Federal Practitioner

The relationship between estrogen levels and heart health makes it particularly important for clinicians to be aware of those patients who might be at risk for cardiovascular disease despite not having other traditional risk factors, according to a presentation Oct. 12 at the North American Menopause Society annual meeting in Atlanta.

”Endogenous estrogens are protective for cardiovascular disease in premenopausal women,” Chrisandra L. Shufelt, MD, chair of the division of general internal medicine and associate director of the Women’s Health Research Center at Mayo Clinic in Jacksonville, Fla., told attendees. Yet, “a substantial population of young women are dying prematurely from cardiovascular disease,” with rates of cardiovascular death increasing in women aged 35-44 even as rates have decreased in postmenopausal women and in men. One potential reason may be premature estrogen loss.

Dr. Shufelt reminded attendees of four major causes of premature estrogen loss: Natural premature menopause, surgical menopause, chemotherapy-induced menopause, and premature ovarian insufficiency. But she would go on to discuss a less widely recognized condition, functional hypothalamic amenorrhea, that also may be contributing to increased cardiovascular risk.

First, Dr. Shufelt reviewed the evidence supporting the relationship between estrogen and cardiovascular health, starting with the Framingham study’s findings that cardiovascular disease is approximately two to four times more common in postmenopausal women than in premenopausal women, depending on the age range.

“Menopause at an early age, particularly under the age of 40, matters,” Dr. Shufelt said. “So we should be discussing this with our patients.”

Surgical menopause makes a difference to cardiovascular health as well, she said. In women under age 35, for example, the risk of a nonfatal heart attack in those with a bilateral oophorectomy was 7.7 times greater than in women who retained both ovaries and their uterus, and 1.5 times greater in women who had a hysterectomy without bilateral oophorectomy.

In a 2019 study, surgical premature menopause was associated with an 87% increased risk of heart disease even after researchers accounted for age, cardiovascular risk factors, and some forms of hormone therapy. The increased risk from natural premature menopause, on the other hand, was lower – a 36% increased risk of heart disease – compared with those producing endogenous hormones. Although randomized controlled trials are unavailable and unlikely to be done, the Nurses’ Health Study and the Danish Nurses Cohort Study, both observational studies, found that heart disease risk was diminished in those taking hormone therapy after surgical premature menopause.

Recommendations for premature or early menopause, from a wide range of different medical societies including NAMS, are that women without contraindications be given estrogen-based hormone therapy until the average age of natural menopause. Though not included in the same guidance, research has also shown that estrogen after oophorectomy does not increase the risk of breast cancer in women with a BRCA1 mutation, Dr. Shufelt said. Hormone therapy for premature or early menopause should adequately replace the levels women have lost and that means younger menopausal women often need higher doses than what older women receive, such as 2 mg/day of oral estradiol rather than the standard doses of 0.5 or 1 mg/day.
 

Functional hypothalamic amenorrhea and cardiovascular risk

Dr. Shufelt then discussed functional hypothalamic amenorrhea (hypogonadotropic hypogonadism), a common type of secondary amenorrhea that affects at least 1.4 million U.S. women. Diagnosis includes lack of a period for at least 3 months in someone who previously menstruated plus lab values below 50 pg/mL for estradiol, below 10 mIU/L for follicle stimulating hormone, and below 10 mIU/L for luteinizing hormone. Causes of this reversible form of infertility can include stress, overexercising, undereating, or some combination of these, plus an underlying genetic predisposition.

“After ruling out polycystic ovary syndrome, prolactinoma, and thyroid dysfunction, clinicians need to consider the diagnosis of hypothalamic amenorrhea,” Dr. Shufelt said. This condition goes beyond low estrogen levels: Women have elevated cortisol, low thyroid levels, low leptin levels, and increased ghrelin.

”This is not going away,” Dr. Shufelt said, sharing data on stress levels among U.S. adults, particularly Gen Z and millennial adults, noting that the ongoing “national mental health crisis” may be contributing to functional hypothalamic amenorrhea.

A 2020 substudy from the Nurses’ Health Study II found an increased risk of premature death in those who didn’t have a period or always had irregular periods starting as early as 14-17 years old. The increased risk of premature death rose with age in those with irregular or absent cycles – a 37% higher risk in 18- to 22-year-olds and a 39% increased risk in 29- to 46-year-olds.

But clinicians aren’t adequately identifying the “phenotype of the hypothalamic women,” Dr. Shufelt said, despite research showing overlap between hypothalamic amenorrhea and a higher risk of cardiovascular disease. Hypothalamic amenorrhea is so understudied that the last original research on the topic was in 2008, Dr. Shufelt said in an interview. ”No research except mine has been done to evaluate heart health in these young women,” she said.

Dr. Shufelt described a study she led involving 30 women with functional hypothalamic amenorrhea, 29 women with normal menstrual cycles, and 30 women who were recently menopausal and not on hormone therapy. The women with hypothalamic amenorrhea had average stress levels but their depression scores were higher than those of the other two groups.

The results showed that women with hypothalamic amenorrhea had lower estradiol and leptin levels and higher testosterone levels compared with the control group, and they had higher cortisol levels than those of both groups. Despite having similar body mass indexes as the control and menopausal groups, women with hypothalamic amenorrhea had lower blood pressure than that of the other two groups, yet they had higher cholesterol levels than those of the control group. EndoPAT^© (Itamar Medical) testing showed that they had poor vascular function.

“In fact, one-third of the women [with hypothalamic amenorrhea] entered the trial with a diagnosis of what would be considered endothelial dysfunction,” Dr. Shufelt said. “Our results demonstrated significantly higher circulating levels of serum proinflammatory cytokines in the women with hypothalamic amenorrhea compared to eumenorrheic controls.”

Dr. Shufelt’s team then tested whether giving estradiol to the women with hypothalamic amenorrhea for 12 weeks would improve their vascular health, but they saw no significant differences between the women who received estrogen and those who received placebo.

“Endothelial function is partly mediated by estrogen, and it was expected that giving back estrogen would ‘fix’ the endothelium, but that is not what happened,” Nanette Santoro, MD, professor and chair of obstetrics and gynecology at the University of Colorado at Denver, Aurora, said in interview. “The mechanisms that maintain vascular function in women are not limited to hormones,” said Dr. Santoro, who was not involved in Dr. Shufelt’s study but attended her lecture. “We need to think beyond the simple model of estrogen-good, no-estrogen-bad.”

Dr. Santoro noted how easy it is to overlook the women who may have cardiovascular risk because of hypothalamic amenorrhea.

“Because many women with functional hypothalamic amenorrhea are super athletic and do not have the typical features of people with cardiometabolic disease – such as glucose intolerance, obesity, abnormal cholesterol or triglycerides, or high blood pressure – clinicians tend to think of them as healthy and to think that simply giving back hormones will fix the problems with bone density and vascular function, but that is not enough,” Dr. Santoro said. “The cognitive-behavioral therapy model for treatment of women with functional hypothalamic amenorrhea addresses the stress-related factors that drive the disorder, and this needs to be considered the standard of care for treatment.”

Stephanie S. Faubion, MD, professor of medicine and director of Mayo Clinic’s Center for Women’s Health in Jacksonville, Fla., who was not involved in Dr. Shufelt’s presentation, also emphasized the importance of recognizing functional hypothalamic amenorrhea.

“This is an underrecognized entity to begin with, and the fact that these women appear to be at increased risk for vascular dysfunction and potentially increased risk for cardiovascular disease down the road makes it even more important for clinicians to identify them and provide interventions early on,” Dr. Faubion said in an interview. “These women need to be identified and the etiology of the amenorrhea addressed, whether it relates to overexercising, being underweight, or experiencing significant stressors that have led to the loss of menstrual cycles.”

Dr. Shufelt’s research was funded by the National Institutes of Health. She had no disclosures. Dr. Santoro is a member of the scientific advisory board for Astellas, Menogenix, Amazon Ember, and Que Oncology, and she consults for Ansh Labs. Dr. Faubion had no disclosures.

The relationship between estrogen levels and heart health makes it particularly important for clinicians to be aware of those patients who might be at risk for cardiovascular disease despite not having other traditional risk factors, according to a presentation Oct. 12 at the North American Menopause Society annual meeting in Atlanta.

”Endogenous estrogens are protective for cardiovascular disease in premenopausal women,” Chrisandra L. Shufelt, MD, chair of the division of general internal medicine and associate director of the Women’s Health Research Center at Mayo Clinic in Jacksonville, Fla., told attendees. Yet, “a substantial population of young women are dying prematurely from cardiovascular disease,” with rates of cardiovascular death increasing in women aged 35-44 even as rates have decreased in postmenopausal women and in men. One potential reason may be premature estrogen loss.

Dr. Shufelt reminded attendees of four major causes of premature estrogen loss: Natural premature menopause, surgical menopause, chemotherapy-induced menopause, and premature ovarian insufficiency. But she would go on to discuss a less widely recognized condition, functional hypothalamic amenorrhea, that also may be contributing to increased cardiovascular risk.

First, Dr. Shufelt reviewed the evidence supporting the relationship between estrogen and cardiovascular health, starting with the Framingham study’s findings that cardiovascular disease is approximately two to four times more common in postmenopausal women than in premenopausal women, depending on the age range.

“Menopause at an early age, particularly under the age of 40, matters,” Dr. Shufelt said. “So we should be discussing this with our patients.”

Surgical menopause makes a difference to cardiovascular health as well, she said. In women under age 35, for example, the risk of a nonfatal heart attack in those with a bilateral oophorectomy was 7.7 times greater than in women who retained both ovaries and their uterus, and 1.5 times greater in women who had a hysterectomy without bilateral oophorectomy.

In a 2019 study, surgical premature menopause was associated with an 87% increased risk of heart disease even after researchers accounted for age, cardiovascular risk factors, and some forms of hormone therapy. The increased risk from natural premature menopause, on the other hand, was lower – a 36% increased risk of heart disease – compared with those producing endogenous hormones. Although randomized controlled trials are unavailable and unlikely to be done, the Nurses’ Health Study and the Danish Nurses Cohort Study, both observational studies, found that heart disease risk was diminished in those taking hormone therapy after surgical premature menopause.

Recommendations for premature or early menopause, from a wide range of different medical societies including NAMS, are that women without contraindications be given estrogen-based hormone therapy until the average age of natural menopause. Though not included in the same guidance, research has also shown that estrogen after oophorectomy does not increase the risk of breast cancer in women with a BRCA1 mutation, Dr. Shufelt said. Hormone therapy for premature or early menopause should adequately replace the levels women have lost and that means younger menopausal women often need higher doses than what older women receive, such as 2 mg/day of oral estradiol rather than the standard doses of 0.5 or 1 mg/day.
 

Functional hypothalamic amenorrhea and cardiovascular risk

Dr. Shufelt then discussed functional hypothalamic amenorrhea (hypogonadotropic hypogonadism), a common type of secondary amenorrhea that affects at least 1.4 million U.S. women. Diagnosis includes lack of a period for at least 3 months in someone who previously menstruated plus lab values below 50 pg/mL for estradiol, below 10 mIU/L for follicle stimulating hormone, and below 10 mIU/L for luteinizing hormone. Causes of this reversible form of infertility can include stress, overexercising, undereating, or some combination of these, plus an underlying genetic predisposition.

“After ruling out polycystic ovary syndrome, prolactinoma, and thyroid dysfunction, clinicians need to consider the diagnosis of hypothalamic amenorrhea,” Dr. Shufelt said. This condition goes beyond low estrogen levels: Women have elevated cortisol, low thyroid levels, low leptin levels, and increased ghrelin.

”This is not going away,” Dr. Shufelt said, sharing data on stress levels among U.S. adults, particularly Gen Z and millennial adults, noting that the ongoing “national mental health crisis” may be contributing to functional hypothalamic amenorrhea.

A 2020 substudy from the Nurses’ Health Study II found an increased risk of premature death in those who didn’t have a period or always had irregular periods starting as early as 14-17 years old. The increased risk of premature death rose with age in those with irregular or absent cycles – a 37% higher risk in 18- to 22-year-olds and a 39% increased risk in 29- to 46-year-olds.

But clinicians aren’t adequately identifying the “phenotype of the hypothalamic women,” Dr. Shufelt said, despite research showing overlap between hypothalamic amenorrhea and a higher risk of cardiovascular disease. Hypothalamic amenorrhea is so understudied that the last original research on the topic was in 2008, Dr. Shufelt said in an interview. ”No research except mine has been done to evaluate heart health in these young women,” she said.

Dr. Shufelt described a study she led involving 30 women with functional hypothalamic amenorrhea, 29 women with normal menstrual cycles, and 30 women who were recently menopausal and not on hormone therapy. The women with hypothalamic amenorrhea had average stress levels but their depression scores were higher than those of the other two groups.

The results showed that women with hypothalamic amenorrhea had lower estradiol and leptin levels and higher testosterone levels compared with the control group, and they had higher cortisol levels than those of both groups. Despite having similar body mass indexes as the control and menopausal groups, women with hypothalamic amenorrhea had lower blood pressure than that of the other two groups, yet they had higher cholesterol levels than those of the control group. EndoPAT^© (Itamar Medical) testing showed that they had poor vascular function.

“In fact, one-third of the women [with hypothalamic amenorrhea] entered the trial with a diagnosis of what would be considered endothelial dysfunction,” Dr. Shufelt said. “Our results demonstrated significantly higher circulating levels of serum proinflammatory cytokines in the women with hypothalamic amenorrhea compared to eumenorrheic controls.”

Dr. Shufelt’s team then tested whether giving estradiol to the women with hypothalamic amenorrhea for 12 weeks would improve their vascular health, but they saw no significant differences between the women who received estrogen and those who received placebo.

“Endothelial function is partly mediated by estrogen, and it was expected that giving back estrogen would ‘fix’ the endothelium, but that is not what happened,” Nanette Santoro, MD, professor and chair of obstetrics and gynecology at the University of Colorado at Denver, Aurora, said in interview. “The mechanisms that maintain vascular function in women are not limited to hormones,” said Dr. Santoro, who was not involved in Dr. Shufelt’s study but attended her lecture. “We need to think beyond the simple model of estrogen-good, no-estrogen-bad.”

Dr. Santoro noted how easy it is to overlook the women who may have cardiovascular risk because of hypothalamic amenorrhea.

“Because many women with functional hypothalamic amenorrhea are super athletic and do not have the typical features of people with cardiometabolic disease – such as glucose intolerance, obesity, abnormal cholesterol or triglycerides, or high blood pressure – clinicians tend to think of them as healthy and to think that simply giving back hormones will fix the problems with bone density and vascular function, but that is not enough,” Dr. Santoro said. “The cognitive-behavioral therapy model for treatment of women with functional hypothalamic amenorrhea addresses the stress-related factors that drive the disorder, and this needs to be considered the standard of care for treatment.”

Stephanie S. Faubion, MD, professor of medicine and director of Mayo Clinic’s Center for Women’s Health in Jacksonville, Fla., who was not involved in Dr. Shufelt’s presentation, also emphasized the importance of recognizing functional hypothalamic amenorrhea.

“This is an underrecognized entity to begin with, and the fact that these women appear to be at increased risk for vascular dysfunction and potentially increased risk for cardiovascular disease down the road makes it even more important for clinicians to identify them and provide interventions early on,” Dr. Faubion said in an interview. “These women need to be identified and the etiology of the amenorrhea addressed, whether it relates to overexercising, being underweight, or experiencing significant stressors that have led to the loss of menstrual cycles.”

