How pandemic made virologist unlikely cult figure.

Hepatic steatosis observed in most adults with obesity, diabetes

Nearly 80% of U.S. adults with obesity and diabetes have hepatic steatosis and an increased risk for advanced fibrosis, according to study findings published in Obesity.

Kenneth Cusi

“In people with diabetes, even those in the early stages of obesity, the majority had steatosis, and the prevalence of fibrosis was high,” Kenneth Cusi, MD, FACP, FACE, chief of the division of endocrinology, diabetes and metabolism at the University of Florida and an Endocrine Today Editorial Board Member, told Healio. “The risk for fibrosis is much higher than we previously thought.”

Cusi and colleagues analyzed data from the National Health and Nutrition Examination Survey from 2015 and 2016. Adults aged 18 years and older who had laboratory results available, no evidence of substantial alcohol consumption and a BMI of 25 kg/m2 or higher were included. Participants with a Fatty Liver Index (FLI) score of more than 60 or a U.S. Fatty Liver Index (USFLI) score of greater than 30 were defined as having nonalcoholic fatty liver disease (NAFLD). The Fibrosis-4 (FIB-4) index was used to determine fibrosis risk. Risk for advanced liver fibrosis was deemed low with a score of less than 1.67 and high with a score of greater than 2.67. NAFLD fibrosis score (NFS) was also used to determine fibrosis risks, with a score of greater than 0.676 defined as high risk.

Steatosis common with obesity, diabetes

Of 3,841 adults included in the study, 56% had obesity and 21.7% had diabetes. When USFLI score was used, more adults with overweight and diabetes had hepatic steatosis compared with those with overweight without diabetes (48.3% vs. 17.4%; P < .01). Similarly, more adults with obesity and diabetes had hepatic steatosis compared with those with obesity and no diabetes (79.9% vs. 57.6%; P < .01).

When FIB-4 score was used, adults with diabetes had a higher prevalence of moderate to advanced fibrosis compared with those without diabetes (31.8% vs. 20.1%; P < .05). Moderate risk for advanced fibrosis was observed in 24.9% of adults with obesity and diabetes compared with 13.7% of those with obesity and no diabetes (P < .05). When NFS score was used, advanced fibrosis was seen among more adults with obesity and diabetes than among those without diabetes (34.1% vs. 6.4%; P < .001).

Obesity plus diabetes increases advanced fibrosis odds

In logistic regression models adjusting for age, adults with obesity and diabetes had a moderate to high risk for fibrosis as measured by FIB-4 (OR = 2.06; 95% CI, 1.3-3.25) and advanced fibrosis as measured by NFS (OR = 5.7; 95% CI, 3.74-8.68). Of adults aged 45 to 64 years, those with obesity and diabetes had a higher prevalence of those with a moderate to high risk for fibrosis compared with those without diabetes (26.3% vs. 8.6%; P < .01).

Cusi said the findings emphasize the importance of screening high-risk patients for NAFLD. As Healio previously reported, in an article published in Gastroenterology, Cusi and colleagues outlined steps providers should take with screening. The steps include analyzing a patient’s history and laboratory tests; noninvasive testing for fibrosis, such as calculating FIB-4; and using liver stiffness measurement for those with an indeterminate risk after FIB-4 is calculated.

“Providers need to pay attention to the high-risk groups: people with obesity, metabolic syndrome, type 2 diabetes and high liver enzymes,” Cusi said. “Those are the groups at the highest risk for cirrhosis. If you do something to treat these patients early on, you can prevent cirrhosis.”


Kanwal F, et al. Gastroenterology. 2021;doi:10.1053/j.gastro.2021.07.049.

Weight loss from bariatric surgery cuts COVID-19 complications risks

Substantial weight loss after bariatric surgery was associated with improved COVID-19 outcomes compared with nonsurgical controls, including a 49% lower risk for hospitalization and a 60% lower risk for developing severe disease, data show.

“Many studies demonstrate a strong link between obesity and clinical outcomes of COVID-19, and all available studies suggest obesity is a major risk factor for severity of COVID-19,” Ali Aminian, MD, professor of surgery and director of Cleveland Clinic’s Bariatric and Metabolic Institute, told Healio. “However, there is no study to examine whether obesity is a modifiable risk factor for COVID-19. We designed and conducted this study to assess the effects of successful weight-loss intervention on the risk for COVID-19.”

