Federal Practitioner

A surgeon in Tulsa shot by a disgruntled patient. A doctor in India beaten by a group of bereaved family members. A general practitioner in the United Kingdom threatened with stabbing. The reality is grim: Health care workers across the globe experience violence while at work. A new study identifies this trend and finds that 25% of health care workers polled were willing to quit because of such violence.

“That was pretty appalling,” Rahul Kashyap, MD, MBA, MBBS, recalls. Dr. Kashyap is one of the leaders of the Violence Study of Healthcare Workers and Systems (ViSHWaS), which polled an international sample of physicians, nurses, and hospital staff. This study has worrying implications, Dr. Kashyap says. In a time when hospital staff are reporting burnout in record numbers, further deterrents may be the last thing our health care system needs. But Dr. Kashyap hopes that bringing awareness to these trends may allow physicians, policymakers, and the public to mobilize and intervene before it’s too late.

Previous studies have revealed similar trends. The rate of workplace violence directed at U.S. health care workers is five times that of workers in any other industry, according to the Bureau of Labor Statistics. The same study found that attacks had increased 63% from 2011 to 2018. Other polls that focus on the pandemic show that nearly half of U.S. nurses believe that violence increased since the world shut down. Well before the pandemic, however, a study from the Indian Medical Association found that 75% of doctors experienced workplace violence.

With this history in mind, perhaps it’s not surprising that the idea for the study came from the authors’ personal experiences. They had seen coworkers go through attacks, or they had endured attacks themselves, Dr. Kashyap says. But they couldn’t find any global data to back up these experiences. So Dr. Kashyap and his colleagues formed a web of volunteers dedicated to creating a cross-sectional study.

They got in touch with researchers from countries across Asia, the Middle East, South America, North America, and Africa. The initial group agreed to reach out to their contacts, casting a wide net. Researchers used WhatsApp, LinkedIn, and text messages to distribute the survey. Health care workers in each country completed the brief questionnaire, recalling their prepandemic world and evaluating their current one.

Within 2 months, they had reached health care workers in more than 100 countries. They concluded the study when they received about 5,000 results, according to Dr. Kashyap, and then began the process of stratifying the data. For this report, they focused on critical care, emergency medicine, and anesthesiology, which resulted in 598 responses from 69 countries. Of these, India and the United States had the highest number of participants.

In all, 73% of participants reported facing physical or verbal violence while in the hospital; 48% said they felt less motivated to work because of that violence; 39% of respondents believed that the amount of violence they experienced was the same as before the COVID-19 pandemic; and 36% of respondents believed that violence had increased. Even though they were trained on guidelines from the Occupational Safety and Health Administration, 20% of participants felt unprepared to face violence.

Although the study didn’t analyze the reasons workers felt this way, Dr. Kashyap speculates that it could be related to the medical distrust that grew during the pandemic or the stress patients and health care professionals experienced during its peak.

Regardless, the researchers say their study is a starting point. Now that the trend has been highlighted, it may be acted on.

Moving forward, Dr. Kashyap believes that controlling for different variables could determine whether factors like gender or shift time put a worker at higher risk for violence. He hopes it’s possible to interrupt these patterns and reestablish trust in the hospital environment. “It’s aspirational, but you’re hoping that through studies like ViSHWaS, which means trust in Hindi ... [we could restore] the trust and confidence among health care providers for the patients and family members.”

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

A surgeon in Tulsa shot by a disgruntled patient. A doctor in India beaten by a group of bereaved family members. A general practitioner in the United Kingdom threatened with stabbing. The reality is grim: Health care workers across the globe experience violence while at work. A new study identifies this trend and finds that 25% of health care workers polled were willing to quit because of such violence.

“That was pretty appalling,” Rahul Kashyap, MD, MBA, MBBS, recalls. Dr. Kashyap is one of the leaders of the Violence Study of Healthcare Workers and Systems (ViSHWaS), which polled an international sample of physicians, nurses, and hospital staff. This study has worrying implications, Dr. Kashyap says. In a time when hospital staff are reporting burnout in record numbers, further deterrents may be the last thing our health care system needs. But Dr. Kashyap hopes that bringing awareness to these trends may allow physicians, policymakers, and the public to mobilize and intervene before it’s too late.

Previous studies have revealed similar trends. The rate of workplace violence directed at U.S. health care workers is five times that of workers in any other industry, according to the Bureau of Labor Statistics. The same study found that attacks had increased 63% from 2011 to 2018. Other polls that focus on the pandemic show that nearly half of U.S. nurses believe that violence increased since the world shut down. Well before the pandemic, however, a study from the Indian Medical Association found that 75% of doctors experienced workplace violence.

With this history in mind, perhaps it’s not surprising that the idea for the study came from the authors’ personal experiences. They had seen coworkers go through attacks, or they had endured attacks themselves, Dr. Kashyap says. But they couldn’t find any global data to back up these experiences. So Dr. Kashyap and his colleagues formed a web of volunteers dedicated to creating a cross-sectional study.

They got in touch with researchers from countries across Asia, the Middle East, South America, North America, and Africa. The initial group agreed to reach out to their contacts, casting a wide net. Researchers used WhatsApp, LinkedIn, and text messages to distribute the survey. Health care workers in each country completed the brief questionnaire, recalling their prepandemic world and evaluating their current one.

Within 2 months, they had reached health care workers in more than 100 countries. They concluded the study when they received about 5,000 results, according to Dr. Kashyap, and then began the process of stratifying the data. For this report, they focused on critical care, emergency medicine, and anesthesiology, which resulted in 598 responses from 69 countries. Of these, India and the United States had the highest number of participants.

In all, 73% of participants reported facing physical or verbal violence while in the hospital; 48% said they felt less motivated to work because of that violence; 39% of respondents believed that the amount of violence they experienced was the same as before the COVID-19 pandemic; and 36% of respondents believed that violence had increased. Even though they were trained on guidelines from the Occupational Safety and Health Administration, 20% of participants felt unprepared to face violence.

Although the study didn’t analyze the reasons workers felt this way, Dr. Kashyap speculates that it could be related to the medical distrust that grew during the pandemic or the stress patients and health care professionals experienced during its peak.

Regardless, the researchers say their study is a starting point. Now that the trend has been highlighted, it may be acted on.

Moving forward, Dr. Kashyap believes that controlling for different variables could determine whether factors like gender or shift time put a worker at higher risk for violence. He hopes it’s possible to interrupt these patterns and reestablish trust in the hospital environment. “It’s aspirational, but you’re hoping that through studies like ViSHWaS, which means trust in Hindi ... [we could restore] the trust and confidence among health care providers for the patients and family members.”

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

A surgeon in Tulsa shot by a disgruntled patient. A doctor in India beaten by a group of bereaved family members. A general practitioner in the United Kingdom threatened with stabbing. The reality is grim: Health care workers across the globe experience violence while at work. A new study identifies this trend and finds that 25% of health care workers polled were willing to quit because of such violence.

“That was pretty appalling,” Rahul Kashyap, MD, MBA, MBBS, recalls. Dr. Kashyap is one of the leaders of the Violence Study of Healthcare Workers and Systems (ViSHWaS), which polled an international sample of physicians, nurses, and hospital staff. This study has worrying implications, Dr. Kashyap says. In a time when hospital staff are reporting burnout in record numbers, further deterrents may be the last thing our health care system needs. But Dr. Kashyap hopes that bringing awareness to these trends may allow physicians, policymakers, and the public to mobilize and intervene before it’s too late.

Previous studies have revealed similar trends. The rate of workplace violence directed at U.S. health care workers is five times that of workers in any other industry, according to the Bureau of Labor Statistics. The same study found that attacks had increased 63% from 2011 to 2018. Other polls that focus on the pandemic show that nearly half of U.S. nurses believe that violence increased since the world shut down. Well before the pandemic, however, a study from the Indian Medical Association found that 75% of doctors experienced workplace violence.

With this history in mind, perhaps it’s not surprising that the idea for the study came from the authors’ personal experiences. They had seen coworkers go through attacks, or they had endured attacks themselves, Dr. Kashyap says. But they couldn’t find any global data to back up these experiences. So Dr. Kashyap and his colleagues formed a web of volunteers dedicated to creating a cross-sectional study.

They got in touch with researchers from countries across Asia, the Middle East, South America, North America, and Africa. The initial group agreed to reach out to their contacts, casting a wide net. Researchers used WhatsApp, LinkedIn, and text messages to distribute the survey. Health care workers in each country completed the brief questionnaire, recalling their prepandemic world and evaluating their current one.

Within 2 months, they had reached health care workers in more than 100 countries. They concluded the study when they received about 5,000 results, according to Dr. Kashyap, and then began the process of stratifying the data. For this report, they focused on critical care, emergency medicine, and anesthesiology, which resulted in 598 responses from 69 countries. Of these, India and the United States had the highest number of participants.

In all, 73% of participants reported facing physical or verbal violence while in the hospital; 48% said they felt less motivated to work because of that violence; 39% of respondents believed that the amount of violence they experienced was the same as before the COVID-19 pandemic; and 36% of respondents believed that violence had increased. Even though they were trained on guidelines from the Occupational Safety and Health Administration, 20% of participants felt unprepared to face violence.

Although the study didn’t analyze the reasons workers felt this way, Dr. Kashyap speculates that it could be related to the medical distrust that grew during the pandemic or the stress patients and health care professionals experienced during its peak.

Regardless, the researchers say their study is a starting point. Now that the trend has been highlighted, it may be acted on.

Moving forward, Dr. Kashyap believes that controlling for different variables could determine whether factors like gender or shift time put a worker at higher risk for violence. He hopes it’s possible to interrupt these patterns and reestablish trust in the hospital environment. “It’s aspirational, but you’re hoping that through studies like ViSHWaS, which means trust in Hindi ... [we could restore] the trust and confidence among health care providers for the patients and family members.”

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

At least one state licensing agency is revoking nursing licenses allegedly obtained in a multistate fake diploma scheme.

The U.S. Department of Justice recently announced charges against 25 owners, operators, and employees of three Florida nursing schools in a fraud scheme in which they sold as many as 7,600 fake nursing degrees.

The purchasers in the diploma scheme paid $10,000 to $15,000 for degrees and transcripts and some 2,800 of the buyers passed the national nursing licensing exam to become registered nurses (RNs) and licensed practice nurses/vocational nurses (LPN/VNs) around the country, according to The New York Times.

Many of the degree recipients went on to work at hospitals, nursing homes, and Veterans Affairs medical centers, according to the U.S. Attorney’s Office for the Southern District of Florida.

Several national nursing organizations cooperated with the investigation, and the Delaware Division of Professional Regulation already annulled 26 licenses, according to the Delaware Nurses Association. Fake licenses were issued in five states, according to federal reports.

“We are deeply unsettled by this egregious act,” DNA President Stephanie McClellan, MSN, RN, CMSRN, said in the group’s press statement. “We want all Delaware nurses to be aware of this active issue and to speak up if there is a concern regarding capacity to practice safely by a colleague/peer,” she said.

The Oregon State Board of Nursing is also investigating at least a dozen nurses who may have paid for their degrees, according to a Portland CBS affiliate.

The National Council of State Boards of Nursing said in a statement that it had helped authorities identify and monitor the individuals who allegedly provided the false degrees.
 

Nursing community reacts

News of the fraud scheme spread through the nursing community, including social media. “The recent report on falsified nursing school degrees is both heartbreaking and serves as an eye-opener,” tweeted Usha Menon, PhD, RN, FAAN, dean and health professor of the University of South Florida Health College of Nursing. “There was enough of a need that prompted these bad actors to develop a scheme that could’ve endangered dozens of lives.”

Jennifer Mensik Kennedy, PhD, MBA, RN, the new president of the American Nurses Association, also weighed in. “The accusation that personnel at once-accredited nursing schools allegedly participated in this scheme is simply deplorable. These unlawful and unethical acts disparage the reputation of actual nurses everywhere who have rightfully earned [their titles] through their education, hard work, dedication, and time.”

The false degrees and transcripts were issued by three once-accredited and now-shuttered nursing schools in South Florida: Palm Beach School of Nursing, Sacred Heart International Institute, and Sienna College.

The alleged co-conspirators reportedly made $114 million from the scheme, which dates back to 2016, according to several news reports. Each defendant faces up to 20 years in prison.

Most LPN programs charge $10,000 to $15,000 to complete a program, Robert Rosseter, a spokesperson for the American Association of Colleges of Nursing (AACN), told this news organization.

None were AACN members, and none were accredited by the Commission on Collegiate Nursing Education, which is AACN’s autonomous accrediting agency, Mr. Rosseter said. AACN membership is voluntary and is open to schools offering baccalaureate or higher degrees, he explained.

“What is disturbing about this investigation is that there are over 7,600 people around the country with fraudulent nursing credentials who are potentially in critical health care roles treating patients,” Chad Yarbrough, acting special agent in charge for the FBI in Miami, said in the federal justice department release.
 

‘Operation Nightingale’ based on tip

The federal action, dubbed “Operation Nightingale” after the nursing pioneer Florence Nightingale, began in 2019. It was based on a tip related to a case in Maryland, according to Nurse.org.

That case ensnared Palm Beach School of Nursing owner Johanah Napoleon, who reportedly was selling fake degrees for $6,000 to $18,000 each to two individuals in Maryland and Virginia. Ms. Napoleon was charged in 2021 and eventually pled guilty. The Florida Board of Nursing shut down the Palm Beach school in 2017 owing to its students’ low passing rate on the national licensing exam.

Two participants in the bigger scheme who had also worked with Ms. Napoleon – Geralda Adrien and Woosvelt Predestin – were indicted in 2021. Ms. Adrien owned private education companies for people who at aspired to be nurses, and Mr. Predestin was an employee. They were sentenced to 27 months in prison last year and helped the federal officials build the larger case.

The 25 individuals who were charged Jan. 25 operated in Delaware, New York, New Jersey, Texas, and Florida.
 

