Utility of the “Surprise” Question to Identify Dialysis Patients with High Mortality

Background and objectives: Dialysis patients are increasingly characterized by older age, multiple comorbidities, and shortened life expectancy. This study investigated whether the “surprise” question, “Would I be surprised if this patient died in the next year?” identifies patients who are at high risk for early mortality.Design, setting, participants, & measurements: This prospective cohort study of 147 patients in three hemodialysis dialysis units classified patients into “yes” and “no” groups on the basis of the “surprise” question response and tracked patient status (alive or dead) at 12 mo. Demographics, Charlson Comorbidity Index score, and Karnofsky Performance Status score were measured.Results: Initially, 34 (23%) patients were classified in the “no” group. Compared with the 113 patients in the “yes” group, the patients in the “no” group were older (72.5 ± 12.8 versus 64.5 ± 14.9), had a higher comorbidity score (7.1 ± 2.3 versus 5.8 ± 2.1), and had a lower performance status score (69.7 ± 17.1 versus 81.6 ± 15.8). At 12 mo, 22 (15%) patients had died; the mortality rate for the “no” group was 29.4% and for the “yes” group was 10.6%. The odds of dying within 1 yr for the patients in the “no” group were 3.5 times higher than for patients in the “yes” group, (odds ratio 3.507, 95% CI 1.356 to 9.067, P = 0.01).Conclusions: The “surprise” question is effective in identifying sicker dialysis patients who have a high risk for early mortality and should receive priority for palliative care interventions.Incident dialysis patients are increasingly characterized by older age, a large number of comorbid illnesses, and a high symptom burden (1). They have a significantly shortened life expectancy and an overall mortality rate more than eight times that of the general Medicare population (2). Researchers and an expert panel have noted the need for improved palliative care for the US dialysis population (3–6). Palliative care begins with establishing the goals of care (7), and estimating the prognosis of dialysis patients sets the context for discussing goals (8–10).The “surprise” question, “Would I be surprised if this patient died in the next 12 mo?” has been recognized as an innovation to improve end-of-life care by identifying patients who have a poor prognosis and who are appropriate for palliative care (11–13). The “surprise” question has been tested and found to be effective in a primary care population in the Franciscan Health System in Tacoma, WA (11), but not in chronic disease populations such as those with kidney disease. The purpose of this study was to study the clinical characteristics of dialysis patients who were classified into a “no, I would not be surprised” group in response to the “surprise” question and to determine the effectiveness of the use of the “surprise” question to identify a subset of dialysis patients who have a high risk for early death and should receive priority for palliative care interventions.     

The impact of continuous positive airway pressure on cardiac mechanics: Findings from a meta‐analysis of echocardiographic studies

Current evidence on the effects of continuous positive airway pressure (CPAP) on cardiac mechanics in patients with obstructive sleep apnea (OSA) is based on a few single studies. The authors investigated this topic through a meta‐analysis of speckle tracking echocardiography (STE) studies that provided data on left ventricular (LV) and right ventricular (RV) mechanics as assessed by global longitudinal strain (GLS). The PubMed, OVID‐MEDLINE, and Cochrane library databases were systematically analyzed to search English‐language review papers published from inception to January 31, 2022. Studies were identified by crossing the following terms: “obstructive sleep apnea”, “sleep quality”, “sleep disordered breathing”, “continuous positive airway pressure therapy”, “noninvasive ventilation”, “left ventricular hypertrophy”, “systolic dysfunction”, “global longitudinal strain”, “left ventricular mechanics”, “right ventricular mechanics”, “echocardiography” and “STE echocardiography”. The meta‐analysis, including a total of 337 patients with OSA from nine studies (follow‐up 2–24 months) showed a significant GLS improvement in both LV and RV after CPAP, standard mean difference (SMD) being 0.51±0.08, CI:0.36–0.66, p = .0001 and 0.28±0.07, CI:0.15–0.42, p = .0001), respectively. Corresponding SMD values for LV ejection fraction (LVEF) and tricuspid annular plane systolic excursion (TAPSE) were 0.20±0.06, CI:0.08–0.33, p = .001 and 0.08±0.06, CI: ‐0.04/0.20, p = .21. Our meta‐analysis suggests that: I) CPAP treatment exerts beneficial effects on biventricular function in patients with OSA; II) the assessment of cardiac mechanics by STE should be routinely recommended for monitoring cardiac function in this setting, due to limitations of conventional echocardiography in evaluating biventricular performance.     

