reassuring friend and mentor to Dr. Wheeler, older moviegoers won’t forget that he launched to stardom by tossing a woman in a wheelchair down the stairs in 1947’s “Kiss of Death.”
Christian Szell (Laurence Olivier, “Marathon Man,” 1976)
He may look harmless, but Christian Szell (Laurence Olivier) is a sadist with a secret, a stash, and throat-slitting skills. Szell, a dentist known as the White Angel of Auschwitz for his war crimes, stops at nothing to protect the diamonds he stole from his victims in the camps. In one of Hollywood’s most infamous torture scenes, Szell tries to extract information from Babe Levy (Dustin Hoffman), an innocent grad student, plying the tools of his trade. When Szell asks, “Is it safe?” he’s not curious about whether Babe’s insurance covers anesthesia.
Orin Scrivello (Steve Martin, “Little Shop of Horrors,” 1986)
Sticking with deranged dentists, Orin Scrivello, DDS, (Steve Martin) sings and dances his way into your nightmares buoyed by copious helpings of nitrous oxide. Orin’s too-encouraging momma told him to parlay his sadistic tendencies into a career “where people will pay you to be inhumane.” Sonny listened. Moviegoers were treated to screeching sound effects of a tooth getting yanked during an Elvis-like musical number shot in part from inside a patient’s mouth. Martin makes a creepy scene more fun than a long, slow root canal.
Henry Frankenstein (Colin Clive, “Frankenstein,” 1931)
His alarming need for fresh corpses forced Henry Frankenstein (Colin Clive) to leave medical school and experiment solo in a castle. He insists to his betrothed that he hasn’t gone mad when she arrives as he is bringing a dead body back to life during a raging lightning storm. When she and Henry’s mentor, Dr Waldman, witness him succeed, Waldman warns Henry that the former owner of the purloined brain was a notorious criminal. When Henry exclaims: “It’s alive, it’s alive !” little did he know that he created the face (Boris Karloff) that would launch a thousand sequels, a spectacular satire, and untold Halloween masks.
Dr. Gogol (Peter Lorre, “Mad Love,” 1935)
A few years after playing doctor Frankenstein, Colin Clive became the patient of a mad medic himself. A concert pianist whose hands have been mangled in a train wreck, Clive’s wife turns to Dr. Gogol (Peter Lorre, in his Hollywood debut), who promises to surgically reattach the musician’s hands. Unfortunately, Gogol is so obsessed with the wife, a star of gory stage shows, that he has created a wax figure of her. He schemes to win her in the flesh by attaching a murderer’s hands to Clive, then frame him for committing murder with those hands. Gogol utters the madman’s lament: “I have conquered science. Why can’t I conquer love?” A modern remake would surely have him asking, “Why do they swipe left?
Hannibal Lecter (Anthony Hopkins, “Silence of the Lambs,” 1991)
The FBI, hunting for a serial killer, sends trainee Clarice Starling (Jodie Foster) to seek insight into the murderer from the imprisoned Dr. Hannibal Lecter (Anthony Hopkins), a brilliant psychiatrist with a penchant for murder — and a taste for the flesh of his victims. Lecter proves to be a menace from their first meeting; the bars and glass surrounding his cell offer Clarice no protection from his gaze and ability to read her mind. In his own way, the urbane, pathologically charming Lecter takes a shine to Clarice, helping with the case while embarking on another murderous spree against men who recently wronged her. When he escapes, his plans do not include dinner with – or of – Clarice, but others, well, they’re not so lucky.
Henry Jekyll (Fredric March, “Dr. Jekyll and Mr. Hyde,” 1931)
Henry Jekyll (Fredric March) is a jumble of personalities. By day, he’s a kindly doctor in Victorian London with an American accent. But he is so determined to split good and evil personalities that he devises a potion to outsource his id. As he watches himself morph into Mr. Hyde – a hairy, cone-headed dude in serious need of an orthodontist – he exclaims, “Free! Free at last!” Free, that is, for his simian side to engage in debauchery, abuse, self-hatred, intimations of rape, and ultimately murder – all of which are explored in this pre-Code film, the first talkie version of Robert Louis Stevenson’s story.
Dr. Moreau (Charles Laughton, “Island of Lost Souls,” 1932)
“Strange-looking natives you have here,” shipwreck victim Edward Parker (Richard Arlen) tells his host, the white-suited, whip-wielding Dr Moreau. Before long, we learn that Moreau’s evil veterinary talents have created an island population of human/beast hybrids who are forced to follow his laws – especially one forbidding them from eating meat or walking on all fours. Lawbreakers get taken to the House of Pain, a medical setting which, as its name suggests, lacks adequate analgesia. Burt Lancaster and Marlon Brando took on the Moreau role in later versions, but Laughton is the creepiest when he asks, “Do you know what it means to feel like God?” The film was banned for years in Britain, and H.G. Wells despised this take on his antivivisection tale.
Charles Nichols (Jeroen Krabbé, “The Fugitive,” 1993)
Richard Kimble, a Chicago vascular surgeon, arrives home to find that a man just brutally murdered his loving wife. The killer escapes, and Kimble falls into the frame-up. Convicted for the murder and headed to prison, Kimble breaks free in an epic escape scene. He spends the rest of the movie all but giving his right arm to find the murderer, while being pursued by a dogged U.S. Marshal played with gusto by Tommy Lee Jones. Kimble eventually discovers that his colleague, Dr. Charles Nichols (Jeroen Krabbé), is not quite the best friend a man could have – or the most ethical of clinical investigators.
Elliot and Beverly Mantle (Jeremy Irons, “Dead Ringers,” 1988)
“You’ve got to try the movie star,” fertility specialist Elliot Mantle (Jeremy Irons) implores to his identical but meek twin brother, Beverly (also Jeremy Irons), talking about an actress-patient (Genevieve Bujold) as if she were a menu item. Beverly shares a practice with Elliot, along with a soul and an easily satisfied drug addiction. Beverly is unaware that Elliot seduces patients before passing them off to his brother, including the actress. Beverly is in love with the actress, which upsets the equilibrium of their shared soul. He aims to fix this, but not without some trauma involving freakish and unsanitary operating implements.
Dean Armitage (Bradley Whitford, “Get Out,” 2017)
Neurosurgeon Dean Armitage (Bradley Whitford) was such a fan of President Obama that he would have voted for him a third time if he could. At least, that’s how he portrays himself to Chris (Daniel Kaluuya), an African American photographer and the new boyfriend of Armitage’s White daughter. The Armitage estate has plenty of people of color – on staff, anyway – but Chris finds them odd and distant. It turns out that a gathering of rich White people is in fact an auction for his eyesight. Horror ensues. The main message from this film is not unlike that of Russian operatives who fall out of favor with the Kremlin: Don’t drink the tea.
A version of this article first appeared on Medscape.com.
Gene ‘cut-and-paste’ treatment could offer hope for inherited immune system diseases
An “exciting” new gene-editing strategy means those born with a rare inherited disease of the immune system could be treated by repairing a fault in their cells.
CTLA-4 is a protein produced by T cells that helps to control the activity of the immune system. Most people carry two working copies of the gene responsible for producing CTLA-4, but those who have only one functional copy produce too little of the protein to sufficiently regulate the immune system.
For patients with the condition, CTLA-4 insufficiency causes regulatory T cells to function abnormally, leading to severe autoimmunity. The authors explained that the condition also affects effector T cells and thereby “hampers their immune system’s ‘memory,’ ” meaning patients can “struggle to fight off recurring infections by the same viruses and bacteria.” In some cases, it can also lead to lymphomas.
Gene editing to ‘cut’ out faulty genes and ‘paste’ in ‘corrected’ ones
The research, published in Science Translational Medicine, and led by scientists from University College London, demonstrated in human cells and in mice that the cell fault can be repaired.
The scientists used “cut-and-paste” gene-editing techniques. First, they used the CRISPR/Cas9 system to target the faulty gene in human T cells taken from patients with CTLA-4 insufficiency, and then snip the faulty CTLA-4 gene in two. Then, to repair the errors a corrected sequence of DNA – delivered to the cell using a modified virus – was pasted over the faulty part of the gene using a cellular DNA repair mechanism known as homology-directed repair.
The authors explained that this allowed them to “preserve” important sequences within the CTLA-4 gene – known as the intron – that allow it to be switched on and off by the cell only when needed.
The outcome was “restored levels of CTLA-4 in the cells to those seen in healthy T cells,” the authors said.
Claire Booth, PhD, Mahboubian professor of gene therapy and pediatric immunology, UCL Great Ormond Street Institute of Child Health, and co–senior author, said that it was “really exciting” to think about taking this treatment forward to patients. “If we can improve their symptoms and reduce their risk of getting lymphoproliferative disease this will be a major step forward.”
In addition, the researchers were also able to improve symptoms of the disease in mice with CTLA-4 insufficiency by giving them injections of gene-edited T cells.
Technique may help tackle many conditions
The current standard treatment for CTLA-4 insufficiency is a bone marrow transplant to replace the stem cells responsible for producing T cells. However, “transplants are risky” and require high doses of chemotherapy and many weeks in hospital, the authors explained. “Older patients with CTLA-4 insufficiency are typically not well enough to tolerate the transplant procedure.”
Dr. Booth highlighted that the approach has many “positive aspects”. By correcting the patient’s T cells, “we think it can improve many of the symptoms of the disease”, she said, and added that this new approach is much less toxic than a bone marrow transplant. “Collecting the T cells is easier and correcting the T cells is easier. With this approach the amount of time in hospital the patients would need would be far less.”
Emma Morris, PhD, professor of clinical cell and gene therapy and director of UCL’s division of infection and immunity, and co–senior author, said: “Genes that play critical roles in controlling immune responses are not switched on all the time and are very tightly regulated. The technique we have used allows us to leave the natural (endogenous) mechanisms controlling gene expression intact, at the same time as correcting the mistake in the gene itself.”
The researchers explained that, although CTLA-4 insufficiency is rare, the gene editing therapy could be a proof of principle of their approach that could be adapted to tackle other conditions.
“It’s a way of correcting genetic mutations that could potentially be applicable for other diseases,” suggested Dr. Morris. “The bigger picture is it allows us to correct genes that are dysregulated or overactive, but also allows us to understand much more about gene expression and gene regulation.”
The study was funded by the Wellcome Trust, the Association for Moleculary Pathology, the Medical Research Council, Alzheimer’s Research UK, and the UCLH/UCL NIHR Biomedical Research Centre. Dr. Morris is a founder sharehold of Quell Therapeutics and has received honoraria from Orchard Therapeutics, GlaxoSmithKline, and AstraZeneca. Dr. Booth has performed ad hoc consulting in the past 3 years for SOBI and Novartis and educational material production for SOBI and Chiesi. A patent on the intronic gene editing approach has been filed in the UK. The other authors declared that they have no completing interests.
A version of this article first appeared on Medscape UK.
An “exciting” new gene-editing strategy means those born with a rare inherited disease of the immune system could be treated by repairing a fault in their cells.
CTLA-4 is a protein produced by T cells that helps to control the activity of the immune system. Most people carry two working copies of the gene responsible for producing CTLA-4, but those who have only one functional copy produce too little of the protein to sufficiently regulate the immune system.
For patients with the condition, CTLA-4 insufficiency causes regulatory T cells to function abnormally, leading to severe autoimmunity. The authors explained that the condition also affects effector T cells and thereby “hampers their immune system’s ‘memory,’ ” meaning patients can “struggle to fight off recurring infections by the same viruses and bacteria.” In some cases, it can also lead to lymphomas.
Gene editing to ‘cut’ out faulty genes and ‘paste’ in ‘corrected’ ones
The research, published in Science Translational Medicine, and led by scientists from University College London, demonstrated in human cells and in mice that the cell fault can be repaired.
The scientists used “cut-and-paste” gene-editing techniques. First, they used the CRISPR/Cas9 system to target the faulty gene in human T cells taken from patients with CTLA-4 insufficiency, and then snip the faulty CTLA-4 gene in two. Then, to repair the errors a corrected sequence of DNA – delivered to the cell using a modified virus – was pasted over the faulty part of the gene using a cellular DNA repair mechanism known as homology-directed repair.
The authors explained that this allowed them to “preserve” important sequences within the CTLA-4 gene – known as the intron – that allow it to be switched on and off by the cell only when needed.
The outcome was “restored levels of CTLA-4 in the cells to those seen in healthy T cells,” the authors said.
Claire Booth, PhD, Mahboubian professor of gene therapy and pediatric immunology, UCL Great Ormond Street Institute of Child Health, and co–senior author, said that it was “really exciting” to think about taking this treatment forward to patients. “If we can improve their symptoms and reduce their risk of getting lymphoproliferative disease this will be a major step forward.”
In addition, the researchers were also able to improve symptoms of the disease in mice with CTLA-4 insufficiency by giving them injections of gene-edited T cells.
Technique may help tackle many conditions
The current standard treatment for CTLA-4 insufficiency is a bone marrow transplant to replace the stem cells responsible for producing T cells. However, “transplants are risky” and require high doses of chemotherapy and many weeks in hospital, the authors explained. “Older patients with CTLA-4 insufficiency are typically not well enough to tolerate the transplant procedure.”
Dr. Booth highlighted that the approach has many “positive aspects”. By correcting the patient’s T cells, “we think it can improve many of the symptoms of the disease”, she said, and added that this new approach is much less toxic than a bone marrow transplant. “Collecting the T cells is easier and correcting the T cells is easier. With this approach the amount of time in hospital the patients would need would be far less.”
Emma Morris, PhD, professor of clinical cell and gene therapy and director of UCL’s division of infection and immunity, and co–senior author, said: “Genes that play critical roles in controlling immune responses are not switched on all the time and are very tightly regulated. The technique we have used allows us to leave the natural (endogenous) mechanisms controlling gene expression intact, at the same time as correcting the mistake in the gene itself.”
The researchers explained that, although CTLA-4 insufficiency is rare, the gene editing therapy could be a proof of principle of their approach that could be adapted to tackle other conditions.
“It’s a way of correcting genetic mutations that could potentially be applicable for other diseases,” suggested Dr. Morris. “The bigger picture is it allows us to correct genes that are dysregulated or overactive, but also allows us to understand much more about gene expression and gene regulation.”
The study was funded by the Wellcome Trust, the Association for Moleculary Pathology, the Medical Research Council, Alzheimer’s Research UK, and the UCLH/UCL NIHR Biomedical Research Centre. Dr. Morris is a founder sharehold of Quell Therapeutics and has received honoraria from Orchard Therapeutics, GlaxoSmithKline, and AstraZeneca. Dr. Booth has performed ad hoc consulting in the past 3 years for SOBI and Novartis and educational material production for SOBI and Chiesi. A patent on the intronic gene editing approach has been filed in the UK. The other authors declared that they have no completing interests.
A version of this article first appeared on Medscape UK.
An “exciting” new gene-editing strategy means those born with a rare inherited disease of the immune system could be treated by repairing a fault in their cells.
CTLA-4 is a protein produced by T cells that helps to control the activity of the immune system. Most people carry two working copies of the gene responsible for producing CTLA-4, but those who have only one functional copy produce too little of the protein to sufficiently regulate the immune system.
For patients with the condition, CTLA-4 insufficiency causes regulatory T cells to function abnormally, leading to severe autoimmunity. The authors explained that the condition also affects effector T cells and thereby “hampers their immune system’s ‘memory,’ ” meaning patients can “struggle to fight off recurring infections by the same viruses and bacteria.” In some cases, it can also lead to lymphomas.
Gene editing to ‘cut’ out faulty genes and ‘paste’ in ‘corrected’ ones
The research, published in Science Translational Medicine, and led by scientists from University College London, demonstrated in human cells and in mice that the cell fault can be repaired.
The scientists used “cut-and-paste” gene-editing techniques. First, they used the CRISPR/Cas9 system to target the faulty gene in human T cells taken from patients with CTLA-4 insufficiency, and then snip the faulty CTLA-4 gene in two. Then, to repair the errors a corrected sequence of DNA – delivered to the cell using a modified virus – was pasted over the faulty part of the gene using a cellular DNA repair mechanism known as homology-directed repair.