COVID-19 outcomes after bariatric surgery
Weight loss after bariatric surgery is associated with lower risks for severe COVID-19 infection, hospitalization and need for supplemental oxygen. Data were derived from Aminian A, et al. JAMA Surg. 2021;doi:10.1001/jamasurg.2021.6496.

In a retrospective, matched-cohort study, Aminian and colleagues analyzed data from 5,053 adults with a BMI of at least 35 kg/m2 who underwent Roux-en-Y gastric bypass or sleeve gastrectomy from 2004 to 2017 at Cleveland Clinic Health System (median age, 46 years; 77.6% women; median BMI, 45 kg/m2). Researchers matched patients in the surgical group 1:3 with 15,159 adults with obesity who did not undergo bariatric surgery, using electronic health record data. Researchers assessed four COVID-19-related outcomes among patients from March 2020 to March 2021: positive COVID-19 test result; hospitalization; need for supplemental oxygen; and severe COVID-19 infection, defined as a composite of ICU admission, need for mechanical ventilation or death. The overall median follow-up duration was 6.1 years.

The findings were published in JAMA Surgery.

Before the COVID-19 outbreak, patients in the surgical group lost more weight vs. controls, with a mean difference at 10 years from baseline of 18.6 percentage points (95% CI, 18.4-18.7) as well as a 53% lower 10-year cumulative incidence of all-cause, non-COVID-19 mortality vs. controls (4.7% vs. 9.4%; P < .001).

Within the cohort, 11,809 patients were available on March 1, 2020, for an assessment of COVID-19-related outcomes. The rates of positive SARS-CoV-2 test results were comparable in the surgical (9.1%) and control groups (8.7%; P = .71). However, undergoing weight-loss surgery was associated with a lower risk for hospitalization (adjusted HR = 0.51; 95% CI, 0.35-0.76), need for supplemental oxygen (aHR = 0.37; 95% CI, 0.23-0.61) and severe COVID-19 infection (aHR = 0.4; 95% CI, 0.18-0.86).

“The large magnitude of effects after losing weight with metabolic surgery was surprising,” Aminian told Healio. “If we help patients lose weight, we can reverse many health consequences of obesity. This study clearly demonstrated that obesity is a modifiable risk factor for COVID-19. Considering the worldwide prevalence of obesity, findings from this study can have significant public health implications in the current pandemic and for future infectious outbreaks.”

The researchers noted that given the observational nature of the study and the low number of infections, the findings should be considered hypothesis-generating and not conclusive.

“Let me be clear about findings of this study,” Aminian told Healio. “Anyone can develop a severe form of COVID-19; however, the risk is greater among patients with obesity. That is why everyone should follow public health recommendations, such as wearing mask and getting vaccinated. Based on our findings, in patients with obesity, losing weight can also be helpful to decrease the severity of COVID-19.”

Cold Dry Air Requires a Little Extra Skin Care

dry winter skin

Here at The Skin Cancer Foundation, we spend a lot of time talking about skin cancer, but we’re also concerned with overall skin health. That means not only protecting your skin from sun damage, but also giving the largest organ in your body some TLC throughout the year.

Bitterly cold weather can be particularly harsh on your skin. Here are some simple tips to keep your skin soft and supple as we get through this final stretch of winter:

  1. Use a humidifier
    A humidifier adds moisture to the air, soothing itchy winter skin and preventing dryness. Make sure to use filtered or distilled water rather than tap water, and replace it daily so that bacteria doesn’t have a chance to grow.
  2. Consider a new moisturizer
    Many people find a moisturizer that they love and stick with it day in and day out. The issue with this approach is that your skin changes as the environment around it changes. With colder weather, your dry skin may require a denser moisturizer. When selecting a product for your winter routine, take a close look at the label and look for ingredients which are well-suited for dry skin. Hyaluronic acid, lactic acid and glycerin have all been proven to hydrate and refresh. Regardless of your preferred product, your moisturizer should contain SPF 15 to protect against incidental sun exposure.
  3. Mind your water temperature
    While your natural instinct may be to take steamy hot showers when the weather is cold, doing so robs the skin of necessary moisture. Instead, opt for warm showers and use a gentle, moisturizing soap or body wash.
  4. Apply moisturizer when skin is wet
    The best time to use cream or lotion is when your skin is still damp (like right after you’ve washed your face or taken a shower). This helps to trap the moisture before it evaporates and is especially important during the winter because the season’s dry air speeds up the process.