Displacement of insulin-like growth factors from their binding proteins as a potential treatment for stroke

Insulin-like growth factors I and II (IGF-I and IGF-II) play an important role in normal growth and brain development and protect brain cells from several forms of injury. The effects of IGFs are mediated by type-I and type-II receptors and modulated by potentially six specific binding proteins that form high-affinity complexes with IGFs in blood and cerebrospinal fluid (CSF) and under most circumstances inactivate them. Because brain injury is commonly associated with increases in IGFs and their associated binding proteins, we hypothesized that displacement of this large “pool” of endogenous IGF from the binding proteins would elevate “free” IGF levels to elicit neuroprotective effects comparable to those produced by administration of exogenous IGF. A human IGF-I analog [(Leu^{24, 59, 60}, Ala³¹)hIGF-I] with high affinity to IGF-binding proteins (K_i = 0.3–3.9 nM) and no biological activity at the IGF receptors (K_i = >10,000 nM) increased the levels of “free, bioavailable” IGF-I in the CSF. Intracerebroventricular administration of this analog up to 1h after an ischemic insult to the rat brain had a potent neuroprotective action comparable to IGF-I. This novel strategy for increasing “free” IGF levels in the brain may be useful for the treatment of stroke and other neurodegenerative diseases.     

Acute and Chronic Pheochromocytoma-Induced Cardiomyopathies: Different Prognoses?: A Systematic Analytical Review

Pheochromocytoma and paraganglioma (PPG) are rare and late-diagnosed catecholamine secreting tumors, which may be associated with unrecognized and/or severe cardiomyopathies.We performed a computer-assisted systematic search of the electronic Medline databases using the MESH terms “myocarditis,” “myocardial infarction,” “Takotsubo,” “stress cardiomyopathy,” “cardiogenic shock”, or “dilated cardiomyopathy,” and “pheochromocytoma” or “paraganglioma” from 1961 to August 2012. All detailed case reports of cardiomyopathy due to a PPG, without coronary stenosis, and revealed by acute symptoms were included and analyzed.A total of 145 cases reports were collected (49 Takotsubo Cardiomyopathies [TTC] and 96 other Catecholamine Cardiomyopathies [CC]). At initial presentation, prevalence of high blood pressure (87.7%), chest pain (49.0%), headaches (47.6%), palpitations (46.9%), sweating (39.3%), and shock (51.0%) were comparable between CC and TTC. Acute pulmonary edema (58.3% vs 38.8%, P = 0.03) was more frequent in CC. There was no difference in proportion of patients with severe left ventricular systolic dysfunction (LV Ejection Fraction [LVEF] < 30%) at initial presentation between both groups (P = 0.15). LVEF recovery before (64.9% vs 40.8%, P = 0.005) and after surgical resection (97.7% vs73.3%, P = 0.001) was higher in the TTC group. Death occurred in 11 cases (7.6%). In multivariate analysis, only TTC was associated with a better LV recovery (0.15 [0.03–0.67], P = 0.03).Pheochromocytoma and paraganglioma can lead to different cardiomyopathies with the same brutal and life-threatening initial clinical presentation but with a different recovery rate. Diagnosis of unexplained dilated cardiomyopathy or TTC should lead clinicians to a specific search for PPG.     

Clinical trial with traditional Chinese medicine intervention 'tonifying the kidney to promote liver regeneration and repair by affecting stem cells and their microenvironment' for chronic hepatitis B-associated liver failure

AIM: To study the clinical efficacy of traditional Chinese medicine (TCM) intervention “tonifying the kidney to promote liver regeneration and repair by affecting stem cells and their microenvironment” (“TTK”) for treating liver failure due to chronic hepatitis B.METHODS: We designed the study as a randomized controlled clinical trial. Registration number of Chinese Clinical Trial Registry is ChiCTR-TRC-12002961. A total of 144 patients with liver failure due to infection with chronic hepatitis B virus were enrolled in this randomized controlled clinical study. Participants were randomly assigned to the following three groups: (1) a modern medicine control group (MMC group, 36 patients); (2) a “tonifying qi and detoxification” (“TQD”) group (72 patients); and (3) a “tonifying the kidney to promote liver regeneration and repair by affecting stem cells and their microenvironment” (“TTK”) group (36 patients). Patients in the MMC group received general internal medicine treatment; patients in the “TQD” group were given a TCM formula “tonifying qi and detoxification” and general internal medicine treatment; patients in the “TTK” group were given a TCM formula of “TTK” and general internal medicine treatment. All participants were treated for 8 wk and then followed at 48 wk following their final treatment. The primary efficacy end point was the patient fatality rate in each group. Measurements of various virological and biochemical indicators served as secondary endpoints. The one-way analysis of variance and the t-test were used to compare patient outcomes in the different treatment groups.RESULTS: At the 48-wk post-treatment time point, the patient fatality rates in the MMC, “TQD”, and “TTK” groups were 51.61%, 35.38%, and 16.67%, respectively, and the differences between groups were statistically significant (P < 0.05). However, there were no significant differences in the levels of hepatitis B virus DNA or prothrombin activity among the three groups (P > 0.05). Patients in the “TTK” group had significantly higher levels of serum total bilirubin compared to MMC subjects (339.40 μmol/L ± 270.09 μmol/L vs 176.13 μmol/L ± 185.70 μmol/L, P = 0.014). Serum albumin levels were significantly increased in both the “TQD” group and “TTK” group as compared with the MMC group (31.30 g/L ± 4.77 g/L, 30.72 g/L ± 2.89 g/L vs 28.57 g/L ± 4.56 g/L, P < 0.05). There were no significant differences in levels of alanine transaminase among the three groups (P > 0.05). Safety data showed that there was one case of stomachache in the “TQD” group and one case of gastrointestinal side effect in the “TTK” group.CONCLUSION: Treatment with “TTK” improved the survival rates of patients with liver failure due to chronic hepatitis B. Additionally, liver tissue was regenerated and liver function was restored.     