The authors explained that this allowed them to “preserve” important sequences within the CTLA-4 gene – known as the intron – that allow it to be switched on and off by the cell only when needed.
The outcome was “restored levels of CTLA-4 in the cells to those seen in healthy T cells,” the authors said.
Claire Booth, PhD, Mahboubian professor of gene therapy and pediatric immunology, UCL Great Ormond Street Institute of Child Health, and co–senior author, said that it was “really exciting” to think about taking this treatment forward to patients. “If we can improve their symptoms and reduce their risk of getting lymphoproliferative disease this will be a major step forward.”
In addition, the researchers were also able to improve symptoms of the disease in mice with CTLA-4 insufficiency by giving them injections of gene-edited T cells.
Technique may help tackle many conditions
The current standard treatment for CTLA-4 insufficiency is a bone marrow transplant to replace the stem cells responsible for producing T cells. However, “transplants are risky” and require high doses of chemotherapy and many weeks in hospital, the authors explained. “Older patients with CTLA-4 insufficiency are typically not well enough to tolerate the transplant procedure.”
Dr. Booth highlighted that the approach has many “positive aspects”. By correcting the patient’s T cells, “we think it can improve many of the symptoms of the disease”, she said, and added that this new approach is much less toxic than a bone marrow transplant. “Collecting the T cells is easier and correcting the T cells is easier. With this approach the amount of time in hospital the patients would need would be far less.”
Emma Morris, PhD, professor of clinical cell and gene therapy and director of UCL’s division of infection and immunity, and co–senior author, said: “Genes that play critical roles in controlling immune responses are not switched on all the time and are very tightly regulated. The technique we have used allows us to leave the natural (endogenous) mechanisms controlling gene expression intact, at the same time as correcting the mistake in the gene itself.”
The researchers explained that, although CTLA-4 insufficiency is rare, the gene editing therapy could be a proof of principle of their approach that could be adapted to tackle other conditions.
“It’s a way of correcting genetic mutations that could potentially be applicable for other diseases,” suggested Dr. Morris. “The bigger picture is it allows us to correct genes that are dysregulated or overactive, but also allows us to understand much more about gene expression and gene regulation.”
The study was funded by the Wellcome Trust, the Association for Moleculary Pathology, the Medical Research Council, Alzheimer’s Research UK, and the UCLH/UCL NIHR Biomedical Research Centre. Dr. Morris is a founder sharehold of Quell Therapeutics and has received honoraria from Orchard Therapeutics, GlaxoSmithKline, and AstraZeneca. Dr. Booth has performed ad hoc consulting in the past 3 years for SOBI and Novartis and educational material production for SOBI and Chiesi. A patent on the intronic gene editing approach has been filed in the UK. The other authors declared that they have no completing interests.
A version of this article first appeared on Medscape UK.
FROM SCIENCE TRANSLATIONAL MEDICINE
Many specialists are on the wrong side of the patient-jargon relationship
Doctor, doctor, gimme the news. I got a bad case of misidentifying you
There are a lot of medical specialties out there. A lot. Everything from allergists to urologists, with something like 150 subspecialties grouped in among the larger specialties. Can you name every one? Do you know what they do?
The point is, telling a patient or anyone in the general public that you’re an ophthalmologist may not be as helpful as you might think, if a recent study is to be believed. In a survey of 204 adults, conducted at the Minnesota State Fair of all places, researchers asked volunteers to define 14 different specialties, as well as five medical seniority titles.
The results were less than stellar. While more than 90% of people correctly defined what cardiologists and dermatologists do, 6 of the other 12 specialists were correctly identified by less than half of those surveyed. Nephrology was at the bottom, correctly identified by just 20% of the fair-attending public, followed by internists (21%), intensivists (29%), hospitalists (31%), pulmonologists (43%), and neonatologists at 48%. The hospitalists are particularly concerning. They’re doctors, but in hospitals. How hard is that? (Yes, it’s obviously more complicated than that, but still.)
The general public didn’t fare much better when it came to correctly lining up the order of progression from medical student to attending. Just 12% managed to place all five in the correct order of med student, intern, senior resident, fellow, then attending, with senior resident proving especially troublesome. More than 40% put senior resident at the end, compared with 27% for attending. Which does make a certain amount of sense, since it has senior in the name.
While the results speak for themselves – maybe elaborate on what the heck your fancy title actually means – it’s too bad the researchers didn’t throw in something really tricky. If two-thirds of the population can’t identify a hospitalist, just imagine how many people would misidentify an otolaryngologist.
Beach-to-table sand could fight obesity
People are always looking for the new weight loss solution. Whether it’s to just look good in a new pair of jeans or reduce the risk of cardiovascular disease, there are millions of diets and exercise routines out here. We’re here to tell you that the next new therapy to reduce fat comes from a very unsuspecting place: Sand.
Like sand from the beach and desert, sand? Well, yes and no.
The research involved engineered porous silica particles made from sand that are designed to have a high surface area. Investigators used a two-step GI model in which gastric digestion was modeled for 30 minutes, followed by a 60-minute intestinal phase, to show that the porous silica particles helped prevent fat and sugar adsorption within the GI tract.
By mimicking the gastrointestinal environment during digestion of a high-fat, high-carb meal, the researchers found that the porous silica created an “anti-obesity effect” by restricting the adsorption of those fats and carbohydrates.
Okay, but how is that on the tummy? Much gentler on the stomach than a drug such as orlistat, said senior researcher Paul Joyce, PhD, of the University of South Australia, Adelaide, who noted the lack of effective therapies without side effects, such as bloating, diarrhea, and abdominal pain, that deter people from treatment.
Obesity affects over 1.9 billion people worldwide, so the researchers think this could be a breakthrough. Reducing obesity may be one of the most preventable ways to reduce the risk of type 2 diabetes, heart disease, and other weight-related chronic conditions. A treatment solution this simple could be the answer to this global health crisis.
Who would have thought the solution would be as simple as sand? But how would the sand get in our stomachs? Do we sprinkle it on our food? Mix it in during cooking? Or will the sand come in pill form? We sure hope it’s that third one.
I am Reliebo. I am here to help you
Halloween is almost here, and the LOTME staff has been trying to make the office look as scary as possible: Headless vampires, ghost clowns, Ted Cruz, gray tombstones, pink hearts, green clovers, red balloons. Wait a second, those last three are Lucky Charms marshmallows, aren’t they? We’ll use those some other time.
What are we not using to decorate? Well, besides marshmallows from cereal, we’re not using Reliebo. That’s what we’re not using. Reliebo is a cute little fuzzy robot, and is not at all scary. Reliebo was designed to be the opposite of scary. Reliebo “may reduce fear as well as alleviate the perception of pain during medical treatments, including vaccinations,” senior author Fumihide Tanaka, PhD, of the University of Tsukuba (Japan) said in a written statement.
The soft, fur-covered robot contains small airbags that can inflate in response to hand movements. When study participants were subjected to a moderate heat stimulus on one arm, those who held the robot with the other arm experienced less pain than those who did not have a Reliebo.
The results also were encouraging when Dr. Tanaka and associates measured the levels of oxytocin and cortisol (biomarkers for stress) from the subjects’ saliva samples and evaluated their fear of injections and their psychological state before and after the experiments.
After looking at that photo of Reliebo for a while, though, we have to admit that we’re having a bit of a rethink about its cuteness. Is it cute, or weird-looking? An office full of fuzzy little inflating robots just could be seriously creepy. Please don’t tell the rest of the staff about this. We want to surprise them on Monday.
Doctor, doctor, gimme the news. I got a bad case of misidentifying you
There are a lot of medical specialties out there. A lot. Everything from allergists to urologists, with something like 150 subspecialties grouped in among the larger specialties. Can you name every one? Do you know what they do?
The point is, telling a patient or anyone in the general public that you’re an ophthalmologist may not be as helpful as you might think, if a recent study is to be believed. In a survey of 204 adults, conducted at the Minnesota State Fair of all places, researchers asked volunteers to define 14 different specialties, as well as five medical seniority titles.
The results were less than stellar. While more than 90% of people correctly defined what cardiologists and dermatologists do, 6 of the other 12 specialists were correctly identified by less than half of those surveyed. Nephrology was at the bottom, correctly identified by just 20% of the fair-attending public, followed by internists (21%), intensivists (29%), hospitalists (31%), pulmonologists (43%), and neonatologists at 48%. The hospitalists are particularly concerning. They’re doctors, but in hospitals. How hard is that? (Yes, it’s obviously more complicated than that, but still.)
The general public didn’t fare much better when it came to correctly lining up the order of progression from medical student to attending. Just 12% managed to place all five in the correct order of med student, intern, senior resident, fellow, then attending, with senior resident proving especially troublesome. More than 40% put senior resident at the end, compared with 27% for attending. Which does make a certain amount of sense, since it has senior in the name.
While the results speak for themselves – maybe elaborate on what the heck your fancy title actually means – it’s too bad the researchers didn’t throw in something really tricky. If two-thirds of the population can’t identify a hospitalist, just imagine how many people would misidentify an otolaryngologist.
Beach-to-table sand could fight obesity
People are always looking for the new weight loss solution. Whether it’s to just look good in a new pair of jeans or reduce the risk of cardiovascular disease, there are millions of diets and exercise routines out here. We’re here to tell you that the next new therapy to reduce fat comes from a very unsuspecting place: Sand.
Like sand from the beach and desert, sand? Well, yes and no.
The research involved engineered porous silica particles made from sand that are designed to have a high surface area. Investigators used a two-step GI model in which gastric digestion was modeled for 30 minutes, followed by a 60-minute intestinal phase, to show that the porous silica particles helped prevent fat and sugar adsorption within the GI tract.
By mimicking the gastrointestinal environment during digestion of a high-fat, high-carb meal, the researchers found that the porous silica created an “anti-obesity effect” by restricting the adsorption of those fats and carbohydrates.
Okay, but how is that on the tummy? Much gentler on the stomach than a drug such as orlistat, said senior researcher Paul Joyce, PhD, of the University of South Australia, Adelaide, who noted the lack of effective therapies without side effects, such as bloating, diarrhea, and abdominal pain, that deter people from treatment.
Obesity affects over 1.9 billion people worldwide, so the researchers think this could be a breakthrough. Reducing obesity may be one of the most preventable ways to reduce the risk of type 2 diabetes, heart disease, and other weight-related chronic conditions. A treatment solution this simple could be the answer to this global health crisis.
Who would have thought the solution would be as simple as sand? But how would the sand get in our stomachs? Do we sprinkle it on our food? Mix it in during cooking? Or will the sand come in pill form? We sure hope it’s that third one.
I am Reliebo. I am here to help you
Halloween is almost here, and the LOTME staff has been trying to make the office look as scary as possible: Headless vampires, ghost clowns, Ted Cruz, gray tombstones, pink hearts, green clovers, red balloons. Wait a second, those last three are Lucky Charms marshmallows, aren’t they? We’ll use those some other time.
What are we not using to decorate? Well, besides marshmallows from cereal, we’re not using Reliebo. That’s what we’re not using. Reliebo is a cute little fuzzy robot, and is not at all scary. Reliebo was designed to be the opposite of scary. Reliebo “may reduce fear as well as alleviate the perception of pain during medical treatments, including vaccinations,” senior author Fumihide Tanaka, PhD, of the University of Tsukuba (Japan) said in a written statement.
The soft, fur-covered robot contains small airbags that can inflate in response to hand movements. When study participants were subjected to a moderate heat stimulus on one arm, those who held the robot with the other arm experienced less pain than those who did not have a Reliebo.
The results also were encouraging when Dr. Tanaka and associates measured the levels of oxytocin and cortisol (biomarkers for stress) from the subjects’ saliva samples and evaluated their fear of injections and their psychological state before and after the experiments.
After looking at that photo of Reliebo for a while, though, we have to admit that we’re having a bit of a rethink about its cuteness. Is it cute, or weird-looking? An office full of fuzzy little inflating robots just could be seriously creepy. Please don’t tell the rest of the staff about this. We want to surprise them on Monday.
Doctor, doctor, gimme the news. I got a bad case of misidentifying you
There are a lot of medical specialties out there. A lot. Everything from allergists to urologists, with something like 150 subspecialties grouped in among the larger specialties. Can you name every one? Do you know what they do?
The point is, telling a patient or anyone in the general public that you’re an ophthalmologist may not be as helpful as you might think, if a recent study is to be believed. In a survey of 204 adults, conducted at the Minnesota State Fair of all places, researchers asked volunteers to define 14 different specialties, as well as five medical seniority titles.
The results were less than stellar. While more than 90% of people correctly defined what cardiologists and dermatologists do, 6 of the other 12 specialists were correctly identified by less than half of those surveyed. Nephrology was at the bottom, correctly identified by just 20% of the fair-attending public, followed by internists (21%), intensivists (29%), hospitalists (31%), pulmonologists (43%), and neonatologists at 48%. The hospitalists are particularly concerning. They’re doctors, but in hospitals. How hard is that? (Yes, it’s obviously more complicated than that, but still.)
The general public didn’t fare much better when it came to correctly lining up the order of progression from medical student to attending. Just 12% managed to place all five in the correct order of med student, intern, senior resident, fellow, then attending, with senior resident proving especially troublesome. More than 40% put senior resident at the end, compared with 27% for attending. Which does make a certain amount of sense, since it has senior in the name.
While the results speak for themselves – maybe elaborate on what the heck your fancy title actually means – it’s too bad the researchers didn’t throw in something really tricky. If two-thirds of the population can’t identify a hospitalist, just imagine how many people would misidentify an otolaryngologist.
Beach-to-table sand could fight obesity
People are always looking for the new weight loss solution. Whether it’s to just look good in a new pair of jeans or reduce the risk of cardiovascular disease, there are millions of diets and exercise routines out here. We’re here to tell you that the next new therapy to reduce fat comes from a very unsuspecting place: Sand.
Like sand from the beach and desert, sand? Well, yes and no.
The research involved engineered porous silica particles made from sand that are designed to have a high surface area. Investigators used a two-step GI model in which gastric digestion was modeled for 30 minutes, followed by a 60-minute intestinal phase, to show that the porous silica particles helped prevent fat and sugar adsorption within the GI tract.
By mimicking the gastrointestinal environment during digestion of a high-fat, high-carb meal, the researchers found that the porous silica created an “anti-obesity effect” by restricting the adsorption of those fats and carbohydrates.
Okay, but how is that on the tummy? Much gentler on the stomach than a drug such as orlistat, said senior researcher Paul Joyce, PhD, of the University of South Australia, Adelaide, who noted the lack of effective therapies without side effects, such as bloating, diarrhea, and abdominal pain, that deter people from treatment.
Obesity affects over 1.9 billion people worldwide, so the researchers think this could be a breakthrough. Reducing obesity may be one of the most preventable ways to reduce the risk of type 2 diabetes, heart disease, and other weight-related chronic conditions. A treatment solution this simple could be the answer to this global health crisis.
Who would have thought the solution would be as simple as sand? But how would the sand get in our stomachs? Do we sprinkle it on our food? Mix it in during cooking? Or will the sand come in pill form? We sure hope it’s that third one.
I am Reliebo. I am here to help you
Halloween is almost here, and the LOTME staff has been trying to make the office look as scary as possible: Headless vampires, ghost clowns, Ted Cruz, gray tombstones, pink hearts, green clovers, red balloons. Wait a second, those last three are Lucky Charms marshmallows, aren’t they? We’ll use those some other time.
What are we not using to decorate? Well, besides marshmallows from cereal, we’re not using Reliebo. That’s what we’re not using. Reliebo is a cute little fuzzy robot, and is not at all scary. Reliebo was designed to be the opposite of scary. Reliebo “may reduce fear as well as alleviate the perception of pain during medical treatments, including vaccinations,” senior author Fumihide Tanaka, PhD, of the University of Tsukuba (Japan) said in a written statement.
The soft, fur-covered robot contains small airbags that can inflate in response to hand movements. When study participants were subjected to a moderate heat stimulus on one arm, those who held the robot with the other arm experienced less pain than those who did not have a Reliebo.