Dr. Shufelt’s research was funded by the National Institutes of Health. She had no disclosures. Dr. Santoro is a member of the scientific advisory board for Astellas, Menogenix, Amazon Ember, and Que Oncology, and she consults for Ansh Labs. Dr. Faubion had no disclosures.

The relationship between estrogen levels and heart health makes it particularly important for clinicians to be aware of those patients who might be at risk for cardiovascular disease despite not having other traditional risk factors, according to a presentation Oct. 12 at the North American Menopause Society annual meeting in Atlanta.

”Endogenous estrogens are protective for cardiovascular disease in premenopausal women,” Chrisandra L. Shufelt, MD, chair of the division of general internal medicine and associate director of the Women’s Health Research Center at Mayo Clinic in Jacksonville, Fla., told attendees. Yet, “a substantial population of young women are dying prematurely from cardiovascular disease,” with rates of cardiovascular death increasing in women aged 35-44 even as rates have decreased in postmenopausal women and in men. One potential reason may be premature estrogen loss.

Dr. Shufelt reminded attendees of four major causes of premature estrogen loss: Natural premature menopause, surgical menopause, chemotherapy-induced menopause, and premature ovarian insufficiency. But she would go on to discuss a less widely recognized condition, functional hypothalamic amenorrhea, that also may be contributing to increased cardiovascular risk.

First, Dr. Shufelt reviewed the evidence supporting the relationship between estrogen and cardiovascular health, starting with the Framingham study’s findings that cardiovascular disease is approximately two to four times more common in postmenopausal women than in premenopausal women, depending on the age range.

“Menopause at an early age, particularly under the age of 40, matters,” Dr. Shufelt said. “So we should be discussing this with our patients.”

Surgical menopause makes a difference to cardiovascular health as well, she said. In women under age 35, for example, the risk of a nonfatal heart attack in those with a bilateral oophorectomy was 7.7 times greater than in women who retained both ovaries and their uterus, and 1.5 times greater in women who had a hysterectomy without bilateral oophorectomy.

In a 2019 study, surgical premature menopause was associated with an 87% increased risk of heart disease even after researchers accounted for age, cardiovascular risk factors, and some forms of hormone therapy. The increased risk from natural premature menopause, on the other hand, was lower – a 36% increased risk of heart disease – compared with those producing endogenous hormones. Although randomized controlled trials are unavailable and unlikely to be done, the Nurses’ Health Study and the Danish Nurses Cohort Study, both observational studies, found that heart disease risk was diminished in those taking hormone therapy after surgical premature menopause.

Recommendations for premature or early menopause, from a wide range of different medical societies including NAMS, are that women without contraindications be given estrogen-based hormone therapy until the average age of natural menopause. Though not included in the same guidance, research has also shown that estrogen after oophorectomy does not increase the risk of breast cancer in women with a BRCA1 mutation, Dr. Shufelt said. Hormone therapy for premature or early menopause should adequately replace the levels women have lost and that means younger menopausal women often need higher doses than what older women receive, such as 2 mg/day of oral estradiol rather than the standard doses of 0.5 or 1 mg/day.
 

Functional hypothalamic amenorrhea and cardiovascular risk

Dr. Shufelt then discussed functional hypothalamic amenorrhea (hypogonadotropic hypogonadism), a common type of secondary amenorrhea that affects at least 1.4 million U.S. women. Diagnosis includes lack of a period for at least 3 months in someone who previously menstruated plus lab values below 50 pg/mL for estradiol, below 10 mIU/L for follicle stimulating hormone, and below 10 mIU/L for luteinizing hormone. Causes of this reversible form of infertility can include stress, overexercising, undereating, or some combination of these, plus an underlying genetic predisposition.

“After ruling out polycystic ovary syndrome, prolactinoma, and thyroid dysfunction, clinicians need to consider the diagnosis of hypothalamic amenorrhea,” Dr. Shufelt said. This condition goes beyond low estrogen levels: Women have elevated cortisol, low thyroid levels, low leptin levels, and increased ghrelin.

”This is not going away,” Dr. Shufelt said, sharing data on stress levels among U.S. adults, particularly Gen Z and millennial adults, noting that the ongoing “national mental health crisis” may be contributing to functional hypothalamic amenorrhea.

A 2020 substudy from the Nurses’ Health Study II found an increased risk of premature death in those who didn’t have a period or always had irregular periods starting as early as 14-17 years old. The increased risk of premature death rose with age in those with irregular or absent cycles – a 37% higher risk in 18- to 22-year-olds and a 39% increased risk in 29- to 46-year-olds.

But clinicians aren’t adequately identifying the “phenotype of the hypothalamic women,” Dr. Shufelt said, despite research showing overlap between hypothalamic amenorrhea and a higher risk of cardiovascular disease. Hypothalamic amenorrhea is so understudied that the last original research on the topic was in 2008, Dr. Shufelt said in an interview. ”No research except mine has been done to evaluate heart health in these young women,” she said.

Dr. Shufelt described a study she led involving 30 women with functional hypothalamic amenorrhea, 29 women with normal menstrual cycles, and 30 women who were recently menopausal and not on hormone therapy. The women with hypothalamic amenorrhea had average stress levels but their depression scores were higher than those of the other two groups.

The results showed that women with hypothalamic amenorrhea had lower estradiol and leptin levels and higher testosterone levels compared with the control group, and they had higher cortisol levels than those of both groups. Despite having similar body mass indexes as the control and menopausal groups, women with hypothalamic amenorrhea had lower blood pressure than that of the other two groups, yet they had higher cholesterol levels than those of the control group. EndoPAT^© (Itamar Medical) testing showed that they had poor vascular function.

“In fact, one-third of the women [with hypothalamic amenorrhea] entered the trial with a diagnosis of what would be considered endothelial dysfunction,” Dr. Shufelt said. “Our results demonstrated significantly higher circulating levels of serum proinflammatory cytokines in the women with hypothalamic amenorrhea compared to eumenorrheic controls.”

Dr. Shufelt’s team then tested whether giving estradiol to the women with hypothalamic amenorrhea for 12 weeks would improve their vascular health, but they saw no significant differences between the women who received estrogen and those who received placebo.

“Endothelial function is partly mediated by estrogen, and it was expected that giving back estrogen would ‘fix’ the endothelium, but that is not what happened,” Nanette Santoro, MD, professor and chair of obstetrics and gynecology at the University of Colorado at Denver, Aurora, said in interview. “The mechanisms that maintain vascular function in women are not limited to hormones,” said Dr. Santoro, who was not involved in Dr. Shufelt’s study but attended her lecture. “We need to think beyond the simple model of estrogen-good, no-estrogen-bad.”

Dr. Santoro noted how easy it is to overlook the women who may have cardiovascular risk because of hypothalamic amenorrhea.

“Because many women with functional hypothalamic amenorrhea are super athletic and do not have the typical features of people with cardiometabolic disease – such as glucose intolerance, obesity, abnormal cholesterol or triglycerides, or high blood pressure – clinicians tend to think of them as healthy and to think that simply giving back hormones will fix the problems with bone density and vascular function, but that is not enough,” Dr. Santoro said. “The cognitive-behavioral therapy model for treatment of women with functional hypothalamic amenorrhea addresses the stress-related factors that drive the disorder, and this needs to be considered the standard of care for treatment.”

Stephanie S. Faubion, MD, professor of medicine and director of Mayo Clinic’s Center for Women’s Health in Jacksonville, Fla., who was not involved in Dr. Shufelt’s presentation, also emphasized the importance of recognizing functional hypothalamic amenorrhea.

“This is an underrecognized entity to begin with, and the fact that these women appear to be at increased risk for vascular dysfunction and potentially increased risk for cardiovascular disease down the road makes it even more important for clinicians to identify them and provide interventions early on,” Dr. Faubion said in an interview. “These women need to be identified and the etiology of the amenorrhea addressed, whether it relates to overexercising, being underweight, or experiencing significant stressors that have led to the loss of menstrual cycles.”

Dr. Shufelt’s research was funded by the National Institutes of Health. She had no disclosures. Dr. Santoro is a member of the scientific advisory board for Astellas, Menogenix, Amazon Ember, and Que Oncology, and she consults for Ansh Labs. Dr. Faubion had no disclosures.

MONTREAL – Remote assessment of atopic dermatitis (AD) severity is possible through the use of patient-provided clinical photos – opening a new avenue for improving access for patients, as well as the possibility of conducting remote clinical trials that would be less expensive and less burdensome for participants, according to investigators, who presented the study at the annual meeting of the International Society of Atopic Dermatitis.

Still, practical barriers need to be addressed, particularly the problem of image quality, noted study investigator Aviël Ragamin, MD, from the department of dermatology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands.

“Good-quality images are crucial, [and] in our study, patients didn’t have any incentive to provide images because they had already received their medical consultation,” he explained. He suggested that this problem could be overcome by providing technical support for patients and compensation for trial participants.

The study included 87 children (median age, 7 years), who were assessed for AD severity at an academic outpatient clinic. The in-person visit included assessment with the Eczema Area and Severity Index (EASI) score, as well as the collection of whole-body clinical images. Parents were then asked to return home and to provide their own clinical images and self-administered EASI assessments of their child for comparison. Four raters were asked to rate all images twice and to compare in-clinic and self-administered EASI scores based on the images.

At the in-clinic visit, the median EASI score of the group was 8.8. The majority of patients had moderate (46.6%) or severe (14.8%) AD. Roughly 40% of the patients had darker skin (Fitzpatrick skin types IV–VI).

Using Spearman rank correlation of 1,534 in-clinic and 425 patient-provided images, the study found good inter- and intra-rater reliability for clinical image assessment and strong agreement between images and the in-clinic EASI scores. The top outliers in the assessment were individuals with either darker skin or significant postinflammatory hyperpigmentation, which are “the most difficult cases to rate, based on images,” Dr. Ragamin noted.

There was only moderate correlation between the in-clinic and self-administered EASI scores, with a significant number of patients either underestimating or overestimating their AD severity, he added.

Overall, the main problem with remote assessment seems to be the feasibility of patients providing images, said Dr. Ragamin. Only 36.8% of parents provided any images at all, and of these, 1 of 5 were deemed too blurry, leaving just 13 for final assessment, he explained.

“Pragmatically, it’s tricky,” said Aaron Drucker, MD, a dermatologist at Women’s College Hospital and associate professor at the University of Toronto, who was asked to comment on the study. “It takes long enough to do an EASI score in person, let alone looking through blurry pictures that take too long to load into your electronic medical record. We know it works, but when our hospital went virtual [during the COVID pandemic] ... most of my patients with chronic eczema weren’t even sending me pictures.”

Regarding the utility of remote, full-body photography in clinical practice, he said, “There’s too many feasibility hoops to jump through at this point. The most promise I see is for clinical trials, where it’s hard to get people to come in.”

Dr. Ragamin and Dr. Drucker have disclosed no relevant financial relationships.

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

MONTREAL – Remote assessment of atopic dermatitis (AD) severity is possible through the use of patient-provided clinical photos – opening a new avenue for improving access for patients, as well as the possibility of conducting remote clinical trials that would be less expensive and less burdensome for participants, according to investigators, who presented the study at the annual meeting of the International Society of Atopic Dermatitis.

Still, practical barriers need to be addressed, particularly the problem of image quality, noted study investigator Aviël Ragamin, MD, from the department of dermatology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands.

“Good-quality images are crucial, [and] in our study, patients didn’t have any incentive to provide images because they had already received their medical consultation,” he explained. He suggested that this problem could be overcome by providing technical support for patients and compensation for trial participants.

The study included 87 children (median age, 7 years), who were assessed for AD severity at an academic outpatient clinic. The in-person visit included assessment with the Eczema Area and Severity Index (EASI) score, as well as the collection of whole-body clinical images. Parents were then asked to return home and to provide their own clinical images and self-administered EASI assessments of their child for comparison. Four raters were asked to rate all images twice and to compare in-clinic and self-administered EASI scores based on the images.

At the in-clinic visit, the median EASI score of the group was 8.8. The majority of patients had moderate (46.6%) or severe (14.8%) AD. Roughly 40% of the patients had darker skin (Fitzpatrick skin types IV–VI).

Using Spearman rank correlation of 1,534 in-clinic and 425 patient-provided images, the study found good inter- and intra-rater reliability for clinical image assessment and strong agreement between images and the in-clinic EASI scores. The top outliers in the assessment were individuals with either darker skin or significant postinflammatory hyperpigmentation, which are “the most difficult cases to rate, based on images,” Dr. Ragamin noted.

There was only moderate correlation between the in-clinic and self-administered EASI scores, with a significant number of patients either underestimating or overestimating their AD severity, he added.

Overall, the main problem with remote assessment seems to be the feasibility of patients providing images, said Dr. Ragamin. Only 36.8% of parents provided any images at all, and of these, 1 of 5 were deemed too blurry, leaving just 13 for final assessment, he explained.

“Pragmatically, it’s tricky,” said Aaron Drucker, MD, a dermatologist at Women’s College Hospital and associate professor at the University of Toronto, who was asked to comment on the study. “It takes long enough to do an EASI score in person, let alone looking through blurry pictures that take too long to load into your electronic medical record. We know it works, but when our hospital went virtual [during the COVID pandemic] ... most of my patients with chronic eczema weren’t even sending me pictures.”

Regarding the utility of remote, full-body photography in clinical practice, he said, “There’s too many feasibility hoops to jump through at this point. The most promise I see is for clinical trials, where it’s hard to get people to come in.”

Dr. Ragamin and Dr. Drucker have disclosed no relevant financial relationships.

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

MONTREAL – Remote assessment of atopic dermatitis (AD) severity is possible through the use of patient-provided clinical photos – opening a new avenue for improving access for patients, as well as the possibility of conducting remote clinical trials that would be less expensive and less burdensome for participants, according to investigators, who presented the study at the annual meeting of the International Society of Atopic Dermatitis.

Still, practical barriers need to be addressed, particularly the problem of image quality, noted study investigator Aviël Ragamin, MD, from the department of dermatology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands.

“Good-quality images are crucial, [and] in our study, patients didn’t have any incentive to provide images because they had already received their medical consultation,” he explained. He suggested that this problem could be overcome by providing technical support for patients and compensation for trial participants.

The study included 87 children (median age, 7 years), who were assessed for AD severity at an academic outpatient clinic. The in-person visit included assessment with the Eczema Area and Severity Index (EASI) score, as well as the collection of whole-body clinical images. Parents were then asked to return home and to provide their own clinical images and self-administered EASI assessments of their child for comparison. Four raters were asked to rate all images twice and to compare in-clinic and self-administered EASI scores based on the images.

At the in-clinic visit, the median EASI score of the group was 8.8. The majority of patients had moderate (46.6%) or severe (14.8%) AD. Roughly 40% of the patients had darker skin (Fitzpatrick skin types IV–VI).

Using Spearman rank correlation of 1,534 in-clinic and 425 patient-provided images, the study found good inter- and intra-rater reliability for clinical image assessment and strong agreement between images and the in-clinic EASI scores. The top outliers in the assessment were individuals with either darker skin or significant postinflammatory hyperpigmentation, which are “the most difficult cases to rate, based on images,” Dr. Ragamin noted.