Mental health of nurses involved with COVID-19 patients in Japan,intention to resign,and influencing factors

The purpose of this study was to investigate the association between mental health (posttraumatic stress disorder, depression, anxiety disorder, and burnout) and intention to resign, and influencing factors regarding nurses involved with COVID-19 patients in A Prefecture as subjects.The design is a cross-sectional questionnaire-based study.Methods are conducted between August 4 and October 26, 2020. Basic attributes (gender, age, years of experience, etc.) were examined. Patient Health Questionnaire-9 and the Generalized Anxiety Disorder-7, Impact of Event Scale-Revised, Maslach Burnout Inventory, “intent to resign,” were used to collect data from nurses working at hospitals treating patients with COVID-19 in Japan.As a result, between 20% and 30% of nurses involved with patients with COVID-19 are in a state of high mental distress. Regarding the associations between psychiatric symptoms and intention to resign, “I want to quit being a nurse” was affected by “cynicism” and “professional efficacy”; “I want to change hospitals/wards” was affected by “cynicism”; and “subthreshold depression,” “anxiety disorder,” and “burnout” affected “I want to continue working as a nurse.” The increase in the number of patients with COVID-19 was a factor affecting mental health and intention to resign. When the number of patients increased, anxiety disorders and intention to resign also increased. Damage from harmful rumors increased the severity of every psychiatric symptom. To prepare for a pandemic such as COVID-19, it is necessary in normal times to construct psychological support systems and community systems to prevent damage from harmful rumors.     

Are faecal markers good indicators of mucosal healing in inflammatory bowel disease?

AIM: To review the published literature concerning the accuracy of faecal inflammatory markers for identifying mucosal healing. METHODS: Bibliographical searches were performed in MEDLINE electronic database up to February 2015,using the following terms: "inflammatory bowel disease","Crohn′s disease","ulcerative colitis","faecal markers","calprotectin","lactoferrin","S100A12","endoscop*","mucosal healing","remission". In addition,relevant references from these studies were also included. Data were extracted from the published papers including odds ratios with 95%CI,P values and correlation coefficients. Data were grouped together according to each faecal marker,Crohn's disease or ulcerative colitis,and paediatric compared with adult study populations. Studies included in this review assessed mucosal inflammation by endoscopic and/or histological means and compared these findings to faecal marker concentrations in inflammatory bowel diseases(IBD) patient cohorts. Articles had to be published between 1990 and February 2015 and written in English. Papers excluded from the review were those where the faecal biomarker concentration was compared between patients with IBD and controls or other disease groups,those where serum biomarkers were used,those with a heterogeneous study population and those only assessing post-operative disease. RESULTS: The available studies show that faecal markers,such as calprotectin and lactoferrin,are promising non-invasive indicators of mucosal healing. However,due to wide variability in study design,especially with regard to the definition of mucosal healing and evaluation of marker cut offs,the available data do not yet indicate the optimal roles of these markers. Thirty-six studies published between 1990 and 2014 were included. Studies comprised variable numbers of study participants,considered CD(15-164 participants) or UC(12-152 participants) separately or as a combined group(11-252 participants). Eight reports included paediatric patients. Several indices were used to document mucosal inflammation,encompassing elevenendoscopic and eight histologic grading systems. The majority of the available reports focused on faecal calprotectin(33 studies),whilst others assessed faecal lactoferrin(13 studies) and one study assessed S100A12. Across all of the biomarkers,there is a wide range of correlation describing the association between faecal markers and endoscopic disease activity(r values ranging from 0.32 to 0.87,P values ranging from 0.0001 to 0.7815). Correlation coefficients are described in almost all studies and are used more commonly than outcome measures such as sensitivity,specificity,PPV and/or NPV. Overall,the studies that have evaluated faecal calprotectin and/or faecal lactoferrin and their relationship with endoscopic disease activity show inconsistent results. CONCLUSION: Future studies should report the results of faecal inflammatory markers in the context of mucosal healing with clear validated cut offs.     