The results also were encouraging when Dr. Tanaka and associates measured the levels of oxytocin and cortisol (biomarkers for stress) from the subjects’ saliva samples and evaluated their fear of injections and their psychological state before and after the experiments.
After looking at that photo of Reliebo for a while, though, we have to admit that we’re having a bit of a rethink about its cuteness. Is it cute, or weird-looking? An office full of fuzzy little inflating robots just could be seriously creepy. Please don’t tell the rest of the staff about this. We want to surprise them on Monday.
‘Financial toxicity’: Harsh side effect of cancer care
When 32-year-old Brittany Dicks was diagnosed with stage II triple negative breast cancer in January 2022, she wasn’t worried about the cost of treatment. A medical assistant in Charleston, S.C., Ms. Dicks had full-time employment with health benefits.
But when she wasn’t able to work for several months because of chemotherapy and its side effects, Ms. Dicks lost her job. Her health insurance coverage ended in May. And although she filed for Medicaid at the beginning of June, it wasn’t approved until September.
Meanwhile, Ms. Dicks still needed treatment. She estimates that she ran up close to $20,000 in medical debt while finishing chemotherapy during the 4 months she was uninsured.
The surgeon she had seen since her diagnosis terminated her care when she could no longer pay her bills. That left her delaying a much-needed mastectomy.
“I don’t sleep at night,” said Ms. Dicks, a single mother of two young kids, ages 3 and 11. “Mentally, I’m drained. Just because I have cancer, doesn’t mean the bills aren’t due every month.”
As soon as she felt well enough over the summer, she started working as a part-time delivery driver for DoorDash to help pay for food and gas.
But that was just a Band-Aid. Even when her new insurance kicked in, covering the costs of daily life remained a struggle.
Ms. Dicks is still in deep medical debt. Her Medicaid has covered new medical expenses, and she hopes Medicaid will reimburse her for the debt she incurred over the summer while she waited for her coverage to kick in. So far, though, Medicaid has not touched her $20,000 debt.
“I fear that I’m not going to be able to dig out of this hole,” Ms. Dicks said.
Researchers who study the financial impacts of cancer have a term for Ms. Dicks’ experience: financial toxicity.
Financial toxicity is a catchall term for the burden many Americans with cancer experience.
“Financial toxicity is a multidimensional concept. There’s both a material burden and a psychosocial one,” said Grace Li Smith, MD, PhD, MPH, a radiation oncologist at the University of Texas MD Anderson Cancer Center, Houston.
Researchers are also now beginning to understand the psychological effects these financial burdens can have on patients and their family.
“Financial toxicity is not unique to the patient,” said Dr. Li Smith. It “very directly impacts the whole family or household.”
Stifling financial pressures
Early in her career, Dr. Li Smith was already seeing how her patients’ worries extended beyond their physical disease.
One of Dr. Li Smith’s first patients told her their greatest worry wasn’t whether the treatment would work or what physical toxicity to expect, it was how they would pay for their care.
“There was much more anxiety and true distress about the financial burden than about the treatment itself,” Dr. Li Smith recalled.
This fear about the costs of cancer care is well founded. In the United States, cancer treatment costs reached an estimated $150 billion in 2020 and continue to rise. Patients shoulder a significant portion of that burden – with one study estimating that patients paid $21 billion for their cancer care in 2019.
The burden is often compounded by decreased income. Between 40% and 85% of patients with cancer needed to take time off work or quit their jobs during treatment. And for those, like Dicks, who find themselves with no insurance, out-of-pocket costs can quickly skyrocket.
In fact, one study of newly diagnosed cancer patients over age 50 reported that more than 42% of patients fully depleted their financial assets and around 30% incurred debt by the second year of their diagnosis.
Younger adults may be even more financially vulnerable. A study of patients in Washington found that those under 65 – which represent about half of cancer cases – were two to five times more likely to declare bankruptcy than patients over 65.
Dr. Li Smith and colleagues have found that younger patients aged 18-64 experienced greater monetary hardships, which meant less money for food, worse adherence to medications, as well as greater distress and anxiety overall. In fact, younger adults were over 4.5 times more likely to encounter severe financial toxicity, compared with older adults, and about 4 times more likely to experience severe psychological effects from this burden.
The distress, if left unchecked, can spiral out of control.
Molly MacDonald had just gone through a financially devastating divorce in 2005 when she was diagnosed with breast cancer. Recently out of work and dealing with a $1,300 monthly COBRA premium, the mother of five had no financial safety net. She risked having her car repossessed and her utilities shut off.
“I gave tentative thought to how I could take my life and make it look like an accident,” said Ms. MacDonald. “I thought the kids would be better off without me.”
For some, the loss of income can be even more worrisome than the medical bills. Some patients may go back to work during treatment, often against medical advice.
When Stephanie Caputo, 43, of Monroe, N.J., began treatment for stage III breast cancer in 2021, her physician recommended she stop working. Treatment would make her immunocompromised, and her job in a medical clinic could expose her to harmful pathogens, including the coronavirus.
Ms. Caputo went on disability and received $900 every 2 weeks. But that wasn’t enough to pay her mortgage, let alone cover her other monthly expenses as a single mother of 4 teenagers.
After finishing chemotherapy, and during radiation, Ms. Caputo went back to work, part time, against her doctor’s advice.
“My doctor is telling me I can’t work, but I also can’t have my house go into default,” said Ms. Caputo.
But being on her feet through 12-hour shifts made treatment side effects, especially back and joint pain, kick into overdrive. “The physicality of my job was really difficult to tolerate,” she said.
The physical burden was too great to take on more work, but the extra money also wasn’t enough to keep her afloat. Fortunately, her brother stepped in and covered 6 months of her mortgage payments.
Financial toxicity impacts families
Although financial toxicity research to date has largely focused on the patient, researchers are also starting to understand that family members and caregivers often share in the burden.
“We are just at the beginning of realizing that this is a real problem,” said Fumiko Chino, MD, a radiation oncologist at Memorial Sloan Kettering Cancer Center, New York.
Dr. Chino and colleagues recently showed that family members of patients with cancer were more likely to delay or forgo medical care than family members of people without cancer. The study found the effect was greatest among family members of younger adults with cancer.
“The caregiver and family burden related to cancer diagnosis and treatment is really underappreciated,” said Dr. Chino. “Family members and caregivers are neglecting their own health concerns, passing up career opportunities, struggling with financial concerns.”
Dr. Chino speaks from personal experience. When her fiancé, later husband, was diagnosed with neuroendocrine carcinoma in 2005, Dr. Chino quit her job as art director at a television production company to take care of him.
The couple, both in their 20s, struggled to afford his care. Dr. Chino put her own dental, medical, and mental health care on hold. She never, for instance, went to physical therapy to address injuries sustained sleeping in hospital chairs and moving around her husband who was over 6 feet tall. At one point, she walked with a limp.
Dr. Chino’s husband passed away in 2007, and even 15 years later, her injury from sleeping in hospital chairs remains “a significant physical burden,” she said. But like many caregivers “I wasn’t really thinking about my own health.”
Danielle Hadfield, 35, an ED nurse in Rochester, N.Y., also delayed her own care when her mom got sick.
Ms. Hadfield quit her job shortly after her mom was diagnosed with cholangiocarcinoma in August 2020. Ms. Hadfield knew her mom, who lived 3.5 hours away in Albany, N.Y., would need a lot of care in the upcoming months.
“I knew this was going to be the last year or so of her life, and I wanted to be there for her,” said Ms. Hadfield.
When Ms. Hadfield quit her job, she and her husband – who was self-employed – purchased health insurance coverage through the New York state marketplace. The monthly insurance payments for Ms. Hadfield, who was pregnant with her second child, her husband, and their toddler cost as much as the family’s monthly mortgage payments.
In addition to providing childcare for her young daughter and making frequent trips to Albany, Ms. Hadfield began a side business as a legal nurse consultant, working mostly at night, to replace a portion of her lost income. During this time, she began to experience pain attacks that would migrate through her body along with intermittent tongue and facial numbness. She ignored these health issues for nearly a year, until after her mother died in November 2021.
Only after her mother passed away did Ms. Hadfield begin seeking answers to her own pain. In September 2022, she finally got them. She had a nerve condition called small-fiber sensory neuropathy.
But even with a diagnosis, she is still facing more tests to root out the cause and understand the best treatment.
Is help out there?
What can physicians do to help patients and families at risk for financial toxicity?
Specific guidelines for dealing with financial toxicity do not exist in most professional guidelines, nor are there standard screening tools to identify it, said Dr. Li Smith.
These gaps put pressure on physicians to ask about financial barriers and concerns, but most do not know how to broach the topic or how to help. “Physicians may not know how to fix the problem or what resources exist,” Dr. Li Smith said.
Patients and family members, on the other hand, are often reluctant to bring up cost with physicians. Some may be ashamed to talk about their financial problems while others may fear doing so will prevent them from being offered the best possible treatments, said Ms. MacDonald.
But, experts say, financial toxicity needs to be dealt with head on. That means involving financial navigators or counselors and social workers who can, for instance, help patients and families find financial support for their basic living expenses.
From a research perspective, more clinical trials should include financial toxicity outcomes, said Joshua Palmer, MD, a radiation oncologist at the University of Michigan, Ann Arbor.
Dr. Palmer and colleagues recently showed that the number of radiation therapy clinical trials including financial toxicity endpoints increased significantly from 2001 to 2020, though the absolute rate of inclusion remains low, at roughly 1.5% of radiation therapy-based clinical trials including financial toxicity endpoints from 2016 to 2020.
“Financial burden is part of the broader discussion about shared decision-making,” said Dr. Palmer.
In shared decision-making, physicians discuss the risks and benefits of different treatment options, empowering the patient to make an informed choice with the physician.
What we want to avoid is patients feeling like they will get inferior care, if they have financial barriers, said Dr. Palmer.
And every little bit can help. In 2006, Ms. MacDonald started the Pink Fund – a nonprofit to help patients with cancer cover nonmedical cost-of-living expenses. Both Ms. Caputo and Ms. Dicks received grants from the Pink Fund. For Ms. Caputo, the funds covered 2 months of car payments and for Ms. Dicks, it covered 2 months of rent.
While the one-time grant was a big help, said Ms. Dicks, “cancer is an everyday thing.” And “we all deserve peace of mind” when trying to heal.
A version of this article first appeared on WebMD.com.
When 32-year-old Brittany Dicks was diagnosed with stage II triple negative breast cancer in January 2022, she wasn’t worried about the cost of treatment. A medical assistant in Charleston, S.C., Ms. Dicks had full-time employment with health benefits.
But when she wasn’t able to work for several months because of chemotherapy and its side effects, Ms. Dicks lost her job. Her health insurance coverage ended in May. And although she filed for Medicaid at the beginning of June, it wasn’t approved until September.
Meanwhile, Ms. Dicks still needed treatment. She estimates that she ran up close to $20,000 in medical debt while finishing chemotherapy during the 4 months she was uninsured.
The surgeon she had seen since her diagnosis terminated her care when she could no longer pay her bills. That left her delaying a much-needed mastectomy.
“I don’t sleep at night,” said Ms. Dicks, a single mother of two young kids, ages 3 and 11. “Mentally, I’m drained. Just because I have cancer, doesn’t mean the bills aren’t due every month.”
As soon as she felt well enough over the summer, she started working as a part-time delivery driver for DoorDash to help pay for food and gas.
But that was just a Band-Aid. Even when her new insurance kicked in, covering the costs of daily life remained a struggle.
Ms. Dicks is still in deep medical debt. Her Medicaid has covered new medical expenses, and she hopes Medicaid will reimburse her for the debt she incurred over the summer while she waited for her coverage to kick in. So far, though, Medicaid has not touched her $20,000 debt.
“I fear that I’m not going to be able to dig out of this hole,” Ms. Dicks said.
Researchers who study the financial impacts of cancer have a term for Ms. Dicks’ experience: financial toxicity.
Financial toxicity is a catchall term for the burden many Americans with cancer experience.
“Financial toxicity is a multidimensional concept. There’s both a material burden and a psychosocial one,” said Grace Li Smith, MD, PhD, MPH, a radiation oncologist at the University of Texas MD Anderson Cancer Center, Houston.
Researchers are also now beginning to understand the psychological effects these financial burdens can have on patients and their family.
“Financial toxicity is not unique to the patient,” said Dr. Li Smith. It “very directly impacts the whole family or household.”
Stifling financial pressures
Early in her career, Dr. Li Smith was already seeing how her patients’ worries extended beyond their physical disease.
One of Dr. Li Smith’s first patients told her their greatest worry wasn’t whether the treatment would work or what physical toxicity to expect, it was how they would pay for their care.
“There was much more anxiety and true distress about the financial burden than about the treatment itself,” Dr. Li Smith recalled.
This fear about the costs of cancer care is well founded. In the United States, cancer treatment costs reached an estimated $150 billion in 2020 and continue to rise. Patients shoulder a significant portion of that burden – with one study estimating that patients paid $21 billion for their cancer care in 2019.
The burden is often compounded by decreased income. Between 40% and 85% of patients with cancer needed to take time off work or quit their jobs during treatment. And for those, like Dicks, who find themselves with no insurance, out-of-pocket costs can quickly skyrocket.
In fact, one study of newly diagnosed cancer patients over age 50 reported that more than 42% of patients fully depleted their financial assets and around 30% incurred debt by the second year of their diagnosis.
Younger adults may be even more financially vulnerable. A study of patients in Washington found that those under 65 – which represent about half of cancer cases – were two to five times more likely to declare bankruptcy than patients over 65.
Dr. Li Smith and colleagues have found that younger patients aged 18-64 experienced greater monetary hardships, which meant less money for food, worse adherence to medications, as well as greater distress and anxiety overall. In fact, younger adults were over 4.5 times more likely to encounter severe financial toxicity, compared with older adults, and about 4 times more likely to experience severe psychological effects from this burden.
The distress, if left unchecked, can spiral out of control.
Molly MacDonald had just gone through a financially devastating divorce in 2005 when she was diagnosed with breast cancer. Recently out of work and dealing with a $1,300 monthly COBRA premium, the mother of five had no financial safety net. She risked having her car repossessed and her utilities shut off.
“I gave tentative thought to how I could take my life and make it look like an accident,” said Ms. MacDonald. “I thought the kids would be better off without me.”
For some, the loss of income can be even more worrisome than the medical bills. Some patients may go back to work during treatment, often against medical advice.
When Stephanie Caputo, 43, of Monroe, N.J., began treatment for stage III breast cancer in 2021, her physician recommended she stop working. Treatment would make her immunocompromised, and her job in a medical clinic could expose her to harmful pathogens, including the coronavirus.
Ms. Caputo went on disability and received $900 every 2 weeks. But that wasn’t enough to pay her mortgage, let alone cover her other monthly expenses as a single mother of 4 teenagers.
After finishing chemotherapy, and during radiation, Ms. Caputo went back to work, part time, against her doctor’s advice.
“My doctor is telling me I can’t work, but I also can’t have my house go into default,” said Ms. Caputo.
But being on her feet through 12-hour shifts made treatment side effects, especially back and joint pain, kick into overdrive. “The physicality of my job was really difficult to tolerate,” she said.
The physical burden was too great to take on more work, but the extra money also wasn’t enough to keep her afloat. Fortunately, her brother stepped in and covered 6 months of her mortgage payments.
Financial toxicity impacts families
Although financial toxicity research to date has largely focused on the patient, researchers are also starting to understand that family members and caregivers often share in the burden.
“We are just at the beginning of realizing that this is a real problem,” said Fumiko Chino, MD, a radiation oncologist at Memorial Sloan Kettering Cancer Center, New York.
Dr. Chino and colleagues recently showed that family members of patients with cancer were more likely to delay or forgo medical care than family members of people without cancer. The study found the effect was greatest among family members of younger adults with cancer.
“The caregiver and family burden related to cancer diagnosis and treatment is really underappreciated,” said Dr. Chino. “Family members and caregivers are neglecting their own health concerns, passing up career opportunities, struggling with financial concerns.”
Dr. Chino speaks from personal experience. When her fiancé, later husband, was diagnosed with neuroendocrine carcinoma in 2005, Dr. Chino quit her job as art director at a television production company to take care of him.