There was only moderate correlation between the in-clinic and self-administered EASI scores, with a significant number of patients either underestimating or overestimating their AD severity, he added.

Overall, the main problem with remote assessment seems to be the feasibility of patients providing images, said Dr. Ragamin. Only 36.8% of parents provided any images at all, and of these, 1 of 5 were deemed too blurry, leaving just 13 for final assessment, he explained.

“Pragmatically, it’s tricky,” said Aaron Drucker, MD, a dermatologist at Women’s College Hospital and associate professor at the University of Toronto, who was asked to comment on the study. “It takes long enough to do an EASI score in person, let alone looking through blurry pictures that take too long to load into your electronic medical record. We know it works, but when our hospital went virtual [during the COVID pandemic] ... most of my patients with chronic eczema weren’t even sending me pictures.”

Regarding the utility of remote, full-body photography in clinical practice, he said, “There’s too many feasibility hoops to jump through at this point. The most promise I see is for clinical trials, where it’s hard to get people to come in.”

Dr. Ragamin and Dr. Drucker have disclosed no relevant financial relationships.

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

A new study shows that Black Americans received ventricular assist devices (VADs) and heart transplants about half as often as White Americans, even when receiving care at an advanced heart failure (HF) center.

The analysis, drawn from 377 patients treated at one of 21 VAD centers in the United States as part of the RIVIVAL study, found that 22.3% of White adults received a heart transplant or VAD, compared with 11% of Black adults.

“That’s what is so concerning to us, that we’re seeing this pattern within this select population. I think it would be too reasonable to hypothesize that it very well could be worse in the general population,” study author Thomas Cascino, MD, MSc, University of Michigan, Ann Arbor, commented.

The study was published online in Circulation: Heart Failure, and it builds on previous work by the researchers, showing that patient preference for early VAD therapy is associated with higher New York Heart Association (NYHA) class and lower income level but not race.

In the present analysis, the number of Black and White participants who said they “definitely or probably” wanted VAD therapy was similar (27% vs. 29%), as was the number wanting “any and all life-sustaining therapies” (74% vs. 65%).

Two-thirds of the cohort was NYHA class III, the average EuroQoL visual analog scale (EQ-VAS) score was 64.6 among the 100 participants who identified as Black and 62.1 in the 277 White participants, and the average age was 58 and 61 years, respectively.

Death rates were also similar during the 2-year follow-up: 18% of Black patients and 13% of White patients.

After controlling for multiple clinical and social determinants of health, including age, Interagency Registry for Mechanically Assisted Circulator Support (INTERMACS) patient profile, EQ-VAS score, and level of education, Black participants had a 55% lower rate of VAD or transplant, compared with White participants (hazard ratio, 0.45; 95% confidence interval, 0.23-0.85). Adding VAD preference to the model did not affect the association.

“Our study suggests that we as providers may be making decisions differently,” Dr. Cascino said. “We can’t say for sure what the reasons are but certainly structural racism, discrimination, and provider biases are the things I worry about.”

“There’s an absolute need for us to look inwards, reflect, and acknowledge that we are likely playing a role in this and then start to be part of the change,” he added.

“The lives disabled or lost are simply too many,” coauthor Wendy Taddei-Peters, PhD, a clinical trials project official at the National Heart, Lung, and Blood Institute, said in an NIH statement. “An immediate step could be to require implicit bias training, particularly for transplant and VAD team members.”

Other suggestions are better tracking of underserved patients and the reasons why they do not receive VAD or become listed for transplant; inclusion of psychosocial components into decision-making about advanced therapy candidacy; and having “disparity experts” join in heart team meetings to help identify biases in real time.

Commenting on the study, Khadijah Breathett, MD, HF/transplant cardiologist and tenured associate professor of medicine, Indiana University Bloomington, said, “I’m glad there’s more push for awareness, because there’s still a population of people that don’t believe this is a real problem.”

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

A new study shows that Black Americans received ventricular assist devices (VADs) and heart transplants about half as often as White Americans, even when receiving care at an advanced heart failure (HF) center.

The analysis, drawn from 377 patients treated at one of 21 VAD centers in the United States as part of the RIVIVAL study, found that 22.3% of White adults received a heart transplant or VAD, compared with 11% of Black adults.

“That’s what is so concerning to us, that we’re seeing this pattern within this select population. I think it would be too reasonable to hypothesize that it very well could be worse in the general population,” study author Thomas Cascino, MD, MSc, University of Michigan, Ann Arbor, commented.

The study was published online in Circulation: Heart Failure, and it builds on previous work by the researchers, showing that patient preference for early VAD therapy is associated with higher New York Heart Association (NYHA) class and lower income level but not race.

In the present analysis, the number of Black and White participants who said they “definitely or probably” wanted VAD therapy was similar (27% vs. 29%), as was the number wanting “any and all life-sustaining therapies” (74% vs. 65%).

Two-thirds of the cohort was NYHA class III, the average EuroQoL visual analog scale (EQ-VAS) score was 64.6 among the 100 participants who identified as Black and 62.1 in the 277 White participants, and the average age was 58 and 61 years, respectively.

Death rates were also similar during the 2-year follow-up: 18% of Black patients and 13% of White patients.

After controlling for multiple clinical and social determinants of health, including age, Interagency Registry for Mechanically Assisted Circulator Support (INTERMACS) patient profile, EQ-VAS score, and level of education, Black participants had a 55% lower rate of VAD or transplant, compared with White participants (hazard ratio, 0.45; 95% confidence interval, 0.23-0.85). Adding VAD preference to the model did not affect the association.

“Our study suggests that we as providers may be making decisions differently,” Dr. Cascino said. “We can’t say for sure what the reasons are but certainly structural racism, discrimination, and provider biases are the things I worry about.”

“There’s an absolute need for us to look inwards, reflect, and acknowledge that we are likely playing a role in this and then start to be part of the change,” he added.

“The lives disabled or lost are simply too many,” coauthor Wendy Taddei-Peters, PhD, a clinical trials project official at the National Heart, Lung, and Blood Institute, said in an NIH statement. “An immediate step could be to require implicit bias training, particularly for transplant and VAD team members.”

Other suggestions are better tracking of underserved patients and the reasons why they do not receive VAD or become listed for transplant; inclusion of psychosocial components into decision-making about advanced therapy candidacy; and having “disparity experts” join in heart team meetings to help identify biases in real time.

Commenting on the study, Khadijah Breathett, MD, HF/transplant cardiologist and tenured associate professor of medicine, Indiana University Bloomington, said, “I’m glad there’s more push for awareness, because there’s still a population of people that don’t believe this is a real problem.”

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

A new study shows that Black Americans received ventricular assist devices (VADs) and heart transplants about half as often as White Americans, even when receiving care at an advanced heart failure (HF) center.

The analysis, drawn from 377 patients treated at one of 21 VAD centers in the United States as part of the RIVIVAL study, found that 22.3% of White adults received a heart transplant or VAD, compared with 11% of Black adults.

“That’s what is so concerning to us, that we’re seeing this pattern within this select population. I think it would be too reasonable to hypothesize that it very well could be worse in the general population,” study author Thomas Cascino, MD, MSc, University of Michigan, Ann Arbor, commented.

The study was published online in Circulation: Heart Failure, and it builds on previous work by the researchers, showing that patient preference for early VAD therapy is associated with higher New York Heart Association (NYHA) class and lower income level but not race.

In the present analysis, the number of Black and White participants who said they “definitely or probably” wanted VAD therapy was similar (27% vs. 29%), as was the number wanting “any and all life-sustaining therapies” (74% vs. 65%).

Two-thirds of the cohort was NYHA class III, the average EuroQoL visual analog scale (EQ-VAS) score was 64.6 among the 100 participants who identified as Black and 62.1 in the 277 White participants, and the average age was 58 and 61 years, respectively.

Death rates were also similar during the 2-year follow-up: 18% of Black patients and 13% of White patients.

After controlling for multiple clinical and social determinants of health, including age, Interagency Registry for Mechanically Assisted Circulator Support (INTERMACS) patient profile, EQ-VAS score, and level of education, Black participants had a 55% lower rate of VAD or transplant, compared with White participants (hazard ratio, 0.45; 95% confidence interval, 0.23-0.85). Adding VAD preference to the model did not affect the association.

“Our study suggests that we as providers may be making decisions differently,” Dr. Cascino said. “We can’t say for sure what the reasons are but certainly structural racism, discrimination, and provider biases are the things I worry about.”

“There’s an absolute need for us to look inwards, reflect, and acknowledge that we are likely playing a role in this and then start to be part of the change,” he added.

“The lives disabled or lost are simply too many,” coauthor Wendy Taddei-Peters, PhD, a clinical trials project official at the National Heart, Lung, and Blood Institute, said in an NIH statement. “An immediate step could be to require implicit bias training, particularly for transplant and VAD team members.”

Other suggestions are better tracking of underserved patients and the reasons why they do not receive VAD or become listed for transplant; inclusion of psychosocial components into decision-making about advanced therapy candidacy; and having “disparity experts” join in heart team meetings to help identify biases in real time.

Commenting on the study, Khadijah Breathett, MD, HF/transplant cardiologist and tenured associate professor of medicine, Indiana University Bloomington, said, “I’m glad there’s more push for awareness, because there’s still a population of people that don’t believe this is a real problem.”

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

Cocaine, methamphetamine, opioids, and cannabis may independently increase risk of atrial fibrillation (AFib), based on data from almost 24 million people.

While more work is needed to uncover causal links, physicians should be aware that these commonly abused substances could be driving new cases of AFib, reported investigators from the University of California, San Francisco.

“Though alcohol and tobacco smoking have each been associated with a heightened risk of [AFib], relationships between other drug use and [AFib] are poorly understood,” they wrote in European Heart Journal.

Some previous studies have ventured into this terrain, but most focused on fatal arrhythmias, or offered anecdotal evidence. This knowledge gap is particularly concerning for cannabis, the researchers noted, as medical and recreational use are on the rise.

American Heart Association

The present analysis included data from 23.5 million adults in California who received care through a hospital, emergency department, or outpatient surgery center during 2005-2015. Based on ICD-9 diagnostic codes, 132,834 of these patients used cannabis, 98,271 used methamphetamines, 48,701 used cocaine, and 10,032 used opiates. Inclusion required lack of AFib at baseline.

Reliance on ICD-9 codes makes the data “quite specific,” but lacking sensitivity, according to principal author Gregory M. Marcus, MD, cardiologist and professor of medicine at UCSF.

“If they were designated as using these drugs, that is very likely true,” Dr. Marcus said in an interview. “But certainly, the absence of any mention of use of these drugs does not exclude the possibility that some people were still using them. That would not create spurious false-positive relationships; if anything, it attenuates existing relationships.”

In other words, using ICD-9 codes reduced the power to detect an association between each drug and AFib, meaning any relationship needed to be sufficiently strong enough to generate a significant result.

At the end of the decade-long study period, 998,747 patients (4.2%) had developed incident AFib. After adjusting for potential confounders and mediators, all four drugs showed significant, independent associations with AFib. Methamphetamines presented the greatest risk (hazard ratio, 1.86%), followed by opiates (HR, 1.74), cocaine (HR, 1.61), and cannabis (HR, 1.35).

“Our findings provide the first evidence utilizing a longitudinal cohort to demonstrate that cannabis use predicts the future onset of AFib,” Dr. Marcus and colleagues wrote.

Dose-response relationships were not detected for any of the substances; however, usage levels were also derived from ICD-9 codes, which may have been insufficient for this purpose, according to the investigators.
 

Causal mechanisms deserve a closer look

Causal links between AFib and each of the drugs remain unclear. Citing prior research, Dr. Marcus and colleagues explained how methamphetamines are capable of “significant cardiac electrical remodeling,” while cocaine may cause sodium channel dysregulation, and opioids can render atrial myocytes more susceptible to oxidative damage. Although cannabis has previously been linked with hospitalization for arrhythmia, a pharmacologic driver of this phenomenon remains largely unexamined.

“We don’t know for sure precisely what the constituents are that are responsible for our findings,” Dr. Marcus said. “It’s possible that there are some effects that are much more generic, such as inhaling a burned substance. There is good evidence that if you inhale pretty much any sort of particulate matter, that increases inflammation in the body. Inflammation is known to be a trigger for atrial fibrillation.”

Alternatively, all four drugs – whether stimulants or depressants – cause “quite dramatic and often rapid effects on the autonomic nervous system,” Dr. Marcus said, noting that these rapid swings are a known trigger for AFib.

Brian Olshansky, MD, emeritus professor of internal medicine-cardiovascular medicine at the University of Iowa, Iowa City, suggested that nonpharmacologic factors are likely also playing a role.

“All these drugs have slightly different mechanisms of action, so there’s not one mechanism that would explain why all of them would cause atrial fibrillation,” Dr. Olshansky said in an interview. “That does suggest that there’s something else going on, besides just the drug itself. It would be potentially concerning if we were to lay the blame totally on these drugs.”

Dr. Olshansky, who recently coauthored a review of stimulant drugs and arrhythmias, suggested that lifestyle, comorbidities, and drug impurities may have added to the risk of AF.

“[The investigators] did try to correct for that kind of stuff, but it’s very hard to correct for a lot of the issues that may be ongoing with individuals who partake in these drugs,” Dr. Olshansky said in an interview. “They may not be a healthy lot, in general.”

Still, considering previous data linking drugs of abuse with arrhythmias, he said the detected risks were “intriguing,” and deserved a closer look.

“It’s a nice groundbreaking study, with regard to the fact that they showed unique relationships that we don’t completely understand,” Dr. Olshansky said. “It opens up a new opportunity for further investigation.”

The investigators disclosed relationships with InCarda, Baylis Medical, Johnson & Johnson, and others. Dr. Olshansky disclosed no relevant competing interests.

Cocaine, methamphetamine, opioids, and cannabis may independently increase risk of atrial fibrillation (AFib), based on data from almost 24 million people.

While more work is needed to uncover causal links, physicians should be aware that these commonly abused substances could be driving new cases of AFib, reported investigators from the University of California, San Francisco.

“Though alcohol and tobacco smoking have each been associated with a heightened risk of [AFib], relationships between other drug use and [AFib] are poorly understood,” they wrote in European Heart Journal.

Some previous studies have ventured into this terrain, but most focused on fatal arrhythmias, or offered anecdotal evidence. This knowledge gap is particularly concerning for cannabis, the researchers noted, as medical and recreational use are on the rise.

American Heart Association

The present analysis included data from 23.5 million adults in California who received care through a hospital, emergency department, or outpatient surgery center during 2005-2015. Based on ICD-9 diagnostic codes, 132,834 of these patients used cannabis, 98,271 used methamphetamines, 48,701 used cocaine, and 10,032 used opiates. Inclusion required lack of AFib at baseline.

Reliance on ICD-9 codes makes the data “quite specific,” but lacking sensitivity, according to principal author Gregory M. Marcus, MD, cardiologist and professor of medicine at UCSF.

“If they were designated as using these drugs, that is very likely true,” Dr. Marcus said in an interview. “But certainly, the absence of any mention of use of these drugs does not exclude the possibility that some people were still using them. That would not create spurious false-positive relationships; if anything, it attenuates existing relationships.”

In other words, using ICD-9 codes reduced the power to detect an association between each drug and AFib, meaning any relationship needed to be sufficiently strong enough to generate a significant result.