Outcome of parapneumonic empyema managed surgically or by fibrinolysis: a multicenter study

BackgroundParapneumonic empyema (PPE) management remains debated. Here we present the outcome of a comparable population with PPE treated over a 4-year period in two Thoracic Surgery University Centers with different approaches: one with an early “surgical” and the other with a “fibrinolytic” approach.MethodsAll operable patients with PPE managed in both centers between January 2014 and January 2018 were reviewed. Patients with persistent pleural effusion/loculations following drainage were managed by a “surgical” approach in one center and by “fibrinolytic” approach in the other. For each patient, we recorded the age, sex, hospital stay, morbidity/mortality and change in pleural opacity on chest X-ray before and at the end of the treatment.ResultsDuring the study period, 66 and 93 patients underwent PPE management in the “surgical” and “fibrinolytic” centers respectively. The population characteristics were comparable. Infection was controlled in all patients. In the “fibrinolytic” group, 20 patients (21.5%) underwent an additional drain placement while 12 patients (12.9%) required surgery to correct PPE. In the “surgical” group, 4 patients (6.1%) developed postoperative arrhythmia while 2 patients (3%) underwent a second surgery to evacuate a hemothorax. Median drainage {3 [2–4] vs. 5 [4–7] days} and hospital {7 [5–10] vs. 11 [7–19] days} durations were significantly lower in the “surgical” compared to the “fibrinolytic” center. Pleural opacity regression with therapy was significantly more important in the “surgical” compared to the “fibrinolytic” group (−22%±18% vs. −16%±17%, P=0.035).ConclusionsSurgical management of PPE was associated with shorter chest tube and hospital duration and better pleural space control. Prospective randomized studies are mandatory.     

Patients with Type 1 Diabetes Treated with Insulin Pumps Need Widely Heterogeneous Basal Rate Profiles Ranging from Negligible to Pronounced Diurnal Variability

Background:Pump-treated patients with type 1 diabetes have widely differing basal insulin infusion profiles. We analyzed consequences of such heterogeneity for glycemic control under fasting conditions.Methods:Data from 339 adult patients with type 1 diabetes on insulin pump therapy undergoing a 24-hour fast (basal rate test) were retrospectively analyzed. Hourly programmed basal insulin infusion rates and plasma glucose concentrations as well as their proportions within, below, or above arbitrarily defined target ranges were assessed for specific periods of the day (eg, 1-7 hours, “dawn” period, 16-19 hours, “dusk” period, reference period 20-1 hours/10-14 hours), by tertiles of a predefined “dawn” index (mean basal insulin infusion rate during the “dawn” divided by the reference periods).Results:The “dawn” index varied interindividually from 0.7 to 4.4. Basal insulin infusion profiles exhibited substantial differences (P = .011), especially overnight. Despite higher insulin infusion rates at 4 and 6.45 hours, patients with the most pronounced “dawn” phenomenon exhibited higher plasma glucose concentrations at those time points (P < .012). Patients with a marked “dawn” phenomenon exhibited a lower probability for low (<4.4 mmol/L) and a higher probability of high values (>7.2 mmol/L) during the dawn period (all P values <.01).Conclusions:We observe substantial interindividual heterogeneity in the “dawn” phenomenon. However, widely different empirically derived basal insulin infusion profiles appear appropriate for individual patients, as indicated by similar plasma glucose concentrations, mainly in the target range, during a 24-hour fasting period.     

Greater Biosynthetic Liver Dysfunction in Primary Sclerosing Cholangitis Suggests Co-existent or Impending Cholangiocarcinoma