The couple, both in their 20s, struggled to afford his care. Dr. Chino put her own dental, medical, and mental health care on hold. She never, for instance, went to physical therapy to address injuries sustained sleeping in hospital chairs and moving around her husband who was over 6 feet tall. At one point, she walked with a limp.
Dr. Chino’s husband passed away in 2007, and even 15 years later, her injury from sleeping in hospital chairs remains “a significant physical burden,” she said. But like many caregivers “I wasn’t really thinking about my own health.”
Danielle Hadfield, 35, an ED nurse in Rochester, N.Y., also delayed her own care when her mom got sick.
Ms. Hadfield quit her job shortly after her mom was diagnosed with cholangiocarcinoma in August 2020. Ms. Hadfield knew her mom, who lived 3.5 hours away in Albany, N.Y., would need a lot of care in the upcoming months.
“I knew this was going to be the last year or so of her life, and I wanted to be there for her,” said Ms. Hadfield.
When Ms. Hadfield quit her job, she and her husband – who was self-employed – purchased health insurance coverage through the New York state marketplace. The monthly insurance payments for Ms. Hadfield, who was pregnant with her second child, her husband, and their toddler cost as much as the family’s monthly mortgage payments.
In addition to providing childcare for her young daughter and making frequent trips to Albany, Ms. Hadfield began a side business as a legal nurse consultant, working mostly at night, to replace a portion of her lost income. During this time, she began to experience pain attacks that would migrate through her body along with intermittent tongue and facial numbness. She ignored these health issues for nearly a year, until after her mother died in November 2021.
Only after her mother passed away did Ms. Hadfield begin seeking answers to her own pain. In September 2022, she finally got them. She had a nerve condition called small-fiber sensory neuropathy.
But even with a diagnosis, she is still facing more tests to root out the cause and understand the best treatment.
Is help out there?
What can physicians do to help patients and families at risk for financial toxicity?
Specific guidelines for dealing with financial toxicity do not exist in most professional guidelines, nor are there standard screening tools to identify it, said Dr. Li Smith.
These gaps put pressure on physicians to ask about financial barriers and concerns, but most do not know how to broach the topic or how to help. “Physicians may not know how to fix the problem or what resources exist,” Dr. Li Smith said.
Patients and family members, on the other hand, are often reluctant to bring up cost with physicians. Some may be ashamed to talk about their financial problems while others may fear doing so will prevent them from being offered the best possible treatments, said Ms. MacDonald.
But, experts say, financial toxicity needs to be dealt with head on. That means involving financial navigators or counselors and social workers who can, for instance, help patients and families find financial support for their basic living expenses.
From a research perspective, more clinical trials should include financial toxicity outcomes, said Joshua Palmer, MD, a radiation oncologist at the University of Michigan, Ann Arbor.
Dr. Palmer and colleagues recently showed that the number of radiation therapy clinical trials including financial toxicity endpoints increased significantly from 2001 to 2020, though the absolute rate of inclusion remains low, at roughly 1.5% of radiation therapy-based clinical trials including financial toxicity endpoints from 2016 to 2020.
“Financial burden is part of the broader discussion about shared decision-making,” said Dr. Palmer.
In shared decision-making, physicians discuss the risks and benefits of different treatment options, empowering the patient to make an informed choice with the physician.
What we want to avoid is patients feeling like they will get inferior care, if they have financial barriers, said Dr. Palmer.
And every little bit can help. In 2006, Ms. MacDonald started the Pink Fund – a nonprofit to help patients with cancer cover nonmedical cost-of-living expenses. Both Ms. Caputo and Ms. Dicks received grants from the Pink Fund. For Ms. Caputo, the funds covered 2 months of car payments and for Ms. Dicks, it covered 2 months of rent.
While the one-time grant was a big help, said Ms. Dicks, “cancer is an everyday thing.” And “we all deserve peace of mind” when trying to heal.
A version of this article first appeared on WebMD.com.
When 32-year-old Brittany Dicks was diagnosed with stage II triple negative breast cancer in January 2022, she wasn’t worried about the cost of treatment. A medical assistant in Charleston, S.C., Ms. Dicks had full-time employment with health benefits.
But when she wasn’t able to work for several months because of chemotherapy and its side effects, Ms. Dicks lost her job. Her health insurance coverage ended in May. And although she filed for Medicaid at the beginning of June, it wasn’t approved until September.
Meanwhile, Ms. Dicks still needed treatment. She estimates that she ran up close to $20,000 in medical debt while finishing chemotherapy during the 4 months she was uninsured.
The surgeon she had seen since her diagnosis terminated her care when she could no longer pay her bills. That left her delaying a much-needed mastectomy.
“I don’t sleep at night,” said Ms. Dicks, a single mother of two young kids, ages 3 and 11. “Mentally, I’m drained. Just because I have cancer, doesn’t mean the bills aren’t due every month.”
As soon as she felt well enough over the summer, she started working as a part-time delivery driver for DoorDash to help pay for food and gas.
But that was just a Band-Aid. Even when her new insurance kicked in, covering the costs of daily life remained a struggle.
Ms. Dicks is still in deep medical debt. Her Medicaid has covered new medical expenses, and she hopes Medicaid will reimburse her for the debt she incurred over the summer while she waited for her coverage to kick in. So far, though, Medicaid has not touched her $20,000 debt.
“I fear that I’m not going to be able to dig out of this hole,” Ms. Dicks said.
Researchers who study the financial impacts of cancer have a term for Ms. Dicks’ experience: financial toxicity.
Financial toxicity is a catchall term for the burden many Americans with cancer experience.
“Financial toxicity is a multidimensional concept. There’s both a material burden and a psychosocial one,” said Grace Li Smith, MD, PhD, MPH, a radiation oncologist at the University of Texas MD Anderson Cancer Center, Houston.
Researchers are also now beginning to understand the psychological effects these financial burdens can have on patients and their family.
“Financial toxicity is not unique to the patient,” said Dr. Li Smith. It “very directly impacts the whole family or household.”
Stifling financial pressures
Early in her career, Dr. Li Smith was already seeing how her patients’ worries extended beyond their physical disease.
One of Dr. Li Smith’s first patients told her their greatest worry wasn’t whether the treatment would work or what physical toxicity to expect, it was how they would pay for their care.
“There was much more anxiety and true distress about the financial burden than about the treatment itself,” Dr. Li Smith recalled.
This fear about the costs of cancer care is well founded. In the United States, cancer treatment costs reached an estimated $150 billion in 2020 and continue to rise. Patients shoulder a significant portion of that burden – with one study estimating that patients paid $21 billion for their cancer care in 2019.
The burden is often compounded by decreased income. Between 40% and 85% of patients with cancer needed to take time off work or quit their jobs during treatment. And for those, like Dicks, who find themselves with no insurance, out-of-pocket costs can quickly skyrocket.
In fact, one study of newly diagnosed cancer patients over age 50 reported that more than 42% of patients fully depleted their financial assets and around 30% incurred debt by the second year of their diagnosis.
Younger adults may be even more financially vulnerable. A study of patients in Washington found that those under 65 – which represent about half of cancer cases – were two to five times more likely to declare bankruptcy than patients over 65.
Dr. Li Smith and colleagues have found that younger patients aged 18-64 experienced greater monetary hardships, which meant less money for food, worse adherence to medications, as well as greater distress and anxiety overall. In fact, younger adults were over 4.5 times more likely to encounter severe financial toxicity, compared with older adults, and about 4 times more likely to experience severe psychological effects from this burden.
The distress, if left unchecked, can spiral out of control.
Molly MacDonald had just gone through a financially devastating divorce in 2005 when she was diagnosed with breast cancer. Recently out of work and dealing with a $1,300 monthly COBRA premium, the mother of five had no financial safety net. She risked having her car repossessed and her utilities shut off.
“I gave tentative thought to how I could take my life and make it look like an accident,” said Ms. MacDonald. “I thought the kids would be better off without me.”
For some, the loss of income can be even more worrisome than the medical bills. Some patients may go back to work during treatment, often against medical advice.
When Stephanie Caputo, 43, of Monroe, N.J., began treatment for stage III breast cancer in 2021, her physician recommended she stop working. Treatment would make her immunocompromised, and her job in a medical clinic could expose her to harmful pathogens, including the coronavirus.
Ms. Caputo went on disability and received $900 every 2 weeks. But that wasn’t enough to pay her mortgage, let alone cover her other monthly expenses as a single mother of 4 teenagers.
After finishing chemotherapy, and during radiation, Ms. Caputo went back to work, part time, against her doctor’s advice.
“My doctor is telling me I can’t work, but I also can’t have my house go into default,” said Ms. Caputo.
But being on her feet through 12-hour shifts made treatment side effects, especially back and joint pain, kick into overdrive. “The physicality of my job was really difficult to tolerate,” she said.
The physical burden was too great to take on more work, but the extra money also wasn’t enough to keep her afloat. Fortunately, her brother stepped in and covered 6 months of her mortgage payments.
Financial toxicity impacts families
Although financial toxicity research to date has largely focused on the patient, researchers are also starting to understand that family members and caregivers often share in the burden.
“We are just at the beginning of realizing that this is a real problem,” said Fumiko Chino, MD, a radiation oncologist at Memorial Sloan Kettering Cancer Center, New York.
Dr. Chino and colleagues recently showed that family members of patients with cancer were more likely to delay or forgo medical care than family members of people without cancer. The study found the effect was greatest among family members of younger adults with cancer.
“The caregiver and family burden related to cancer diagnosis and treatment is really underappreciated,” said Dr. Chino. “Family members and caregivers are neglecting their own health concerns, passing up career opportunities, struggling with financial concerns.”
Dr. Chino speaks from personal experience. When her fiancé, later husband, was diagnosed with neuroendocrine carcinoma in 2005, Dr. Chino quit her job as art director at a television production company to take care of him.
The couple, both in their 20s, struggled to afford his care. Dr. Chino put her own dental, medical, and mental health care on hold. She never, for instance, went to physical therapy to address injuries sustained sleeping in hospital chairs and moving around her husband who was over 6 feet tall. At one point, she walked with a limp.
Dr. Chino’s husband passed away in 2007, and even 15 years later, her injury from sleeping in hospital chairs remains “a significant physical burden,” she said. But like many caregivers “I wasn’t really thinking about my own health.”
Danielle Hadfield, 35, an ED nurse in Rochester, N.Y., also delayed her own care when her mom got sick.
Ms. Hadfield quit her job shortly after her mom was diagnosed with cholangiocarcinoma in August 2020. Ms. Hadfield knew her mom, who lived 3.5 hours away in Albany, N.Y., would need a lot of care in the upcoming months.
“I knew this was going to be the last year or so of her life, and I wanted to be there for her,” said Ms. Hadfield.
When Ms. Hadfield quit her job, she and her husband – who was self-employed – purchased health insurance coverage through the New York state marketplace. The monthly insurance payments for Ms. Hadfield, who was pregnant with her second child, her husband, and their toddler cost as much as the family’s monthly mortgage payments.
In addition to providing childcare for her young daughter and making frequent trips to Albany, Ms. Hadfield began a side business as a legal nurse consultant, working mostly at night, to replace a portion of her lost income. During this time, she began to experience pain attacks that would migrate through her body along with intermittent tongue and facial numbness. She ignored these health issues for nearly a year, until after her mother died in November 2021.
Only after her mother passed away did Ms. Hadfield begin seeking answers to her own pain. In September 2022, she finally got them. She had a nerve condition called small-fiber sensory neuropathy.
But even with a diagnosis, she is still facing more tests to root out the cause and understand the best treatment.
Is help out there?
What can physicians do to help patients and families at risk for financial toxicity?
Specific guidelines for dealing with financial toxicity do not exist in most professional guidelines, nor are there standard screening tools to identify it, said Dr. Li Smith.
These gaps put pressure on physicians to ask about financial barriers and concerns, but most do not know how to broach the topic or how to help. “Physicians may not know how to fix the problem or what resources exist,” Dr. Li Smith said.
Patients and family members, on the other hand, are often reluctant to bring up cost with physicians. Some may be ashamed to talk about their financial problems while others may fear doing so will prevent them from being offered the best possible treatments, said Ms. MacDonald.
But, experts say, financial toxicity needs to be dealt with head on. That means involving financial navigators or counselors and social workers who can, for instance, help patients and families find financial support for their basic living expenses.
From a research perspective, more clinical trials should include financial toxicity outcomes, said Joshua Palmer, MD, a radiation oncologist at the University of Michigan, Ann Arbor.
Dr. Palmer and colleagues recently showed that the number of radiation therapy clinical trials including financial toxicity endpoints increased significantly from 2001 to 2020, though the absolute rate of inclusion remains low, at roughly 1.5% of radiation therapy-based clinical trials including financial toxicity endpoints from 2016 to 2020.
“Financial burden is part of the broader discussion about shared decision-making,” said Dr. Palmer.
In shared decision-making, physicians discuss the risks and benefits of different treatment options, empowering the patient to make an informed choice with the physician.
What we want to avoid is patients feeling like they will get inferior care, if they have financial barriers, said Dr. Palmer.
And every little bit can help. In 2006, Ms. MacDonald started the Pink Fund – a nonprofit to help patients with cancer cover nonmedical cost-of-living expenses. Both Ms. Caputo and Ms. Dicks received grants from the Pink Fund. For Ms. Caputo, the funds covered 2 months of car payments and for Ms. Dicks, it covered 2 months of rent.
While the one-time grant was a big help, said Ms. Dicks, “cancer is an everyday thing.” And “we all deserve peace of mind” when trying to heal.
A version of this article first appeared on WebMD.com.
Health care workers face unimaginable decisions in Ukraine
The effects of the Russian invasion of Ukraine have been devastating, with the loss of tens of thousands of civilian lives and about one-third of the population having been displaced. The war has put a great strain on health care in the country.
“The Russian army is targeting civilian infrastructure, trying to plunge Ukrainians into cold and darkness. (It) is also deliberately targeting hospitals and clinics in Ukraine,” said Nataliya Kovalchuk, PhD, during a session on Ukraine health care at the annual meeting of the American Society for Radiation Oncology held this week in San Antonio. She is a clinical associate professor of radiation oncology at Stanford (Calif.) University.
Analysis of previous wars have shown an increase in cancer incidence and mortality, and the same should be expected in the future in Ukraine, according to Ruslan Zelinskyi, MS, who is president of the Ukrainian Association of Medical Physicists and practices at Spizhenko Clinic in Ukraine. “We must prepare for it now, and we do it. During the full-scale war in Ukraine, three new linear accelerators were installed and put into clinical use,” he said during his talk.
He also gave a personal perspective of the terrible conditions and choices facing Ukrainian health care workers. “I have often heard that science is outside of politics. Perhaps in peacetime, but when fragments of missiles pass through the wall” – here, Mr. Zelinskyi paused to swing the camera around to show bomb damage on the walls of the room where he was conducting his virtual talk – “it is impossible to be outside of politics when 900 medical facilities were destroyed or damaged.” Health care workers have been killed, and patients have lost months or years because they could not receive medical care.
That reality is forcing Ukrainians to make choices most health care workers would struggle to imagine. “For many years, I put on medical clothes and fight against cancer. But (for) me comes the moment when I will change my medical clothes to military (clothes), like many, many other Ukrainians of various professions, because we must preserve the freedom of Ukraine and the security of Europe to do science in a peaceful world,” Mr. Zelinskyi said.
Following Mr. Zelinskyi’s talk, Asya Agulnik, MD, MPH, director of the St. Jude’s Global Critical Care Program and a pediatric intensivist at St. Jude’s Children’s Research Hospital, Memphis, described St. Jude’s efforts with pediatric cancer patients. St. Jude’s Global Critical Care Program created a Eurasian Regional Program in 2018 to serve Central Asia and Eastern Europe, which now includes 48 institutions and more than 250 clinicians and members that help care for children with cancer.