With a few weeks left in winter, you still have plenty of time to perfect your cold weather skin routine and master tricks for keeping your skin healthy for years to come. Stay tuned for updates to Sun & Skin News; we’ll share skin tips for spring and summer in the coming months.

Sleep-disordered breathing early in pregnancy linked to insulin resistance

Sleep disordered breathing is associated with an increase in insulin resistance but not insulin secretion during early pregnancy among women with overweight and obesity, according to a study published in Sleep.

“We decided to conduct this study to better understand the association between maternal sleep disordered breathing (SDB) and glucose metabolism in early pregnancy,” author Laura Sanapo, MD, MSHS, RDMS, a research scientist with the Miriam Hospital, Women’s Medicine Collaborative in Providence, Rhode Island, told Healio.

Women often experience snoring and obstructive sleep apnea (OSA) during pregnancy, Sanapo said. SDB also is underdiagnosed, although it affects up to 70% of high-risk pregnancies, she continued, especially those complicated by maternal obesity, and it is more common than other obstetric complications such as diabetes and hypertension.

Previous research has demonstrated that women with SDB during pregnancy have a higher risk for developing diabetes in late gestation than women without SDB after controlling for obesity and other confounding factors, according to Sanapo.

Yet whether women with SDB at the beginning of gestation start pregnancy with glucose abnormalities that precede the onset of diabetes such as reduced insulin sensitivity was unknown, Sanapo added.

What the study showed

The cross-sectional study was based on the baseline characteristics of 192 women with singleton pregnancies and risk factors for OSA such as a BMI equal to or greater than 27 kg/m2 and snoring three or more days per week.

The researchers conducted home sleep apnea testing (HSAT) at 11 weeks of gestation and homeostatic model assessments (HOMA) at 15 weeks.

HSAT found 61 participants (32%) with OSA based on respiratory-event index (REI) values of five events or more per hour. These participants were older, had a higher BMI and were more likely to be multipara than those not diagnosed with OSA.

Virtually all the respiratory events were obstructive, and both groups saw minimal sleep hypoxemia. The median REI was categorized as mild (fewer than 15 events per hour), though 10 women had REI values of more than 15 events per hour.

HOMA, designed to yield an estimate of insulin resistance, sensitivity and B cell function (HOMA %B), measured fasting glucose and c-peptide. Venipuncture following an 8-hour fast provided morning blood.

Participants who were diagnosed with OSA exhibited higher glucose and c-peptide values and had a higher degree of insulin resistance (HOMA-IR) than the participants who were not diagnosed with OSA, the researchers said.

For each 10-unit increase in REI, there was a 0.3-unit increase in HOMA-IR and a 4-unit increase in fasting glucose levels. However, there was no significant association between REI and HOMA %B.

The researchers also found an association between HOMA-IR and oxygen desaturation index (ODI), but they did not find an association between ODI and HOMA %B.

Further, 20 participants (32.8%) in the OSA group and 22 (16.8%) in the non-OSA group had fasting glucose levels of 95 mg/dL or higher. REI and ODI both were associated with fasting glucose levels after adjusting for the same covariates (B = .22; P = .012 and B = .27; P = .003, respectively).

Laura Sanapo

“Among a group of women without pregestational diabetes, those who are diagnosed with SDB at the beginning of pregnancy have lower sensitivity to insulin and higher fasting glucose levels compared to pregnant women without SDB,” Sanapo said.

The researchers controlled for several factors that may contribute to abnormal glucose markers in pregnancy such as maternal BMI, age, race, ethnicity and number of previous pregnancies.

Why the findings are important

Sanapo said these results were important for four reasons.

First, a reduced sensitivity to insulin usually precedes the development of diabetes. Second, the study showed this association between SDB and reduced insulin sensitivity very early in pregnancy, approximately 10 weeks before typical screenings for gestational diabetes in the general pregnant population.

Third, Sanapo noted that the normal range of insulin resistance in pregnancy is very narrow, so even mild changes related to maternal SDB can lead to abnormal values. Finally, SDB is a modifiable risk factor that can be treated by non-pharmacological interventions that are safe in pregnancy.

“Therefore, women with overweight and obesity may benefit from SDB screening before conception or early pregnancy to improve glucose metabolic outcome and decrease the risk of developing diabetes in pregnancy,” Sanapo said.