Background and Aim: Patients with primary sclerosing cholangitis (PSC) who develop cholangiocarcinoma (CCA) have a median survival of less than 6 months. In half of cases, PSC and CCA will be diagnosed either concurrently or within a year of one another. The aim of the present study is to demonstrate that the degree of biochemical liver dysfunction is associated with concomitant or impending CCA. Methods: We did a chart review of patients diagnosed with PSC and CCA up to 18 months from presentation (“CCA” group) as well as patients with PSC that underwent transplantation with no sign of CCA in their explanted liver (“nCCA” group). Along with demographic data and follow-up length, we recorded their presenting liver function tests, including alanine and aspartate aminotransferases (ALT, AST), total bilirubin (TBil), alkaline phosphatase (ALP), international normalization ratio (INR), and serum Ca 19-9 levels. Differences between mean values of the two groups were analyzed with a student’s t-test. Results: Twenty-four patients were included. The “CCA” group consisted of eight patients, and the “non-CCA” group had 16 patients. There was no significant difference between the two groups in their presenting values of ALT, ALP, or serum Ca 19-9. However, the “CCA” group had significantly higher levels of AST, TBil, and INR. Conclusion: Patients with PSC and concurrent or impending CCA appear to exhibit significantly greater biochemical liver dysfunction than those who do not develop CCA. Therefore, newly-diagnosed PSC patients presenting with these findings may warrant more rigorous evaluation.     

Case Report: Ackee Fruit Poisoning in Eight Siblings: Implications for Public Health Awareness

Ackee apple fruit is a native fruit to Jamaica and some parts of west Africa. Its toxicity known as “Jamaican vomiting sickness” dates back to the nineteenth century. However, there is a dearth of reported published data on toxicity from Nigeria where it is popularly known in the southwest as “ishin.” We report a case series of eight previously well Nigerian siblings who presented at various intervals after ingestion of roasted seeds and aril of the ackee fruit.     

Predictors of High Motivation Score for Performing Research Initiation Fellowship,Master 1, Research Master 2, and PhD Curricula During Medical Studies: A Strobe-Compliant Article

Translational research plays a crucial role in bridging the gap between fundamental and clinical research. The importance of integrating research training into medical education has been emphasized. Predictive factors that help to identify the most motivated medical students to perform academic research are unknown. In a cross-sectional study on a representative sample of 315 medical students, residents and attending physicians, using a comprehensive structured questionnaire we assessed motivations and obstacles to perform academic research curricula (ie, research initiation fellowship, Master 1, Research Master 2, and PhD). Independent predictive factors associated with high “motivation score” (top quartile on motivation score ranging from 0 to 10) to enroll in academic research curricula were derived using multivariate logistic regression analysis. Independent predictors of high motivation score for performing Master 1 curriculum were: “considering that the integration of translational research in medical curriculum is essential” (OR, 3.79; 95% CI, 1.49–9.59; P = 0.005) and “knowledge of at least 2 research units within the university” (OR, 3.60; 95% CI, 2.01–6.47; P < 0.0001). Independent predictors of high motivation score for performing Research Master 2 curriculum were: “attending physician” (OR, 4.60; 95% CI, 1.86–11.37; P = 0.001); “considering that the integration of translational research in medical curriculum is essential” (OR, 4.12; 95% CI, 1.51–11.23; P = 0.006); “knowledge of at least 2 research units within the university” (OR, 3.51; 95% CI, 1.91–6.46; P = 0.0001); and “male gender” (OR, 1.82; 95% CI, 1.02–3.25; P = 0.04). Independent predictors of high motivation score for performing PhD curriculum were: “considering that the integration of translational research in medical curriculum is essential” (OR, 5.94; 95% CI, 2.33–15.19; P = 0.0002) and “knowledge of at least 2 research units within the university” (OR, 2.63; 95% CI, 1.46–4.77; P = 0.001). This is the first study that has identified factors determining motivations and barriers to carry out academic research curricula among undergraduate and postgraduate medical students. Improving these 2 areas will certainly have an impact on a better involvement of the next generation of physicians in translational medicine.     

Role of Helicobacter pylori infection in autoimmune systemic rheumatic diseases

The relationship between infection and autoimmunity has been increasingly defined over the last 20 years. The systemic rheumatic diseases are characterized by dysregulation of the immune system resulting in a loss of tolerance to self-antigen. The exact etiology for the majority of these diseases is unknown; however, a complex combination of host and environmental factors are believed to play a pivotal role. Helicobacter pylori (H. pylori) is one of the most widely studied infectious agents proposed as agents triggering autoimmune response. The persistent presence of H. pylori in the gastric mucosa results in chronic immune system activation with ongoing cytokine signaling, infiltration of gastric mucosa by neutrophils, macrophages, lymphocytes, as well as production of antibodies and effector T-cells. Various mechanisms have been proposed in an attempt to explain the extra-intestinal manifestations of H. pylori infections. These include: molecular mimicry, endothelial cell damage, superantigens and microchimerism. I performed a systematic literature review using the keywords “rheumatoid arthritis”, “Sjögren’s syndrome”, “systemic sclerosis”, “systemic lupus erythematosus”, “Helicobacter pylori” and “pathogenesis”. A systematic literature search was carried out in MEDLINE; EMBASE; Cochrane Library and ACR/EULAR meeting abstracts. In systemic rheumatic diseases H. pylori infection prevalence alone should not be expected to provide sufficient evidence for or against a pathologic role in the disease. In this article I review studies examining the potential involvement of H. pylori infection in autoimmune systemic rheumatic diseases. Further studies of the immunological response to H. pylori and its role in the pathogenesis of systemic rheumatic diseases are warranted.     