In the aftermath of the invasion, the Eurasian Regional Program launched the Safer Ukraine network to ensure continued care for children with cancer and blood disorders. Initially, the patient’s family or physician identifies a child has having a medical need that cannot be met locally and requiring evacuation. The nongovernmental organization Tabletochki, which has worked with children with cancer in Ukraine since 2011, then arranges transport of the child and his or her medical records to the Ukrainian Specialized Children’s Center in Lviv, Ukraine, for evaluation and stabilization. From there, patients along with their mother and sometimes siblings are transferred to Poland. Transportation methods include ambulance, helicopter, bus, and medical trains that have a full intensive care unit aboard.
In Poland, hospitals estimated they could take on another 200 patients without compromising care for their existing patients, but evacuations reached that number within the first few weeks of the war. It was clear patients would have to be transferred to other countries. To do that, Safer Ukraine set up the Unicorn Marian Wilemski Clinic, which is a converted hotel operated as a partnership between many foundations and governments. It sends unstable patients to nearby emergency rooms, and stable patients stay at the clinic until they can be evaluated and matched with an international care provider from a registry of more than 200 hospitals in 29 countries that have agreed to take patients. A 24/7 Zoom call began on the first day of the war, initially staffed by St. Jude volunteers and now by a contractor. It serves as a command center.
Over the first 12 weeks of the war, the program evacuated over 1,000 children, and over 200 medical records per week were being translated at peak activity. Nearly 300 patients went to Poland, and the rest to 18 countries in Europe and North America.
The success of the initiative stems in part from the fact that it leveraged preexisting collaborations that focused on childhood cancer, according to Dr. Agulnik. “Many stakeholders that came together had previously worked together, but then quickly came together around this unified initiative with the goal of helping these patients,” she said during her talk.
Roman Kowalchuk, MD, who is a radiation oncology resident at Mayo Clinic, spoke about telemedicine efforts to assist physicians and patients in Ukraine.
“I’ve been especially interested in trying to help through telemedicine. We have so much expertise, so many things that we can offer, even if we can’t be there physically, through some of these avenues that really, especially through COVID, have been further developed in terms of virtual support, virtual expertise, and consultations. That presents the opportunity to be able to share some of that knowledge, some of that expertise, to help clinical care in Ukraine given the current circumstance,” said Dr. Kowalchuk during his presentation.
Efforts have used technology like the telemedicine platform Viveo, based in Estonia. One app, called HealUA, takes descriptions from physicians needing advice, and volunteers can scroll through inquiries and provide input. This is especially useful since most physicians in Ukraine are generalists, according to Dr. Kowalchuk, and so may need assistance with diagnosis and management of rare conditions.
Other telehealth approaches include TeleHelp Ukraine. There are WhatsApp groups with hundreds of volunteers who translate Ukrainian medical records to other languages to help non-Ukrainian physicians understand a patient’s history. Expertise is also needed in engineering, emergency medicine, surgery, various fields of oncology, and other specialties. Dr. Kowalchuk noted that Good Samaritan laws generally shield volunteers in these types of programs from legal liability.
International hospital networks taking part in these efforts include St. Jude, European Cancer Organization, American Cancer Society, American Society for Clinical Oncology, and ASTRO.
None of the presenters have relevant financial disclosures.
The effects of the Russian invasion of Ukraine have been devastating, with the loss of tens of thousands of civilian lives and about one-third of the population having been displaced. The war has put a great strain on health care in the country.
“The Russian army is targeting civilian infrastructure, trying to plunge Ukrainians into cold and darkness. (It) is also deliberately targeting hospitals and clinics in Ukraine,” said Nataliya Kovalchuk, PhD, during a session on Ukraine health care at the annual meeting of the American Society for Radiation Oncology held this week in San Antonio. She is a clinical associate professor of radiation oncology at Stanford (Calif.) University.
Analysis of previous wars have shown an increase in cancer incidence and mortality, and the same should be expected in the future in Ukraine, according to Ruslan Zelinskyi, MS, who is president of the Ukrainian Association of Medical Physicists and practices at Spizhenko Clinic in Ukraine. “We must prepare for it now, and we do it. During the full-scale war in Ukraine, three new linear accelerators were installed and put into clinical use,” he said during his talk.
He also gave a personal perspective of the terrible conditions and choices facing Ukrainian health care workers. “I have often heard that science is outside of politics. Perhaps in peacetime, but when fragments of missiles pass through the wall” – here, Mr. Zelinskyi paused to swing the camera around to show bomb damage on the walls of the room where he was conducting his virtual talk – “it is impossible to be outside of politics when 900 medical facilities were destroyed or damaged.” Health care workers have been killed, and patients have lost months or years because they could not receive medical care.
That reality is forcing Ukrainians to make choices most health care workers would struggle to imagine. “For many years, I put on medical clothes and fight against cancer. But (for) me comes the moment when I will change my medical clothes to military (clothes), like many, many other Ukrainians of various professions, because we must preserve the freedom of Ukraine and the security of Europe to do science in a peaceful world,” Mr. Zelinskyi said.
Following Mr. Zelinskyi’s talk, Asya Agulnik, MD, MPH, director of the St. Jude’s Global Critical Care Program and a pediatric intensivist at St. Jude’s Children’s Research Hospital, Memphis, described St. Jude’s efforts with pediatric cancer patients. St. Jude’s Global Critical Care Program created a Eurasian Regional Program in 2018 to serve Central Asia and Eastern Europe, which now includes 48 institutions and more than 250 clinicians and members that help care for children with cancer.
In the aftermath of the invasion, the Eurasian Regional Program launched the Safer Ukraine network to ensure continued care for children with cancer and blood disorders. Initially, the patient’s family or physician identifies a child has having a medical need that cannot be met locally and requiring evacuation. The nongovernmental organization Tabletochki, which has worked with children with cancer in Ukraine since 2011, then arranges transport of the child and his or her medical records to the Ukrainian Specialized Children’s Center in Lviv, Ukraine, for evaluation and stabilization. From there, patients along with their mother and sometimes siblings are transferred to Poland. Transportation methods include ambulance, helicopter, bus, and medical trains that have a full intensive care unit aboard.
In Poland, hospitals estimated they could take on another 200 patients without compromising care for their existing patients, but evacuations reached that number within the first few weeks of the war. It was clear patients would have to be transferred to other countries. To do that, Safer Ukraine set up the Unicorn Marian Wilemski Clinic, which is a converted hotel operated as a partnership between many foundations and governments. It sends unstable patients to nearby emergency rooms, and stable patients stay at the clinic until they can be evaluated and matched with an international care provider from a registry of more than 200 hospitals in 29 countries that have agreed to take patients. A 24/7 Zoom call began on the first day of the war, initially staffed by St. Jude volunteers and now by a contractor. It serves as a command center.
Over the first 12 weeks of the war, the program evacuated over 1,000 children, and over 200 medical records per week were being translated at peak activity. Nearly 300 patients went to Poland, and the rest to 18 countries in Europe and North America.
The success of the initiative stems in part from the fact that it leveraged preexisting collaborations that focused on childhood cancer, according to Dr. Agulnik. “Many stakeholders that came together had previously worked together, but then quickly came together around this unified initiative with the goal of helping these patients,” she said during her talk.
Roman Kowalchuk, MD, who is a radiation oncology resident at Mayo Clinic, spoke about telemedicine efforts to assist physicians and patients in Ukraine.
“I’ve been especially interested in trying to help through telemedicine. We have so much expertise, so many things that we can offer, even if we can’t be there physically, through some of these avenues that really, especially through COVID, have been further developed in terms of virtual support, virtual expertise, and consultations. That presents the opportunity to be able to share some of that knowledge, some of that expertise, to help clinical care in Ukraine given the current circumstance,” said Dr. Kowalchuk during his presentation.
Efforts have used technology like the telemedicine platform Viveo, based in Estonia. One app, called HealUA, takes descriptions from physicians needing advice, and volunteers can scroll through inquiries and provide input. This is especially useful since most physicians in Ukraine are generalists, according to Dr. Kowalchuk, and so may need assistance with diagnosis and management of rare conditions.
Other telehealth approaches include TeleHelp Ukraine. There are WhatsApp groups with hundreds of volunteers who translate Ukrainian medical records to other languages to help non-Ukrainian physicians understand a patient’s history. Expertise is also needed in engineering, emergency medicine, surgery, various fields of oncology, and other specialties. Dr. Kowalchuk noted that Good Samaritan laws generally shield volunteers in these types of programs from legal liability.
International hospital networks taking part in these efforts include St. Jude, European Cancer Organization, American Cancer Society, American Society for Clinical Oncology, and ASTRO.
None of the presenters have relevant financial disclosures.
The effects of the Russian invasion of Ukraine have been devastating, with the loss of tens of thousands of civilian lives and about one-third of the population having been displaced. The war has put a great strain on health care in the country.
“The Russian army is targeting civilian infrastructure, trying to plunge Ukrainians into cold and darkness. (It) is also deliberately targeting hospitals and clinics in Ukraine,” said Nataliya Kovalchuk, PhD, during a session on Ukraine health care at the annual meeting of the American Society for Radiation Oncology held this week in San Antonio. She is a clinical associate professor of radiation oncology at Stanford (Calif.) University.
Analysis of previous wars have shown an increase in cancer incidence and mortality, and the same should be expected in the future in Ukraine, according to Ruslan Zelinskyi, MS, who is president of the Ukrainian Association of Medical Physicists and practices at Spizhenko Clinic in Ukraine. “We must prepare for it now, and we do it. During the full-scale war in Ukraine, three new linear accelerators were installed and put into clinical use,” he said during his talk.
He also gave a personal perspective of the terrible conditions and choices facing Ukrainian health care workers. “I have often heard that science is outside of politics. Perhaps in peacetime, but when fragments of missiles pass through the wall” – here, Mr. Zelinskyi paused to swing the camera around to show bomb damage on the walls of the room where he was conducting his virtual talk – “it is impossible to be outside of politics when 900 medical facilities were destroyed or damaged.” Health care workers have been killed, and patients have lost months or years because they could not receive medical care.
That reality is forcing Ukrainians to make choices most health care workers would struggle to imagine. “For many years, I put on medical clothes and fight against cancer. But (for) me comes the moment when I will change my medical clothes to military (clothes), like many, many other Ukrainians of various professions, because we must preserve the freedom of Ukraine and the security of Europe to do science in a peaceful world,” Mr. Zelinskyi said.
Following Mr. Zelinskyi’s talk, Asya Agulnik, MD, MPH, director of the St. Jude’s Global Critical Care Program and a pediatric intensivist at St. Jude’s Children’s Research Hospital, Memphis, described St. Jude’s efforts with pediatric cancer patients. St. Jude’s Global Critical Care Program created a Eurasian Regional Program in 2018 to serve Central Asia and Eastern Europe, which now includes 48 institutions and more than 250 clinicians and members that help care for children with cancer.
In the aftermath of the invasion, the Eurasian Regional Program launched the Safer Ukraine network to ensure continued care for children with cancer and blood disorders. Initially, the patient’s family or physician identifies a child has having a medical need that cannot be met locally and requiring evacuation. The nongovernmental organization Tabletochki, which has worked with children with cancer in Ukraine since 2011, then arranges transport of the child and his or her medical records to the Ukrainian Specialized Children’s Center in Lviv, Ukraine, for evaluation and stabilization. From there, patients along with their mother and sometimes siblings are transferred to Poland. Transportation methods include ambulance, helicopter, bus, and medical trains that have a full intensive care unit aboard.
In Poland, hospitals estimated they could take on another 200 patients without compromising care for their existing patients, but evacuations reached that number within the first few weeks of the war. It was clear patients would have to be transferred to other countries. To do that, Safer Ukraine set up the Unicorn Marian Wilemski Clinic, which is a converted hotel operated as a partnership between many foundations and governments. It sends unstable patients to nearby emergency rooms, and stable patients stay at the clinic until they can be evaluated and matched with an international care provider from a registry of more than 200 hospitals in 29 countries that have agreed to take patients. A 24/7 Zoom call began on the first day of the war, initially staffed by St. Jude volunteers and now by a contractor. It serves as a command center.
Over the first 12 weeks of the war, the program evacuated over 1,000 children, and over 200 medical records per week were being translated at peak activity. Nearly 300 patients went to Poland, and the rest to 18 countries in Europe and North America.
The success of the initiative stems in part from the fact that it leveraged preexisting collaborations that focused on childhood cancer, according to Dr. Agulnik. “Many stakeholders that came together had previously worked together, but then quickly came together around this unified initiative with the goal of helping these patients,” she said during her talk.
Roman Kowalchuk, MD, who is a radiation oncology resident at Mayo Clinic, spoke about telemedicine efforts to assist physicians and patients in Ukraine.
“I’ve been especially interested in trying to help through telemedicine. We have so much expertise, so many things that we can offer, even if we can’t be there physically, through some of these avenues that really, especially through COVID, have been further developed in terms of virtual support, virtual expertise, and consultations. That presents the opportunity to be able to share some of that knowledge, some of that expertise, to help clinical care in Ukraine given the current circumstance,” said Dr. Kowalchuk during his presentation.
Efforts have used technology like the telemedicine platform Viveo, based in Estonia. One app, called HealUA, takes descriptions from physicians needing advice, and volunteers can scroll through inquiries and provide input. This is especially useful since most physicians in Ukraine are generalists, according to Dr. Kowalchuk, and so may need assistance with diagnosis and management of rare conditions.
Other telehealth approaches include TeleHelp Ukraine. There are WhatsApp groups with hundreds of volunteers who translate Ukrainian medical records to other languages to help non-Ukrainian physicians understand a patient’s history. Expertise is also needed in engineering, emergency medicine, surgery, various fields of oncology, and other specialties. Dr. Kowalchuk noted that Good Samaritan laws generally shield volunteers in these types of programs from legal liability.
International hospital networks taking part in these efforts include St. Jude, European Cancer Organization, American Cancer Society, American Society for Clinical Oncology, and ASTRO.
None of the presenters have relevant financial disclosures.
FROM ASTRO 2022
Brussels terror attack victim euthanized in Belgium at age 23
This article was originally published on MediQuality.com, an online service for health care professionals in the Benelux and a member of the Medscape Professional Network.
Performing euthanasia for “mental suffering that cannot be alleviated” is still considered an extraordinary measure in Belgium. Indeed, fewer than 2% of the requests for euthanasia fall within that category, and few such requests are made by young patients.
to be applicable. It’s something that Belgian broadcaster RTBF brought up during a recent episode of #Investigation, which reported on the aftermath of the 2016 Brussels attacks.
On May 7, surrounded by her family, Ms. De Corte was euthanized. She was 23 years old. Six years earlier, on March 22, 2016, Ms. De Corte had been at Brussels Airport when terrorists set off bombs. She was in the departures area with 90 other students from Sint-Rita Campus College, located in the northern town of Kontich. Ms. De Corte was only a few meters away from the blast. Although she was not physically injured, the Flemish teen was traumatized by the attack. This was confirmed by the school psychologist who treated the students. “There were some students who reacted worse than others to these traumatic events. And having had two discussions with Shanti, I can tell you that she was one of these students who were more sensitive to the effects. To me, it’s quite clear. Even before the attacks, she’d experienced serious psychological issues. Therefore, I referred her for psychiatric care.”
Eleven antidepressants daily
A few weeks after that March day, Ms. De Corte was admitted to a psychiatric hospital in Antwerp. It was a place she knew well, having been an inpatient there several times before the attacks. Ms. De Corte was treated with antidepressants. She shared her thoughts about them on numerous occasions. “I get several drugs at breakfast and up to 11 antidepressants a day. I couldn’t do without them. With all the drugs I take, I feel like a ghost who doesn’t feel anything anymore. Perhaps there were solutions other than the drugs.”
It was a brief respite. In 2020, Ms. De Corte attempted suicide. Her spirits were at their lowest. She was heavily medicated, and her medication had been increased over time. She turned down therapeutic help that was offered by a therapist who specializes in treating the victims of the Brussels attacks. The student got in touch with the Life End Information Forum, an association that supports the right to die with dignity. In April 2022, Ms. De Corte submitted a new euthanasia request, stating that she was in a medically futile condition of mental suffering. Two psychiatrists granted their approval.