At the end of the decade-long study period, 998,747 patients (4.2%) had developed incident AFib. After adjusting for potential confounders and mediators, all four drugs showed significant, independent associations with AFib. Methamphetamines presented the greatest risk (hazard ratio, 1.86%), followed by opiates (HR, 1.74), cocaine (HR, 1.61), and cannabis (HR, 1.35).

“Our findings provide the first evidence utilizing a longitudinal cohort to demonstrate that cannabis use predicts the future onset of AFib,” Dr. Marcus and colleagues wrote.

Dose-response relationships were not detected for any of the substances; however, usage levels were also derived from ICD-9 codes, which may have been insufficient for this purpose, according to the investigators.
 

Causal mechanisms deserve a closer look

Causal links between AFib and each of the drugs remain unclear. Citing prior research, Dr. Marcus and colleagues explained how methamphetamines are capable of “significant cardiac electrical remodeling,” while cocaine may cause sodium channel dysregulation, and opioids can render atrial myocytes more susceptible to oxidative damage. Although cannabis has previously been linked with hospitalization for arrhythmia, a pharmacologic driver of this phenomenon remains largely unexamined.

“We don’t know for sure precisely what the constituents are that are responsible for our findings,” Dr. Marcus said. “It’s possible that there are some effects that are much more generic, such as inhaling a burned substance. There is good evidence that if you inhale pretty much any sort of particulate matter, that increases inflammation in the body. Inflammation is known to be a trigger for atrial fibrillation.”

Alternatively, all four drugs – whether stimulants or depressants – cause “quite dramatic and often rapid effects on the autonomic nervous system,” Dr. Marcus said, noting that these rapid swings are a known trigger for AFib.

Brian Olshansky, MD, emeritus professor of internal medicine-cardiovascular medicine at the University of Iowa, Iowa City, suggested that nonpharmacologic factors are likely also playing a role.

“All these drugs have slightly different mechanisms of action, so there’s not one mechanism that would explain why all of them would cause atrial fibrillation,” Dr. Olshansky said in an interview. “That does suggest that there’s something else going on, besides just the drug itself. It would be potentially concerning if we were to lay the blame totally on these drugs.”

Dr. Olshansky, who recently coauthored a review of stimulant drugs and arrhythmias, suggested that lifestyle, comorbidities, and drug impurities may have added to the risk of AF.

“[The investigators] did try to correct for that kind of stuff, but it’s very hard to correct for a lot of the issues that may be ongoing with individuals who partake in these drugs,” Dr. Olshansky said in an interview. “They may not be a healthy lot, in general.”

Still, considering previous data linking drugs of abuse with arrhythmias, he said the detected risks were “intriguing,” and deserved a closer look.

“It’s a nice groundbreaking study, with regard to the fact that they showed unique relationships that we don’t completely understand,” Dr. Olshansky said. “It opens up a new opportunity for further investigation.”

The investigators disclosed relationships with InCarda, Baylis Medical, Johnson & Johnson, and others. Dr. Olshansky disclosed no relevant competing interests.

Cocaine, methamphetamine, opioids, and cannabis may independently increase risk of atrial fibrillation (AFib), based on data from almost 24 million people.

While more work is needed to uncover causal links, physicians should be aware that these commonly abused substances could be driving new cases of AFib, reported investigators from the University of California, San Francisco.

“Though alcohol and tobacco smoking have each been associated with a heightened risk of [AFib], relationships between other drug use and [AFib] are poorly understood,” they wrote in European Heart Journal.

Some previous studies have ventured into this terrain, but most focused on fatal arrhythmias, or offered anecdotal evidence. This knowledge gap is particularly concerning for cannabis, the researchers noted, as medical and recreational use are on the rise.

American Heart Association

The present analysis included data from 23.5 million adults in California who received care through a hospital, emergency department, or outpatient surgery center during 2005-2015. Based on ICD-9 diagnostic codes, 132,834 of these patients used cannabis, 98,271 used methamphetamines, 48,701 used cocaine, and 10,032 used opiates. Inclusion required lack of AFib at baseline.

Reliance on ICD-9 codes makes the data “quite specific,” but lacking sensitivity, according to principal author Gregory M. Marcus, MD, cardiologist and professor of medicine at UCSF.

“If they were designated as using these drugs, that is very likely true,” Dr. Marcus said in an interview. “But certainly, the absence of any mention of use of these drugs does not exclude the possibility that some people were still using them. That would not create spurious false-positive relationships; if anything, it attenuates existing relationships.”

In other words, using ICD-9 codes reduced the power to detect an association between each drug and AFib, meaning any relationship needed to be sufficiently strong enough to generate a significant result.

At the end of the decade-long study period, 998,747 patients (4.2%) had developed incident AFib. After adjusting for potential confounders and mediators, all four drugs showed significant, independent associations with AFib. Methamphetamines presented the greatest risk (hazard ratio, 1.86%), followed by opiates (HR, 1.74), cocaine (HR, 1.61), and cannabis (HR, 1.35).

“Our findings provide the first evidence utilizing a longitudinal cohort to demonstrate that cannabis use predicts the future onset of AFib,” Dr. Marcus and colleagues wrote.

Dose-response relationships were not detected for any of the substances; however, usage levels were also derived from ICD-9 codes, which may have been insufficient for this purpose, according to the investigators.
 

Causal mechanisms deserve a closer look

Causal links between AFib and each of the drugs remain unclear. Citing prior research, Dr. Marcus and colleagues explained how methamphetamines are capable of “significant cardiac electrical remodeling,” while cocaine may cause sodium channel dysregulation, and opioids can render atrial myocytes more susceptible to oxidative damage. Although cannabis has previously been linked with hospitalization for arrhythmia, a pharmacologic driver of this phenomenon remains largely unexamined.

“We don’t know for sure precisely what the constituents are that are responsible for our findings,” Dr. Marcus said. “It’s possible that there are some effects that are much more generic, such as inhaling a burned substance. There is good evidence that if you inhale pretty much any sort of particulate matter, that increases inflammation in the body. Inflammation is known to be a trigger for atrial fibrillation.”

Alternatively, all four drugs – whether stimulants or depressants – cause “quite dramatic and often rapid effects on the autonomic nervous system,” Dr. Marcus said, noting that these rapid swings are a known trigger for AFib.

Brian Olshansky, MD, emeritus professor of internal medicine-cardiovascular medicine at the University of Iowa, Iowa City, suggested that nonpharmacologic factors are likely also playing a role.

“All these drugs have slightly different mechanisms of action, so there’s not one mechanism that would explain why all of them would cause atrial fibrillation,” Dr. Olshansky said in an interview. “That does suggest that there’s something else going on, besides just the drug itself. It would be potentially concerning if we were to lay the blame totally on these drugs.”

Dr. Olshansky, who recently coauthored a review of stimulant drugs and arrhythmias, suggested that lifestyle, comorbidities, and drug impurities may have added to the risk of AF.

“[The investigators] did try to correct for that kind of stuff, but it’s very hard to correct for a lot of the issues that may be ongoing with individuals who partake in these drugs,” Dr. Olshansky said in an interview. “They may not be a healthy lot, in general.”

Still, considering previous data linking drugs of abuse with arrhythmias, he said the detected risks were “intriguing,” and deserved a closer look.

“It’s a nice groundbreaking study, with regard to the fact that they showed unique relationships that we don’t completely understand,” Dr. Olshansky said. “It opens up a new opportunity for further investigation.”

The investigators disclosed relationships with InCarda, Baylis Medical, Johnson & Johnson, and others. Dr. Olshansky disclosed no relevant competing interests.

CHARLOTTE, N.C. – In a small proof-of-concept study, patients with small unresectable pancreatic cancers treated with endoscopic ultrasound–guided radiofrequency ablation (EUS-RFA) had a more than twofold improvement in overall survival compared with historical controls with a similar disease history, investigators in Thailand found.

In a weighted analysis, median weighted overall survival – the primary outcome – was 14 months among 11 patients who underwent EUS-RFA, compared with 6.1 months for 35 matched controls, translating into a hazard ratio for death with EUS-RFA of 0.38 (P = .016), reported Chawin Lopimpisuth, MD, from King Chulalongkorn Memorial Hospital in Bangkok, Thailand.

Median weighted progression-free survival (PFS) was longer among cases than controls, but did not differ significantly, at 6.1 months and 3.9 months, respectively.

“In patients with unresectable pancreatic ductal adenocarcinomas that are less than 4 cm, EUS-RFA alone or combined with chemotherapy resulted in significantly improved overall survival and tended to improve progression-free survival with minimal adverse events,” Dr. Lopimpisuth reported at the annual meeting of the American College of Gastroenterology.
 

Small but unresectable tumors

Endoscopically guided radiofrequency ablation of pancreatic ductal tumors has been shown to be both feasible and safe in previous studies, he said, prompting his group to explore whether EUS-RFA could help to control the primary tumor and improve survival outcomes.

They enrolled 11 patients with primary pancreatic ductal adenocarcinoma tumors less than 4 cm in diameter that were unresectable due to blood vessel involvement or distant metastasis, and used propensity-score matching to pair them with a total of 35 controls. Controls were matched by tumor size, staging, age-adjusted Charlson Comorbidity Index, chemotherapy regimen received, and interactions between CCI, regimen, and staging.

The results were weighted to assure that covariate distribution among patients treated with chemotherapy only equaled that of patients who underwent EUS-RFA.

Patients underwent EUS-RFA with a 19-gauge needle, with 50 watts of energy delivered with an impedance of 100 ohms. Those patients deemed able to tolerate chemotherapy received that as well.

After a minimum of 1 year of follow-up, the median weighted survival, as noted before, was 14 months for patients who received EUS-RFA, compared with 6.1 months for controls.

Adjusted survival probabilities at 6 and 12 months were 73% and 64%, respectively, for patients in the EUS-RFA group, compared with 69% and 17% for controls. Adjusted PFS rates at 6 and 12 months were 55% and 36% in the EUS-RFA group, compared with 28% and 4% in the control group.

The only adverse event of significance was mild abdominal pain, reported by 8.3% of total EUS-RFA procedures.
 

Promising but preliminary

In an interview with this news organization, ACG President Samir A. Shah, MD, from Brown University and Miriam Hospital in Providence, R.I., who was not involved in the study, commented that “we have limited options with these patients, so it’s really exciting to see an initial trend toward efficacy, and their survival improvement was significant by several months.”

Dr. Shah was a moderator of the presidential symposium where the data were presented.

Comoderator Brooks D. Cash, MD, from the University of Texas Health Science Center at Houston, said that the advantage of EUS-RFA is that it’s only minimally invasive and appears to offer a significant survival advantage for patients with few effective treatment options.

He cautioned, however, that “it’s a small study and needs to be replicated in a larger venue and different sites as well, but I think it looks very promising.”

The investigators did not report a funding source for the study. Dr. Lopimpisuth, Dr. Shah, and Dr. Cash all reported having no relevant financial relationships to disclose.

CHARLOTTE, N.C. – In a small proof-of-concept study, patients with small unresectable pancreatic cancers treated with endoscopic ultrasound–guided radiofrequency ablation (EUS-RFA) had a more than twofold improvement in overall survival compared with historical controls with a similar disease history, investigators in Thailand found.

In a weighted analysis, median weighted overall survival – the primary outcome – was 14 months among 11 patients who underwent EUS-RFA, compared with 6.1 months for 35 matched controls, translating into a hazard ratio for death with EUS-RFA of 0.38 (P = .016), reported Chawin Lopimpisuth, MD, from King Chulalongkorn Memorial Hospital in Bangkok, Thailand.

Median weighted progression-free survival (PFS) was longer among cases than controls, but did not differ significantly, at 6.1 months and 3.9 months, respectively.

“In patients with unresectable pancreatic ductal adenocarcinomas that are less than 4 cm, EUS-RFA alone or combined with chemotherapy resulted in significantly improved overall survival and tended to improve progression-free survival with minimal adverse events,” Dr. Lopimpisuth reported at the annual meeting of the American College of Gastroenterology.
 

Small but unresectable tumors

Endoscopically guided radiofrequency ablation of pancreatic ductal tumors has been shown to be both feasible and safe in previous studies, he said, prompting his group to explore whether EUS-RFA could help to control the primary tumor and improve survival outcomes.

They enrolled 11 patients with primary pancreatic ductal adenocarcinoma tumors less than 4 cm in diameter that were unresectable due to blood vessel involvement or distant metastasis, and used propensity-score matching to pair them with a total of 35 controls. Controls were matched by tumor size, staging, age-adjusted Charlson Comorbidity Index, chemotherapy regimen received, and interactions between CCI, regimen, and staging.

The results were weighted to assure that covariate distribution among patients treated with chemotherapy only equaled that of patients who underwent EUS-RFA.

Patients underwent EUS-RFA with a 19-gauge needle, with 50 watts of energy delivered with an impedance of 100 ohms. Those patients deemed able to tolerate chemotherapy received that as well.

After a minimum of 1 year of follow-up, the median weighted survival, as noted before, was 14 months for patients who received EUS-RFA, compared with 6.1 months for controls.

Adjusted survival probabilities at 6 and 12 months were 73% and 64%, respectively, for patients in the EUS-RFA group, compared with 69% and 17% for controls. Adjusted PFS rates at 6 and 12 months were 55% and 36% in the EUS-RFA group, compared with 28% and 4% in the control group.

The only adverse event of significance was mild abdominal pain, reported by 8.3% of total EUS-RFA procedures.
 

Promising but preliminary

In an interview with this news organization, ACG President Samir A. Shah, MD, from Brown University and Miriam Hospital in Providence, R.I., who was not involved in the study, commented that “we have limited options with these patients, so it’s really exciting to see an initial trend toward efficacy, and their survival improvement was significant by several months.”

Dr. Shah was a moderator of the presidential symposium where the data were presented.

Comoderator Brooks D. Cash, MD, from the University of Texas Health Science Center at Houston, said that the advantage of EUS-RFA is that it’s only minimally invasive and appears to offer a significant survival advantage for patients with few effective treatment options.

He cautioned, however, that “it’s a small study and needs to be replicated in a larger venue and different sites as well, but I think it looks very promising.”

The investigators did not report a funding source for the study. Dr. Lopimpisuth, Dr. Shah, and Dr. Cash all reported having no relevant financial relationships to disclose.

CHARLOTTE, N.C. – In a small proof-of-concept study, patients with small unresectable pancreatic cancers treated with endoscopic ultrasound–guided radiofrequency ablation (EUS-RFA) had a more than twofold improvement in overall survival compared with historical controls with a similar disease history, investigators in Thailand found.

In a weighted analysis, median weighted overall survival – the primary outcome – was 14 months among 11 patients who underwent EUS-RFA, compared with 6.1 months for 35 matched controls, translating into a hazard ratio for death with EUS-RFA of 0.38 (P = .016), reported Chawin Lopimpisuth, MD, from King Chulalongkorn Memorial Hospital in Bangkok, Thailand.

Median weighted progression-free survival (PFS) was longer among cases than controls, but did not differ significantly, at 6.1 months and 3.9 months, respectively.

“In patients with unresectable pancreatic ductal adenocarcinomas that are less than 4 cm, EUS-RFA alone or combined with chemotherapy resulted in significantly improved overall survival and tended to improve progression-free survival with minimal adverse events,” Dr. Lopimpisuth reported at the annual meeting of the American College of Gastroenterology.
 