Does an Obesity Paradox Really Exist After Cardiovascular Intervention?: A Systematic Review and Meta-Analysis of Randomized Controlled Trials and Observational Studies

Several studies have shown the existence of an obesity paradox after Percutaneous Coronary Intervention (PCI). However, other studies have shown its absence. This study sought to perform a systematic review and meta-analysis of studies comparing the mortality risk between high body mass index patients and normal weight patients after PCI.We have searched PubMed, Embase, and Chinese medical journal for randomized controlled trials (RCTs) and observational studies published between the year 2000 and 2015 by typing the keywords “percutaneous coronary intervention” and “obesity paradox.” The main outcome was “all-cause mortality”. RevMan 5.3 software was used to calculate the risk ratio (RR) with 95% confidence interval (CI) to express the pooled effect on discontinuous variables.Twenty-two studies have been included in this meta-analysis consisting of a total of 242,377 patients with 73,143 normal weight patients, 103,608 overweight, and 65,626 obese patients. Younger age, higher cardiovascular risk factors and the intensive use of medications have mainly been observed among obese patients followed by overweight and normal weight patients respectively. In-hospital, 12 months and ≥ 1 year (long-term) mortality risks were significantly lower in the overweight and obese groups with (RR: 0.67; 95% CI: 0.63–0.72, P < 0.00001) and (RR: 0.60; 95% CI: 0.56–0.65, P < 0.00001) respectively in the in-hospital follow-up (RR: 0.62; 95% CI: 0.55–0.71 and 0.57; 95% CI: 0.52–0.63, P < 0.00001) at 12 months, and (RR: 0.70; 95% CI: 0.64–0.76; P < 0.00001) and (RR: 0.80; 95% CI: 0.71–0.91, P = 0.0006) respectively for the long-term follow-up after PCI.This “obesity paradox” does exist after PCI. The mortality in overweight and obese patients is really significantly lower compared to the normal weight patients. However, the exact reasons for this phenomenon need further exploration and research in the future.     

On Gifts and Heroes

The language of gratitude and of heroism, pervasive in public discourse about essential workers, is well-intended but belies a problematic blurring of the difference between gifts, contracts, and professionalism. “Heroism,” a term frequently invoked by society, usually describes the giving of oneself beyond reasonable boundaries. This noble concept affirms our essential connections to each other. However, labeling someone’s labor as a gift can make givers feel obligated exceed both contracts and professionalism. Contracts define the boundaries of expected work for expected compensation. Like heroism, professionalism in healthcare implies undertaking duties to others beyond the contractual. Careless use of these words, however, can lead to negative consequences. Gifts and heroism are best applied to special needs in special circumstances. Professionalism goes beyond special circumstances to address ongoing commitments to others. When the language of gifts, heroism, or professionalism are used to promote the ongoing performance of dangerous, excessive work, however, they become instruments of injustice and burnout. The experiences of the COVID pandemic can help identify the proper scope of gift-giving, heroism and professionalism - which cement our social bonds – while avoiding misuses of these terms, in order to improve the safety and fairness of the work environment.