A small proportion
Last March, Belgium’s Federal Commission for the Control and Evaluation of Euthanasia reported on data from 2021. “There continues to be a very small number of euthanasia requests that cite mental and behavioral disorders (psychiatric conditions, such as personality disorders, and cognitive issues, like Alzheimer’s disease, are included in this group): 1.9% of all cases of euthanasia. Like all euthanasia files, these requests meet the legal conditions (the patient is legally competent, the request is in writing, the condition is medically futile, and the suffering – which is constant, unbearable, and cannot be alleviated – results from a serious and incurable disorder; the request is well-considered and repeated),” the report states.
This article was translated from MediQuality and appeared on Medscape.com.
This article was originally published on MediQuality.com, an online service for health care professionals in the Benelux and a member of the Medscape Professional Network.
Performing euthanasia for “mental suffering that cannot be alleviated” is still considered an extraordinary measure in Belgium. Indeed, fewer than 2% of the requests for euthanasia fall within that category, and few such requests are made by young patients.
to be applicable. It’s something that Belgian broadcaster RTBF brought up during a recent episode of #Investigation, which reported on the aftermath of the 2016 Brussels attacks.
On May 7, surrounded by her family, Ms. De Corte was euthanized. She was 23 years old. Six years earlier, on March 22, 2016, Ms. De Corte had been at Brussels Airport when terrorists set off bombs. She was in the departures area with 90 other students from Sint-Rita Campus College, located in the northern town of Kontich. Ms. De Corte was only a few meters away from the blast. Although she was not physically injured, the Flemish teen was traumatized by the attack. This was confirmed by the school psychologist who treated the students. “There were some students who reacted worse than others to these traumatic events. And having had two discussions with Shanti, I can tell you that she was one of these students who were more sensitive to the effects. To me, it’s quite clear. Even before the attacks, she’d experienced serious psychological issues. Therefore, I referred her for psychiatric care.”
Eleven antidepressants daily
A few weeks after that March day, Ms. De Corte was admitted to a psychiatric hospital in Antwerp. It was a place she knew well, having been an inpatient there several times before the attacks. Ms. De Corte was treated with antidepressants. She shared her thoughts about them on numerous occasions. “I get several drugs at breakfast and up to 11 antidepressants a day. I couldn’t do without them. With all the drugs I take, I feel like a ghost who doesn’t feel anything anymore. Perhaps there were solutions other than the drugs.”
It was a brief respite. In 2020, Ms. De Corte attempted suicide. Her spirits were at their lowest. She was heavily medicated, and her medication had been increased over time. She turned down therapeutic help that was offered by a therapist who specializes in treating the victims of the Brussels attacks. The student got in touch with the Life End Information Forum, an association that supports the right to die with dignity. In April 2022, Ms. De Corte submitted a new euthanasia request, stating that she was in a medically futile condition of mental suffering. Two psychiatrists granted their approval.
A small proportion
Last March, Belgium’s Federal Commission for the Control and Evaluation of Euthanasia reported on data from 2021. “There continues to be a very small number of euthanasia requests that cite mental and behavioral disorders (psychiatric conditions, such as personality disorders, and cognitive issues, like Alzheimer’s disease, are included in this group): 1.9% of all cases of euthanasia. Like all euthanasia files, these requests meet the legal conditions (the patient is legally competent, the request is in writing, the condition is medically futile, and the suffering – which is constant, unbearable, and cannot be alleviated – results from a serious and incurable disorder; the request is well-considered and repeated),” the report states.
This article was translated from MediQuality and appeared on Medscape.com.
This article was originally published on MediQuality.com, an online service for health care professionals in the Benelux and a member of the Medscape Professional Network.
Performing euthanasia for “mental suffering that cannot be alleviated” is still considered an extraordinary measure in Belgium. Indeed, fewer than 2% of the requests for euthanasia fall within that category, and few such requests are made by young patients.
to be applicable. It’s something that Belgian broadcaster RTBF brought up during a recent episode of #Investigation, which reported on the aftermath of the 2016 Brussels attacks.
On May 7, surrounded by her family, Ms. De Corte was euthanized. She was 23 years old. Six years earlier, on March 22, 2016, Ms. De Corte had been at Brussels Airport when terrorists set off bombs. She was in the departures area with 90 other students from Sint-Rita Campus College, located in the northern town of Kontich. Ms. De Corte was only a few meters away from the blast. Although she was not physically injured, the Flemish teen was traumatized by the attack. This was confirmed by the school psychologist who treated the students. “There were some students who reacted worse than others to these traumatic events. And having had two discussions with Shanti, I can tell you that she was one of these students who were more sensitive to the effects. To me, it’s quite clear. Even before the attacks, she’d experienced serious psychological issues. Therefore, I referred her for psychiatric care.”
Eleven antidepressants daily
A few weeks after that March day, Ms. De Corte was admitted to a psychiatric hospital in Antwerp. It was a place she knew well, having been an inpatient there several times before the attacks. Ms. De Corte was treated with antidepressants. She shared her thoughts about them on numerous occasions. “I get several drugs at breakfast and up to 11 antidepressants a day. I couldn’t do without them. With all the drugs I take, I feel like a ghost who doesn’t feel anything anymore. Perhaps there were solutions other than the drugs.”
It was a brief respite. In 2020, Ms. De Corte attempted suicide. Her spirits were at their lowest. She was heavily medicated, and her medication had been increased over time. She turned down therapeutic help that was offered by a therapist who specializes in treating the victims of the Brussels attacks. The student got in touch with the Life End Information Forum, an association that supports the right to die with dignity. In April 2022, Ms. De Corte submitted a new euthanasia request, stating that she was in a medically futile condition of mental suffering. Two psychiatrists granted their approval.
A small proportion
Last March, Belgium’s Federal Commission for the Control and Evaluation of Euthanasia reported on data from 2021. “There continues to be a very small number of euthanasia requests that cite mental and behavioral disorders (psychiatric conditions, such as personality disorders, and cognitive issues, like Alzheimer’s disease, are included in this group): 1.9% of all cases of euthanasia. Like all euthanasia files, these requests meet the legal conditions (the patient is legally competent, the request is in writing, the condition is medically futile, and the suffering – which is constant, unbearable, and cannot be alleviated – results from a serious and incurable disorder; the request is well-considered and repeated),” the report states.
This article was translated from MediQuality and appeared on Medscape.com.
Vitamin D deficiency linked to death, new study finds
Vitamin D deficiency increases mortality risk and raising levels even slightly could decrease the risk, researchers examining data from the UK Biobank have found.
They used a Mendelian randomization approach, which uses genetic variants as “proxy indicators” for external factors that affect vitamin D levels, such as sun exposure or dietary intake. It allows for analysis of the relationship between deficiency and outcomes including mortality, which can’t be done in randomized clinical trials for ethical reasons.
Using this method, nutritionist Joshua P. Sutherland, PhD, of the Australian Centre for Precision Health, Adelaide, and colleagues found an association between genetically predicted vitamin D levels [25-(OH)D] and mortality from several major causes, with evidence of causality among people with measured concentrations below, but not above, 50 nmol/L. The findings were published online in Annals of Internal Medicine.
“Unlike other types of observational studies, we have overcome some of the methodological obstacles. What is special about this new study is we were able to look at people with very low vitamin D concentrations and what would happen if their concentrations were a little bit higher. Most randomized controlled trials don’t show much of an effect. That’s because most people have sufficient concentrations. Ethically you can’t do a trial of people with very low levels without treating them,” senior author Elina Hypp
The data support the 50 nmol/L cut-off endorsed by the United States National Academy of Medicine and align with previous data suggesting the benefit of vitamin D supplementation is largely seen in people with deficiency.
“Everybody with vitamin D levels less than 50 nmol/L is recommended to increase their levels. Our results suggest there’s no need to go very high. The positive message is that if we are able to raise levels to just the current U.S. recommendations, that’s fine. There’s no need to use large supplement doses,” Dr. Hyppönen explained.
Thus, she advised, “Supplementation will clearly help, especially during wintertime or if a person isn’t getting enough vitamin D from the sun or in places where food isn’t fortified with vitamin D.”
But the data don’t support the approach of using large intermittent doses, she added.
“Sometimes doctors want to fix the deficiency quickly with a large ‘bolus’ dose, then continue with a maintenance dose. Increasing evidence suggests that’s not beneficial and might disturb the body’s metabolism so that it can’t get the amount it needs. It’s safe overall but might not work the way we want it to work.”
Rather, Dr. Hyppönen said, “My sense is that daily modest vitamin D dose supplementation when it’s needed is the best way forward.”
Genetic approach reveals causal relationship
The investigators analyzed data from 307,601 individuals in the UK Biobank, a prospective cohort of people recruited from England, Scotland, and Wales during March 2006 and July 2010. Most were of White European ancestry and were aged 37-73 years at baseline.
Genetically predicted vitamin D levels were estimated using 35 confirmed 25-(OH)D variants. Participants were followed for outcomes up to June 2020.
The average baseline measured 25-(OH)D concentration was 45.2 nmol/L, and 11.7% (n = 36,009) of participants had levels between 10.0 and 24.9 nmol/L. Higher levels were seen in people living in southern areas and nonsmokers as well as those with a higher level of physical activity, less socioeconomic deprivation, and lower body mass index.
During follow-up, 6.1% of participants died (n = 18,700). After adjustment for variables, odds ratios for all causes of mortality were highest among people with 25-(OH)D levels below 25 nmol/L and appeared to plateau between 50 and 75 nmol/L, with no further reduction in mortality at values of 75-125 nmol/L.
Mortality 36% higher in those deficient in vitamin D
The risk for mortality was a significant 36% higher for participants with 25-(OH)D 25 nmol/L compared with 50 nmol/L.
With the Mendelian randomization, there was an L-shaped association between genetically predicted 25-(OH)D level and all-cause mortality (P for nonlinearity < .001) and for mortality because of cancer and cardiovascular disease (P for nonlinearity ≤ .033).
Again, the strongest association with those outcomes and genetically predicted 25-(OH)D was found at levels below 25 nmol/L and a plateau was seen by 50 nmol/L.
Compared with a measured 25-(OH)D concentration of 50 nmol/L, investigators estimated that the genetically predicted odds of all-cause mortality would increase sixfold (odds ratio, 6.00) for participants at 10 nmol/L and by 25% (OR, 1.25) for those at 25 nmol/L.
And, compared with a measured 25-(OH)D concentration of 50 nmol/L, those with 10 nmol/L had genetically predicted odds ratios of 5.98 for cardiovascular mortality, 3.37 for cancer mortality, and 12.44 for respiratory mortality.
Comparing measured 25-(OH)D concentrations of 25 nmol/L versus 50 nmol/L, odds ratios for those outcomes were 1.25, 1.16, and 1.96 (95% confidence interval, 1.88-4.67), respectively. All were statistically significant.
Consistent results supportive of a causal effect of genetically predicted 25-(OH)D on all-cause mortality in those with low measured vitamin D concentrations were also found in a sensitivity analysis of 20,837 people of non-White ethnic origin.
The study was funded by the Australian National Health and Medical Research Council. Dr. Sutherland’s studentship is funded by an Australian Research Training Program Scholarship.
A version of this article first appeared on Medscape.com.
Vitamin D deficiency increases mortality risk and raising levels even slightly could decrease the risk, researchers examining data from the UK Biobank have found.
They used a Mendelian randomization approach, which uses genetic variants as “proxy indicators” for external factors that affect vitamin D levels, such as sun exposure or dietary intake. It allows for analysis of the relationship between deficiency and outcomes including mortality, which can’t be done in randomized clinical trials for ethical reasons.
Using this method, nutritionist Joshua P. Sutherland, PhD, of the Australian Centre for Precision Health, Adelaide, and colleagues found an association between genetically predicted vitamin D levels [25-(OH)D] and mortality from several major causes, with evidence of causality among people with measured concentrations below, but not above, 50 nmol/L. The findings were published online in Annals of Internal Medicine.
“Unlike other types of observational studies, we have overcome some of the methodological obstacles. What is special about this new study is we were able to look at people with very low vitamin D concentrations and what would happen if their concentrations were a little bit higher. Most randomized controlled trials don’t show much of an effect. That’s because most people have sufficient concentrations. Ethically you can’t do a trial of people with very low levels without treating them,” senior author Elina Hypp
The data support the 50 nmol/L cut-off endorsed by the United States National Academy of Medicine and align with previous data suggesting the benefit of vitamin D supplementation is largely seen in people with deficiency.
“Everybody with vitamin D levels less than 50 nmol/L is recommended to increase their levels. Our results suggest there’s no need to go very high. The positive message is that if we are able to raise levels to just the current U.S. recommendations, that’s fine. There’s no need to use large supplement doses,” Dr. Hyppönen explained.
Thus, she advised, “Supplementation will clearly help, especially during wintertime or if a person isn’t getting enough vitamin D from the sun or in places where food isn’t fortified with vitamin D.”
But the data don’t support the approach of using large intermittent doses, she added.
“Sometimes doctors want to fix the deficiency quickly with a large ‘bolus’ dose, then continue with a maintenance dose. Increasing evidence suggests that’s not beneficial and might disturb the body’s metabolism so that it can’t get the amount it needs. It’s safe overall but might not work the way we want it to work.”
Rather, Dr. Hyppönen said, “My sense is that daily modest vitamin D dose supplementation when it’s needed is the best way forward.”
Genetic approach reveals causal relationship
The investigators analyzed data from 307,601 individuals in the UK Biobank, a prospective cohort of people recruited from England, Scotland, and Wales during March 2006 and July 2010. Most were of White European ancestry and were aged 37-73 years at baseline.
Genetically predicted vitamin D levels were estimated using 35 confirmed 25-(OH)D variants. Participants were followed for outcomes up to June 2020.
The average baseline measured 25-(OH)D concentration was 45.2 nmol/L, and 11.7% (n = 36,009) of participants had levels between 10.0 and 24.9 nmol/L. Higher levels were seen in people living in southern areas and nonsmokers as well as those with a higher level of physical activity, less socioeconomic deprivation, and lower body mass index.
During follow-up, 6.1% of participants died (n = 18,700). After adjustment for variables, odds ratios for all causes of mortality were highest among people with 25-(OH)D levels below 25 nmol/L and appeared to plateau between 50 and 75 nmol/L, with no further reduction in mortality at values of 75-125 nmol/L.
Mortality 36% higher in those deficient in vitamin D
The risk for mortality was a significant 36% higher for participants with 25-(OH)D 25 nmol/L compared with 50 nmol/L.
With the Mendelian randomization, there was an L-shaped association between genetically predicted 25-(OH)D level and all-cause mortality (P for nonlinearity < .001) and for mortality because of cancer and cardiovascular disease (P for nonlinearity ≤ .033).
Again, the strongest association with those outcomes and genetically predicted 25-(OH)D was found at levels below 25 nmol/L and a plateau was seen by 50 nmol/L.
Compared with a measured 25-(OH)D concentration of 50 nmol/L, investigators estimated that the genetically predicted odds of all-cause mortality would increase sixfold (odds ratio, 6.00) for participants at 10 nmol/L and by 25% (OR, 1.25) for those at 25 nmol/L.
And, compared with a measured 25-(OH)D concentration of 50 nmol/L, those with 10 nmol/L had genetically predicted odds ratios of 5.98 for cardiovascular mortality, 3.37 for cancer mortality, and 12.44 for respiratory mortality.
Comparing measured 25-(OH)D concentrations of 25 nmol/L versus 50 nmol/L, odds ratios for those outcomes were 1.25, 1.16, and 1.96 (95% confidence interval, 1.88-4.67), respectively. All were statistically significant.
Consistent results supportive of a causal effect of genetically predicted 25-(OH)D on all-cause mortality in those with low measured vitamin D concentrations were also found in a sensitivity analysis of 20,837 people of non-White ethnic origin.
The study was funded by the Australian National Health and Medical Research Council. Dr. Sutherland’s studentship is funded by an Australian Research Training Program Scholarship.
A version of this article first appeared on Medscape.com.
Vitamin D deficiency increases mortality risk and raising levels even slightly could decrease the risk, researchers examining data from the UK Biobank have found.
They used a Mendelian randomization approach, which uses genetic variants as “proxy indicators” for external factors that affect vitamin D levels, such as sun exposure or dietary intake. It allows for analysis of the relationship between deficiency and outcomes including mortality, which can’t be done in randomized clinical trials for ethical reasons.