Small but unresectable tumors

Endoscopically guided radiofrequency ablation of pancreatic ductal tumors has been shown to be both feasible and safe in previous studies, he said, prompting his group to explore whether EUS-RFA could help to control the primary tumor and improve survival outcomes.

They enrolled 11 patients with primary pancreatic ductal adenocarcinoma tumors less than 4 cm in diameter that were unresectable due to blood vessel involvement or distant metastasis, and used propensity-score matching to pair them with a total of 35 controls. Controls were matched by tumor size, staging, age-adjusted Charlson Comorbidity Index, chemotherapy regimen received, and interactions between CCI, regimen, and staging.

The results were weighted to assure that covariate distribution among patients treated with chemotherapy only equaled that of patients who underwent EUS-RFA.

Patients underwent EUS-RFA with a 19-gauge needle, with 50 watts of energy delivered with an impedance of 100 ohms. Those patients deemed able to tolerate chemotherapy received that as well.

After a minimum of 1 year of follow-up, the median weighted survival, as noted before, was 14 months for patients who received EUS-RFA, compared with 6.1 months for controls.

Adjusted survival probabilities at 6 and 12 months were 73% and 64%, respectively, for patients in the EUS-RFA group, compared with 69% and 17% for controls. Adjusted PFS rates at 6 and 12 months were 55% and 36% in the EUS-RFA group, compared with 28% and 4% in the control group.

The only adverse event of significance was mild abdominal pain, reported by 8.3% of total EUS-RFA procedures.
 

Promising but preliminary

In an interview with this news organization, ACG President Samir A. Shah, MD, from Brown University and Miriam Hospital in Providence, R.I., who was not involved in the study, commented that “we have limited options with these patients, so it’s really exciting to see an initial trend toward efficacy, and their survival improvement was significant by several months.”

Dr. Shah was a moderator of the presidential symposium where the data were presented.

Comoderator Brooks D. Cash, MD, from the University of Texas Health Science Center at Houston, said that the advantage of EUS-RFA is that it’s only minimally invasive and appears to offer a significant survival advantage for patients with few effective treatment options.

He cautioned, however, that “it’s a small study and needs to be replicated in a larger venue and different sites as well, but I think it looks very promising.”

The investigators did not report a funding source for the study. Dr. Lopimpisuth, Dr. Shah, and Dr. Cash all reported having no relevant financial relationships to disclose.

Black mothers giving birth in hospitals are 53% more likely to die during childbirth than are Hispanic and White women, according to researchers who attributed the gap at least in part to bias among physicians and the health care system.

The United States is in the midst of a maternal healthcare crisis, said Robert White, MD, assistant professor of anesthesiology at Weill Cornell Medicine, New York, and lead author of the study. The maternal death rate among U.S. women in 2018, for instance, was 17.4 per 100,000 births, more than twice the figure in Canada (8.6 per 100,000 live births) and the United Kingdom (6.5 per 100,000 live births in 2016), according to the Commonwealth Fund.

“At baseline, our maternal mortality rates are higher than other comparable Western nations, and at the same time, there’s a huge spread in the maternal mortality ratio between White mothers and Black mothers, where Black mothers are experiencing maternal mortality about two or three times higher,” Dr. White told this news organization.

Previous research has shown racial disparities in rates of maternal mortality. But Dr. White said that his study controlled for income level, type of insurance, and other social factors that may have affected the health of the women.

“The research that I conducted is one of the largest of its kind, and the logistic regression model that we were able to run was able to control for a lot of these factors,” he said.

For the new study, presented at the 2022 annual meeting of the American Society of Anesthesiologists, Dr. White and his team analyzed data from 9.5 million deliveries across six states (California, Florida, Kentucky, Maryland, New York, and Washington) between 2007 and 2018. They found that 49,472 mothers (0.5%) either died in the hospital or experienced an injury during childbirth, which included damages to the brain, heart, eyes, or kidneys.

Overall, 0.8% of Black women experienced either a death or an injury, compared with 0.5% of Hispanic women and 0.4% of White women. The researchers concluded that Black women had a 53% increased chance of dying during childbirth in a hospital, even after adjusting for factors such as insurance type, hospital type, and income.

If income, insurance type, and other social factors aren’t driving this disparity in maternal mortality, what is? Dr. White said that the study didn’t uncover the underlying cause, but in his opinion, racial bias and systemic racism are likely contributing to the gap in deaths.

“I think the takeaway for physicians should be that we should humbly accept that prejudice, bias, and racism does exist among physicians,” Dr. White said.

Adi Davidov, MD, associate chair of obstetrics and gynecology at Staten Island (N.Y.) University Hospital, said that both anesthesiologists and ob.gyns. have been aware of these disparate health outcomes for years but have historically attributed the higher odds of injuries and death amongst Black women to health issues rather than racism.

“It is now quite evident that there is more to the story and that there is a degree of unconscious bias as well as systemic racism in health care that contributes to the disparities in outcomes,” said Dr. Davidov, who was not involved in the study.

Meanwhile, new data show that maternal mortality worsened during the COVID-19 pandemic, particularly for Black women. The rate of maternal death for Black women was 44 per 100,000 live births in 2019, 55.3 in 2020, and 68.9 in 2021, according to the U.S. Government Accountability Office. In contrast, White women had death rates of 17.9, 19.1, and 26.1, respectively.

“Bias or discrimination within the health care system can create communication challenges between providers and their patients, which may increase the risk of adverse outcomes,” the report stated.
 

What can be done

The most important thing physicians can do is to understand and acknowledge unconscious bias, Dr. Davidov told this news organization. “It is important to learn how to identify biases and make sure that it does not affect your medical decision making,” he said.

Dr. White suggested that physicians receive training in implicit bias and cultural competency and stay up to date on research regarding race and medicine as well as learning and using inclusive language.

He also urged physicians closely follow protocols for standard care for their discipline.

“Standardized care protocols have been shown to reduce variance between care of patients of different social structures and shown to decrease this disparity gap,” he said.

The study was supported by a Foundation for Anesthesia Education and Research Mentored Research Training Grant. Dr. White and Dr. Davidov report no relevant financial relationships.

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

Black mothers giving birth in hospitals are 53% more likely to die during childbirth than are Hispanic and White women, according to researchers who attributed the gap at least in part to bias among physicians and the health care system.

The United States is in the midst of a maternal healthcare crisis, said Robert White, MD, assistant professor of anesthesiology at Weill Cornell Medicine, New York, and lead author of the study. The maternal death rate among U.S. women in 2018, for instance, was 17.4 per 100,000 births, more than twice the figure in Canada (8.6 per 100,000 live births) and the United Kingdom (6.5 per 100,000 live births in 2016), according to the Commonwealth Fund.

“At baseline, our maternal mortality rates are higher than other comparable Western nations, and at the same time, there’s a huge spread in the maternal mortality ratio between White mothers and Black mothers, where Black mothers are experiencing maternal mortality about two or three times higher,” Dr. White told this news organization.

Previous research has shown racial disparities in rates of maternal mortality. But Dr. White said that his study controlled for income level, type of insurance, and other social factors that may have affected the health of the women.

“The research that I conducted is one of the largest of its kind, and the logistic regression model that we were able to run was able to control for a lot of these factors,” he said.

For the new study, presented at the 2022 annual meeting of the American Society of Anesthesiologists, Dr. White and his team analyzed data from 9.5 million deliveries across six states (California, Florida, Kentucky, Maryland, New York, and Washington) between 2007 and 2018. They found that 49,472 mothers (0.5%) either died in the hospital or experienced an injury during childbirth, which included damages to the brain, heart, eyes, or kidneys.

Overall, 0.8% of Black women experienced either a death or an injury, compared with 0.5% of Hispanic women and 0.4% of White women. The researchers concluded that Black women had a 53% increased chance of dying during childbirth in a hospital, even after adjusting for factors such as insurance type, hospital type, and income.

If income, insurance type, and other social factors aren’t driving this disparity in maternal mortality, what is? Dr. White said that the study didn’t uncover the underlying cause, but in his opinion, racial bias and systemic racism are likely contributing to the gap in deaths.

“I think the takeaway for physicians should be that we should humbly accept that prejudice, bias, and racism does exist among physicians,” Dr. White said.

Adi Davidov, MD, associate chair of obstetrics and gynecology at Staten Island (N.Y.) University Hospital, said that both anesthesiologists and ob.gyns. have been aware of these disparate health outcomes for years but have historically attributed the higher odds of injuries and death amongst Black women to health issues rather than racism.

“It is now quite evident that there is more to the story and that there is a degree of unconscious bias as well as systemic racism in health care that contributes to the disparities in outcomes,” said Dr. Davidov, who was not involved in the study.

Meanwhile, new data show that maternal mortality worsened during the COVID-19 pandemic, particularly for Black women. The rate of maternal death for Black women was 44 per 100,000 live births in 2019, 55.3 in 2020, and 68.9 in 2021, according to the U.S. Government Accountability Office. In contrast, White women had death rates of 17.9, 19.1, and 26.1, respectively.

“Bias or discrimination within the health care system can create communication challenges between providers and their patients, which may increase the risk of adverse outcomes,” the report stated.
 

What can be done

The most important thing physicians can do is to understand and acknowledge unconscious bias, Dr. Davidov told this news organization. “It is important to learn how to identify biases and make sure that it does not affect your medical decision making,” he said.

Dr. White suggested that physicians receive training in implicit bias and cultural competency and stay up to date on research regarding race and medicine as well as learning and using inclusive language.

He also urged physicians closely follow protocols for standard care for their discipline.

“Standardized care protocols have been shown to reduce variance between care of patients of different social structures and shown to decrease this disparity gap,” he said.

The study was supported by a Foundation for Anesthesia Education and Research Mentored Research Training Grant. Dr. White and Dr. Davidov report no relevant financial relationships.

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

Black mothers giving birth in hospitals are 53% more likely to die during childbirth than are Hispanic and White women, according to researchers who attributed the gap at least in part to bias among physicians and the health care system.

The United States is in the midst of a maternal healthcare crisis, said Robert White, MD, assistant professor of anesthesiology at Weill Cornell Medicine, New York, and lead author of the study. The maternal death rate among U.S. women in 2018, for instance, was 17.4 per 100,000 births, more than twice the figure in Canada (8.6 per 100,000 live births) and the United Kingdom (6.5 per 100,000 live births in 2016), according to the Commonwealth Fund.

“At baseline, our maternal mortality rates are higher than other comparable Western nations, and at the same time, there’s a huge spread in the maternal mortality ratio between White mothers and Black mothers, where Black mothers are experiencing maternal mortality about two or three times higher,” Dr. White told this news organization.

Previous research has shown racial disparities in rates of maternal mortality. But Dr. White said that his study controlled for income level, type of insurance, and other social factors that may have affected the health of the women.

“The research that I conducted is one of the largest of its kind, and the logistic regression model that we were able to run was able to control for a lot of these factors,” he said.

For the new study, presented at the 2022 annual meeting of the American Society of Anesthesiologists, Dr. White and his team analyzed data from 9.5 million deliveries across six states (California, Florida, Kentucky, Maryland, New York, and Washington) between 2007 and 2018. They found that 49,472 mothers (0.5%) either died in the hospital or experienced an injury during childbirth, which included damages to the brain, heart, eyes, or kidneys.

Overall, 0.8% of Black women experienced either a death or an injury, compared with 0.5% of Hispanic women and 0.4% of White women. The researchers concluded that Black women had a 53% increased chance of dying during childbirth in a hospital, even after adjusting for factors such as insurance type, hospital type, and income.

If income, insurance type, and other social factors aren’t driving this disparity in maternal mortality, what is? Dr. White said that the study didn’t uncover the underlying cause, but in his opinion, racial bias and systemic racism are likely contributing to the gap in deaths.

“I think the takeaway for physicians should be that we should humbly accept that prejudice, bias, and racism does exist among physicians,” Dr. White said.

Adi Davidov, MD, associate chair of obstetrics and gynecology at Staten Island (N.Y.) University Hospital, said that both anesthesiologists and ob.gyns. have been aware of these disparate health outcomes for years but have historically attributed the higher odds of injuries and death amongst Black women to health issues rather than racism.

“It is now quite evident that there is more to the story and that there is a degree of unconscious bias as well as systemic racism in health care that contributes to the disparities in outcomes,” said Dr. Davidov, who was not involved in the study.

Meanwhile, new data show that maternal mortality worsened during the COVID-19 pandemic, particularly for Black women. The rate of maternal death for Black women was 44 per 100,000 live births in 2019, 55.3 in 2020, and 68.9 in 2021, according to the U.S. Government Accountability Office. In contrast, White women had death rates of 17.9, 19.1, and 26.1, respectively.

“Bias or discrimination within the health care system can create communication challenges between providers and their patients, which may increase the risk of adverse outcomes,” the report stated.
 

What can be done

The most important thing physicians can do is to understand and acknowledge unconscious bias, Dr. Davidov told this news organization. “It is important to learn how to identify biases and make sure that it does not affect your medical decision making,” he said.

Dr. White suggested that physicians receive training in implicit bias and cultural competency and stay up to date on research regarding race and medicine as well as learning and using inclusive language.

He also urged physicians closely follow protocols for standard care for their discipline.

“Standardized care protocols have been shown to reduce variance between care of patients of different social structures and shown to decrease this disparity gap,” he said.

The study was supported by a Foundation for Anesthesia Education and Research Mentored Research Training Grant. Dr. White and Dr. Davidov report no relevant financial relationships.

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

For years, the US Department of Veterans Affairs (VA) has painstakingly labored to track, research, and address veteran suicide. Their exceptional work was dealt an unwarranted blow a month ago with the publication of an incomplete report entitled Operation Deep Dive (OpDD). The $3.9 million study from America’s Warrior Partnership (AWP) examined death data of former service members in 8 states between 2014 and 2018. The interim report criticized the VA for minimizing the extent of veteran suicide, asserting, “former service members take their own lives each year at a rate approximately 2.4 times greater than previously reported by the VA.”

The sensational results were accepted at face value and immediately garnered negative nationwide headlines, with lawmakers, media outlets, and veterans rushing to impugn the VA. Senate Committee on Veterans’ Affairs Ranking Republican Member Jerry Moran of Kansas opined, “The disparity between the numbers of veteran suicides reported by the VA and [OpDD] is concerning. We need an honest assessment of the scope of the problem.” A U.S. Medicine headline stated “VA undercounted thousands of veteran suicides. [OpDD] posited daily suicide rate is 240% higher.” Fox News declared, “Veterans committing suicide at rate 2 times higher than VA data show: study,” as did Military Times, “Veterans suicide rate may be double federal estimates, study suggests.”

Disturbingly, those who echoed AWP’s claims got the story backward. It’s AWP, not VA, whose suicide data and conclusions are faulty.

For starters, the VA data encompasses veterans across all 50 states, the District of Columbia, Puerto Rico, and the US Virgin Islands. In contrast, AWP inferred national veteran suicide figures based on partial, skewed data. As delineated by researchers in an in-press Military Medicine letter to the Editor, 7 of the 8 states sampled (Alabama, Florida, Maine, Massachusetts, Michigan, Minnesota, Montana, and Oregon) had suicide rates above the national average for the years under investigation. This factor alone overinflates AWP’s purported suicide numbers.