For a few months this spring I found, wherever I walked, paths covered in pastel chalk, offering gratitude and lauding essential workers as “heroes.” The same message was audible overhead as people leaned out their windows at seven each spring evening in New York City, clapping and sounding bells and horns repurposed from sports games past. The number of times that I personally have been thanked for working as a physician in this city during COVID-19 is lovely and staggering. At the same time, some US medical residents who merely inquired about hazard pay have been told that such questions were “not becoming,”¹ and could lead to career penalties. I think it is likely that these individuals were trying to define professionalism for themselves and their families.Something feels flimsy and tautological about the current state of affairs for healthcare essential workers. Doing the work renders us heroes. The society thanks us by giving us, again and again, this title of “hero,” and we reciprocate that gift by in turn giving more of our heroic work, without asking whether the type of work or the limitations of the work conditions we are experiencing go beyond our commitments to serve our patients trustworthily.Let me digress a moment for this: I love being a doctor. Moreover, I willingly undertook a career with significant occupational hazard—from unpredictable hours, to patients whose illness might cause volatility or aggression, to communicable diseases. This was the deal, in exchange for a career that brings such wonder and joy. I love meeting and listening to patients, solving diagnostic puzzles, devising therapeutic regimens, and working under fast and sometimes heart-racing conditions. I even love the bitter privilege of ministering to a patients’ suffering or death, because it is so rare to accompany another human being in that way, and moreover so rare to have had mentors who taught me, I hope, how to be useful, self-effacing, and awed when I do so. I see these actions as part of my professionalism, and among the gifts that patients bestow on me, because they go beyond the specifics of my work contract.Much of my work, however, falls within my work contract. When someone’s blood culture grows Staphylococcus aureus and I prescribe a dose of vancomycin, I am not giving a gift; I’m doing my job. When an administrator assigns me to a particular shift date and I arrive at that shift, neither of us is giving the other a gift; we’re at work, in accordance with contracts that bind us to each other and our institutions by firm pacts. I am willing to go beyond the specifics of my contract because I love and respect my role as a physician. Ongoing extreme risk without appropriate compensation or risk reduction should not be expected of healthcare workers, however, under the label of gifts or heroism. Instead, efforts should be made to improve work circumstances.As a faculty physician, I am well paid, have reasonable job security, and receive benefits such as health insurance and vacations. For medical residents, some benefits will only be experienced in the future. For other essential healthcare workers, compensation and benefits are much more limited. Yet less-compensated workers are bearing a share of the COVID risks and demands that is often equal to or greater than those experienced by higher paid professionals. This raises issues of justice, a fundamental ethical principle. A better distinction is needed between the heroism or giving-of-self necessary to meet unanticipated temporary job conditions, and the enforced “giving” or “heroism” that simply becomes an ongoing, uncompensated or unremediated job expectation.The early twentieth-century sociologist Marcel Mauss observed gift-giving practices around the world to tease out the difference between gifts and other transactional contracts. In his 1925 The Gift: Form and Reason for Exchange in Archaic Societies, he writes that contracts are easier to define: they are quantitative and specific, with precise and predetermined mutual profits for each party when the contract is upheld, and equally precise penalties if broken.² Gifts, on the other hand, tacitly (sometimes explicitly) demand reciprocity, but their enforcement mechanism is through the honor and selfhood of people and their communities. There aren’t legal penalties for lack of gift giving. However, the stakes of not giving are high: one’s very self is on the line. And a loss of “honor,” such as was experienced by the residents who questioned the breadth of their work commitments, can have long-term consequences.“What is wrong with the so-called free gift is the donor’s intention to be exempt from return gifts coming from the recipient. Refusing requital puts the act of giving outside any mutual ties,” says anthropologist and Mauss scholar Mary Douglas.³ True gifts are those that prompt cycles of action that “engage persons in permanent commitments.” When we construe labor as “gifts” and expect the giver to continue giving freely, without tangible reciprocation, we break these cycles of action.There is danger in gifts. When someone’s working conditions become abruptly unjust or untenable, for instance, then there is no longer a valid contract governing that work, and whatever a worker chooses to continue to do in accordance with that prior, no longer pertaining, contract shades into the realm of gift. For those who work for reasons of need, precarity, and vulnerability, or who have limited options for changing jobs, being expected to continue gifting not only may be unjust but also may lead to a diminished sense of accomplishment or self-worth.In everyday life, we use the gift-related words “thank you” and “you’re welcome” even when non-gift transactional work is involved—handing someone a syringe or mopping a hospital corridor, for instance—mostly, I think, because we recognize that the particular style, grace, or personal presence that an individual brings to that work is indeed a gift, one worthy of esteem and prompting future exchanges. And gifts are, in Lewis Hyde’s words, “social faith,” sorely needed at present.But it can be dangerously easy for hoped—for “gifts” to become “expectations”—obligatory, quasi- or pseudo-contractual. This is what struck me as the evening vuvuzelas and cowbells, the soundtrack of World Cups and marathons, greeted me as I entered the hospital to begin my night shifts this past spring. Turning my work into a “gift” binds my honor and integrity into the exchange. It’s flattering, but as the months go on, it’s also harder to call attention to the need for workplace improvements if one has internalized this view of one’s higher-risk or unprecedented work as a gift to society. Moreover, converting one’s particular, idiosyncratic self into a “hero” can make one believe over time in the attendant expectation to be “ungrudging” and “strong” rather than (perhaps appropriately) inquisitive, pragmatic, or skeptical. I am fortunate to work under fair and reasonable conditions. But I know this is not the case for many essential healthcare workers. I fear that the pervasive gift/hero mentality makes it harder to fight for justice for them—and harder to convince oneself of what one deserves.Shifting our attention from the “gifts” of individual “heroes” to a discourse of protections and rights is a necessary move, one which mirrors the evolving definition of “medical professionalism.” As Frederic Hafferty and Dana Levinson have written, for too long the concept of “professionalism” focused on a view of medicine that privileged “individual motives and behaviors,” while a more useful redefinition should call our attention to “how systems and structures affect individuals and how organizations themselves might embody professional principles.”³ We know, too, that long before the pandemic, burnout has been pervasive in American medicine.⁴ Clarifying what can and should be asked of doctors and their teams, versus what constitutes taking advantage of our “hero” complex, might be helpful. Most healthcare professionals see going above and beyond written contracts in times of need as part of the work. No one, however, wants to foolishly continue to carry excessive burdens in perpetuity. Simply making it possible to discuss and address such issues might go far in improving the health of the workplace.Since the pandemic began, I’ve found myself consciously smiling more, saying “thanks,” trying to make sure I explicitly notice the infinite forms of labor that construct the world I live in. And I should—we should—be grateful. I am grateful to those who encouraged me during a difficult time with their communal displays of thanks, and I appreciate and am warmed by the community spirit that prompted those displays. At the same time, it’s important to remain wary of excessive use of displays of gratitude to reinforce the ongoing behavior of accepting excessive or remediable work risks or demands. Long after the pandemic is over, this striving for conceptual clarity will remain a cornerstone for building a more just and a healthier healthcare workplace.     