Using this method, nutritionist Joshua P. Sutherland, PhD, of the Australian Centre for Precision Health, Adelaide, and colleagues found an association between genetically predicted vitamin D levels [25-(OH)D] and mortality from several major causes, with evidence of causality among people with measured concentrations below, but not above, 50 nmol/L. The findings were published online in Annals of Internal Medicine.
“Unlike other types of observational studies, we have overcome some of the methodological obstacles. What is special about this new study is we were able to look at people with very low vitamin D concentrations and what would happen if their concentrations were a little bit higher. Most randomized controlled trials don’t show much of an effect. That’s because most people have sufficient concentrations. Ethically you can’t do a trial of people with very low levels without treating them,” senior author Elina Hypp
The data support the 50 nmol/L cut-off endorsed by the United States National Academy of Medicine and align with previous data suggesting the benefit of vitamin D supplementation is largely seen in people with deficiency.
“Everybody with vitamin D levels less than 50 nmol/L is recommended to increase their levels. Our results suggest there’s no need to go very high. The positive message is that if we are able to raise levels to just the current U.S. recommendations, that’s fine. There’s no need to use large supplement doses,” Dr. Hyppönen explained.
Thus, she advised, “Supplementation will clearly help, especially during wintertime or if a person isn’t getting enough vitamin D from the sun or in places where food isn’t fortified with vitamin D.”
But the data don’t support the approach of using large intermittent doses, she added.
“Sometimes doctors want to fix the deficiency quickly with a large ‘bolus’ dose, then continue with a maintenance dose. Increasing evidence suggests that’s not beneficial and might disturb the body’s metabolism so that it can’t get the amount it needs. It’s safe overall but might not work the way we want it to work.”
Rather, Dr. Hyppönen said, “My sense is that daily modest vitamin D dose supplementation when it’s needed is the best way forward.”
Genetic approach reveals causal relationship
The investigators analyzed data from 307,601 individuals in the UK Biobank, a prospective cohort of people recruited from England, Scotland, and Wales during March 2006 and July 2010. Most were of White European ancestry and were aged 37-73 years at baseline.
Genetically predicted vitamin D levels were estimated using 35 confirmed 25-(OH)D variants. Participants were followed for outcomes up to June 2020.
The average baseline measured 25-(OH)D concentration was 45.2 nmol/L, and 11.7% (n = 36,009) of participants had levels between 10.0 and 24.9 nmol/L. Higher levels were seen in people living in southern areas and nonsmokers as well as those with a higher level of physical activity, less socioeconomic deprivation, and lower body mass index.
During follow-up, 6.1% of participants died (n = 18,700). After adjustment for variables, odds ratios for all causes of mortality were highest among people with 25-(OH)D levels below 25 nmol/L and appeared to plateau between 50 and 75 nmol/L, with no further reduction in mortality at values of 75-125 nmol/L.
Mortality 36% higher in those deficient in vitamin D
The risk for mortality was a significant 36% higher for participants with 25-(OH)D 25 nmol/L compared with 50 nmol/L.
With the Mendelian randomization, there was an L-shaped association between genetically predicted 25-(OH)D level and all-cause mortality (P for nonlinearity < .001) and for mortality because of cancer and cardiovascular disease (P for nonlinearity ≤ .033).
Again, the strongest association with those outcomes and genetically predicted 25-(OH)D was found at levels below 25 nmol/L and a plateau was seen by 50 nmol/L.
Compared with a measured 25-(OH)D concentration of 50 nmol/L, investigators estimated that the genetically predicted odds of all-cause mortality would increase sixfold (odds ratio, 6.00) for participants at 10 nmol/L and by 25% (OR, 1.25) for those at 25 nmol/L.
And, compared with a measured 25-(OH)D concentration of 50 nmol/L, those with 10 nmol/L had genetically predicted odds ratios of 5.98 for cardiovascular mortality, 3.37 for cancer mortality, and 12.44 for respiratory mortality.
Comparing measured 25-(OH)D concentrations of 25 nmol/L versus 50 nmol/L, odds ratios for those outcomes were 1.25, 1.16, and 1.96 (95% confidence interval, 1.88-4.67), respectively. All were statistically significant.
Consistent results supportive of a causal effect of genetically predicted 25-(OH)D on all-cause mortality in those with low measured vitamin D concentrations were also found in a sensitivity analysis of 20,837 people of non-White ethnic origin.
The study was funded by the Australian National Health and Medical Research Council. Dr. Sutherland’s studentship is funded by an Australian Research Training Program Scholarship.
A version of this article first appeared on Medscape.com.
FROM ANNALS OF INTERNAL MEDICINE
Four commonly abused drugs linked with atrial fibrillation
Cocaine, methamphetamine, opioids, and cannabis may independently increase risk of atrial fibrillation (AFib), based on data from almost 24 million people.
While more work is needed to uncover causal links, physicians should be aware that these commonly abused substances could be driving new cases of AFib, reported investigators from the University of California, San Francisco.
“Though alcohol and tobacco smoking have each been associated with a heightened risk of [AFib], relationships between other drug use and [AFib] are poorly understood,” they wrote in European Heart Journal.
Some previous studies have ventured into this terrain, but most focused on fatal arrhythmias, or offered anecdotal evidence. This knowledge gap is particularly concerning for cannabis, the researchers noted, as medical and recreational use are on the rise.
The present analysis included data from 23.5 million adults in California who received care through a hospital, emergency department, or outpatient surgery center during 2005-2015. Based on ICD-9 diagnostic codes, 132,834 of these patients used cannabis, 98,271 used methamphetamines, 48,701 used cocaine, and 10,032 used opiates. Inclusion required lack of AFib at baseline.
Reliance on ICD-9 codes makes the data “quite specific,” but lacking sensitivity, according to principal author Gregory M. Marcus, MD, cardiologist and professor of medicine at UCSF.
“If they were designated as using these drugs, that is very likely true,” Dr. Marcus said in an interview. “But certainly, the absence of any mention of use of these drugs does not exclude the possibility that some people were still using them. That would not create spurious false-positive relationships; if anything, it attenuates existing relationships.”
In other words, using ICD-9 codes reduced the power to detect an association between each drug and AFib, meaning any relationship needed to be sufficiently strong enough to generate a significant result.
At the end of the decade-long study period, 998,747 patients (4.2%) had developed incident AFib. After adjusting for potential confounders and mediators, all four drugs showed significant, independent associations with AFib. Methamphetamines presented the greatest risk (hazard ratio, 1.86%), followed by opiates (HR, 1.74), cocaine (HR, 1.61), and cannabis (HR, 1.35).
“Our findings provide the first evidence utilizing a longitudinal cohort to demonstrate that cannabis use predicts the future onset of AFib,” Dr. Marcus and colleagues wrote.
Dose-response relationships were not detected for any of the substances; however, usage levels were also derived from ICD-9 codes, which may have been insufficient for this purpose, according to the investigators.
Causal mechanisms deserve a closer look
Causal links between AFib and each of the drugs remain unclear. Citing prior research, Dr. Marcus and colleagues explained how methamphetamines are capable of “significant cardiac electrical remodeling,” while cocaine may cause sodium channel dysregulation, and opioids can render atrial myocytes more susceptible to oxidative damage. Although cannabis has previously been linked with hospitalization for arrhythmia, a pharmacologic driver of this phenomenon remains largely unexamined.
“We don’t know for sure precisely what the constituents are that are responsible for our findings,” Dr. Marcus said. “It’s possible that there are some effects that are much more generic, such as inhaling a burned substance. There is good evidence that if you inhale pretty much any sort of particulate matter, that increases inflammation in the body. Inflammation is known to be a trigger for atrial fibrillation.”
Alternatively, all four drugs – whether stimulants or depressants – cause “quite dramatic and often rapid effects on the autonomic nervous system,” Dr. Marcus said, noting that these rapid swings are a known trigger for AFib.
Brian Olshansky, MD, emeritus professor of internal medicine-cardiovascular medicine at the University of Iowa, Iowa City, suggested that nonpharmacologic factors are likely also playing a role.
“All these drugs have slightly different mechanisms of action, so there’s not one mechanism that would explain why all of them would cause atrial fibrillation,” Dr. Olshansky said in an interview. “That does suggest that there’s something else going on, besides just the drug itself. It would be potentially concerning if we were to lay the blame totally on these drugs.”
Dr. Olshansky, who recently coauthored a review of stimulant drugs and arrhythmias, suggested that lifestyle, comorbidities, and drug impurities may have added to the risk of AF.
“[The investigators] did try to correct for that kind of stuff, but it’s very hard to correct for a lot of the issues that may be ongoing with individuals who partake in these drugs,” Dr. Olshansky said in an interview. “They may not be a healthy lot, in general.”
Still, considering previous data linking drugs of abuse with arrhythmias, he said the detected risks were “intriguing,” and deserved a closer look.
“It’s a nice groundbreaking study, with regard to the fact that they showed unique relationships that we don’t completely understand,” Dr. Olshansky said. “It opens up a new opportunity for further investigation.”
The investigators disclosed relationships with InCarda, Baylis Medical, Johnson & Johnson, and others. Dr. Olshansky disclosed no relevant competing interests.
Cocaine, methamphetamine, opioids, and cannabis may independently increase risk of atrial fibrillation (AFib), based on data from almost 24 million people.
While more work is needed to uncover causal links, physicians should be aware that these commonly abused substances could be driving new cases of AFib, reported investigators from the University of California, San Francisco.
“Though alcohol and tobacco smoking have each been associated with a heightened risk of [AFib], relationships between other drug use and [AFib] are poorly understood,” they wrote in European Heart Journal.
Some previous studies have ventured into this terrain, but most focused on fatal arrhythmias, or offered anecdotal evidence. This knowledge gap is particularly concerning for cannabis, the researchers noted, as medical and recreational use are on the rise.
The present analysis included data from 23.5 million adults in California who received care through a hospital, emergency department, or outpatient surgery center during 2005-2015. Based on ICD-9 diagnostic codes, 132,834 of these patients used cannabis, 98,271 used methamphetamines, 48,701 used cocaine, and 10,032 used opiates. Inclusion required lack of AFib at baseline.
Reliance on ICD-9 codes makes the data “quite specific,” but lacking sensitivity, according to principal author Gregory M. Marcus, MD, cardiologist and professor of medicine at UCSF.
“If they were designated as using these drugs, that is very likely true,” Dr. Marcus said in an interview. “But certainly, the absence of any mention of use of these drugs does not exclude the possibility that some people were still using them. That would not create spurious false-positive relationships; if anything, it attenuates existing relationships.”
In other words, using ICD-9 codes reduced the power to detect an association between each drug and AFib, meaning any relationship needed to be sufficiently strong enough to generate a significant result.
At the end of the decade-long study period, 998,747 patients (4.2%) had developed incident AFib. After adjusting for potential confounders and mediators, all four drugs showed significant, independent associations with AFib. Methamphetamines presented the greatest risk (hazard ratio, 1.86%), followed by opiates (HR, 1.74), cocaine (HR, 1.61), and cannabis (HR, 1.35).
“Our findings provide the first evidence utilizing a longitudinal cohort to demonstrate that cannabis use predicts the future onset of AFib,” Dr. Marcus and colleagues wrote.
Dose-response relationships were not detected for any of the substances; however, usage levels were also derived from ICD-9 codes, which may have been insufficient for this purpose, according to the investigators.
Causal mechanisms deserve a closer look
Causal links between AFib and each of the drugs remain unclear. Citing prior research, Dr. Marcus and colleagues explained how methamphetamines are capable of “significant cardiac electrical remodeling,” while cocaine may cause sodium channel dysregulation, and opioids can render atrial myocytes more susceptible to oxidative damage. Although cannabis has previously been linked with hospitalization for arrhythmia, a pharmacologic driver of this phenomenon remains largely unexamined.
“We don’t know for sure precisely what the constituents are that are responsible for our findings,” Dr. Marcus said. “It’s possible that there are some effects that are much more generic, such as inhaling a burned substance. There is good evidence that if you inhale pretty much any sort of particulate matter, that increases inflammation in the body. Inflammation is known to be a trigger for atrial fibrillation.”
Alternatively, all four drugs – whether stimulants or depressants – cause “quite dramatic and often rapid effects on the autonomic nervous system,” Dr. Marcus said, noting that these rapid swings are a known trigger for AFib.
Brian Olshansky, MD, emeritus professor of internal medicine-cardiovascular medicine at the University of Iowa, Iowa City, suggested that nonpharmacologic factors are likely also playing a role.
“All these drugs have slightly different mechanisms of action, so there’s not one mechanism that would explain why all of them would cause atrial fibrillation,” Dr. Olshansky said in an interview. “That does suggest that there’s something else going on, besides just the drug itself. It would be potentially concerning if we were to lay the blame totally on these drugs.”
Dr. Olshansky, who recently coauthored a review of stimulant drugs and arrhythmias, suggested that lifestyle, comorbidities, and drug impurities may have added to the risk of AF.
“[The investigators] did try to correct for that kind of stuff, but it’s very hard to correct for a lot of the issues that may be ongoing with individuals who partake in these drugs,” Dr. Olshansky said in an interview. “They may not be a healthy lot, in general.”
Still, considering previous data linking drugs of abuse with arrhythmias, he said the detected risks were “intriguing,” and deserved a closer look.
“It’s a nice groundbreaking study, with regard to the fact that they showed unique relationships that we don’t completely understand,” Dr. Olshansky said. “It opens up a new opportunity for further investigation.”
The investigators disclosed relationships with InCarda, Baylis Medical, Johnson & Johnson, and others. Dr. Olshansky disclosed no relevant competing interests.
Cocaine, methamphetamine, opioids, and cannabis may independently increase risk of atrial fibrillation (AFib), based on data from almost 24 million people.
While more work is needed to uncover causal links, physicians should be aware that these commonly abused substances could be driving new cases of AFib, reported investigators from the University of California, San Francisco.
“Though alcohol and tobacco smoking have each been associated with a heightened risk of [AFib], relationships between other drug use and [AFib] are poorly understood,” they wrote in European Heart Journal.
Some previous studies have ventured into this terrain, but most focused on fatal arrhythmias, or offered anecdotal evidence. This knowledge gap is particularly concerning for cannabis, the researchers noted, as medical and recreational use are on the rise.
The present analysis included data from 23.5 million adults in California who received care through a hospital, emergency department, or outpatient surgery center during 2005-2015. Based on ICD-9 diagnostic codes, 132,834 of these patients used cannabis, 98,271 used methamphetamines, 48,701 used cocaine, and 10,032 used opiates. Inclusion required lack of AFib at baseline.
Reliance on ICD-9 codes makes the data “quite specific,” but lacking sensitivity, according to principal author Gregory M. Marcus, MD, cardiologist and professor of medicine at UCSF.
“If they were designated as using these drugs, that is very likely true,” Dr. Marcus said in an interview. “But certainly, the absence of any mention of use of these drugs does not exclude the possibility that some people were still using them. That would not create spurious false-positive relationships; if anything, it attenuates existing relationships.”
In other words, using ICD-9 codes reduced the power to detect an association between each drug and AFib, meaning any relationship needed to be sufficiently strong enough to generate a significant result.
At the end of the decade-long study period, 998,747 patients (4.2%) had developed incident AFib. After adjusting for potential confounders and mediators, all four drugs showed significant, independent associations with AFib. Methamphetamines presented the greatest risk (hazard ratio, 1.86%), followed by opiates (HR, 1.74), cocaine (HR, 1.61), and cannabis (HR, 1.35).
“Our findings provide the first evidence utilizing a longitudinal cohort to demonstrate that cannabis use predicts the future onset of AFib,” Dr. Marcus and colleagues wrote.
Dose-response relationships were not detected for any of the substances; however, usage levels were also derived from ICD-9 codes, which may have been insufficient for this purpose, according to the investigators.
Causal mechanisms deserve a closer look
Causal links between AFib and each of the drugs remain unclear. Citing prior research, Dr. Marcus and colleagues explained how methamphetamines are capable of “significant cardiac electrical remodeling,” while cocaine may cause sodium channel dysregulation, and opioids can render atrial myocytes more susceptible to oxidative damage. Although cannabis has previously been linked with hospitalization for arrhythmia, a pharmacologic driver of this phenomenon remains largely unexamined.