Schemes lured immigrants

In the scheme involving Siena College, some of the individuals acted as recruiters to direct nurses who were looking for employment to the school, where they allegedly would then pay for an RN or LPN/VN degree. The recipients of the false documents then used them to obtain jobs, including at a hospital in Georgia and a Veterans Affairs medical center in Maryland, according to one indictment. The president of Siena and her co-conspirators sold more than 2,000 fake diplomas, according to charging documents.

At the Palm Beach College of Nursing, individuals at various nursing prep and education programs allegedly helped others obtain fake degrees and transcripts, which were then used to pass RN and LPN/VN licensing exams in states that included Massachusetts, New Jersey, New York, and Ohio, according to the indictment.

Some individuals then secured employment with a nursing home in Ohio, a home health agency for pediatric patients in Massachusetts, and skilled nursing facilities in New York and New Jersey.

Prosecutors allege that the president of Sacred Heart International Institute and two other co-conspirators sold 588 fake diplomas.

The FBI said that some of the aspiring nurses who were talked into buying the degrees were LPNs who wanted to become RNs and that most of those lured into the scheme were from South Florida’s Haitian American immigrant community, Nurse.org reported.

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

At least one state licensing agency is revoking nursing licenses allegedly obtained in a multistate fake diploma scheme.

The U.S. Department of Justice recently announced charges against 25 owners, operators, and employees of three Florida nursing schools in a fraud scheme in which they sold as many as 7,600 fake nursing degrees.

The purchasers in the diploma scheme paid $10,000 to $15,000 for degrees and transcripts and some 2,800 of the buyers passed the national nursing licensing exam to become registered nurses (RNs) and licensed practice nurses/vocational nurses (LPN/VNs) around the country, according to The New York Times.

Many of the degree recipients went on to work at hospitals, nursing homes, and Veterans Affairs medical centers, according to the U.S. Attorney’s Office for the Southern District of Florida.

Several national nursing organizations cooperated with the investigation, and the Delaware Division of Professional Regulation already annulled 26 licenses, according to the Delaware Nurses Association. Fake licenses were issued in five states, according to federal reports.

“We are deeply unsettled by this egregious act,” DNA President Stephanie McClellan, MSN, RN, CMSRN, said in the group’s press statement. “We want all Delaware nurses to be aware of this active issue and to speak up if there is a concern regarding capacity to practice safely by a colleague/peer,” she said.

The Oregon State Board of Nursing is also investigating at least a dozen nurses who may have paid for their degrees, according to a Portland CBS affiliate.

The National Council of State Boards of Nursing said in a statement that it had helped authorities identify and monitor the individuals who allegedly provided the false degrees.
 

Nursing community reacts

News of the fraud scheme spread through the nursing community, including social media. “The recent report on falsified nursing school degrees is both heartbreaking and serves as an eye-opener,” tweeted Usha Menon, PhD, RN, FAAN, dean and health professor of the University of South Florida Health College of Nursing. “There was enough of a need that prompted these bad actors to develop a scheme that could’ve endangered dozens of lives.”

Jennifer Mensik Kennedy, PhD, MBA, RN, the new president of the American Nurses Association, also weighed in. “The accusation that personnel at once-accredited nursing schools allegedly participated in this scheme is simply deplorable. These unlawful and unethical acts disparage the reputation of actual nurses everywhere who have rightfully earned [their titles] through their education, hard work, dedication, and time.”

The false degrees and transcripts were issued by three once-accredited and now-shuttered nursing schools in South Florida: Palm Beach School of Nursing, Sacred Heart International Institute, and Sienna College.

The alleged co-conspirators reportedly made $114 million from the scheme, which dates back to 2016, according to several news reports. Each defendant faces up to 20 years in prison.

Most LPN programs charge $10,000 to $15,000 to complete a program, Robert Rosseter, a spokesperson for the American Association of Colleges of Nursing (AACN), told this news organization.

None were AACN members, and none were accredited by the Commission on Collegiate Nursing Education, which is AACN’s autonomous accrediting agency, Mr. Rosseter said. AACN membership is voluntary and is open to schools offering baccalaureate or higher degrees, he explained.

“What is disturbing about this investigation is that there are over 7,600 people around the country with fraudulent nursing credentials who are potentially in critical health care roles treating patients,” Chad Yarbrough, acting special agent in charge for the FBI in Miami, said in the federal justice department release.
 

‘Operation Nightingale’ based on tip

The federal action, dubbed “Operation Nightingale” after the nursing pioneer Florence Nightingale, began in 2019. It was based on a tip related to a case in Maryland, according to Nurse.org.

That case ensnared Palm Beach School of Nursing owner Johanah Napoleon, who reportedly was selling fake degrees for $6,000 to $18,000 each to two individuals in Maryland and Virginia. Ms. Napoleon was charged in 2021 and eventually pled guilty. The Florida Board of Nursing shut down the Palm Beach school in 2017 owing to its students’ low passing rate on the national licensing exam.

Two participants in the bigger scheme who had also worked with Ms. Napoleon – Geralda Adrien and Woosvelt Predestin – were indicted in 2021. Ms. Adrien owned private education companies for people who at aspired to be nurses, and Mr. Predestin was an employee. They were sentenced to 27 months in prison last year and helped the federal officials build the larger case.

The 25 individuals who were charged Jan. 25 operated in Delaware, New York, New Jersey, Texas, and Florida.
 

Schemes lured immigrants

In the scheme involving Siena College, some of the individuals acted as recruiters to direct nurses who were looking for employment to the school, where they allegedly would then pay for an RN or LPN/VN degree. The recipients of the false documents then used them to obtain jobs, including at a hospital in Georgia and a Veterans Affairs medical center in Maryland, according to one indictment. The president of Siena and her co-conspirators sold more than 2,000 fake diplomas, according to charging documents.

At the Palm Beach College of Nursing, individuals at various nursing prep and education programs allegedly helped others obtain fake degrees and transcripts, which were then used to pass RN and LPN/VN licensing exams in states that included Massachusetts, New Jersey, New York, and Ohio, according to the indictment.

Some individuals then secured employment with a nursing home in Ohio, a home health agency for pediatric patients in Massachusetts, and skilled nursing facilities in New York and New Jersey.

Prosecutors allege that the president of Sacred Heart International Institute and two other co-conspirators sold 588 fake diplomas.

The FBI said that some of the aspiring nurses who were talked into buying the degrees were LPNs who wanted to become RNs and that most of those lured into the scheme were from South Florida’s Haitian American immigrant community, Nurse.org reported.

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

At least one state licensing agency is revoking nursing licenses allegedly obtained in a multistate fake diploma scheme.

The U.S. Department of Justice recently announced charges against 25 owners, operators, and employees of three Florida nursing schools in a fraud scheme in which they sold as many as 7,600 fake nursing degrees.

The purchasers in the diploma scheme paid $10,000 to $15,000 for degrees and transcripts and some 2,800 of the buyers passed the national nursing licensing exam to become registered nurses (RNs) and licensed practice nurses/vocational nurses (LPN/VNs) around the country, according to The New York Times.

Many of the degree recipients went on to work at hospitals, nursing homes, and Veterans Affairs medical centers, according to the U.S. Attorney’s Office for the Southern District of Florida.

Several national nursing organizations cooperated with the investigation, and the Delaware Division of Professional Regulation already annulled 26 licenses, according to the Delaware Nurses Association. Fake licenses were issued in five states, according to federal reports.

“We are deeply unsettled by this egregious act,” DNA President Stephanie McClellan, MSN, RN, CMSRN, said in the group’s press statement. “We want all Delaware nurses to be aware of this active issue and to speak up if there is a concern regarding capacity to practice safely by a colleague/peer,” she said.

The Oregon State Board of Nursing is also investigating at least a dozen nurses who may have paid for their degrees, according to a Portland CBS affiliate.

The National Council of State Boards of Nursing said in a statement that it had helped authorities identify and monitor the individuals who allegedly provided the false degrees.
 

Nursing community reacts

News of the fraud scheme spread through the nursing community, including social media. “The recent report on falsified nursing school degrees is both heartbreaking and serves as an eye-opener,” tweeted Usha Menon, PhD, RN, FAAN, dean and health professor of the University of South Florida Health College of Nursing. “There was enough of a need that prompted these bad actors to develop a scheme that could’ve endangered dozens of lives.”

Jennifer Mensik Kennedy, PhD, MBA, RN, the new president of the American Nurses Association, also weighed in. “The accusation that personnel at once-accredited nursing schools allegedly participated in this scheme is simply deplorable. These unlawful and unethical acts disparage the reputation of actual nurses everywhere who have rightfully earned [their titles] through their education, hard work, dedication, and time.”

The false degrees and transcripts were issued by three once-accredited and now-shuttered nursing schools in South Florida: Palm Beach School of Nursing, Sacred Heart International Institute, and Sienna College.

The alleged co-conspirators reportedly made $114 million from the scheme, which dates back to 2016, according to several news reports. Each defendant faces up to 20 years in prison.

Most LPN programs charge $10,000 to $15,000 to complete a program, Robert Rosseter, a spokesperson for the American Association of Colleges of Nursing (AACN), told this news organization.

None were AACN members, and none were accredited by the Commission on Collegiate Nursing Education, which is AACN’s autonomous accrediting agency, Mr. Rosseter said. AACN membership is voluntary and is open to schools offering baccalaureate or higher degrees, he explained.

“What is disturbing about this investigation is that there are over 7,600 people around the country with fraudulent nursing credentials who are potentially in critical health care roles treating patients,” Chad Yarbrough, acting special agent in charge for the FBI in Miami, said in the federal justice department release.
 

‘Operation Nightingale’ based on tip

The federal action, dubbed “Operation Nightingale” after the nursing pioneer Florence Nightingale, began in 2019. It was based on a tip related to a case in Maryland, according to Nurse.org.

That case ensnared Palm Beach School of Nursing owner Johanah Napoleon, who reportedly was selling fake degrees for $6,000 to $18,000 each to two individuals in Maryland and Virginia. Ms. Napoleon was charged in 2021 and eventually pled guilty. The Florida Board of Nursing shut down the Palm Beach school in 2017 owing to its students’ low passing rate on the national licensing exam.

Two participants in the bigger scheme who had also worked with Ms. Napoleon – Geralda Adrien and Woosvelt Predestin – were indicted in 2021. Ms. Adrien owned private education companies for people who at aspired to be nurses, and Mr. Predestin was an employee. They were sentenced to 27 months in prison last year and helped the federal officials build the larger case.

The 25 individuals who were charged Jan. 25 operated in Delaware, New York, New Jersey, Texas, and Florida.
 

Schemes lured immigrants

In the scheme involving Siena College, some of the individuals acted as recruiters to direct nurses who were looking for employment to the school, where they allegedly would then pay for an RN or LPN/VN degree. The recipients of the false documents then used them to obtain jobs, including at a hospital in Georgia and a Veterans Affairs medical center in Maryland, according to one indictment. The president of Siena and her co-conspirators sold more than 2,000 fake diplomas, according to charging documents.

At the Palm Beach College of Nursing, individuals at various nursing prep and education programs allegedly helped others obtain fake degrees and transcripts, which were then used to pass RN and LPN/VN licensing exams in states that included Massachusetts, New Jersey, New York, and Ohio, according to the indictment.

Some individuals then secured employment with a nursing home in Ohio, a home health agency for pediatric patients in Massachusetts, and skilled nursing facilities in New York and New Jersey.

Prosecutors allege that the president of Sacred Heart International Institute and two other co-conspirators sold 588 fake diplomas.

The FBI said that some of the aspiring nurses who were talked into buying the degrees were LPNs who wanted to become RNs and that most of those lured into the scheme were from South Florida’s Haitian American immigrant community, Nurse.org reported.

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

The two national emergency declarations dealing with the COVID-19 pandemic will end May 11, President Joe Biden said on Jan. 30.

Doing so will have many effects, including the end of free vaccines and health services to fight the pandemic. The public health emergency has been renewed every 90 days since it was declared by the Trump administration in January 2020.

The declaration allowed major changes throughout the health care system to deal with the pandemic, including the free distribution of vaccines, testing, and treatments. In addition, telehealth services were expanded, and Medicaid and the Children’s Health Insurance Program were extended to millions more Americans.

Biden said the COVID-19 national emergency is set to expire March 1 while the declared public health emergency would currently expire on April 11. The president said both will be extended to end May 11.

There were nearly 300,000 newly reported COVID-19 cases in the United States for the week ending Jan. 25, according to CDC data, as well as more than 3,750 deaths.

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

The two national emergency declarations dealing with the COVID-19 pandemic will end May 11, President Joe Biden said on Jan. 30.

Doing so will have many effects, including the end of free vaccines and health services to fight the pandemic. The public health emergency has been renewed every 90 days since it was declared by the Trump administration in January 2020.

The declaration allowed major changes throughout the health care system to deal with the pandemic, including the free distribution of vaccines, testing, and treatments. In addition, telehealth services were expanded, and Medicaid and the Children’s Health Insurance Program were extended to millions more Americans.

Biden said the COVID-19 national emergency is set to expire March 1 while the declared public health emergency would currently expire on April 11. The president said both will be extended to end May 11.

There were nearly 300,000 newly reported COVID-19 cases in the United States for the week ending Jan. 25, according to CDC data, as well as more than 3,750 deaths.

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

The two national emergency declarations dealing with the COVID-19 pandemic will end May 11, President Joe Biden said on Jan. 30.

Doing so will have many effects, including the end of free vaccines and health services to fight the pandemic. The public health emergency has been renewed every 90 days since it was declared by the Trump administration in January 2020.

The declaration allowed major changes throughout the health care system to deal with the pandemic, including the free distribution of vaccines, testing, and treatments. In addition, telehealth services were expanded, and Medicaid and the Children’s Health Insurance Program were extended to millions more Americans.

Biden said the COVID-19 national emergency is set to expire March 1 while the declared public health emergency would currently expire on April 11. The president said both will be extended to end May 11.

There were nearly 300,000 newly reported COVID-19 cases in the United States for the week ending Jan. 25, according to CDC data, as well as more than 3,750 deaths.