Additionally, AWP altered the definition of “taking one’s life” and then misapplied that designation. Conventionally, the term refers to suicide, but AWP used it to also include nonnatural deaths assessed by coroners and medical examiners as accidental or undetermined. Two examples of this self-injury mortality (SIM) are opioid overdoses and single-driver car crash deaths. AWP added suicides and SIMs to derive a total number of veterans who took their life and falsely contrasted that aggregate against the VA count of suicides. That’s like comparing the whole category of fruit to the subcategory of apples.

AWP should be applauded for drawing attention to and accounting for accidental and undetermined deaths. However, the standard protocol is to consider SIMs distinctly from suicides. Among the many reasons for precise labeling is so that grieving family members aren’t mistakenly informed that their loved one died by suicide. VA conveys the rate of veteran overdose deaths in separate reports, for example, the Veteran Drug Overdose Mortality, 2010-2019 publication. Those numbers were ignored in AWP’s calculations.

AWP was neglectful in another way. The second phase of the project—a deep examination of community-level factors preceding suicides and nonnatural deaths—began in 2019. This information was collected and analyzed through sociocultural death investigation (SDI) interviews of 3 to 4 family members, friends, and colleagues of the deceased. SDIs consisted of 19 factors, such as history of the veteran’s mental health problems, social connectedness, finances, group memberships, and access to firearms. However, the interim report omitted the preliminary analysis of these factors, which AWP stated would be made available this year.

OpDD conclusions were so unfounded that AWP’s analytic research partner, the University of Alabama, distanced itself from the interim report. “We were not consulted on the released figures,” Dr. Karl Hamner, the University of Alabama principal investigator on the study, told me. “We did not make any conclusions and we don’t endorse the reported findings about national rates or numbers per day. Nor did we make any statements about the VA’s data.”

As it happens, the VA’s 2022 National Veteran Suicide Prevention Annual Report was issued the same week as the OpDD report. VA found that veteran suicides decreased by 9.7% over the last 2 years, nearly twice the decrease for nonveterans. Yet, in a contemporaneous hearing of the House Committee on Veterans’ Affairs, AWP’s President and CEO Jim Lorraine testified that the progress preventing veteran suicide was “a disgrace” and “a failure.” He misattributed that it was VA (not AWP) that “must be more open and transparent about their data.”

Unsupported denigration of the VA tarnishes its reputation, undermining veterans’ trust in the health care system and increasing barriers to seeking needed services. More broadly, it fortifies those forces who wish to redirect allocations away from VA and towards non-VA veterans’ entities like AWP. The media and other stakeholders must take a lesson about getting the story straight before reflexively amplifying false accusations about the VA. Veterans deserve better.

For years, the US Department of Veterans Affairs (VA) has painstakingly labored to track, research, and address veteran suicide. Their exceptional work was dealt an unwarranted blow a month ago with the publication of an incomplete report entitled Operation Deep Dive (OpDD). The $3.9 million study from America’s Warrior Partnership (AWP) examined death data of former service members in 8 states between 2014 and 2018. The interim report criticized the VA for minimizing the extent of veteran suicide, asserting, “former service members take their own lives each year at a rate approximately 2.4 times greater than previously reported by the VA.”

The sensational results were accepted at face value and immediately garnered negative nationwide headlines, with lawmakers, media outlets, and veterans rushing to impugn the VA. Senate Committee on Veterans’ Affairs Ranking Republican Member Jerry Moran of Kansas opined, “The disparity between the numbers of veteran suicides reported by the VA and [OpDD] is concerning. We need an honest assessment of the scope of the problem.” A U.S. Medicine headline stated “VA undercounted thousands of veteran suicides. [OpDD] posited daily suicide rate is 240% higher.” Fox News declared, “Veterans committing suicide at rate 2 times higher than VA data show: study,” as did Military Times, “Veterans suicide rate may be double federal estimates, study suggests.”

Disturbingly, those who echoed AWP’s claims got the story backward. It’s AWP, not VA, whose suicide data and conclusions are faulty.

For starters, the VA data encompasses veterans across all 50 states, the District of Columbia, Puerto Rico, and the US Virgin Islands. In contrast, AWP inferred national veteran suicide figures based on partial, skewed data. As delineated by researchers in an in-press Military Medicine letter to the Editor, 7 of the 8 states sampled (Alabama, Florida, Maine, Massachusetts, Michigan, Minnesota, Montana, and Oregon) had suicide rates above the national average for the years under investigation. This factor alone overinflates AWP’s purported suicide numbers.

Additionally, AWP altered the definition of “taking one’s life” and then misapplied that designation. Conventionally, the term refers to suicide, but AWP used it to also include nonnatural deaths assessed by coroners and medical examiners as accidental or undetermined. Two examples of this self-injury mortality (SIM) are opioid overdoses and single-driver car crash deaths. AWP added suicides and SIMs to derive a total number of veterans who took their life and falsely contrasted that aggregate against the VA count of suicides. That’s like comparing the whole category of fruit to the subcategory of apples.

AWP should be applauded for drawing attention to and accounting for accidental and undetermined deaths. However, the standard protocol is to consider SIMs distinctly from suicides. Among the many reasons for precise labeling is so that grieving family members aren’t mistakenly informed that their loved one died by suicide. VA conveys the rate of veteran overdose deaths in separate reports, for example, the Veteran Drug Overdose Mortality, 2010-2019 publication. Those numbers were ignored in AWP’s calculations.

AWP was neglectful in another way. The second phase of the project—a deep examination of community-level factors preceding suicides and nonnatural deaths—began in 2019. This information was collected and analyzed through sociocultural death investigation (SDI) interviews of 3 to 4 family members, friends, and colleagues of the deceased. SDIs consisted of 19 factors, such as history of the veteran’s mental health problems, social connectedness, finances, group memberships, and access to firearms. However, the interim report omitted the preliminary analysis of these factors, which AWP stated would be made available this year.

OpDD conclusions were so unfounded that AWP’s analytic research partner, the University of Alabama, distanced itself from the interim report. “We were not consulted on the released figures,” Dr. Karl Hamner, the University of Alabama principal investigator on the study, told me. “We did not make any conclusions and we don’t endorse the reported findings about national rates or numbers per day. Nor did we make any statements about the VA’s data.”

As it happens, the VA’s 2022 National Veteran Suicide Prevention Annual Report was issued the same week as the OpDD report. VA found that veteran suicides decreased by 9.7% over the last 2 years, nearly twice the decrease for nonveterans. Yet, in a contemporaneous hearing of the House Committee on Veterans’ Affairs, AWP’s President and CEO Jim Lorraine testified that the progress preventing veteran suicide was “a disgrace” and “a failure.” He misattributed that it was VA (not AWP) that “must be more open and transparent about their data.”

Unsupported denigration of the VA tarnishes its reputation, undermining veterans’ trust in the health care system and increasing barriers to seeking needed services. More broadly, it fortifies those forces who wish to redirect allocations away from VA and towards non-VA veterans’ entities like AWP. The media and other stakeholders must take a lesson about getting the story straight before reflexively amplifying false accusations about the VA. Veterans deserve better.

For years, the US Department of Veterans Affairs (VA) has painstakingly labored to track, research, and address veteran suicide. Their exceptional work was dealt an unwarranted blow a month ago with the publication of an incomplete report entitled Operation Deep Dive (OpDD). The $3.9 million study from America’s Warrior Partnership (AWP) examined death data of former service members in 8 states between 2014 and 2018. The interim report criticized the VA for minimizing the extent of veteran suicide, asserting, “former service members take their own lives each year at a rate approximately 2.4 times greater than previously reported by the VA.”

The sensational results were accepted at face value and immediately garnered negative nationwide headlines, with lawmakers, media outlets, and veterans rushing to impugn the VA. Senate Committee on Veterans’ Affairs Ranking Republican Member Jerry Moran of Kansas opined, “The disparity between the numbers of veteran suicides reported by the VA and [OpDD] is concerning. We need an honest assessment of the scope of the problem.” A U.S. Medicine headline stated “VA undercounted thousands of veteran suicides. [OpDD] posited daily suicide rate is 240% higher.” Fox News declared, “Veterans committing suicide at rate 2 times higher than VA data show: study,” as did Military Times, “Veterans suicide rate may be double federal estimates, study suggests.”

Disturbingly, those who echoed AWP’s claims got the story backward. It’s AWP, not VA, whose suicide data and conclusions are faulty.

For starters, the VA data encompasses veterans across all 50 states, the District of Columbia, Puerto Rico, and the US Virgin Islands. In contrast, AWP inferred national veteran suicide figures based on partial, skewed data. As delineated by researchers in an in-press Military Medicine letter to the Editor, 7 of the 8 states sampled (Alabama, Florida, Maine, Massachusetts, Michigan, Minnesota, Montana, and Oregon) had suicide rates above the national average for the years under investigation. This factor alone overinflates AWP’s purported suicide numbers.

Additionally, AWP altered the definition of “taking one’s life” and then misapplied that designation. Conventionally, the term refers to suicide, but AWP used it to also include nonnatural deaths assessed by coroners and medical examiners as accidental or undetermined. Two examples of this self-injury mortality (SIM) are opioid overdoses and single-driver car crash deaths. AWP added suicides and SIMs to derive a total number of veterans who took their life and falsely contrasted that aggregate against the VA count of suicides. That’s like comparing the whole category of fruit to the subcategory of apples.

AWP should be applauded for drawing attention to and accounting for accidental and undetermined deaths. However, the standard protocol is to consider SIMs distinctly from suicides. Among the many reasons for precise labeling is so that grieving family members aren’t mistakenly informed that their loved one died by suicide. VA conveys the rate of veteran overdose deaths in separate reports, for example, the Veteran Drug Overdose Mortality, 2010-2019 publication. Those numbers were ignored in AWP’s calculations.

AWP was neglectful in another way. The second phase of the project—a deep examination of community-level factors preceding suicides and nonnatural deaths—began in 2019. This information was collected and analyzed through sociocultural death investigation (SDI) interviews of 3 to 4 family members, friends, and colleagues of the deceased. SDIs consisted of 19 factors, such as history of the veteran’s mental health problems, social connectedness, finances, group memberships, and access to firearms. However, the interim report omitted the preliminary analysis of these factors, which AWP stated would be made available this year.

OpDD conclusions were so unfounded that AWP’s analytic research partner, the University of Alabama, distanced itself from the interim report. “We were not consulted on the released figures,” Dr. Karl Hamner, the University of Alabama principal investigator on the study, told me. “We did not make any conclusions and we don’t endorse the reported findings about national rates or numbers per day. Nor did we make any statements about the VA’s data.”

As it happens, the VA’s 2022 National Veteran Suicide Prevention Annual Report was issued the same week as the OpDD report. VA found that veteran suicides decreased by 9.7% over the last 2 years, nearly twice the decrease for nonveterans. Yet, in a contemporaneous hearing of the House Committee on Veterans’ Affairs, AWP’s President and CEO Jim Lorraine testified that the progress preventing veteran suicide was “a disgrace” and “a failure.” He misattributed that it was VA (not AWP) that “must be more open and transparent about their data.”

Unsupported denigration of the VA tarnishes its reputation, undermining veterans’ trust in the health care system and increasing barriers to seeking needed services. More broadly, it fortifies those forces who wish to redirect allocations away from VA and towards non-VA veterans’ entities like AWP. The media and other stakeholders must take a lesson about getting the story straight before reflexively amplifying false accusations about the VA. Veterans deserve better.

Words including death, die, dying, or stillborn were frequently replaced by euphemisms in meetings between clinicians and families of critically ill children, based on data from 33 family meetings that involved discussions of death.

Clear communication is essential in discussing death with patients and families and current consensus guidelines recommend against use of euphemisms; data also suggest that patients and families prefer clear and direct language, wrote Margaret H. Barlet, of Duke University, Durham, N.C., and colleagues.

However, data on the language used in discussions of death in neonatal or pediatric contexts are limited, they said.

In a study published in JAMA Network Open, the researchers reviewed conversations between clinicians and parents of critically ill children. The study participants included 20 parents of 13 infants with neurological conditions who were hospitalized in a pediatric ICU in a single center in the southeastern United States between September 2018 and September 2020. Family meetings were scheduled to discuss prognosis and whether to start, not start, or discontinue life-sustaining treatment. The discussions were recorded, transcribed, and deidentified. The median age of the parents was 28.5 years; 60% identified as Black, 40% as White, and 10% as Asian; with some selecting more than one race.

For all 13 infants, one parent identified as the infant’s mother, and another parent identified as the father for seven of the infants. The median gestational age of the infants was 37 weeks; 54% were female, and the median hospital stay was 86 days.

Twelve infants (92%) required mechanical ventilation, six required chest compressions, and five had a do-not-attempt resuscitation order placed. Two infants died during the hospital admission process.

The primary outcome of the study was language used to reference death during family meetings between doctors and families. In the family conversations, death was referenced 406 times (275 times by clinicians and 131 times by family members).

Families were more likely than were clinicians to use the words die, death, dying, or stillborn; these terms appeared in 19 of 131 references by families and 13 of 275 references by clinicians (15% vs. 5%).

In addition to a category for use of words such as die, death, dying, or stillborn, the researchers identified four types of euphemisms used in place of these terms. They characterized the types of euphemisms as survival framing (for example, not live), colloquialisms (for example, pass away), medical jargon or use of physiologic terms (for example, code event or irrecoverable heart rate drop) and the use of pronouns without an antecedent (for example, it might happen soon).

Overall, 92% of references to death in the conversations were euphemistic. Medical jargon was the most common type of euphemism used by clinicians (118 of 275 references, 43%), while colloquialism was the most common type used by family members (44 of 131 references, 34%).

The results are consistent with limited research on this topic and show the high rates of euphemistic language used in discussions of death, the researchers wrote in their discussion. “Although our work did not directly evaluate the comparative clarity of different ways to reference death, our results raise questions about what language is most clear,” they said. The researchers proposed that their classification of euphemistic language may provide a framework for the use of language in discussions of death and may prompt clinicians to notice the language they use and hear from patients and families. “Empirically evaluating the perceived clarity of euphemism types and their effects on shared decision-making should be a priority for future study and should be used to inform interventions for improving communication in this context,” they said.

The findings were limited by several factors including the use of data from a single institution and the exclusion of non-English speaking families, the researchers noted. In addition, the researchers studied only what was said, therefore “questions about speaker motivation, listener understanding, and the effects of language choice on decision-making remain unanswered,” they added.

However, the results reflect the frequent use of euphemisms by both clinicians and families, and more research is needed to assess the effect of language on understanding, decision-making, and doctor-patient relationships, the researchers concluded.
 

Euphemisms can create confusion but may increase empathy

“Ms. Barlet and colleagues provide further consideration of types of speech that may obscure a clinician’s intended meaning or distract from their true point in the context of family discussions about critically ill patients,” Michael B. Pitt, MD, of the University of Minnesota, Minneapolis, and colleagues wrote in an accompanying editorial. Using a euphemism such as “pass on” instead of “die” may be an intentional choice by physicians to use less harsh language but it may still cause confusion, they noted.

The study showed how frequently physicians use euphemisms to talk about death but was distinctive in the inclusion of data on language use by families as well, they said.

“This pattern of use identified among the infants’ families may indicate that despite the clinical recommendation that end-of-life discussions avoid the use of euphemisms, it may be worth noting and responding to families’ language preferences accordingly once it is clear they have expressed understanding that the clinician is speaking of death,” they said. For example, if a family is consistently using softer terminology, clinicians should consider responding with similar terms, rather than using medical jargon or the words death or dying, they wrote.