“We don’t know for sure precisely what the constituents are that are responsible for our findings,” Dr. Marcus said. “It’s possible that there are some effects that are much more generic, such as inhaling a burned substance. There is good evidence that if you inhale pretty much any sort of particulate matter, that increases inflammation in the body. Inflammation is known to be a trigger for atrial fibrillation.”
Alternatively, all four drugs – whether stimulants or depressants – cause “quite dramatic and often rapid effects on the autonomic nervous system,” Dr. Marcus said, noting that these rapid swings are a known trigger for AFib.
Brian Olshansky, MD, emeritus professor of internal medicine-cardiovascular medicine at the University of Iowa, Iowa City, suggested that nonpharmacologic factors are likely also playing a role.
“All these drugs have slightly different mechanisms of action, so there’s not one mechanism that would explain why all of them would cause atrial fibrillation,” Dr. Olshansky said in an interview. “That does suggest that there’s something else going on, besides just the drug itself. It would be potentially concerning if we were to lay the blame totally on these drugs.”
Dr. Olshansky, who recently coauthored a review of stimulant drugs and arrhythmias, suggested that lifestyle, comorbidities, and drug impurities may have added to the risk of AF.
“[The investigators] did try to correct for that kind of stuff, but it’s very hard to correct for a lot of the issues that may be ongoing with individuals who partake in these drugs,” Dr. Olshansky said in an interview. “They may not be a healthy lot, in general.”
Still, considering previous data linking drugs of abuse with arrhythmias, he said the detected risks were “intriguing,” and deserved a closer look.
“It’s a nice groundbreaking study, with regard to the fact that they showed unique relationships that we don’t completely understand,” Dr. Olshansky said. “It opens up a new opportunity for further investigation.”
The investigators disclosed relationships with InCarda, Baylis Medical, Johnson & Johnson, and others. Dr. Olshansky disclosed no relevant competing interests.
FROM EUROPEAN HEART JOURNAL
Time to ditch clarithromycin for H. pylori?
Rates of resistance to clarithromycin among Helicobacter pylori isolates in the United States and Europe are high enough to warrant discontinuation of empiric use of proton pump inhibitor (PPI)–based triple therapy that includes the antibiotic in these regions, a new study has found.
Overall, 22.2% of participants were resistant to clarithromycin – a rate that is above the currently recommended threshold of 15% or higher for avoidance of PPI-based triple therapy that includes clarithromycin.
, study investigator William Chey, MD, professor and chief, Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, said in an interview.
Judith Kim, MD, a gastroenterologist at NYU Langone Health and clinical instructor of medicine at NYU Grossman School of Medicine, who wasn’t involved in the study, agrees.
“The use of PPI-based triple therapy is still common practice despite recent recommendations to avoid clarithromycin in areas with high resistance rates,” Dr. Kim told this news organization.
“This study shows that multiple parts of the United States and Europe have high resistance rates,” rendering clarithromycin-based regimens “more likely to ineffectively eradicate H pylori,” Dr. Kim said.
The study was published online in The American Journal of Gastroenterology.
Better options now available
Guidelines advise against the use of PPI-based triple regimens with clarithromycin for H. pylori infection in areas where resistance is 15% or higher or for patients who have previously received macrolides. However, up-to-date information on H. pylori antimicrobial resistance patterns is limited, especially in the United States.
Dr. Chey and colleagues assessed resistance rates to antibiotics commonly used to treat H. pylori in isolates from 907 adults with the infection in the United States and Europe. They included four U.S. subregions and five participating European countries.
In all U.S. subregions and European countries, clarithromycin resistance rates were above 15% except possibly in the United Kingdom, where the sample size was too small to provide a reliable estimate.
Three-quarters of the clarithromycin-resistant isolates were also resistant to metronidazole.
The study also found that, overall, 1.2% of patients had isolates that were resistant to amoxicillin, and 69.2% had isolates resistant to metronidazole. Resistance patterns were similar in the United States and Europe; metronidazole resistance was the most common (50%-79% of isolates), and amoxicillin was the least common (≤ 5%).
“Overall, these data provide robust evidence to support a shift away from the default empiric prescription of triple combinations containing a PPI and clarithromycin for H. pylori infection in the United States and Europe,” the study team writes.
The high prevalence of resistance, including dual resistance, highlights the need for antibiotic stewardship and resistance surveillance, as well as novel treatment strategies for H. pylori infection, they add.
Last spring, as previously reported, the United States Food and Drug Administration approved two vonoprazan-based treatments for H. pylori: Voquezna Triple Pak (vonoprazan, amoxicillin, clarithromycin) and Voquezna Dual Pak (vonoprazan, amoxicillin), both from Phathom Pharmaceuticals.
“Vonoprazan-based treatment may be superior to standard PPI triple therapy for clarithromycin-resistant infections based on prior studies and is a potential good option,” Dr. Kim said.
Still, she added, she “would most likely first recommend regimens that do not have clarithromycin, such as bismuth quadruple therapy.”
Study’s importance
Because the study drew upon the largest dataset to date on U.S. resistance rates, it should be used to more precisely guide first-line therapy decisions, said Richard Peek, Jr., MD, professor of medicine and director of gastroenterology at Vanderbilt University Medical Center, Nashville, Tenn.
“To date, there has been a dearth of information in the United States regarding H. pylori resistance rates, which has often led to the use of ineffective empiric therapies and inappropriate exposure to antibiotics,” Dr. Peek, who wasn’t involved in the study, told this news organization.
“These data are particularly exciting when viewed within the context of new genomic sequencing tests that can determine H. pylori resistance patterns using DNA isolated from the stomach or the stool,” he said.
Dr. Peek agreed that the recent approval of vonoprazan-based therapies “adds another regimen to the therapeutic armamentarium available for eradicating H. pylori, and its value seems to be particularly beneficial for eradication failures.”
The research was funded by Phathom Pharmaceuticals. Dr. Chey is a board member of the American College of Gastroenterology, GI on Demand, the International Foundation of Functional GI Disorders, and the Rome Foundation. He has received compensation as a consultant from AbbVie, Alfasigma, Allakos, Alnylam, Bayer, BioAmerica, Cosmo, Intrinsic Medicine, Ironwood Pharmaceuticals, QOL Medical, Nestle, Phathom Pharmaceuticals, RedHill Biopharma, Salix/Valeant, Takeda, Urovant, and Vibrant; grant/research support from BioAmerica, Commonwealth Diagnostics International, QOL Medical, Salix, and Vibrant; owns stock/stock options in GI on Demand and Modify Health; and owns patents relating to methods and kits for identifying food sensitivities and intolerances, digital manometry, and a rectal expulsion device. Dr. Peek and Dr. Kim report no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Rates of resistance to clarithromycin among Helicobacter pylori isolates in the United States and Europe are high enough to warrant discontinuation of empiric use of proton pump inhibitor (PPI)–based triple therapy that includes the antibiotic in these regions, a new study has found.
Overall, 22.2% of participants were resistant to clarithromycin – a rate that is above the currently recommended threshold of 15% or higher for avoidance of PPI-based triple therapy that includes clarithromycin.
, study investigator William Chey, MD, professor and chief, Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, said in an interview.
Judith Kim, MD, a gastroenterologist at NYU Langone Health and clinical instructor of medicine at NYU Grossman School of Medicine, who wasn’t involved in the study, agrees.
“The use of PPI-based triple therapy is still common practice despite recent recommendations to avoid clarithromycin in areas with high resistance rates,” Dr. Kim told this news organization.
“This study shows that multiple parts of the United States and Europe have high resistance rates,” rendering clarithromycin-based regimens “more likely to ineffectively eradicate H pylori,” Dr. Kim said.
The study was published online in The American Journal of Gastroenterology.
Better options now available
Guidelines advise against the use of PPI-based triple regimens with clarithromycin for H. pylori infection in areas where resistance is 15% or higher or for patients who have previously received macrolides. However, up-to-date information on H. pylori antimicrobial resistance patterns is limited, especially in the United States.
Dr. Chey and colleagues assessed resistance rates to antibiotics commonly used to treat H. pylori in isolates from 907 adults with the infection in the United States and Europe. They included four U.S. subregions and five participating European countries.
In all U.S. subregions and European countries, clarithromycin resistance rates were above 15% except possibly in the United Kingdom, where the sample size was too small to provide a reliable estimate.
Three-quarters of the clarithromycin-resistant isolates were also resistant to metronidazole.
The study also found that, overall, 1.2% of patients had isolates that were resistant to amoxicillin, and 69.2% had isolates resistant to metronidazole. Resistance patterns were similar in the United States and Europe; metronidazole resistance was the most common (50%-79% of isolates), and amoxicillin was the least common (≤ 5%).
“Overall, these data provide robust evidence to support a shift away from the default empiric prescription of triple combinations containing a PPI and clarithromycin for H. pylori infection in the United States and Europe,” the study team writes.
The high prevalence of resistance, including dual resistance, highlights the need for antibiotic stewardship and resistance surveillance, as well as novel treatment strategies for H. pylori infection, they add.
Last spring, as previously reported, the United States Food and Drug Administration approved two vonoprazan-based treatments for H. pylori: Voquezna Triple Pak (vonoprazan, amoxicillin, clarithromycin) and Voquezna Dual Pak (vonoprazan, amoxicillin), both from Phathom Pharmaceuticals.
“Vonoprazan-based treatment may be superior to standard PPI triple therapy for clarithromycin-resistant infections based on prior studies and is a potential good option,” Dr. Kim said.
Still, she added, she “would most likely first recommend regimens that do not have clarithromycin, such as bismuth quadruple therapy.”
Study’s importance
Because the study drew upon the largest dataset to date on U.S. resistance rates, it should be used to more precisely guide first-line therapy decisions, said Richard Peek, Jr., MD, professor of medicine and director of gastroenterology at Vanderbilt University Medical Center, Nashville, Tenn.
“To date, there has been a dearth of information in the United States regarding H. pylori resistance rates, which has often led to the use of ineffective empiric therapies and inappropriate exposure to antibiotics,” Dr. Peek, who wasn’t involved in the study, told this news organization.
“These data are particularly exciting when viewed within the context of new genomic sequencing tests that can determine H. pylori resistance patterns using DNA isolated from the stomach or the stool,” he said.
Dr. Peek agreed that the recent approval of vonoprazan-based therapies “adds another regimen to the therapeutic armamentarium available for eradicating H. pylori, and its value seems to be particularly beneficial for eradication failures.”
The research was funded by Phathom Pharmaceuticals. Dr. Chey is a board member of the American College of Gastroenterology, GI on Demand, the International Foundation of Functional GI Disorders, and the Rome Foundation. He has received compensation as a consultant from AbbVie, Alfasigma, Allakos, Alnylam, Bayer, BioAmerica, Cosmo, Intrinsic Medicine, Ironwood Pharmaceuticals, QOL Medical, Nestle, Phathom Pharmaceuticals, RedHill Biopharma, Salix/Valeant, Takeda, Urovant, and Vibrant; grant/research support from BioAmerica, Commonwealth Diagnostics International, QOL Medical, Salix, and Vibrant; owns stock/stock options in GI on Demand and Modify Health; and owns patents relating to methods and kits for identifying food sensitivities and intolerances, digital manometry, and a rectal expulsion device. Dr. Peek and Dr. Kim report no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Rates of resistance to clarithromycin among Helicobacter pylori isolates in the United States and Europe are high enough to warrant discontinuation of empiric use of proton pump inhibitor (PPI)–based triple therapy that includes the antibiotic in these regions, a new study has found.
Overall, 22.2% of participants were resistant to clarithromycin – a rate that is above the currently recommended threshold of 15% or higher for avoidance of PPI-based triple therapy that includes clarithromycin.
, study investigator William Chey, MD, professor and chief, Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, said in an interview.
Judith Kim, MD, a gastroenterologist at NYU Langone Health and clinical instructor of medicine at NYU Grossman School of Medicine, who wasn’t involved in the study, agrees.
“The use of PPI-based triple therapy is still common practice despite recent recommendations to avoid clarithromycin in areas with high resistance rates,” Dr. Kim told this news organization.
“This study shows that multiple parts of the United States and Europe have high resistance rates,” rendering clarithromycin-based regimens “more likely to ineffectively eradicate H pylori,” Dr. Kim said.
The study was published online in The American Journal of Gastroenterology.
Better options now available
Guidelines advise against the use of PPI-based triple regimens with clarithromycin for H. pylori infection in areas where resistance is 15% or higher or for patients who have previously received macrolides. However, up-to-date information on H. pylori antimicrobial resistance patterns is limited, especially in the United States.
Dr. Chey and colleagues assessed resistance rates to antibiotics commonly used to treat H. pylori in isolates from 907 adults with the infection in the United States and Europe. They included four U.S. subregions and five participating European countries.
In all U.S. subregions and European countries, clarithromycin resistance rates were above 15% except possibly in the United Kingdom, where the sample size was too small to provide a reliable estimate.
Three-quarters of the clarithromycin-resistant isolates were also resistant to metronidazole.
The study also found that, overall, 1.2% of patients had isolates that were resistant to amoxicillin, and 69.2% had isolates resistant to metronidazole. Resistance patterns were similar in the United States and Europe; metronidazole resistance was the most common (50%-79% of isolates), and amoxicillin was the least common (≤ 5%).
“Overall, these data provide robust evidence to support a shift away from the default empiric prescription of triple combinations containing a PPI and clarithromycin for H. pylori infection in the United States and Europe,” the study team writes.
The high prevalence of resistance, including dual resistance, highlights the need for antibiotic stewardship and resistance surveillance, as well as novel treatment strategies for H. pylori infection, they add.
Last spring, as previously reported, the United States Food and Drug Administration approved two vonoprazan-based treatments for H. pylori: Voquezna Triple Pak (vonoprazan, amoxicillin, clarithromycin) and Voquezna Dual Pak (vonoprazan, amoxicillin), both from Phathom Pharmaceuticals.
“Vonoprazan-based treatment may be superior to standard PPI triple therapy for clarithromycin-resistant infections based on prior studies and is a potential good option,” Dr. Kim said.
Still, she added, she “would most likely first recommend regimens that do not have clarithromycin, such as bismuth quadruple therapy.”
Study’s importance
Because the study drew upon the largest dataset to date on U.S. resistance rates, it should be used to more precisely guide first-line therapy decisions, said Richard Peek, Jr., MD, professor of medicine and director of gastroenterology at Vanderbilt University Medical Center, Nashville, Tenn.
“To date, there has been a dearth of information in the United States regarding H. pylori resistance rates, which has often led to the use of ineffective empiric therapies and inappropriate exposure to antibiotics,” Dr. Peek, who wasn’t involved in the study, told this news organization.
“These data are particularly exciting when viewed within the context of new genomic sequencing tests that can determine H. pylori resistance patterns using DNA isolated from the stomach or the stool,” he said.
Dr. Peek agreed that the recent approval of vonoprazan-based therapies “adds another regimen to the therapeutic armamentarium available for eradicating H. pylori, and its value seems to be particularly beneficial for eradication failures.”
The research was funded by Phathom Pharmaceuticals. Dr. Chey is a board member of the American College of Gastroenterology, GI on Demand, the International Foundation of Functional GI Disorders, and the Rome Foundation. He has received compensation as a consultant from AbbVie, Alfasigma, Allakos, Alnylam, Bayer, BioAmerica, Cosmo, Intrinsic Medicine, Ironwood Pharmaceuticals, QOL Medical, Nestle, Phathom Pharmaceuticals, RedHill Biopharma, Salix/Valeant, Takeda, Urovant, and Vibrant; grant/research support from BioAmerica, Commonwealth Diagnostics International, QOL Medical, Salix, and Vibrant; owns stock/stock options in GI on Demand and Modify Health; and owns patents relating to methods and kits for identifying food sensitivities and intolerances, digital manometry, and a rectal expulsion device. Dr. Peek and Dr. Kim report no relevant financial relationships.
A version of this article first appeared on Medscape.com.