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

To paraphrase Winston Churchill, Gulf War Illness (GWI) is a mystery wrapped in an enigma—a complex interplay of multiple symptoms, caused by a variety of environmental and chemical hazards. To make things more difficult, there are no diagnostic biomarkers or objective laboratory tests with which to confirm a GWI case. Instead, clinicians rely on patients’ reports of symptoms and the absence of other explanations for the symptoms.

Looking to provide more information on the epidemiology and biology of GWI, US Department of Veterans Affairs (VA) researchers analyzed data from the VA Cooperative Studies Program 2006/Million Veteran Program 029 cohort, the largest sample of GW-era veterans available for research to date: 35,902 veterans, of whom 13,107 deployed to a post 9/11 Persian Gulf conflict.

The researchers used the Kansas (KS) and Centers for Disease Control and Prevention (CDC) definitions of GWI, both of which are based on patient self-reports. The KS GWI criteria for phenotype KS Sym+ require ≥ 2 mild symptoms or ≥ 1 moderate or severe symptoms in at least 3 of 6 domains: fatigue/sleep problems, pain, neurologic/cognitive/mood, gastrointestinal, respiratory, and skin. The criteria for phenotype KS Sym+/Dx- also exclude some diagnosed health conditions, such as cancer, diabetes mellitus, and heart disease. The researchers examined both of these phenotypes.

They also used 2 phenotypes of the CDC definition: CDC GWI is met if the veteran reports ≥ 1 symptoms in 2 of 3 domains (fatigue, musculoskeletal, and mood/cognition). The second, CDC GWI severe, is met if the veteran rates ≥ 1 symptoms as severe in ≥ 2 domains.

Of the veterans studied, 67.1% met the KS Sym+ phenotype; 21.5% met the KS Sym+/Dx– definition. A majority (81.1%) met the CDC GWI phenotype; 18.6% met the severe phenotype. The most prevalent KS GWI domains were neurologic/cognitive/mood (81.9%), fatigue/sleep problems (73.9%), and pain (71.5%).

Although their findings mainly laid a foundation for further research, the researchers pointed to some potential new avenues for exploration. For instance, “Importantly,” the researchers say, “we consistently observed that deployed relative to nondeployed veterans had higher odds of meeting each GWI phenotype.” For both deployed and nondeployed veterans, those who served in the Army or Marine Corps had higher odds of meeting the KS Sym+, CDC GWI, and CDC GWI severe phenotypes. Among the deployed, Reservists had higher odds of CDC GWI and CDC GWI severe than did active-duty veterans.

Their findings also revealed that older age was associated with lower odds of meeting the GWI phenotypes. “[S]omewhat surprisingly,” they note, this finding held in both nondeployed and deployed samples, even after adjusting for military rank during the war. The researchers cite other research that has suggested younger service members are at greater risk for GWI (because they’re more likely, for example, to be exposed to deployment-related toxins). Most studies, the researchers note, have shown GWI and related symptoms to be more common among enlisted personnel than officers. Biomarkers of aging, such as epigenetic age acceleration, they suggest, “may be useful in untangling the relationship between age and GWI case status.” 

Because they separately examined the association of demographic characteristics with the GWI phenotypes, the researchers also found that women, regardless of deployment status, had higher odds of meeting the GWI phenotypes compared with men.

Their findings will be used, the researchers say, “to understand how genetic variation is associated with the GWI phenotypes and to identify potential pathophysiologic underpinnings of GWI, pleiotropy with other traits, and gene by environment interactions.” With information from this large dataset of GW-era veterans, they will have a “powerful tool” for in-depth study of exposures and underlying genetic susceptibility to GWI—studies that could not be performed, they say, without the full description of the GWI phenotypes they have documented.

The study had several strengths, the researchers say. For example, unlike previous studies, this one had a sample size large enough to allow more representation of subpopulations, including age, sex, race, ethnicity, education, and military service. The researchers also collected data from surveys, especially data on veterans’ self-reported symptoms and other information “incompletely and infrequently documented in medical records.”

Finally, the data for the study were collected more than 27 years after the GW. It, therefore, gives an “updated, detailed description” of symptoms and conditions affecting GW-era veterans, decades after their return from service.

To paraphrase Winston Churchill, Gulf War Illness (GWI) is a mystery wrapped in an enigma—a complex interplay of multiple symptoms, caused by a variety of environmental and chemical hazards. To make things more difficult, there are no diagnostic biomarkers or objective laboratory tests with which to confirm a GWI case. Instead, clinicians rely on patients’ reports of symptoms and the absence of other explanations for the symptoms.

Looking to provide more information on the epidemiology and biology of GWI, US Department of Veterans Affairs (VA) researchers analyzed data from the VA Cooperative Studies Program 2006/Million Veteran Program 029 cohort, the largest sample of GW-era veterans available for research to date: 35,902 veterans, of whom 13,107 deployed to a post 9/11 Persian Gulf conflict.

The researchers used the Kansas (KS) and Centers for Disease Control and Prevention (CDC) definitions of GWI, both of which are based on patient self-reports. The KS GWI criteria for phenotype KS Sym+ require ≥ 2 mild symptoms or ≥ 1 moderate or severe symptoms in at least 3 of 6 domains: fatigue/sleep problems, pain, neurologic/cognitive/mood, gastrointestinal, respiratory, and skin. The criteria for phenotype KS Sym+/Dx- also exclude some diagnosed health conditions, such as cancer, diabetes mellitus, and heart disease. The researchers examined both of these phenotypes.

They also used 2 phenotypes of the CDC definition: CDC GWI is met if the veteran reports ≥ 1 symptoms in 2 of 3 domains (fatigue, musculoskeletal, and mood/cognition). The second, CDC GWI severe, is met if the veteran rates ≥ 1 symptoms as severe in ≥ 2 domains.

Of the veterans studied, 67.1% met the KS Sym+ phenotype; 21.5% met the KS Sym+/Dx– definition. A majority (81.1%) met the CDC GWI phenotype; 18.6% met the severe phenotype. The most prevalent KS GWI domains were neurologic/cognitive/mood (81.9%), fatigue/sleep problems (73.9%), and pain (71.5%).

Although their findings mainly laid a foundation for further research, the researchers pointed to some potential new avenues for exploration. For instance, “Importantly,” the researchers say, “we consistently observed that deployed relative to nondeployed veterans had higher odds of meeting each GWI phenotype.” For both deployed and nondeployed veterans, those who served in the Army or Marine Corps had higher odds of meeting the KS Sym+, CDC GWI, and CDC GWI severe phenotypes. Among the deployed, Reservists had higher odds of CDC GWI and CDC GWI severe than did active-duty veterans.

Their findings also revealed that older age was associated with lower odds of meeting the GWI phenotypes. “[S]omewhat surprisingly,” they note, this finding held in both nondeployed and deployed samples, even after adjusting for military rank during the war. The researchers cite other research that has suggested younger service members are at greater risk for GWI (because they’re more likely, for example, to be exposed to deployment-related toxins). Most studies, the researchers note, have shown GWI and related symptoms to be more common among enlisted personnel than officers. Biomarkers of aging, such as epigenetic age acceleration, they suggest, “may be useful in untangling the relationship between age and GWI case status.” 

Because they separately examined the association of demographic characteristics with the GWI phenotypes, the researchers also found that women, regardless of deployment status, had higher odds of meeting the GWI phenotypes compared with men.

Their findings will be used, the researchers say, “to understand how genetic variation is associated with the GWI phenotypes and to identify potential pathophysiologic underpinnings of GWI, pleiotropy with other traits, and gene by environment interactions.” With information from this large dataset of GW-era veterans, they will have a “powerful tool” for in-depth study of exposures and underlying genetic susceptibility to GWI—studies that could not be performed, they say, without the full description of the GWI phenotypes they have documented.

The study had several strengths, the researchers say. For example, unlike previous studies, this one had a sample size large enough to allow more representation of subpopulations, including age, sex, race, ethnicity, education, and military service. The researchers also collected data from surveys, especially data on veterans’ self-reported symptoms and other information “incompletely and infrequently documented in medical records.”

Finally, the data for the study were collected more than 27 years after the GW. It, therefore, gives an “updated, detailed description” of symptoms and conditions affecting GW-era veterans, decades after their return from service.

To paraphrase Winston Churchill, Gulf War Illness (GWI) is a mystery wrapped in an enigma—a complex interplay of multiple symptoms, caused by a variety of environmental and chemical hazards. To make things more difficult, there are no diagnostic biomarkers or objective laboratory tests with which to confirm a GWI case. Instead, clinicians rely on patients’ reports of symptoms and the absence of other explanations for the symptoms.

Looking to provide more information on the epidemiology and biology of GWI, US Department of Veterans Affairs (VA) researchers analyzed data from the VA Cooperative Studies Program 2006/Million Veteran Program 029 cohort, the largest sample of GW-era veterans available for research to date: 35,902 veterans, of whom 13,107 deployed to a post 9/11 Persian Gulf conflict.

The researchers used the Kansas (KS) and Centers for Disease Control and Prevention (CDC) definitions of GWI, both of which are based on patient self-reports. The KS GWI criteria for phenotype KS Sym+ require ≥ 2 mild symptoms or ≥ 1 moderate or severe symptoms in at least 3 of 6 domains: fatigue/sleep problems, pain, neurologic/cognitive/mood, gastrointestinal, respiratory, and skin. The criteria for phenotype KS Sym+/Dx- also exclude some diagnosed health conditions, such as cancer, diabetes mellitus, and heart disease. The researchers examined both of these phenotypes.

They also used 2 phenotypes of the CDC definition: CDC GWI is met if the veteran reports ≥ 1 symptoms in 2 of 3 domains (fatigue, musculoskeletal, and mood/cognition). The second, CDC GWI severe, is met if the veteran rates ≥ 1 symptoms as severe in ≥ 2 domains.

Of the veterans studied, 67.1% met the KS Sym+ phenotype; 21.5% met the KS Sym+/Dx– definition. A majority (81.1%) met the CDC GWI phenotype; 18.6% met the severe phenotype. The most prevalent KS GWI domains were neurologic/cognitive/mood (81.9%), fatigue/sleep problems (73.9%), and pain (71.5%).

Although their findings mainly laid a foundation for further research, the researchers pointed to some potential new avenues for exploration. For instance, “Importantly,” the researchers say, “we consistently observed that deployed relative to nondeployed veterans had higher odds of meeting each GWI phenotype.” For both deployed and nondeployed veterans, those who served in the Army or Marine Corps had higher odds of meeting the KS Sym+, CDC GWI, and CDC GWI severe phenotypes. Among the deployed, Reservists had higher odds of CDC GWI and CDC GWI severe than did active-duty veterans.

Their findings also revealed that older age was associated with lower odds of meeting the GWI phenotypes. “[S]omewhat surprisingly,” they note, this finding held in both nondeployed and deployed samples, even after adjusting for military rank during the war. The researchers cite other research that has suggested younger service members are at greater risk for GWI (because they’re more likely, for example, to be exposed to deployment-related toxins). Most studies, the researchers note, have shown GWI and related symptoms to be more common among enlisted personnel than officers. Biomarkers of aging, such as epigenetic age acceleration, they suggest, “may be useful in untangling the relationship between age and GWI case status.” 

Because they separately examined the association of demographic characteristics with the GWI phenotypes, the researchers also found that women, regardless of deployment status, had higher odds of meeting the GWI phenotypes compared with men.

Their findings will be used, the researchers say, “to understand how genetic variation is associated with the GWI phenotypes and to identify potential pathophysiologic underpinnings of GWI, pleiotropy with other traits, and gene by environment interactions.” With information from this large dataset of GW-era veterans, they will have a “powerful tool” for in-depth study of exposures and underlying genetic susceptibility to GWI—studies that could not be performed, they say, without the full description of the GWI phenotypes they have documented.

The study had several strengths, the researchers say. For example, unlike previous studies, this one had a sample size large enough to allow more representation of subpopulations, including age, sex, race, ethnicity, education, and military service. The researchers also collected data from surveys, especially data on veterans’ self-reported symptoms and other information “incompletely and infrequently documented in medical records.”

Finally, the data for the study were collected more than 27 years after the GW. It, therefore, gives an “updated, detailed description” of symptoms and conditions affecting GW-era veterans, decades after their return from service.

People with diabetes who adhere to a healthy diet, exercise regularly, and follow other healthy lifestyle practices have a significantly lower risk of microvascular complications from the disease, such as diabetic neuropathy, retinopathy, and nephropathy, as well as foot disorders, than counterparts with diabetes who don’t, a prospective cohort study of more than 7,000 patients with type 2 diabetes has found.

“We believe this is one of the first large-scale analyses among diabetes patients that specifically examined an overall healthy lifestyle in relation to the risk of developing microvascular complications,” senior study author Qi Sun, MD, ScD, said in an interview. “The results are not surprising that the healthy lifestyle is associated with lower risk of developing these complications and the enhanced adherence to the healthy lifestyle is associated with lower risk as well. And these findings bear lots of public health significance as they suggest the important role of living a healthy lifestyle in the prevention of diabetes complications, on top of the clinical treatment.”

Dr. Sun is an associate professor of nutrition and epidemiology at the Harvard T.H. Chan School of Public Health, Boston.

The study stated that the findings “lend support” for the American Diabetes Association guidelines for healthy lifestyle practices in people with diabetes.

The study used a cohort from two large prospective cohort studies, the Nurses’ Health Study (NHS) and the Health Professionals Follow-up Study (HPFS), comprising 4,982 women and 2,095 men who were diagnosed with type 2 diabetes during follow-up. They had no cardiovascular disease or cancer at the time of their diabetes diagnosis. Both NHS and HPFS used validated questionnaires to gather information on diet, lifestyle, medical history, and newly diagnosed diseases every 2-4 years. The latter study included NHS and HPFS participants who also completed supplementary questionnaires about their diabetes.