“As the authors note, family preferences for this type of discussion are an important target for future research aimed at optimizing family-centered communication,” the editorialists added.
 

Families seek clarity in communication

“Clinicians have an important role in helping parents of seriously ill children understand their child’s health condition and make value-driven decisions about care,” Jennifer W. Mack, MD, of Harvard Medical School and the Dana-Farber Cancer Institute, Boston, said in an interview. “The words that clinicians use can have a significant impact on the knowledge parents take away from encounters and the decisions they make. While there is evidence of euphemistic language in the adult setting, there is limited information about this in children,” said Dr. Mack, a pediatric hematologist/oncologist who was not involved in the study.

Dr. Mack said she was not entirely surprised that in the current study, clinician language often includes medical jargon and an avoidance of direct language about death. “This is consistent with what I have seen in clinical practice,” she said. “One striking aspect of the study is that parents used terms like death or die more often than clinicians, and they sometimes used these terms as a way to clarify what the clinician was saying. This suggests to me that parents often want clarity, even if the information is very difficult,” she said.

The key message of the study is that clinicians should pay attention to the words they use to talk about the possibility of death and recognize the tendency of many clinicians to fall back on medical jargon, said Dr. Mack.

“My personal belief is that it is possible to be both clear and compassionate, and clinicians should strive for both in these conversations, to support families and help them make their best decisions for their children,” she said. “We need to remember a single communication strategy or choice of words is not likely to feel supportive to every family; what is helpful for one family may feel painful to another,” she emphasized. “Being willing to listen to the needs they express and their own language choice can help us to be responsive to individual needs,” she added.

An important next step for research is to learn more about what families experience as supportive during conversations with clinicians about death and dying, Dr. Mack said.

The study was supported by the National Institute of Neurological Disorders and Stroke, National Institutes of Health, and the Doris Duke Charitable Foundation. The researchers, editorial authors, and Dr. Mack had no financial conflicts to disclose.

Words including death, die, dying, or stillborn were frequently replaced by euphemisms in meetings between clinicians and families of critically ill children, based on data from 33 family meetings that involved discussions of death.

Clear communication is essential in discussing death with patients and families and current consensus guidelines recommend against use of euphemisms; data also suggest that patients and families prefer clear and direct language, wrote Margaret H. Barlet, of Duke University, Durham, N.C., and colleagues.

However, data on the language used in discussions of death in neonatal or pediatric contexts are limited, they said.

In a study published in JAMA Network Open, the researchers reviewed conversations between clinicians and parents of critically ill children. The study participants included 20 parents of 13 infants with neurological conditions who were hospitalized in a pediatric ICU in a single center in the southeastern United States between September 2018 and September 2020. Family meetings were scheduled to discuss prognosis and whether to start, not start, or discontinue life-sustaining treatment. The discussions were recorded, transcribed, and deidentified. The median age of the parents was 28.5 years; 60% identified as Black, 40% as White, and 10% as Asian; with some selecting more than one race.

For all 13 infants, one parent identified as the infant’s mother, and another parent identified as the father for seven of the infants. The median gestational age of the infants was 37 weeks; 54% were female, and the median hospital stay was 86 days.

Twelve infants (92%) required mechanical ventilation, six required chest compressions, and five had a do-not-attempt resuscitation order placed. Two infants died during the hospital admission process.

The primary outcome of the study was language used to reference death during family meetings between doctors and families. In the family conversations, death was referenced 406 times (275 times by clinicians and 131 times by family members).

Families were more likely than were clinicians to use the words die, death, dying, or stillborn; these terms appeared in 19 of 131 references by families and 13 of 275 references by clinicians (15% vs. 5%).

In addition to a category for use of words such as die, death, dying, or stillborn, the researchers identified four types of euphemisms used in place of these terms. They characterized the types of euphemisms as survival framing (for example, not live), colloquialisms (for example, pass away), medical jargon or use of physiologic terms (for example, code event or irrecoverable heart rate drop) and the use of pronouns without an antecedent (for example, it might happen soon).

Overall, 92% of references to death in the conversations were euphemistic. Medical jargon was the most common type of euphemism used by clinicians (118 of 275 references, 43%), while colloquialism was the most common type used by family members (44 of 131 references, 34%).

The results are consistent with limited research on this topic and show the high rates of euphemistic language used in discussions of death, the researchers wrote in their discussion. “Although our work did not directly evaluate the comparative clarity of different ways to reference death, our results raise questions about what language is most clear,” they said. The researchers proposed that their classification of euphemistic language may provide a framework for the use of language in discussions of death and may prompt clinicians to notice the language they use and hear from patients and families. “Empirically evaluating the perceived clarity of euphemism types and their effects on shared decision-making should be a priority for future study and should be used to inform interventions for improving communication in this context,” they said.

The findings were limited by several factors including the use of data from a single institution and the exclusion of non-English speaking families, the researchers noted. In addition, the researchers studied only what was said, therefore “questions about speaker motivation, listener understanding, and the effects of language choice on decision-making remain unanswered,” they added.

However, the results reflect the frequent use of euphemisms by both clinicians and families, and more research is needed to assess the effect of language on understanding, decision-making, and doctor-patient relationships, the researchers concluded.
 

Euphemisms can create confusion but may increase empathy

“Ms. Barlet and colleagues provide further consideration of types of speech that may obscure a clinician’s intended meaning or distract from their true point in the context of family discussions about critically ill patients,” Michael B. Pitt, MD, of the University of Minnesota, Minneapolis, and colleagues wrote in an accompanying editorial. Using a euphemism such as “pass on” instead of “die” may be an intentional choice by physicians to use less harsh language but it may still cause confusion, they noted.

The study showed how frequently physicians use euphemisms to talk about death but was distinctive in the inclusion of data on language use by families as well, they said.

“This pattern of use identified among the infants’ families may indicate that despite the clinical recommendation that end-of-life discussions avoid the use of euphemisms, it may be worth noting and responding to families’ language preferences accordingly once it is clear they have expressed understanding that the clinician is speaking of death,” they said. For example, if a family is consistently using softer terminology, clinicians should consider responding with similar terms, rather than using medical jargon or the words death or dying, they wrote.

“As the authors note, family preferences for this type of discussion are an important target for future research aimed at optimizing family-centered communication,” the editorialists added.
 

Families seek clarity in communication

“Clinicians have an important role in helping parents of seriously ill children understand their child’s health condition and make value-driven decisions about care,” Jennifer W. Mack, MD, of Harvard Medical School and the Dana-Farber Cancer Institute, Boston, said in an interview. “The words that clinicians use can have a significant impact on the knowledge parents take away from encounters and the decisions they make. While there is evidence of euphemistic language in the adult setting, there is limited information about this in children,” said Dr. Mack, a pediatric hematologist/oncologist who was not involved in the study.

Dr. Mack said she was not entirely surprised that in the current study, clinician language often includes medical jargon and an avoidance of direct language about death. “This is consistent with what I have seen in clinical practice,” she said. “One striking aspect of the study is that parents used terms like death or die more often than clinicians, and they sometimes used these terms as a way to clarify what the clinician was saying. This suggests to me that parents often want clarity, even if the information is very difficult,” she said.

The key message of the study is that clinicians should pay attention to the words they use to talk about the possibility of death and recognize the tendency of many clinicians to fall back on medical jargon, said Dr. Mack.

“My personal belief is that it is possible to be both clear and compassionate, and clinicians should strive for both in these conversations, to support families and help them make their best decisions for their children,” she said. “We need to remember a single communication strategy or choice of words is not likely to feel supportive to every family; what is helpful for one family may feel painful to another,” she emphasized. “Being willing to listen to the needs they express and their own language choice can help us to be responsive to individual needs,” she added.

An important next step for research is to learn more about what families experience as supportive during conversations with clinicians about death and dying, Dr. Mack said.

The study was supported by the National Institute of Neurological Disorders and Stroke, National Institutes of Health, and the Doris Duke Charitable Foundation. The researchers, editorial authors, and Dr. Mack had no financial conflicts to disclose.

Words including death, die, dying, or stillborn were frequently replaced by euphemisms in meetings between clinicians and families of critically ill children, based on data from 33 family meetings that involved discussions of death.

Clear communication is essential in discussing death with patients and families and current consensus guidelines recommend against use of euphemisms; data also suggest that patients and families prefer clear and direct language, wrote Margaret H. Barlet, of Duke University, Durham, N.C., and colleagues.

However, data on the language used in discussions of death in neonatal or pediatric contexts are limited, they said.

In a study published in JAMA Network Open, the researchers reviewed conversations between clinicians and parents of critically ill children. The study participants included 20 parents of 13 infants with neurological conditions who were hospitalized in a pediatric ICU in a single center in the southeastern United States between September 2018 and September 2020. Family meetings were scheduled to discuss prognosis and whether to start, not start, or discontinue life-sustaining treatment. The discussions were recorded, transcribed, and deidentified. The median age of the parents was 28.5 years; 60% identified as Black, 40% as White, and 10% as Asian; with some selecting more than one race.

For all 13 infants, one parent identified as the infant’s mother, and another parent identified as the father for seven of the infants. The median gestational age of the infants was 37 weeks; 54% were female, and the median hospital stay was 86 days.

Twelve infants (92%) required mechanical ventilation, six required chest compressions, and five had a do-not-attempt resuscitation order placed. Two infants died during the hospital admission process.

The primary outcome of the study was language used to reference death during family meetings between doctors and families. In the family conversations, death was referenced 406 times (275 times by clinicians and 131 times by family members).

Families were more likely than were clinicians to use the words die, death, dying, or stillborn; these terms appeared in 19 of 131 references by families and 13 of 275 references by clinicians (15% vs. 5%).

In addition to a category for use of words such as die, death, dying, or stillborn, the researchers identified four types of euphemisms used in place of these terms. They characterized the types of euphemisms as survival framing (for example, not live), colloquialisms (for example, pass away), medical jargon or use of physiologic terms (for example, code event or irrecoverable heart rate drop) and the use of pronouns without an antecedent (for example, it might happen soon).

Overall, 92% of references to death in the conversations were euphemistic. Medical jargon was the most common type of euphemism used by clinicians (118 of 275 references, 43%), while colloquialism was the most common type used by family members (44 of 131 references, 34%).

The results are consistent with limited research on this topic and show the high rates of euphemistic language used in discussions of death, the researchers wrote in their discussion. “Although our work did not directly evaluate the comparative clarity of different ways to reference death, our results raise questions about what language is most clear,” they said. The researchers proposed that their classification of euphemistic language may provide a framework for the use of language in discussions of death and may prompt clinicians to notice the language they use and hear from patients and families. “Empirically evaluating the perceived clarity of euphemism types and their effects on shared decision-making should be a priority for future study and should be used to inform interventions for improving communication in this context,” they said.

The findings were limited by several factors including the use of data from a single institution and the exclusion of non-English speaking families, the researchers noted. In addition, the researchers studied only what was said, therefore “questions about speaker motivation, listener understanding, and the effects of language choice on decision-making remain unanswered,” they added.

However, the results reflect the frequent use of euphemisms by both clinicians and families, and more research is needed to assess the effect of language on understanding, decision-making, and doctor-patient relationships, the researchers concluded.
 

Euphemisms can create confusion but may increase empathy

“Ms. Barlet and colleagues provide further consideration of types of speech that may obscure a clinician’s intended meaning or distract from their true point in the context of family discussions about critically ill patients,” Michael B. Pitt, MD, of the University of Minnesota, Minneapolis, and colleagues wrote in an accompanying editorial. Using a euphemism such as “pass on” instead of “die” may be an intentional choice by physicians to use less harsh language but it may still cause confusion, they noted.

The study showed how frequently physicians use euphemisms to talk about death but was distinctive in the inclusion of data on language use by families as well, they said.

“This pattern of use identified among the infants’ families may indicate that despite the clinical recommendation that end-of-life discussions avoid the use of euphemisms, it may be worth noting and responding to families’ language preferences accordingly once it is clear they have expressed understanding that the clinician is speaking of death,” they said. For example, if a family is consistently using softer terminology, clinicians should consider responding with similar terms, rather than using medical jargon or the words death or dying, they wrote.

“As the authors note, family preferences for this type of discussion are an important target for future research aimed at optimizing family-centered communication,” the editorialists added.
 

Families seek clarity in communication

“Clinicians have an important role in helping parents of seriously ill children understand their child’s health condition and make value-driven decisions about care,” Jennifer W. Mack, MD, of Harvard Medical School and the Dana-Farber Cancer Institute, Boston, said in an interview. “The words that clinicians use can have a significant impact on the knowledge parents take away from encounters and the decisions they make. While there is evidence of euphemistic language in the adult setting, there is limited information about this in children,” said Dr. Mack, a pediatric hematologist/oncologist who was not involved in the study.

Dr. Mack said she was not entirely surprised that in the current study, clinician language often includes medical jargon and an avoidance of direct language about death. “This is consistent with what I have seen in clinical practice,” she said. “One striking aspect of the study is that parents used terms like death or die more often than clinicians, and they sometimes used these terms as a way to clarify what the clinician was saying. This suggests to me that parents often want clarity, even if the information is very difficult,” she said.

The key message of the study is that clinicians should pay attention to the words they use to talk about the possibility of death and recognize the tendency of many clinicians to fall back on medical jargon, said Dr. Mack.

“My personal belief is that it is possible to be both clear and compassionate, and clinicians should strive for both in these conversations, to support families and help them make their best decisions for their children,” she said. “We need to remember a single communication strategy or choice of words is not likely to feel supportive to every family; what is helpful for one family may feel painful to another,” she emphasized. “Being willing to listen to the needs they express and their own language choice can help us to be responsive to individual needs,” she added.

An important next step for research is to learn more about what families experience as supportive during conversations with clinicians about death and dying, Dr. Mack said.

The study was supported by the National Institute of Neurological Disorders and Stroke, National Institutes of Health, and the Doris Duke Charitable Foundation. The researchers, editorial authors, and Dr. Mack had no financial conflicts to disclose.

Results from an observational study exploring the link between dairy intake and risk of cardiovascular disease events in patients with stable angina pectoris suggest different dairy products may have different health effects.

The study, which analyzed a cohort from the Western Norway B-vitamin Intervention Trial (WENBIT), showed that higher dairy and milk consumption were associated with increased risk of mortality and stroke and butter was associated with an increased risk of acute myocardial infarction (AMI), but that cheese was associated with a decreased risk of AMI.

The findings are published in the European Journal of Preventive Cardiology.

“Dairy is a diverse food group, and different dairy products should be considered individually and not only in combination,” senior author Vegard Lysne, MSc, of the Centre for Nutrition, University of Bergen and the department of heart disease, Haukeland University Hospital, Bergen, Norway, said in an interview.

“Today’s dietary recommendations regarding dairy products are mainly based on the nutrient contents, with a focus on calcium, iodine, and saturated fat,” Dr. Lysne said.

Previous studies have indicated that different dairy products may influence cardiovascular health differently, even in opposite directions, but this has primarily been investigated in healthy populations, he noted.

“Data on CVD patients are scarce, and therefore, we wanted to investigate this in a population of patients with established CVD. Our primary aim in this study was to explore how the intake of different dairy products might be linked to cardiovascular outcomes and mortality in such a population,” he said.