Global trends of researches on bone metastasis: A bibliometric and visualization study

Background:Bone metastasis (BM) has become an important health problem. In recent years, studies on BM are growing rapidly, but there were no bibliometric studies regarding BM. This study aimed to illustrate the overall knowledge structure and development trends of BM.Methods:Research datasets were acquired from the Web of Science database. The time span was defined as “1980–2020”. VOS viewer and Citespace software was provided to analyze the data and generate visualization knowledge maps. Annual trends of publications, distribution, H-index status, co-authorship status, and research hotspots were analyzed.Results:Six hundred eighty-two publications met the requirement. USA published most papers (264, 38.7%), and both total citations (13,997) and H-index (57) of USA ranked first. The most productive institution on BM is Amgen Inc. (43). Supportive Care in Cancer (24) published the most papers on BM. “Safety”, “skeletal related event”, “open label”, “management”, “health”, and “prognosis” are the research hotspots in the recent years.Conclusion:In this study, we conduct a systematic and comprehensive analysis on the research in BM field. The publication number was rising in recent years stably. USA contributed mostly not only in quality, but also in quantity. Amgen Inc. published the largest number of articles, Supportive Care in Cancer was the most productive journal related to BM. “Safety”, “skeletal related event”, “open label”, “management”, “health”, and “prognosis” are the research hotspots in recent years. We believe this study can not only show the global research overview in past 40 years but also point the research trend of BM in the future.     

The efficacy of acupuncture and moxibustion for early and middle-stage osteonecrosis of the femeral head: A systematic review and meta-analysis of randomized controlled trials

Background:Osteonecrosis of the femeral head (ONFH) occurs predominantly in young- and middle-aged people, and the disability rate is high in the late stage of the disease and most patients have to undergo total hip replacement. Clinically, increasing attention is paid to intervening early and middle-stage ONFH so as to delay its progress. Acupuncture and moxibustion (AM) is a unique method for treating ONFH in China. This study aims to summarize the advantages of AM for the treatment of ONFH.Methods:A comprehensive literature search was conducted on the database with languages of English and Chinese. The medical subject titles used are “Osteonecrosis of the femoral head” and “acupuncture and moxibustion.” Related words in the title or abstract including but were not limited to “necrosis of the femoral head,” “avascular necrosis of the femoral head,” “ischemic necrosis of the femoral head,” “caput femoris necrosis,” “bone paralysis,” “bone erosion,” and “bone atrophy.”Results:Nine randomized controlled trials were identified in this meta-analysis that included 630 subjects. Meta-analysis showed that the trial group that treated with conventional therapy combined with AM had a higher effective rate (Z = 2.27 P = 0.02) and excellent and good rate (Z = 4.85 P < 0.00001) and Harris hip function score (HHS) (Z = 2.31 P = 0.02) and lower incidence of related adverse reactions during treatment (Z = 2.82 P = 0.005) compared with the control group that treated with conventional therapy alone.Conclusions:AM for early and middle-stage ONFH is an effective and relatively safe intervention, which can improve the effective rate and excellent and good rate and HHS, and reduce the adverse reaction rate. Clinically, early and middle-stage ONFH can be intervened by combining with AM while taking conventional therapy to improve the efficacy.