The latest study took into account five modifiable lifestyle-related factors: diet, body weight, smoking status, alcohol, and physical activity. For diet, both large studies used the 2010 Alternate Healthy Eating Index to assess diet quality; those in the upper 40th percentile of the study population were defined as healthy diet. Healthy body weight was defined at a body mass index of 18.5-25 kg/m².

Among the latter study cohort, 2,878 incident cases of diabetic microvascular complications were documented during follow-up. Patients who adhered to a healthy lifestyle before their diabetes diagnosis, defined as having four or more low-risk lifestyle factors, had a 27% lower relative risk of developing any microvascular complication than counterparts with no low-risk lifestyle factors (relative risk, 0.73; 95% confidence interval, 0.35-1; P = .006).

The study found similar outcomes for those who adopted a healthy lifestyle after their diabetes diagnosis, with a 32% reduction in relative risk compared with those who didn’t adopt any healthy lifestyle practices (RR, 0.68; 95% CI, 0.55-0.83; P < .001).

Dr. Sun noted what was noteworthy about his group’s cohort study. “The unique design is truly the prospective follow-up over time so that we could examine the lifestyle at diabetes diagnosis as well as changes in lifestyle before and after diabetes in relation to the future risk of developing the complications,” he said.

A randomized trial would be a more rigorous way to evaluate the impact of a healthy lifestyle, he added, “although it’s much more expensive than a cohort study like what we did with this investigation.”

As for future research, Dr. Sun said, “It will be interesting to understand mechanisms underlying these observations. It’s also critical to understand why certain diabetes patients may not benefit from a healthy lifestyle, since some of them, even when living a healthy lifestyle, still develop the complications.”

This trial shows in a new light the benefits of healthy lifestyle practices on microvascular complications of type 2 diabetes, Paul S. Jellinger, MD, of the Center for Diabetes and Endocrine Care in Hollywood, Fla., and a professor at the University of Miami, said in a comment. “These benefits have always been surmised and demonstrated in a limited way in previous trials, but not subject to the level of analysis seen in this prospective cohort trial.”

He called the study design “excellent,” adding, “ ‘Validated’ self-reported questionnaires were used widely, although minimal detail is provided about the validation process.” One limitation, he noted, was “the homogeneity of the participants; all were health professionals.”

The study “affirms” and “quantitates” the benefits of a healthy lifestyle in type 2 diabetes. “The issue is not unawareness but rather application,” Dr. Jellinger said. “Modifying long-held lifestyle habits is a real challenge. Perhaps by ‘quantitating’ the benefit, as shown in this trial and hopefully additional studies, impetus will be provided to refocus on this approach, which is too often simply given lip service.”

The National Institutes of Health provided funding for the study. Dr. Sun has no relevant disclosures. Dr. Jellinger disclosed relationships with Amgen and Esperion.
 

People with diabetes who adhere to a healthy diet, exercise regularly, and follow other healthy lifestyle practices have a significantly lower risk of microvascular complications from the disease, such as diabetic neuropathy, retinopathy, and nephropathy, as well as foot disorders, than counterparts with diabetes who don’t, a prospective cohort study of more than 7,000 patients with type 2 diabetes has found.

“We believe this is one of the first large-scale analyses among diabetes patients that specifically examined an overall healthy lifestyle in relation to the risk of developing microvascular complications,” senior study author Qi Sun, MD, ScD, said in an interview. “The results are not surprising that the healthy lifestyle is associated with lower risk of developing these complications and the enhanced adherence to the healthy lifestyle is associated with lower risk as well. And these findings bear lots of public health significance as they suggest the important role of living a healthy lifestyle in the prevention of diabetes complications, on top of the clinical treatment.”

Dr. Sun is an associate professor of nutrition and epidemiology at the Harvard T.H. Chan School of Public Health, Boston.

The study stated that the findings “lend support” for the American Diabetes Association guidelines for healthy lifestyle practices in people with diabetes.

The study used a cohort from two large prospective cohort studies, the Nurses’ Health Study (NHS) and the Health Professionals Follow-up Study (HPFS), comprising 4,982 women and 2,095 men who were diagnosed with type 2 diabetes during follow-up. They had no cardiovascular disease or cancer at the time of their diabetes diagnosis. Both NHS and HPFS used validated questionnaires to gather information on diet, lifestyle, medical history, and newly diagnosed diseases every 2-4 years. The latter study included NHS and HPFS participants who also completed supplementary questionnaires about their diabetes.

The latest study took into account five modifiable lifestyle-related factors: diet, body weight, smoking status, alcohol, and physical activity. For diet, both large studies used the 2010 Alternate Healthy Eating Index to assess diet quality; those in the upper 40th percentile of the study population were defined as healthy diet. Healthy body weight was defined at a body mass index of 18.5-25 kg/m².

Among the latter study cohort, 2,878 incident cases of diabetic microvascular complications were documented during follow-up. Patients who adhered to a healthy lifestyle before their diabetes diagnosis, defined as having four or more low-risk lifestyle factors, had a 27% lower relative risk of developing any microvascular complication than counterparts with no low-risk lifestyle factors (relative risk, 0.73; 95% confidence interval, 0.35-1; P = .006).

The study found similar outcomes for those who adopted a healthy lifestyle after their diabetes diagnosis, with a 32% reduction in relative risk compared with those who didn’t adopt any healthy lifestyle practices (RR, 0.68; 95% CI, 0.55-0.83; P < .001).

Dr. Sun noted what was noteworthy about his group’s cohort study. “The unique design is truly the prospective follow-up over time so that we could examine the lifestyle at diabetes diagnosis as well as changes in lifestyle before and after diabetes in relation to the future risk of developing the complications,” he said.

A randomized trial would be a more rigorous way to evaluate the impact of a healthy lifestyle, he added, “although it’s much more expensive than a cohort study like what we did with this investigation.”

As for future research, Dr. Sun said, “It will be interesting to understand mechanisms underlying these observations. It’s also critical to understand why certain diabetes patients may not benefit from a healthy lifestyle, since some of them, even when living a healthy lifestyle, still develop the complications.”

This trial shows in a new light the benefits of healthy lifestyle practices on microvascular complications of type 2 diabetes, Paul S. Jellinger, MD, of the Center for Diabetes and Endocrine Care in Hollywood, Fla., and a professor at the University of Miami, said in a comment. “These benefits have always been surmised and demonstrated in a limited way in previous trials, but not subject to the level of analysis seen in this prospective cohort trial.”

He called the study design “excellent,” adding, “ ‘Validated’ self-reported questionnaires were used widely, although minimal detail is provided about the validation process.” One limitation, he noted, was “the homogeneity of the participants; all were health professionals.”

The study “affirms” and “quantitates” the benefits of a healthy lifestyle in type 2 diabetes. “The issue is not unawareness but rather application,” Dr. Jellinger said. “Modifying long-held lifestyle habits is a real challenge. Perhaps by ‘quantitating’ the benefit, as shown in this trial and hopefully additional studies, impetus will be provided to refocus on this approach, which is too often simply given lip service.”

The National Institutes of Health provided funding for the study. Dr. Sun has no relevant disclosures. Dr. Jellinger disclosed relationships with Amgen and Esperion.
 

People with diabetes who adhere to a healthy diet, exercise regularly, and follow other healthy lifestyle practices have a significantly lower risk of microvascular complications from the disease, such as diabetic neuropathy, retinopathy, and nephropathy, as well as foot disorders, than counterparts with diabetes who don’t, a prospective cohort study of more than 7,000 patients with type 2 diabetes has found.

“We believe this is one of the first large-scale analyses among diabetes patients that specifically examined an overall healthy lifestyle in relation to the risk of developing microvascular complications,” senior study author Qi Sun, MD, ScD, said in an interview. “The results are not surprising that the healthy lifestyle is associated with lower risk of developing these complications and the enhanced adherence to the healthy lifestyle is associated with lower risk as well. And these findings bear lots of public health significance as they suggest the important role of living a healthy lifestyle in the prevention of diabetes complications, on top of the clinical treatment.”

Dr. Sun is an associate professor of nutrition and epidemiology at the Harvard T.H. Chan School of Public Health, Boston.

The study stated that the findings “lend support” for the American Diabetes Association guidelines for healthy lifestyle practices in people with diabetes.

The study used a cohort from two large prospective cohort studies, the Nurses’ Health Study (NHS) and the Health Professionals Follow-up Study (HPFS), comprising 4,982 women and 2,095 men who were diagnosed with type 2 diabetes during follow-up. They had no cardiovascular disease or cancer at the time of their diabetes diagnosis. Both NHS and HPFS used validated questionnaires to gather information on diet, lifestyle, medical history, and newly diagnosed diseases every 2-4 years. The latter study included NHS and HPFS participants who also completed supplementary questionnaires about their diabetes.

The latest study took into account five modifiable lifestyle-related factors: diet, body weight, smoking status, alcohol, and physical activity. For diet, both large studies used the 2010 Alternate Healthy Eating Index to assess diet quality; those in the upper 40th percentile of the study population were defined as healthy diet. Healthy body weight was defined at a body mass index of 18.5-25 kg/m².

Among the latter study cohort, 2,878 incident cases of diabetic microvascular complications were documented during follow-up. Patients who adhered to a healthy lifestyle before their diabetes diagnosis, defined as having four or more low-risk lifestyle factors, had a 27% lower relative risk of developing any microvascular complication than counterparts with no low-risk lifestyle factors (relative risk, 0.73; 95% confidence interval, 0.35-1; P = .006).

The study found similar outcomes for those who adopted a healthy lifestyle after their diabetes diagnosis, with a 32% reduction in relative risk compared with those who didn’t adopt any healthy lifestyle practices (RR, 0.68; 95% CI, 0.55-0.83; P < .001).

Dr. Sun noted what was noteworthy about his group’s cohort study. “The unique design is truly the prospective follow-up over time so that we could examine the lifestyle at diabetes diagnosis as well as changes in lifestyle before and after diabetes in relation to the future risk of developing the complications,” he said.

A randomized trial would be a more rigorous way to evaluate the impact of a healthy lifestyle, he added, “although it’s much more expensive than a cohort study like what we did with this investigation.”

As for future research, Dr. Sun said, “It will be interesting to understand mechanisms underlying these observations. It’s also critical to understand why certain diabetes patients may not benefit from a healthy lifestyle, since some of them, even when living a healthy lifestyle, still develop the complications.”

This trial shows in a new light the benefits of healthy lifestyle practices on microvascular complications of type 2 diabetes, Paul S. Jellinger, MD, of the Center for Diabetes and Endocrine Care in Hollywood, Fla., and a professor at the University of Miami, said in a comment. “These benefits have always been surmised and demonstrated in a limited way in previous trials, but not subject to the level of analysis seen in this prospective cohort trial.”

He called the study design “excellent,” adding, “ ‘Validated’ self-reported questionnaires were used widely, although minimal detail is provided about the validation process.” One limitation, he noted, was “the homogeneity of the participants; all were health professionals.”

The study “affirms” and “quantitates” the benefits of a healthy lifestyle in type 2 diabetes. “The issue is not unawareness but rather application,” Dr. Jellinger said. “Modifying long-held lifestyle habits is a real challenge. Perhaps by ‘quantitating’ the benefit, as shown in this trial and hopefully additional studies, impetus will be provided to refocus on this approach, which is too often simply given lip service.”

The National Institutes of Health provided funding for the study. Dr. Sun has no relevant disclosures. Dr. Jellinger disclosed relationships with Amgen and Esperion.
 

In 2021, Eugene Kim, MD, division director of pediatric surgery and vice chair in the department of surgery at Cedars-Sinai Medical Center, Los Angeles, gave his presidential address to the Association for Academic Surgery.

“Presidents tend to give a message of hope or inspiration; I probably took it in a different way,” he said.

Dr. Kim told the story of one of his clinical partners, Eveline Shue, who, after five rounds of in vitro fertilization (IVF), became pregnant with twins. A high-achiever in her field, Ms. Shue continued working the grueling hours required by her job throughout pregnancy until she noticed concerning symptoms – musculoskeletal issues, extreme swelling, and more. She and her group decided that she should step back from work in her third trimester. A few days later, Ms. Shue suffered a stroke. She was rushed to the hospital where her babies were delivered by emergency C-section. Ms. Shue underwent brain surgery but later recovered and is still practicing in Southern California.

“I remember being at her bedside thinking, ‘How could we have let this happen? How could we have prevented this?’ ”

Dr. Kim’s speech kicked off a firestorm of awareness about pregnancy complications among physicians. “I got scores of emails from women around the country, surgeons in particular, who felt like their issues had been seen. The conversation was long overdue,” he said.

Family planning issues, pregnancy complications, infertility, and pregnancy loss are common, pervasive, and often silent issues in medicine. In July 2021, Dr. Kim and a group of other researchers published a study in JAMA Surgery. It revealed staggering truths: When compared to non-surgeons, female surgeons were more likely to delay pregnancy, use assisted reproductive technology such as IVF, have non-elective C-sections, and suffer pregnancy loss. In the study, 42% of surgeons had experienced pregnancy loss – more than double the rate of the general population. Almost half had serious pregnancy complications.

Research has found that female physicians in general have a significantly greater incidence of miscarriage, infertility, and pregnancy complications than the general population. According to a 2016 survey in the Journal of Women’s Health, the infertility rate for physicians is nearly 1 in 4, about double the rate of the general public.
 

The barriers to starting a family

Physicians face significant professional barriers that impact family planning. Demanding jobs with exhausting and often unpredictable hours contribute to a culture that, traditionally, has been far from family friendly. As a result, many physicians start families later. “For a pediatric surgeon, you finish training at age 35 – minimum,” says Dr. Kim. “Simply being a surgeon makes you a high-risk pregnancy candidate just because of the career.”

In 2020, Ariela L. Marshall, MD, an associate professor of clinical medicine at the University of Pennsylvania’s Perelman school of medicine, co-authored a commentary article in Academic Medicine titled “Physician Fertility: A Call to Action” which was based on her own experiences with infertility. Dr. Marshall was 34 when she and her husband decided to start a family, and she says her infertility diagnosis “came as a shock.”