The researchers analyzed 1,929 patients who had stable angina pectoris and were participants in WENBIT, a randomized, double-blind, placebo-controlled prospective secondary prevention study investigating the effect of vitamin B treatment on mortality and cardiovascular outcomes.

The majority, 80%, of the cohort were men, and the mean age of the patients was 61.8 years. In addition to stable angina pectoris, 47% of the cohort had hypertension, 31% had diabetes, and 29% were smokers. Most (90%) of the patients were taking acetylsalicylic acid, 90% were taking statins, and 77% were on beta-blockers.

Dietary data were obtained by a food frequency questionnaire that was given to patients at their first visit and returned either by mail or at a follow-up visit 1 month after the initial visit.

Frequency of consumption was given as times per day, week, month, or never consumed. Quantity was estimated using units such as slices, pieces, etc., or household measures.

The milk variable included high-fat, low-fat, skimmed, or unspecified milk. Cheese included brown cheese, which is a Norwegian caramel-like cheese made from whey, milk, and cream; white cheese; cream cheeses; cooked or processed cheeses; and boxed cheeses.

Total dairy was calculated as the sum, in grams, of milk, cheese, yogurt, cream, sour cream, ice cream, and butter.

Median follow-up times were 5.2 years for stroke, 7.8 years for AMI, and 14.1 years for mortality.

Patients who reported a higher intake of total dairy and milk had a higher risk of stroke and mortality.

Among those who reported a higher intake of total dairy, the hazard ratio for stroke was 1.4 (95% confidence interval [CI], 1.02-1.27).

Among those who reported a higher intake of milk, the HR for stroke was 1.13 (95% CI, 1.02-1.27).

Cardiovascular mortality appeared heightened in those who reported a higher intake of total dairy (HR, 1.06; 95% CI, 1.00-1.12) and in those who reported a higher intake of milk (HR, 1.07; 95% CI, 1.01-1.13).

Similarly, all-cause mortality was greater in those who reported higher total dairy consumption (HR, 1.07; 95% CI, 1.03-1.11) and in those who reported higher milk consumption (HR, 1.06; 95% CI, 1.03-1.10).

Higher cheese intake was inversely associated with AMI risk (HR, 0.92; 95% CI, 0.83-1.02).

Butter was associated with increased AMI risk (HR, 1.10; 95% CI, 0.97-1.24), as well as all-cause mortality (HR, 1.10; 95% CI, 1.00-1.20).

Dr. Lysne stressed that the results are from an observational study, and that doctors should not change what they tell their patients based on the results alone.

“There is a growing literature indicating that cheese might be linked to reduced cardiovascular risk, but if this is a causal effect, or if cheese is a marker of higher socioeconomic status and a healthier overall lifestyle remains unknown,” he said.

“I would like for future studies to evaluate dairy products on an individual basis, rather than a collective one. If the data suggest that different dairy products have distinct health effects, this should be implemented in dietary recommendations,” Dr. Lysne added.
 

Dairy a heterogeneous food group

“These results are not really surprising, because we have been hearing advice to consume low-fat milk, avoid whole milk, and so on, for a long time, so this study confirms what we already know,” Qi Sun, MD, ScD, associate professor in the departments of nutrition and epidemiology, Harvard T.H. Chan School of Public Health, Boston, told this news organization.

“However, I would be more specific about milk, and I don’t see any data regarding the fat content of the different types of milk. Their data only show the association for total milk. I would like to see data for low-fat milk versus high-fat milk in relation to heart disease,” Dr. Sun said.

“They also say in their conclusion that cheese was associated with a decreased risk of acute myocardial infarction, but as the hazard ratio shows, this is a nonsignificant association,” he said.

Dr. Sun agrees that dairy is a heterogeneous group of foods and that it is best to consider each type separately with regard to cardiovascular health.

“For example, heavy cream contains tons of saturated fat, butter contains a lot of saturated fat. Then there is yogurt, which also comes in regular, reduced-fat and low-fat varieties, which is a fantastic food. I would say it’s very healthy and is associated with a lower risk of heart disease and diabetes, so a good type of dairy. Yogurt and fermented dairy products should be beneficial, at least more so than full-fat milk or butter. I think butter and full-fat milk are still the primary dairy foods for people to avoid to reduce risk for cardiovascular disease,” he said.

Dr. Lysne and Dr. Sun have disclosed no relevant financial relationships.

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

Results from an observational study exploring the link between dairy intake and risk of cardiovascular disease events in patients with stable angina pectoris suggest different dairy products may have different health effects.

The study, which analyzed a cohort from the Western Norway B-vitamin Intervention Trial (WENBIT), showed that higher dairy and milk consumption were associated with increased risk of mortality and stroke and butter was associated with an increased risk of acute myocardial infarction (AMI), but that cheese was associated with a decreased risk of AMI.

The findings are published in the European Journal of Preventive Cardiology.

“Dairy is a diverse food group, and different dairy products should be considered individually and not only in combination,” senior author Vegard Lysne, MSc, of the Centre for Nutrition, University of Bergen and the department of heart disease, Haukeland University Hospital, Bergen, Norway, said in an interview.

“Today’s dietary recommendations regarding dairy products are mainly based on the nutrient contents, with a focus on calcium, iodine, and saturated fat,” Dr. Lysne said.

Previous studies have indicated that different dairy products may influence cardiovascular health differently, even in opposite directions, but this has primarily been investigated in healthy populations, he noted.

“Data on CVD patients are scarce, and therefore, we wanted to investigate this in a population of patients with established CVD. Our primary aim in this study was to explore how the intake of different dairy products might be linked to cardiovascular outcomes and mortality in such a population,” he said.

The researchers analyzed 1,929 patients who had stable angina pectoris and were participants in WENBIT, a randomized, double-blind, placebo-controlled prospective secondary prevention study investigating the effect of vitamin B treatment on mortality and cardiovascular outcomes.

The majority, 80%, of the cohort were men, and the mean age of the patients was 61.8 years. In addition to stable angina pectoris, 47% of the cohort had hypertension, 31% had diabetes, and 29% were smokers. Most (90%) of the patients were taking acetylsalicylic acid, 90% were taking statins, and 77% were on beta-blockers.

Dietary data were obtained by a food frequency questionnaire that was given to patients at their first visit and returned either by mail or at a follow-up visit 1 month after the initial visit.

Frequency of consumption was given as times per day, week, month, or never consumed. Quantity was estimated using units such as slices, pieces, etc., or household measures.

The milk variable included high-fat, low-fat, skimmed, or unspecified milk. Cheese included brown cheese, which is a Norwegian caramel-like cheese made from whey, milk, and cream; white cheese; cream cheeses; cooked or processed cheeses; and boxed cheeses.

Total dairy was calculated as the sum, in grams, of milk, cheese, yogurt, cream, sour cream, ice cream, and butter.

Median follow-up times were 5.2 years for stroke, 7.8 years for AMI, and 14.1 years for mortality.

Patients who reported a higher intake of total dairy and milk had a higher risk of stroke and mortality.

Among those who reported a higher intake of total dairy, the hazard ratio for stroke was 1.4 (95% confidence interval [CI], 1.02-1.27).

Among those who reported a higher intake of milk, the HR for stroke was 1.13 (95% CI, 1.02-1.27).

Cardiovascular mortality appeared heightened in those who reported a higher intake of total dairy (HR, 1.06; 95% CI, 1.00-1.12) and in those who reported a higher intake of milk (HR, 1.07; 95% CI, 1.01-1.13).

Similarly, all-cause mortality was greater in those who reported higher total dairy consumption (HR, 1.07; 95% CI, 1.03-1.11) and in those who reported higher milk consumption (HR, 1.06; 95% CI, 1.03-1.10).

Higher cheese intake was inversely associated with AMI risk (HR, 0.92; 95% CI, 0.83-1.02).

Butter was associated with increased AMI risk (HR, 1.10; 95% CI, 0.97-1.24), as well as all-cause mortality (HR, 1.10; 95% CI, 1.00-1.20).

Dr. Lysne stressed that the results are from an observational study, and that doctors should not change what they tell their patients based on the results alone.

“There is a growing literature indicating that cheese might be linked to reduced cardiovascular risk, but if this is a causal effect, or if cheese is a marker of higher socioeconomic status and a healthier overall lifestyle remains unknown,” he said.

“I would like for future studies to evaluate dairy products on an individual basis, rather than a collective one. If the data suggest that different dairy products have distinct health effects, this should be implemented in dietary recommendations,” Dr. Lysne added.
 

Dairy a heterogeneous food group

“These results are not really surprising, because we have been hearing advice to consume low-fat milk, avoid whole milk, and so on, for a long time, so this study confirms what we already know,” Qi Sun, MD, ScD, associate professor in the departments of nutrition and epidemiology, Harvard T.H. Chan School of Public Health, Boston, told this news organization.

“However, I would be more specific about milk, and I don’t see any data regarding the fat content of the different types of milk. Their data only show the association for total milk. I would like to see data for low-fat milk versus high-fat milk in relation to heart disease,” Dr. Sun said.

“They also say in their conclusion that cheese was associated with a decreased risk of acute myocardial infarction, but as the hazard ratio shows, this is a nonsignificant association,” he said.

Dr. Sun agrees that dairy is a heterogeneous group of foods and that it is best to consider each type separately with regard to cardiovascular health.

“For example, heavy cream contains tons of saturated fat, butter contains a lot of saturated fat. Then there is yogurt, which also comes in regular, reduced-fat and low-fat varieties, which is a fantastic food. I would say it’s very healthy and is associated with a lower risk of heart disease and diabetes, so a good type of dairy. Yogurt and fermented dairy products should be beneficial, at least more so than full-fat milk or butter. I think butter and full-fat milk are still the primary dairy foods for people to avoid to reduce risk for cardiovascular disease,” he said.

Dr. Lysne and Dr. Sun have disclosed no relevant financial relationships.

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

Results from an observational study exploring the link between dairy intake and risk of cardiovascular disease events in patients with stable angina pectoris suggest different dairy products may have different health effects.

The study, which analyzed a cohort from the Western Norway B-vitamin Intervention Trial (WENBIT), showed that higher dairy and milk consumption were associated with increased risk of mortality and stroke and butter was associated with an increased risk of acute myocardial infarction (AMI), but that cheese was associated with a decreased risk of AMI.

The findings are published in the European Journal of Preventive Cardiology.

“Dairy is a diverse food group, and different dairy products should be considered individually and not only in combination,” senior author Vegard Lysne, MSc, of the Centre for Nutrition, University of Bergen and the department of heart disease, Haukeland University Hospital, Bergen, Norway, said in an interview.

“Today’s dietary recommendations regarding dairy products are mainly based on the nutrient contents, with a focus on calcium, iodine, and saturated fat,” Dr. Lysne said.

Previous studies have indicated that different dairy products may influence cardiovascular health differently, even in opposite directions, but this has primarily been investigated in healthy populations, he noted.

“Data on CVD patients are scarce, and therefore, we wanted to investigate this in a population of patients with established CVD. Our primary aim in this study was to explore how the intake of different dairy products might be linked to cardiovascular outcomes and mortality in such a population,” he said.

The researchers analyzed 1,929 patients who had stable angina pectoris and were participants in WENBIT, a randomized, double-blind, placebo-controlled prospective secondary prevention study investigating the effect of vitamin B treatment on mortality and cardiovascular outcomes.

The majority, 80%, of the cohort were men, and the mean age of the patients was 61.8 years. In addition to stable angina pectoris, 47% of the cohort had hypertension, 31% had diabetes, and 29% were smokers. Most (90%) of the patients were taking acetylsalicylic acid, 90% were taking statins, and 77% were on beta-blockers.

Dietary data were obtained by a food frequency questionnaire that was given to patients at their first visit and returned either by mail or at a follow-up visit 1 month after the initial visit.

Frequency of consumption was given as times per day, week, month, or never consumed. Quantity was estimated using units such as slices, pieces, etc., or household measures.

The milk variable included high-fat, low-fat, skimmed, or unspecified milk. Cheese included brown cheese, which is a Norwegian caramel-like cheese made from whey, milk, and cream; white cheese; cream cheeses; cooked or processed cheeses; and boxed cheeses.

Total dairy was calculated as the sum, in grams, of milk, cheese, yogurt, cream, sour cream, ice cream, and butter.

Median follow-up times were 5.2 years for stroke, 7.8 years for AMI, and 14.1 years for mortality.

Patients who reported a higher intake of total dairy and milk had a higher risk of stroke and mortality.

Among those who reported a higher intake of total dairy, the hazard ratio for stroke was 1.4 (95% confidence interval [CI], 1.02-1.27).

Among those who reported a higher intake of milk, the HR for stroke was 1.13 (95% CI, 1.02-1.27).

Cardiovascular mortality appeared heightened in those who reported a higher intake of total dairy (HR, 1.06; 95% CI, 1.00-1.12) and in those who reported a higher intake of milk (HR, 1.07; 95% CI, 1.01-1.13).

Similarly, all-cause mortality was greater in those who reported higher total dairy consumption (HR, 1.07; 95% CI, 1.03-1.11) and in those who reported higher milk consumption (HR, 1.06; 95% CI, 1.03-1.10).

Higher cheese intake was inversely associated with AMI risk (HR, 0.92; 95% CI, 0.83-1.02).

Butter was associated with increased AMI risk (HR, 1.10; 95% CI, 0.97-1.24), as well as all-cause mortality (HR, 1.10; 95% CI, 1.00-1.20).

Dr. Lysne stressed that the results are from an observational study, and that doctors should not change what they tell their patients based on the results alone.

“There is a growing literature indicating that cheese might be linked to reduced cardiovascular risk, but if this is a causal effect, or if cheese is a marker of higher socioeconomic status and a healthier overall lifestyle remains unknown,” he said.

“I would like for future studies to evaluate dairy products on an individual basis, rather than a collective one. If the data suggest that different dairy products have distinct health effects, this should be implemented in dietary recommendations,” Dr. Lysne added.
 

Dairy a heterogeneous food group

“These results are not really surprising, because we have been hearing advice to consume low-fat milk, avoid whole milk, and so on, for a long time, so this study confirms what we already know,” Qi Sun, MD, ScD, associate professor in the departments of nutrition and epidemiology, Harvard T.H. Chan School of Public Health, Boston, told this news organization.

“However, I would be more specific about milk, and I don’t see any data regarding the fat content of the different types of milk. Their data only show the association for total milk. I would like to see data for low-fat milk versus high-fat milk in relation to heart disease,” Dr. Sun said.

“They also say in their conclusion that cheese was associated with a decreased risk of acute myocardial infarction, but as the hazard ratio shows, this is a nonsignificant association,” he said.

Dr. Sun agrees that dairy is a heterogeneous group of foods and that it is best to consider each type separately with regard to cardiovascular health.

“For example, heavy cream contains tons of saturated fat, butter contains a lot of saturated fat. Then there is yogurt, which also comes in regular, reduced-fat and low-fat varieties, which is a fantastic food. I would say it’s very healthy and is associated with a lower risk of heart disease and diabetes, so a good type of dairy. Yogurt and fermented dairy products should be beneficial, at least more so than full-fat milk or butter. I think butter and full-fat milk are still the primary dairy foods for people to avoid to reduce risk for cardiovascular disease,” he said.

Dr. Lysne and Dr. Sun have disclosed no relevant financial relationships.

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