“I never stopped to think about the consequences of a career path where I’m not going to be established until my 30s,” Dr. Marshall says. “I never thought about how long hours, overnight shifts, or working all the time could impact my fertility.”

It would take four cycles of IVF egg retrieval to create embryos and one failed implantation before Dr. Marshall became pregnant with her son.

When it comes to the timing of pregnancy, medical culture also plays a role. “There’s a lot of messaging around when it’s appropriate to carry a baby – and it’s not until after training is done,” says Arghavan Salles, MD, PhD, a clinical associate professor and special advisor for DEI programs at Stanford (Calif.) University’s department of medicine.

There are always exceptions. Some institutions are more flexible than others about pregnancy during residency. But Dr. Salles notes that this attitude is “not universal,” partly because of the lack of a comprehensive approach to pregnancy or parenthood in the United States. “There’s no federal paid parental leave in this country,” reminds Dr. Salles. “That signals that we don’t value parenting.”

The trickle-down effect of this in medicine is more like a waterfall. Some physicians complain when other physicians are out on leave. There’s an additional burden of work when people take time away, and there are often no support structures in place for backup or fill-in care. Dr. Salles said doctors often tell her that they were responsible for finding coverage for any time off during pregnancy or after becoming a parent. A paper of hers published in JAMA Surgery found that, for physicians, a fear of burdening others was a major barrier to getting pregnant during residency in the first place.
 

The physical consequences

Although research supports the benefits of physical activity throughout pregnancy, a job such as surgery that requires being on your feet for long periods of time “is not the same as exercise,” explains Erika Lu Rangel, MD, a gastrointestinal surgeon at Brigham and Women’s Hospital, Boston, and Dr. Kim’s lead author on the JAMA Surgery article.

Surgeons operating for more than 12 hours a week are at higher risk for pregnancy complications, the study found. Dr. Rangel also cites data suggesting that night shifts or swing shifts (the hours between day and night) put women at higher risk for pregnancy complications.

Equally alarming: Medical trainees appear to have “almost as high a rate of pregnancy complications as surgeons who have already completed their training,” said Dr. Rangel. It is a concerning finding since, as a younger cohort, they should have lower complication rates based on their age. But doctors in training may be on their feet even more than surgeons during long shifts.

Like Dr. Salles, Dr. Rangel sees these issues as part of a pervasive culture of “presenteeism” in medicine, and she points out that many surgeons don’t even take time off to grieve pregnancy loss or physically recover from it. “We work even when we’re sick and even when it’s not good for our health,” she said. “I think that’s an unhealthy behavior that we cultivate from the time that we’re trainees, and we carry it on through when we’re in practice.”

Penn Medicine’s Dr. Marshall remembers that her own maternity leave was “not an easy process to navigate.” From her hospital room on a magnesium drip for preeclampsia, she still attended Zoom meetings with her colleagues. “Nobody says, ‘Oh, you have to do this,’ ” Dr. Marshall explains, “but you wind up feeling guilty if you’re not there at all moments for everyone. That’s also something that needs to change.” 

Dr. Rangel was pregnant with her oldest son as a fourth-year surgery resident. The day she gave birth to him she remembers waking up with a flu-like illness and a fever. She went to work anyway, because “you don’t call in sick as a resident.” She was barely able to complete her rounds and then had to lie down between cases. A co-resident found her and took her to labor and delivery. She had gone into premature labor at 37 weeks, and her son went into the NICU with complications.

“I remember feeling this enormous guilt,” says Dr. Rangel. “I’d been a mom for just a few minutes, and I felt like I had already failed him because I had prioritized what the residency thought of me above what I knew was necessary for his health.”
 

Hope for the future

Disturbed by the status quo, many physicians are pushing for change. “I think there’s a really important and positive conversation going on in the medical community right now about ways that we need to support new parent physicians,” said Dr. Rangel.

Parental leave is a key part of that support. Last year, The American Board of Medical Specialties enacted a mandate that all specialty boards 2 years or more in duration must provide at least 6 weeks of parental and caregiver leave. In 2023, the Accreditation Council for Graduate Medical Education (ACGME) required that all training programs match that policy. “This sends a message to policymakers and leaders in American medicine that this is a priority,” said Dr. Rangel.

In January 2022, a group from the University of Michigan also published an article in the Annals of Surgery called “Safe and Supported Pregnancy: A Call to Action for Surgery Chairs and Program Directors”. The essay urged leading groups such as the ACGME and the American Board of Surgery to “directly address the health and safety of pregnant trainees” and specifically, to “allow for further flexibility during training for pregnancy and peripartum periods,” calling these “fundamental necessities for cultural progress.”

Others have recommended allowing pregnant trainees more flexibility in their schedules or front-loading certain parts of the training that may be more difficult as a pregnancy progresses. Insurance coverage for fertility preservation and reproductive endocrinology services, and support for reentry (including lactation and childcare) are also issues that must be addressed, says Dr. Salles.

A new paper of Dr. Rangel’s, published in JAMA Surgery, suggests that things like mentorship for residents from faculty can also be important pieces of the puzzle.

Education about reproductive health must start earlier, too – as early as medical school. Research suggests only 8% of physicians receive education on the risks of delaying pregnancy. Those who do are significantly less likely to experience pregnancy loss or seek infertility treatment.

Dr. Salles recalls sitting in a classroom learning about advanced maternal age at a time when age 35 seemed unimaginably distant. “It was never taught – at least to my recollection – in a way that was like, ‘this could be your future,’ ” Dr. Salles says.” It was more like this abstract patient who might have advanced maternal age and what the consequences would be. Maybe some of my colleagues put two and two together, but I definitely didn’t.”

Dr. Marshall is the curriculum chair for the IGNITEMed Initiative, which aims to educate medical students about issues not discussed in traditional medical school curricula. Dr. Marshall and her colleague Julia Files, MD, talk with IGNITEMed students about reproductive life planning.

“Raising awareness is a very big thing. That’s not just true for medical students but for professionals at every level of medicine,” Dr. Marshall said. “Residency and fellowship training program directors, department chairs, and hospital CEOs all need to understand that these issues are very common in the people they oversee – and that they are medical issues, like any other medical issue, where people need time off and support.”

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

In 2021, Eugene Kim, MD, division director of pediatric surgery and vice chair in the department of surgery at Cedars-Sinai Medical Center, Los Angeles, gave his presidential address to the Association for Academic Surgery.

“Presidents tend to give a message of hope or inspiration; I probably took it in a different way,” he said.

Dr. Kim told the story of one of his clinical partners, Eveline Shue, who, after five rounds of in vitro fertilization (IVF), became pregnant with twins. A high-achiever in her field, Ms. Shue continued working the grueling hours required by her job throughout pregnancy until she noticed concerning symptoms – musculoskeletal issues, extreme swelling, and more. She and her group decided that she should step back from work in her third trimester. A few days later, Ms. Shue suffered a stroke. She was rushed to the hospital where her babies were delivered by emergency C-section. Ms. Shue underwent brain surgery but later recovered and is still practicing in Southern California.

“I remember being at her bedside thinking, ‘How could we have let this happen? How could we have prevented this?’ ”

Dr. Kim’s speech kicked off a firestorm of awareness about pregnancy complications among physicians. “I got scores of emails from women around the country, surgeons in particular, who felt like their issues had been seen. The conversation was long overdue,” he said.

Family planning issues, pregnancy complications, infertility, and pregnancy loss are common, pervasive, and often silent issues in medicine. In July 2021, Dr. Kim and a group of other researchers published a study in JAMA Surgery. It revealed staggering truths: When compared to non-surgeons, female surgeons were more likely to delay pregnancy, use assisted reproductive technology such as IVF, have non-elective C-sections, and suffer pregnancy loss. In the study, 42% of surgeons had experienced pregnancy loss – more than double the rate of the general population. Almost half had serious pregnancy complications.

Research has found that female physicians in general have a significantly greater incidence of miscarriage, infertility, and pregnancy complications than the general population. According to a 2016 survey in the Journal of Women’s Health, the infertility rate for physicians is nearly 1 in 4, about double the rate of the general public.
 

The barriers to starting a family

Physicians face significant professional barriers that impact family planning. Demanding jobs with exhausting and often unpredictable hours contribute to a culture that, traditionally, has been far from family friendly. As a result, many physicians start families later. “For a pediatric surgeon, you finish training at age 35 – minimum,” says Dr. Kim. “Simply being a surgeon makes you a high-risk pregnancy candidate just because of the career.”

In 2020, Ariela L. Marshall, MD, an associate professor of clinical medicine at the University of Pennsylvania’s Perelman school of medicine, co-authored a commentary article in Academic Medicine titled “Physician Fertility: A Call to Action” which was based on her own experiences with infertility. Dr. Marshall was 34 when she and her husband decided to start a family, and she says her infertility diagnosis “came as a shock.”

“I never stopped to think about the consequences of a career path where I’m not going to be established until my 30s,” Dr. Marshall says. “I never thought about how long hours, overnight shifts, or working all the time could impact my fertility.”

It would take four cycles of IVF egg retrieval to create embryos and one failed implantation before Dr. Marshall became pregnant with her son.

When it comes to the timing of pregnancy, medical culture also plays a role. “There’s a lot of messaging around when it’s appropriate to carry a baby – and it’s not until after training is done,” says Arghavan Salles, MD, PhD, a clinical associate professor and special advisor for DEI programs at Stanford (Calif.) University’s department of medicine.

There are always exceptions. Some institutions are more flexible than others about pregnancy during residency. But Dr. Salles notes that this attitude is “not universal,” partly because of the lack of a comprehensive approach to pregnancy or parenthood in the United States. “There’s no federal paid parental leave in this country,” reminds Dr. Salles. “That signals that we don’t value parenting.”

The trickle-down effect of this in medicine is more like a waterfall. Some physicians complain when other physicians are out on leave. There’s an additional burden of work when people take time away, and there are often no support structures in place for backup or fill-in care. Dr. Salles said doctors often tell her that they were responsible for finding coverage for any time off during pregnancy or after becoming a parent. A paper of hers published in JAMA Surgery found that, for physicians, a fear of burdening others was a major barrier to getting pregnant during residency in the first place.
 

The physical consequences

Although research supports the benefits of physical activity throughout pregnancy, a job such as surgery that requires being on your feet for long periods of time “is not the same as exercise,” explains Erika Lu Rangel, MD, a gastrointestinal surgeon at Brigham and Women’s Hospital, Boston, and Dr. Kim’s lead author on the JAMA Surgery article.

Surgeons operating for more than 12 hours a week are at higher risk for pregnancy complications, the study found. Dr. Rangel also cites data suggesting that night shifts or swing shifts (the hours between day and night) put women at higher risk for pregnancy complications.

Equally alarming: Medical trainees appear to have “almost as high a rate of pregnancy complications as surgeons who have already completed their training,” said Dr. Rangel. It is a concerning finding since, as a younger cohort, they should have lower complication rates based on their age. But doctors in training may be on their feet even more than surgeons during long shifts.

Like Dr. Salles, Dr. Rangel sees these issues as part of a pervasive culture of “presenteeism” in medicine, and she points out that many surgeons don’t even take time off to grieve pregnancy loss or physically recover from it. “We work even when we’re sick and even when it’s not good for our health,” she said. “I think that’s an unhealthy behavior that we cultivate from the time that we’re trainees, and we carry it on through when we’re in practice.”

Penn Medicine’s Dr. Marshall remembers that her own maternity leave was “not an easy process to navigate.” From her hospital room on a magnesium drip for preeclampsia, she still attended Zoom meetings with her colleagues. “Nobody says, ‘Oh, you have to do this,’ ” Dr. Marshall explains, “but you wind up feeling guilty if you’re not there at all moments for everyone. That’s also something that needs to change.” 

Dr. Rangel was pregnant with her oldest son as a fourth-year surgery resident. The day she gave birth to him she remembers waking up with a flu-like illness and a fever. She went to work anyway, because “you don’t call in sick as a resident.” She was barely able to complete her rounds and then had to lie down between cases. A co-resident found her and took her to labor and delivery. She had gone into premature labor at 37 weeks, and her son went into the NICU with complications.

“I remember feeling this enormous guilt,” says Dr. Rangel. “I’d been a mom for just a few minutes, and I felt like I had already failed him because I had prioritized what the residency thought of me above what I knew was necessary for his health.”
 

Hope for the future

Disturbed by the status quo, many physicians are pushing for change. “I think there’s a really important and positive conversation going on in the medical community right now about ways that we need to support new parent physicians,” said Dr. Rangel.

Parental leave is a key part of that support. Last year, The American Board of Medical Specialties enacted a mandate that all specialty boards 2 years or more in duration must provide at least 6 weeks of parental and caregiver leave. In 2023, the Accreditation Council for Graduate Medical Education (ACGME) required that all training programs match that policy. “This sends a message to policymakers and leaders in American medicine that this is a priority,” said Dr. Rangel.

In January 2022, a group from the University of Michigan also published an article in the Annals of Surgery called “Safe and Supported Pregnancy: A Call to Action for Surgery Chairs and Program Directors”. The essay urged leading groups such as the ACGME and the American Board of Surgery to “directly address the health and safety of pregnant trainees” and specifically, to “allow for further flexibility during training for pregnancy and peripartum periods,” calling these “fundamental necessities for cultural progress.”

Others have recommended allowing pregnant trainees more flexibility in their schedules or front-loading certain parts of the training that may be more difficult as a pregnancy progresses. Insurance coverage for fertility preservation and reproductive endocrinology services, and support for reentry (including lactation and childcare) are also issues that must be addressed, says Dr. Salles.

A new paper of Dr. Rangel’s, published in JAMA Surgery, suggests that things like mentorship for residents from faculty can also be important pieces of the puzzle.

Education about reproductive health must start earlier, too – as early as medical school. Research suggests only 8% of physicians receive education on the risks of delaying pregnancy. Those who do are significantly less likely to experience pregnancy loss or seek infertility treatment.

Dr. Salles recalls sitting in a classroom learning about advanced maternal age at a time when age 35 seemed unimaginably distant. “It was never taught – at least to my recollection – in a way that was like, ‘this could be your future,’ ” Dr. Salles says.” It was more like this abstract patient who might have advanced maternal age and what the consequences would be. Maybe some of my colleagues put two and two together, but I definitely didn’t.”

Dr. Marshall is the curriculum chair for the IGNITEMed Initiative, which aims to educate medical students about issues not discussed in traditional medical school curricula. Dr. Marshall and her colleague Julia Files, MD, talk with IGNITEMed students about reproductive life planning.

“Raising awareness is a very big thing. That’s not just true for medical students but for professionals at every level of medicine,” Dr. Marshall said. “Residency and fellowship training program directors, department chairs, and hospital CEOs all need to understand that these issues are very common in the people they oversee – and that they are medical issues, like any other medical issue, where people need time off and support.”

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

In 2021, Eugene Kim, MD, division director of pediatric surgery and vice chair in the department of surgery at Cedars-Sinai Medical Center, Los Angeles, gave his presidential address to the Association for Academic Surgery.

“Presidents tend to give a message of hope or inspiration; I probably took it in a different way,” he said.

Dr. Kim told the story of one of his clinical partners, Eveline Shue, who, after five rounds of in vitro fertilization (IVF), became pregnant with twins. A high-achiever in her field, Ms. Shue continued working the grueling hours required by her job throughout pregnancy until she noticed concerning symptoms – musculoskeletal issues, extreme swelling, and more. She and her group decided that she should step back from work in her third trimester. A few days later, Ms. Shue suffered a stroke. She was rushed to the hospital where her babies were delivered by emergency C-section. Ms. Shue underwent brain surgery but later recovered and is still practicing in Southern California.

“I remember being at her bedside thinking, ‘How could we have let this happen? How could we have prevented this?’ ”

Dr. Kim’s speech kicked off a firestorm of awareness about pregnancy complications among physicians. “I got scores of emails from women around the country, surgeons in particular, who felt like their issues had been seen. The conversation was long overdue,” he said.

Family planning issues, pregnancy complications, infertility, and pregnancy loss are common, pervasive, and often silent issues in medicine. In July 2021, Dr. Kim and a group of other researchers published a study in JAMA Surgery. It revealed staggering truths: When compared to non-surgeons, female surgeons were more likely to delay pregnancy, use assisted reproductive technology such as IVF, have non-elective C-sections, and suffer pregnancy loss. In the study, 42% of surgeons had experienced pregnancy loss – more than double the rate of the general population. Almost half had serious pregnancy complications.

Research has found that female physicians in general have a significantly greater incidence of miscarriage, infertility, and pregnancy complications than the general population. According to a 2016 survey in the Journal of Women’s Health, the infertility rate for physicians is nearly 1 in 4, about double the rate of the general public.
 

The barriers to starting a family

Physicians face significant professional barriers that impact family planning. Demanding jobs with exhausting and often unpredictable hours contribute to a culture that, traditionally, has been far from family friendly. As a result, many physicians start families later. “For a pediatric surgeon, you finish training at age 35 – minimum,” says Dr. Kim. “Simply being a surgeon makes you a high-risk pregnancy candidate just because of the career.”

In 2020, Ariela L. Marshall, MD, an associate professor of clinical medicine at the University of Pennsylvania’s Perelman school of medicine, co-authored a commentary article in Academic Medicine titled “Physician Fertility: A Call to Action” which was based on her own experiences with infertility. Dr. Marshall was 34 when she and her husband decided to start a family, and she says her infertility diagnosis “came as a shock.”

“I never stopped to think about the consequences of a career path where I’m not going to be established until my 30s,” Dr. Marshall says. “I never thought about how long hours, overnight shifts, or working all the time could impact my fertility.”

It would take four cycles of IVF egg retrieval to create embryos and one failed implantation before Dr. Marshall became pregnant with her son.

When it comes to the timing of pregnancy, medical culture also plays a role. “There’s a lot of messaging around when it’s appropriate to carry a baby – and it’s not until after training is done,” says Arghavan Salles, MD, PhD, a clinical associate professor and special advisor for DEI programs at Stanford (Calif.) University’s department of medicine.

There are always exceptions. Some institutions are more flexible than others about pregnancy during residency. But Dr. Salles notes that this attitude is “not universal,” partly because of the lack of a comprehensive approach to pregnancy or parenthood in the United States. “There’s no federal paid parental leave in this country,” reminds Dr. Salles. “That signals that we don’t value parenting.”

The trickle-down effect of this in medicine is more like a waterfall. Some physicians complain when other physicians are out on leave. There’s an additional burden of work when people take time away, and there are often no support structures in place for backup or fill-in care. Dr. Salles said doctors often tell her that they were responsible for finding coverage for any time off during pregnancy or after becoming a parent. A paper of hers published in JAMA Surgery found that, for physicians, a fear of burdening others was a major barrier to getting pregnant during residency in the first place.
 

The physical consequences

Although research supports the benefits of physical activity throughout pregnancy, a job such as surgery that requires being on your feet for long periods of time “is not the same as exercise,” explains Erika Lu Rangel, MD, a gastrointestinal surgeon at Brigham and Women’s Hospital, Boston, and Dr. Kim’s lead author on the JAMA Surgery article.

Surgeons operating for more than 12 hours a week are at higher risk for pregnancy complications, the study found. Dr. Rangel also cites data suggesting that night shifts or swing shifts (the hours between day and night) put women at higher risk for pregnancy complications.

Equally alarming: Medical trainees appear to have “almost as high a rate of pregnancy complications as surgeons who have already completed their training,” said Dr. Rangel. It is a concerning finding since, as a younger cohort, they should have lower complication rates based on their age. But doctors in training may be on their feet even more than surgeons during long shifts.

Like Dr. Salles, Dr. Rangel sees these issues as part of a pervasive culture of “presenteeism” in medicine, and she points out that many surgeons don’t even take time off to grieve pregnancy loss or physically recover from it. “We work even when we’re sick and even when it’s not good for our health,” she said. “I think that’s an unhealthy behavior that we cultivate from the time that we’re trainees, and we carry it on through when we’re in practice.”

Penn Medicine’s Dr. Marshall remembers that her own maternity leave was “not an easy process to navigate.” From her hospital room on a magnesium drip for preeclampsia, she still attended Zoom meetings with her colleagues. “Nobody says, ‘Oh, you have to do this,’ ” Dr. Marshall explains, “but you wind up feeling guilty if you’re not there at all moments for everyone. That’s also something that needs to change.” 

Dr. Rangel was pregnant with her oldest son as a fourth-year surgery resident. The day she gave birth to him she remembers waking up with a flu-like illness and a fever. She went to work anyway, because “you don’t call in sick as a resident.” She was barely able to complete her rounds and then had to lie down between cases. A co-resident found her and took her to labor and delivery. She had gone into premature labor at 37 weeks, and her son went into the NICU with complications.

“I remember feeling this enormous guilt,” says Dr. Rangel. “I’d been a mom for just a few minutes, and I felt like I had already failed him because I had prioritized what the residency thought of me above what I knew was necessary for his health.”
 

Hope for the future

Disturbed by the status quo, many physicians are pushing for change. “I think there’s a really important and positive conversation going on in the medical community right now about ways that we need to support new parent physicians,” said Dr. Rangel.

Parental leave is a key part of that support. Last year, The American Board of Medical Specialties enacted a mandate that all specialty boards 2 years or more in duration must provide at least 6 weeks of parental and caregiver leave. In 2023, the Accreditation Council for Graduate Medical Education (ACGME) required that all training programs match that policy. “This sends a message to policymakers and leaders in American medicine that this is a priority,” said Dr. Rangel.

In January 2022, a group from the University of Michigan also published an article in the Annals of Surgery called “Safe and Supported Pregnancy: A Call to Action for Surgery Chairs and Program Directors”. The essay urged leading groups such as the ACGME and the American Board of Surgery to “directly address the health and safety of pregnant trainees” and specifically, to “allow for further flexibility during training for pregnancy and peripartum periods,” calling these “fundamental necessities for cultural progress.”

Others have recommended allowing pregnant trainees more flexibility in their schedules or front-loading certain parts of the training that may be more difficult as a pregnancy progresses. Insurance coverage for fertility preservation and reproductive endocrinology services, and support for reentry (including lactation and childcare) are also issues that must be addressed, says Dr. Salles.

A new paper of Dr. Rangel’s, published in JAMA Surgery, suggests that things like mentorship for residents from faculty can also be important pieces of the puzzle.

Education about reproductive health must start earlier, too – as early as medical school. Research suggests only 8% of physicians receive education on the risks of delaying pregnancy. Those who do are significantly less likely to experience pregnancy loss or seek infertility treatment.

Dr. Salles recalls sitting in a classroom learning about advanced maternal age at a time when age 35 seemed unimaginably distant. “It was never taught – at least to my recollection – in a way that was like, ‘this could be your future,’ ” Dr. Salles says.” It was more like this abstract patient who might have advanced maternal age and what the consequences would be. Maybe some of my colleagues put two and two together, but I definitely didn’t.”

Dr. Marshall is the curriculum chair for the IGNITEMed Initiative, which aims to educate medical students about issues not discussed in traditional medical school curricula. Dr. Marshall and her colleague Julia Files, MD, talk with IGNITEMed students about reproductive life planning.

“Raising awareness is a very big thing. That’s not just true for medical students but for professionals at every level of medicine,” Dr. Marshall said. “Residency and fellowship training program directors, department chairs, and hospital CEOs all need to understand that these issues are very common in the people they oversee – and that they are medical issues, like any other medical issue, where people need time off and support.”

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

The U.S. Surgeon General says 13 years old is too young to begin using social media.

Most social media platforms including TikTok, Snapchat, Instagram, and Facebook allow users to create accounts if they say they are at least 13 years old.

“I, personally, based on the data I’ve seen, believe that 13 is too early. ... It’s a time where it’s really important for us to be thoughtful about what’s going into how they think about their own self-worth and their relationships, and the skewed and often distorted environment of social media often does a disservice to many of those children,” U.S. Surgeon General Vivek Murthy, MD, told CNN.

Research has shown that teens are susceptible to cyberbullying and serious mental health impacts from social media usage and online activity during an era when the influence of the Internet has become everywhere for young people.

According to the Pew Research Center, 95% of teens age 13 and up have a smartphone, and 97% of teens say they use the Internet daily. Among 13- and 14-year-olds, 61% say they use TikTok and 51% say they use Snapchat. Older teens ages 15-17 use those social media platforms at higher rates, with 71% saying they use TikTok and 65% using Snapchat.

“If parents can band together and say you know, as a group, we’re not going to allow our kids to use social media until 16 or 17 or 18 or whatever age they choose, that’s a much more effective strategy in making sure your kids don’t get exposed to harm early,” Dr. Murthy said.

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

The U.S. Surgeon General says 13 years old is too young to begin using social media.

Most social media platforms including TikTok, Snapchat, Instagram, and Facebook allow users to create accounts if they say they are at least 13 years old.

“I, personally, based on the data I’ve seen, believe that 13 is too early. ... It’s a time where it’s really important for us to be thoughtful about what’s going into how they think about their own self-worth and their relationships, and the skewed and often distorted environment of social media often does a disservice to many of those children,” U.S. Surgeon General Vivek Murthy, MD, told CNN.

Research has shown that teens are susceptible to cyberbullying and serious mental health impacts from social media usage and online activity during an era when the influence of the Internet has become everywhere for young people.

According to the Pew Research Center, 95% of teens age 13 and up have a smartphone, and 97% of teens say they use the Internet daily. Among 13- and 14-year-olds, 61% say they use TikTok and 51% say they use Snapchat. Older teens ages 15-17 use those social media platforms at higher rates, with 71% saying they use TikTok and 65% using Snapchat.

“If parents can band together and say you know, as a group, we’re not going to allow our kids to use social media until 16 or 17 or 18 or whatever age they choose, that’s a much more effective strategy in making sure your kids don’t get exposed to harm early,” Dr. Murthy said.

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

The U.S. Surgeon General says 13 years old is too young to begin using social media.

Most social media platforms including TikTok, Snapchat, Instagram, and Facebook allow users to create accounts if they say they are at least 13 years old.

“I, personally, based on the data I’ve seen, believe that 13 is too early. ... It’s a time where it’s really important for us to be thoughtful about what’s going into how they think about their own self-worth and their relationships, and the skewed and often distorted environment of social media often does a disservice to many of those children,” U.S. Surgeon General Vivek Murthy, MD, told CNN.

Research has shown that teens are susceptible to cyberbullying and serious mental health impacts from social media usage and online activity during an era when the influence of the Internet has become everywhere for young people.

According to the Pew Research Center, 95% of teens age 13 and up have a smartphone, and 97% of teens say they use the Internet daily. Among 13- and 14-year-olds, 61% say they use TikTok and 51% say they use Snapchat. Older teens ages 15-17 use those social media platforms at higher rates, with 71% saying they use TikTok and 65% using Snapchat.

“If parents can band together and say you know, as a group, we’re not going to allow our kids to use social media until 16 or 17 or 18 or whatever age they choose, that’s a much more effective strategy in making sure your kids don’t get exposed to harm early,” Dr. Murthy said.

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

Montrouge, France – Whether you are a cisgender woman or a transgender man who has kept his uterus, regardless of the sex of your partner, and even if you are a woman who is no longer sexually active, you must take part in cervical cancer screening. This is the reminder issued by Julia Maruani, MD, a medical gynecologist in Marseille, France, at a press conference ahead of the 46th meeting of the French Colposcopy and Cervical-Vaginal Diseases Society (SFCPCV).

Cervical screening currently targets asymptomatic, immunocompetent, and sexually active women between ages 25 and 65 years. During her presentation, Dr. Maruani insisted that screening should not discriminate based on a patient’s sexual activity.
 

Sex between women

There is a widely held belief that only men can transmit human papillomavirus (HPV). “If you are in a sexual relationship with a man, then yes, you can get HPV from him. But it’s also possible for HPV to be transmitted in a sexual relationship between two women via touch, bodily fluids, or sex toys,” said Dr. Maruani, who pointed out that 20% of lesbians and 30% of bisexual women are HPV carriers.

Because women who have sexual relationships with other women have the mistaken view that their demographic is less affected, they are less likely to take part in cervical screening. They also present more often with advanced lesions and with cancer because of the lack of screening in this group.
 

Transgender men

Dr. Maruani defines transgender men as “women who have changed gender and who have become men.” Why are they affected by cervical screening? Not all of them are. Those who’ve had their uterus removed no longer have a cervix, so this screening doesn’t affect them. But hysterectomies are rarely performed, as they’re not required in most European countries to legally change gender.

The figures are concerning: 27% of transgender men are screened versus 60% of cisgender females.

“For this demographic, specialist gynecology appointments are hard to come by. Sitting in a women’s waiting room is not easy,” said Dr. Maruani, recalling that often discussion about the transition phase takes up the entire appointment time. It’s also usually the case that any medical problems or health care prevention issues not related to the topic of transitioning are not discussed.

Moreover, the online appointment-booking software doesn’t allow transgender men who have kept their cervix and legally identify as men to make an appointment. “Gynecologists must disable this default option,” said Dr. Maruani.

Likewise, transgender men will not receive an invitation to take part in cervical or breast cancer screening, as they are identified as male by social security services and screening sites. Furthermore, in what Dr. Maruani referred to as an “administrative head-scratcher that needs to change,” some medical procedures are not funded for men.

Yet the risk of contracting HPV is higher among transgender men than in the rest of the population because of different sexual practices in this demographic, as well as the propensity to have multiple sexual partners. The risk of finding abnormalities on cytology screening is greater.

Although data regarding cancer are lacking, “if screening is inadequate but the risk of infection with HPV is great, logic tells us that there will be more lesions, more cancer” in this demographic, said Dr. Maruani.
 

Celibate women

Nowadays, screening drops with age in women, especially after menopause. This is especially true for women who are no longer sexually active. Another preconceived notion to be addressed is that women who are no longer sexually active no longer need screening. But this concept completely goes against the natural history of HPV infection. “There are years, at least 5, between infection and the development of precancerous lesions. There is a further 5 years between a precancerous lesion and cancer,” said Dr. Maruani.

A woman could still be at risk even 20 years after contracting HPV. Approximately 80% of women are exposed to HPV, and 5%-10% have a persistent infection that could lead to the development of precancerous lesions.

“So, a woman who is no longer sexually active can’t stop participating in cervical screening, especially since there aren’t any symptoms until a fairly advanced stage of cancer.” No longer having sex does not mean that screening can be stopped.

What treatment is appropriate for partners of a woman who is no longer sexually active? None. During the press conference, the specialists agreed that a positive HPV test would be of importance to her partner. Even so, they recalled that the infection would generally be an old one and that the woman’s partner (whether male or female) would therefore have probably already been exposed to it. Patients should also be reminded that, in the past, cytology testing did not look for HPV, so the virus could already have been there. According to these specialists, you don’t need to change your sexual habits, just continue to monitor yourself.

This article was translated from the Medscape French edition and a version first appeared on Medscape.com.

Montrouge, France – Whether you are a cisgender woman or a transgender man who has kept his uterus, regardless of the sex of your partner, and even if you are a woman who is no longer sexually active, you must take part in cervical cancer screening. This is the reminder issued by Julia Maruani, MD, a medical gynecologist in Marseille, France, at a press conference ahead of the 46th meeting of the French Colposcopy and Cervical-Vaginal Diseases Society (SFCPCV).

Cervical screening currently targets asymptomatic, immunocompetent, and sexually active women between ages 25 and 65 years. During her presentation, Dr. Maruani insisted that screening should not discriminate based on a patient’s sexual activity.
 

Sex between women

There is a widely held belief that only men can transmit human papillomavirus (HPV). “If you are in a sexual relationship with a man, then yes, you can get HPV from him. But it’s also possible for HPV to be transmitted in a sexual relationship between two women via touch, bodily fluids, or sex toys,” said Dr. Maruani, who pointed out that 20% of lesbians and 30% of bisexual women are HPV carriers.

Because women who have sexual relationships with other women have the mistaken view that their demographic is less affected, they are less likely to take part in cervical screening. They also present more often with advanced lesions and with cancer because of the lack of screening in this group.
 

Transgender men

Dr. Maruani defines transgender men as “women who have changed gender and who have become men.” Why are they affected by cervical screening? Not all of them are. Those who’ve had their uterus removed no longer have a cervix, so this screening doesn’t affect them. But hysterectomies are rarely performed, as they’re not required in most European countries to legally change gender.

The figures are concerning: 27% of transgender men are screened versus 60% of cisgender females.

“For this demographic, specialist gynecology appointments are hard to come by. Sitting in a women’s waiting room is not easy,” said Dr. Maruani, recalling that often discussion about the transition phase takes up the entire appointment time. It’s also usually the case that any medical problems or health care prevention issues not related to the topic of transitioning are not discussed.

Moreover, the online appointment-booking software doesn’t allow transgender men who have kept their cervix and legally identify as men to make an appointment. “Gynecologists must disable this default option,” said Dr. Maruani.

Likewise, transgender men will not receive an invitation to take part in cervical or breast cancer screening, as they are identified as male by social security services and screening sites. Furthermore, in what Dr. Maruani referred to as an “administrative head-scratcher that needs to change,” some medical procedures are not funded for men.

Yet the risk of contracting HPV is higher among transgender men than in the rest of the population because of different sexual practices in this demographic, as well as the propensity to have multiple sexual partners. The risk of finding abnormalities on cytology screening is greater.

Although data regarding cancer are lacking, “if screening is inadequate but the risk of infection with HPV is great, logic tells us that there will be more lesions, more cancer” in this demographic, said Dr. Maruani.
 

Celibate women

Nowadays, screening drops with age in women, especially after menopause. This is especially true for women who are no longer sexually active. Another preconceived notion to be addressed is that women who are no longer sexually active no longer need screening. But this concept completely goes against the natural history of HPV infection. “There are years, at least 5, between infection and the development of precancerous lesions. There is a further 5 years between a precancerous lesion and cancer,” said Dr. Maruani.

A woman could still be at risk even 20 years after contracting HPV. Approximately 80% of women are exposed to HPV, and 5%-10% have a persistent infection that could lead to the development of precancerous lesions.

“So, a woman who is no longer sexually active can’t stop participating in cervical screening, especially since there aren’t any symptoms until a fairly advanced stage of cancer.” No longer having sex does not mean that screening can be stopped.

What treatment is appropriate for partners of a woman who is no longer sexually active? None. During the press conference, the specialists agreed that a positive HPV test would be of importance to her partner. Even so, they recalled that the infection would generally be an old one and that the woman’s partner (whether male or female) would therefore have probably already been exposed to it. Patients should also be reminded that, in the past, cytology testing did not look for HPV, so the virus could already have been there. According to these specialists, you don’t need to change your sexual habits, just continue to monitor yourself.

This article was translated from the Medscape French edition and a version first appeared on Medscape.com.

Montrouge, France – Whether you are a cisgender woman or a transgender man who has kept his uterus, regardless of the sex of your partner, and even if you are a woman who is no longer sexually active, you must take part in cervical cancer screening. This is the reminder issued by Julia Maruani, MD, a medical gynecologist in Marseille, France, at a press conference ahead of the 46th meeting of the French Colposcopy and Cervical-Vaginal Diseases Society (SFCPCV).

Cervical screening currently targets asymptomatic, immunocompetent, and sexually active women between ages 25 and 65 years. During her presentation, Dr. Maruani insisted that screening should not discriminate based on a patient’s sexual activity.
 

Sex between women

There is a widely held belief that only men can transmit human papillomavirus (HPV). “If you are in a sexual relationship with a man, then yes, you can get HPV from him. But it’s also possible for HPV to be transmitted in a sexual relationship between two women via touch, bodily fluids, or sex toys,” said Dr. Maruani, who pointed out that 20% of lesbians and 30% of bisexual women are HPV carriers.

Because women who have sexual relationships with other women have the mistaken view that their demographic is less affected, they are less likely to take part in cervical screening. They also present more often with advanced lesions and with cancer because of the lack of screening in this group.
 

Transgender men

Dr. Maruani defines transgender men as “women who have changed gender and who have become men.” Why are they affected by cervical screening? Not all of them are. Those who’ve had their uterus removed no longer have a cervix, so this screening doesn’t affect them. But hysterectomies are rarely performed, as they’re not required in most European countries to legally change gender.

The figures are concerning: 27% of transgender men are screened versus 60% of cisgender females.

“For this demographic, specialist gynecology appointments are hard to come by. Sitting in a women’s waiting room is not easy,” said Dr. Maruani, recalling that often discussion about the transition phase takes up the entire appointment time. It’s also usually the case that any medical problems or health care prevention issues not related to the topic of transitioning are not discussed.

Moreover, the online appointment-booking software doesn’t allow transgender men who have kept their cervix and legally identify as men to make an appointment. “Gynecologists must disable this default option,” said Dr. Maruani.

Likewise, transgender men will not receive an invitation to take part in cervical or breast cancer screening, as they are identified as male by social security services and screening sites. Furthermore, in what Dr. Maruani referred to as an “administrative head-scratcher that needs to change,” some medical procedures are not funded for men.

Yet the risk of contracting HPV is higher among transgender men than in the rest of the population because of different sexual practices in this demographic, as well as the propensity to have multiple sexual partners. The risk of finding abnormalities on cytology screening is greater.

Although data regarding cancer are lacking, “if screening is inadequate but the risk of infection with HPV is great, logic tells us that there will be more lesions, more cancer” in this demographic, said Dr. Maruani.
 

Celibate women

Nowadays, screening drops with age in women, especially after menopause. This is especially true for women who are no longer sexually active. Another preconceived notion to be addressed is that women who are no longer sexually active no longer need screening. But this concept completely goes against the natural history of HPV infection. “There are years, at least 5, between infection and the development of precancerous lesions. There is a further 5 years between a precancerous lesion and cancer,” said Dr. Maruani.

A woman could still be at risk even 20 years after contracting HPV. Approximately 80% of women are exposed to HPV, and 5%-10% have a persistent infection that could lead to the development of precancerous lesions.

“So, a woman who is no longer sexually active can’t stop participating in cervical screening, especially since there aren’t any symptoms until a fairly advanced stage of cancer.” No longer having sex does not mean that screening can be stopped.

What treatment is appropriate for partners of a woman who is no longer sexually active? None. During the press conference, the specialists agreed that a positive HPV test would be of importance to her partner. Even so, they recalled that the infection would generally be an old one and that the woman’s partner (whether male or female) would therefore have probably already been exposed to it. Patients should also be reminded that, in the past, cytology testing did not look for HPV, so the virus could already have been there. According to these specialists, you don’t need to change your sexual habits, just continue to monitor yourself.

This article was translated from the Medscape French edition and a version first appeared on Medscape.com.

A Mendelian randomization study employing data from nearly 300,000 individuals has linked elevated levels of the PCSK9 enzyme with an increased risk of psoriasis, suggesting it might be targetable as an intervention.

Independent of low-density lipoprotein cholesterol (LDL-C), which is reduced when PCSK9 is inhibited, a reduction in PCSK9 levels appears to have a direct impact on lowering psoriasis risk. Conversely, psoriasis risk did not appear to be affected when LDL-C was reduced by other pathways of lipid control.

petekarici/Getty Images

This study “suggests that PCSK9 inhibition is causally associated with reduced risk of psoriasis,” reported a team of investigators led by Sizheng Steven Zhao, MD, PhD, of the division of musculoskeletal and dermatological sciences, University of Manchester (England). “Existing PCSK9 inhibitors hold potential as therapeutic targets for prevention, and possibly treatment, of psoriasis, although further clinical studies are needed,” they concluded.

In an interview, Dr. Zhao also noted that it will be interesting to look at psoriasis susceptibility in post hoc analyses of large randomized controlled trials of PCSK9 inhibitors for cardiovascular disease.

“Genetically proxied” inhibition of HMG-CoA reductase, which is targeted by statins, and NPC1L1 which is targeted by ezetimibe, “were not associated with psoriasis risk,” the investigators reported in the study, published in JAMA Dermatology.

Abnormal lipid metabolism is sufficiently common among people with psoriasis that screening in patients with moderate to severe disease is recommended in 2019 psoriasis guidelines from the American Academy of Dermatology and the National Psoriasis Foundation. However, the link between these diseases is unclear. This study was launched to explore genetically proxied relationships between psoriasis and LDL-C reductions as well as specific treatments for elevated LDL-C.

Mendelian randomizations were applied to deidentified data from two sources, a UK biobank and FinnGen, a Finnish-based project for identifying genotype-to-phenotype correlations. Genetic proxies for these variables were established on the basis of genomewide association studies on large population samples.

Ultimately, 34 genetic variants were selected to proxy for lipid lowering by PCSK9, 19 were selected to proxy for HMG-CoA reductase, and 9 for NPC1L1. In the Mendelian analyses performed on the two sources, genetically proxied PCSK9 inhibition was associated with about a 30% reduction in the odds ratio of psoriasis (OR, 0.69; P = .003). There were no robust associations with proxies for reductions in either HMG-CoA reductase or NPC1L1.

In sensitivity analyses, there was no evidence of bias from pleiotropy or genetic confounding, according to Dr. Zhao and his coauthors, who noted that the relationship between reductions in PCSK9 and reduced risk of psoriasis appeared to be independent of change in circulating LDL-C.

Given the prior evidence implicating the PCSK9 enzyme in psoriasis risk, “this is an exciting study that really highlights the importance of studying and targeting lipid metabolism in psoriasis for a few reasons,” according to Michael S. Garshick, MD, a researcher, cardiologist, and director of the cardio-rheumatology program, New York University Langone Health.

An investigator who has participated in several studies evaluating the relationship between cardiovascular risk and psoriasis, Dr. Garshick said there is increasing interest in PCSK9 as a biomarker or even a mediator of inflammation independent of blood lipid levels.

“In psoriasis regarding PCSK9, we and others have shown PCSK9 is elevated in psoriatic lesion skin, and studies are starting to investigate the unique lipidomic profile in psoriasis,” Dr. Garshick said in an interview. The study he led that showed elevated PCSK9 levels in psoriatic skin was published in 2021 in the Journal of Investigative Dermatology.

While the Mendelian randomization provides only “an inference” that PCSK9 plays a role in mediating risk of psoriasis, Dr. Zhao and coauthors cited numerous studies linking elevated PCSK9 to psoriasis pathophysiology. This not only includes the elevated PCSK9 expression in psoriatic plaques as shown by Dr. Garshick and others but several sets of experimental evidence linking PCSK9 to inflammatory pathways, including upregulation of interleukin-17 and stimulation of macrophage activation.

While Dr. Zhao and coauthors suggested that clinical trials are now needed to test the potential of PCSK9 inhibitors to modify the risk of psoriasis, Dr. Garshick indicated that there are numerous variables to unravel in the relationship between elevated lipids, PCSK9, and psoriasis.

“In our own studies, we did see a statistical correlation between circulating PCSK9 and psoriasis severity,” Dr. Garshick said. But he added, “I think we are just beginning to understand the functions of circulating (extrahepatic) PCSK9 independent of lipid metabolism.”

While he is intrigued by the evidence that PCSK9 is linked to systemic inflammation, he pointed out that several medications used to treat dyslipidemias, such as statins, are associated with an anti-inflammatory effect.

This study “further emphasizes the need to conduct clinical trials treating dyslipidemia in psoriasis, including the targeting of PCSK9, whether it is with statins with lipid lowering and potential pleiotropic anti-inflammatory properties or PCSK9 inhibition,” he said. If positive, “both would be exciting.“

From a cardiologist’s point of view, there is an upside for including patients with psoriasis in lipid-lowering trials even if the effect on psoriasis is modest. Either way, “you still get the lipid-lowering benefit, which is important for reducing atherosclerotic cardiovascular disease,” Dr. Garshick said.

Dr. Zhao reported financial relationships with UCB, although UCB did not provide funding for this study. One author reported grants from Versus Arthritis and the National Institute for Health Research Manchester Biomedical Research Centre during the study, grants from Bristol Myers Squibb, Galapagos, and Pfizer, and personal fees from Chugai Roche outside the submitted work. No other disclosures were reported. The study was supported by grants from Versus Arthritis and the NIHR Manchester Biomedical Research Centre. Dr. Garshick reported financial relationships with AbbVie and Horizon Therapeutics.

A Mendelian randomization study employing data from nearly 300,000 individuals has linked elevated levels of the PCSK9 enzyme with an increased risk of psoriasis, suggesting it might be targetable as an intervention.

Independent of low-density lipoprotein cholesterol (LDL-C), which is reduced when PCSK9 is inhibited, a reduction in PCSK9 levels appears to have a direct impact on lowering psoriasis risk. Conversely, psoriasis risk did not appear to be affected when LDL-C was reduced by other pathways of lipid control.

petekarici/Getty Images

This study “suggests that PCSK9 inhibition is causally associated with reduced risk of psoriasis,” reported a team of investigators led by Sizheng Steven Zhao, MD, PhD, of the division of musculoskeletal and dermatological sciences, University of Manchester (England). “Existing PCSK9 inhibitors hold potential as therapeutic targets for prevention, and possibly treatment, of psoriasis, although further clinical studies are needed,” they concluded.

In an interview, Dr. Zhao also noted that it will be interesting to look at psoriasis susceptibility in post hoc analyses of large randomized controlled trials of PCSK9 inhibitors for cardiovascular disease.

“Genetically proxied” inhibition of HMG-CoA reductase, which is targeted by statins, and NPC1L1 which is targeted by ezetimibe, “were not associated with psoriasis risk,” the investigators reported in the study, published in JAMA Dermatology.

Abnormal lipid metabolism is sufficiently common among people with psoriasis that screening in patients with moderate to severe disease is recommended in 2019 psoriasis guidelines from the American Academy of Dermatology and the National Psoriasis Foundation. However, the link between these diseases is unclear. This study was launched to explore genetically proxied relationships between psoriasis and LDL-C reductions as well as specific treatments for elevated LDL-C.

Mendelian randomizations were applied to deidentified data from two sources, a UK biobank and FinnGen, a Finnish-based project for identifying genotype-to-phenotype correlations. Genetic proxies for these variables were established on the basis of genomewide association studies on large population samples.

Ultimately, 34 genetic variants were selected to proxy for lipid lowering by PCSK9, 19 were selected to proxy for HMG-CoA reductase, and 9 for NPC1L1. In the Mendelian analyses performed on the two sources, genetically proxied PCSK9 inhibition was associated with about a 30% reduction in the odds ratio of psoriasis (OR, 0.69; P = .003). There were no robust associations with proxies for reductions in either HMG-CoA reductase or NPC1L1.

In sensitivity analyses, there was no evidence of bias from pleiotropy or genetic confounding, according to Dr. Zhao and his coauthors, who noted that the relationship between reductions in PCSK9 and reduced risk of psoriasis appeared to be independent of change in circulating LDL-C.

Given the prior evidence implicating the PCSK9 enzyme in psoriasis risk, “this is an exciting study that really highlights the importance of studying and targeting lipid metabolism in psoriasis for a few reasons,” according to Michael S. Garshick, MD, a researcher, cardiologist, and director of the cardio-rheumatology program, New York University Langone Health.

An investigator who has participated in several studies evaluating the relationship between cardiovascular risk and psoriasis, Dr. Garshick said there is increasing interest in PCSK9 as a biomarker or even a mediator of inflammation independent of blood lipid levels.

“In psoriasis regarding PCSK9, we and others have shown PCSK9 is elevated in psoriatic lesion skin, and studies are starting to investigate the unique lipidomic profile in psoriasis,” Dr. Garshick said in an interview. The study he led that showed elevated PCSK9 levels in psoriatic skin was published in 2021 in the Journal of Investigative Dermatology.

While the Mendelian randomization provides only “an inference” that PCSK9 plays a role in mediating risk of psoriasis, Dr. Zhao and coauthors cited numerous studies linking elevated PCSK9 to psoriasis pathophysiology. This not only includes the elevated PCSK9 expression in psoriatic plaques as shown by Dr. Garshick and others but several sets of experimental evidence linking PCSK9 to inflammatory pathways, including upregulation of interleukin-17 and stimulation of macrophage activation.

While Dr. Zhao and coauthors suggested that clinical trials are now needed to test the potential of PCSK9 inhibitors to modify the risk of psoriasis, Dr. Garshick indicated that there are numerous variables to unravel in the relationship between elevated lipids, PCSK9, and psoriasis.

“In our own studies, we did see a statistical correlation between circulating PCSK9 and psoriasis severity,” Dr. Garshick said. But he added, “I think we are just beginning to understand the functions of circulating (extrahepatic) PCSK9 independent of lipid metabolism.”

While he is intrigued by the evidence that PCSK9 is linked to systemic inflammation, he pointed out that several medications used to treat dyslipidemias, such as statins, are associated with an anti-inflammatory effect.

This study “further emphasizes the need to conduct clinical trials treating dyslipidemia in psoriasis, including the targeting of PCSK9, whether it is with statins with lipid lowering and potential pleiotropic anti-inflammatory properties or PCSK9 inhibition,” he said. If positive, “both would be exciting.“

From a cardiologist’s point of view, there is an upside for including patients with psoriasis in lipid-lowering trials even if the effect on psoriasis is modest. Either way, “you still get the lipid-lowering benefit, which is important for reducing atherosclerotic cardiovascular disease,” Dr. Garshick said.

Dr. Zhao reported financial relationships with UCB, although UCB did not provide funding for this study. One author reported grants from Versus Arthritis and the National Institute for Health Research Manchester Biomedical Research Centre during the study, grants from Bristol Myers Squibb, Galapagos, and Pfizer, and personal fees from Chugai Roche outside the submitted work. No other disclosures were reported. The study was supported by grants from Versus Arthritis and the NIHR Manchester Biomedical Research Centre. Dr. Garshick reported financial relationships with AbbVie and Horizon Therapeutics.

A Mendelian randomization study employing data from nearly 300,000 individuals has linked elevated levels of the PCSK9 enzyme with an increased risk of psoriasis, suggesting it might be targetable as an intervention.

Independent of low-density lipoprotein cholesterol (LDL-C), which is reduced when PCSK9 is inhibited, a reduction in PCSK9 levels appears to have a direct impact on lowering psoriasis risk. Conversely, psoriasis risk did not appear to be affected when LDL-C was reduced by other pathways of lipid control.

petekarici/Getty Images

This study “suggests that PCSK9 inhibition is causally associated with reduced risk of psoriasis,” reported a team of investigators led by Sizheng Steven Zhao, MD, PhD, of the division of musculoskeletal and dermatological sciences, University of Manchester (England). “Existing PCSK9 inhibitors hold potential as therapeutic targets for prevention, and possibly treatment, of psoriasis, although further clinical studies are needed,” they concluded.

In an interview, Dr. Zhao also noted that it will be interesting to look at psoriasis susceptibility in post hoc analyses of large randomized controlled trials of PCSK9 inhibitors for cardiovascular disease.

“Genetically proxied” inhibition of HMG-CoA reductase, which is targeted by statins, and NPC1L1 which is targeted by ezetimibe, “were not associated with psoriasis risk,” the investigators reported in the study, published in JAMA Dermatology.

Abnormal lipid metabolism is sufficiently common among people with psoriasis that screening in patients with moderate to severe disease is recommended in 2019 psoriasis guidelines from the American Academy of Dermatology and the National Psoriasis Foundation. However, the link between these diseases is unclear. This study was launched to explore genetically proxied relationships between psoriasis and LDL-C reductions as well as specific treatments for elevated LDL-C.

Mendelian randomizations were applied to deidentified data from two sources, a UK biobank and FinnGen, a Finnish-based project for identifying genotype-to-phenotype correlations. Genetic proxies for these variables were established on the basis of genomewide association studies on large population samples.

Ultimately, 34 genetic variants were selected to proxy for lipid lowering by PCSK9, 19 were selected to proxy for HMG-CoA reductase, and 9 for NPC1L1. In the Mendelian analyses performed on the two sources, genetically proxied PCSK9 inhibition was associated with about a 30% reduction in the odds ratio of psoriasis (OR, 0.69; P = .003). There were no robust associations with proxies for reductions in either HMG-CoA reductase or NPC1L1.

In sensitivity analyses, there was no evidence of bias from pleiotropy or genetic confounding, according to Dr. Zhao and his coauthors, who noted that the relationship between reductions in PCSK9 and reduced risk of psoriasis appeared to be independent of change in circulating LDL-C.

Given the prior evidence implicating the PCSK9 enzyme in psoriasis risk, “this is an exciting study that really highlights the importance of studying and targeting lipid metabolism in psoriasis for a few reasons,” according to Michael S. Garshick, MD, a researcher, cardiologist, and director of the cardio-rheumatology program, New York University Langone Health.

An investigator who has participated in several studies evaluating the relationship between cardiovascular risk and psoriasis, Dr. Garshick said there is increasing interest in PCSK9 as a biomarker or even a mediator of inflammation independent of blood lipid levels.

“In psoriasis regarding PCSK9, we and others have shown PCSK9 is elevated in psoriatic lesion skin, and studies are starting to investigate the unique lipidomic profile in psoriasis,” Dr. Garshick said in an interview. The study he led that showed elevated PCSK9 levels in psoriatic skin was published in 2021 in the Journal of Investigative Dermatology.

While the Mendelian randomization provides only “an inference” that PCSK9 plays a role in mediating risk of psoriasis, Dr. Zhao and coauthors cited numerous studies linking elevated PCSK9 to psoriasis pathophysiology. This not only includes the elevated PCSK9 expression in psoriatic plaques as shown by Dr. Garshick and others but several sets of experimental evidence linking PCSK9 to inflammatory pathways, including upregulation of interleukin-17 and stimulation of macrophage activation.

While Dr. Zhao and coauthors suggested that clinical trials are now needed to test the potential of PCSK9 inhibitors to modify the risk of psoriasis, Dr. Garshick indicated that there are numerous variables to unravel in the relationship between elevated lipids, PCSK9, and psoriasis.

“In our own studies, we did see a statistical correlation between circulating PCSK9 and psoriasis severity,” Dr. Garshick said. But he added, “I think we are just beginning to understand the functions of circulating (extrahepatic) PCSK9 independent of lipid metabolism.”

While he is intrigued by the evidence that PCSK9 is linked to systemic inflammation, he pointed out that several medications used to treat dyslipidemias, such as statins, are associated with an anti-inflammatory effect.

This study “further emphasizes the need to conduct clinical trials treating dyslipidemia in psoriasis, including the targeting of PCSK9, whether it is with statins with lipid lowering and potential pleiotropic anti-inflammatory properties or PCSK9 inhibition,” he said. If positive, “both would be exciting.“

From a cardiologist’s point of view, there is an upside for including patients with psoriasis in lipid-lowering trials even if the effect on psoriasis is modest. Either way, “you still get the lipid-lowering benefit, which is important for reducing atherosclerotic cardiovascular disease,” Dr. Garshick said.

Dr. Zhao reported financial relationships with UCB, although UCB did not provide funding for this study. One author reported grants from Versus Arthritis and the National Institute for Health Research Manchester Biomedical Research Centre during the study, grants from Bristol Myers Squibb, Galapagos, and Pfizer, and personal fees from Chugai Roche outside the submitted work. No other disclosures were reported. The study was supported by grants from Versus Arthritis and the NIHR Manchester Biomedical Research Centre. Dr. Garshick reported financial relationships with AbbVie and Horizon Therapeutics.