These women then may benefit from tailored interventions to improve pregnancy outcomes such as early gestational diabetes screenings and SDB therapy, though weight loss or exercise programs are not usually advised in pregnancy, Sanapo said.

“Hence, the ideal time to actually screen and intervene would be in reproductive-age women considering pregnancy,” she said.

The researchers now aim to better understand the mechanistic processes that connect these disorders to identify therapeutic targets. They also seek to establish whether screenings should be universal or for select groups of high-risk pregnancies, or if screenings should occur before conception.

Further, the researchers aim to evaluate whether SDB treatment can prevent the development of gestational diabetes or other adverse perinatal outcomes.

“SDB represents a common morbidity in high-risk pregnancies and is associated with many disorders that are directly linked or considered an important contributor to maternal mortality,” Sanapo said. “Research in this field is needed and may greatly impact maternal health.”


For more information:

Laura Sanapo, MD, MSHS, RDMS, can be reached at


Uma M. Reddy, MD, MPH

Previous studies have shown that SDB is associated with gestational diabetes, which is typically diagnosed at 24 to 28 weeks of pregnancy and affects 7% of all pregnancies. It is not clear if both conditions coexist in the same patients because they are at increased risk for both SDB and gestational diabetes mellitus.

The results of this study are significant and novel in that SDB early in pregnancy was associated with increased insulin resistance early in pregnancy, which may be the pathway for the development of gestational diabetes later in pregnancy. Therefore, SDB is a potentially modifiable risk factor that, if treated early in pregnancy, may decrease the risk of gestational diabetes.

Prior to changing care, further research is needed to understand if screening pregnant people for SDB early in pregnancy and treating with CPAP decreases the rate of development of gestational diabetes. Also, it is important to study if pregnant people with normal or low BMI diagnosed with SDB are at increased risk for gestational diabetes, as only a high-risk population was studied.Uma M. Reddy, MD, MPHProfessor of obstetrics and gynecology, vice chair of research, department of obstetrics and gynecology, Columbia University Irving Medical Center

Hyperpigmentation in Vitamin B12 Deficiency

A 59-year-old man presented to the endocrinology clinic with a 2-month history of fatigue and a 1-year history of progressively darkening skin on his palms and soles. He worked as a tile layer and had initially attributed his symptoms to occupational exposures. On physical examination, his tongue was smooth with patchy areas of mucosal darkening (Panel A). There was also hyperpigmentation on the palms (Panel B) and soles. Laboratory studies showed a hemoglobin level of 9.4 g per deciliter (reference range, 14 to 18), a mean corpuscular volume of 117 fl (reference range, 80 to 94), and mild leukopenia and thrombocytopenia. The vitamin B12 level was 40 pg per milliliter (30 pmol per liter; reference range, 200 to 1100 pg per milliliter [150 to 810 pmol per liter]), and the serum level of intrinsic factor antibody was greater than 200 reference units per milliliter (reference value, <18), findings consistent with a diagnosis of vitamin B12 deficiency due to autoimmune gastritis. Skin hyperpigmentation occurs in persons with vitamin B12 deficiency owing to increased melanin synthesis and is seen more frequently in persons with darker skin. The hyperpigmentation typically reverses with treatment. The patient received treatment with parenteral vitamin B12, and at follow-up 4 months after presentation, the hyperpigmentation had resolved (Panels C and D), as had his fatigue.

Nurses Struggle through a New COVID Wave with Rage and Compassion

A critical care nurse confronts the Omicron surge filling her hospital


Kathryn Ivey is a critical care nurse at a medical center in Nashville, Tenn.

Nurses Struggle through a New COVID Wave with Rage and Compassion

To health care workers in the COVID era, holidays mean death, and we knew Omicron was coming before it had a name. The wave caused by this variant has barely begun, rapidly gathering steam, and we are exhausted, attempting to pull from reserves badly drained by earlier surges.

Back in August, the beds of my hospital in Tennessee filled with COVID patients in varying stages of respiratory distress. Some wore a plastic mask that covered their mouth and nose, hooked up to a machine that delivered forceful breaths into the patient’s open mouth. Others were sedated, paralyzed, with a plastic tube down their throat, every breath driven by the ventilator that kept them alive. The anger of the nurses, myself included, surged along with the patient population. Rage seeped along the halls of the intensive care unit, burned in the quick conversations in the medication supply room, and settled around all of us as we tried to keep our heads above water for yet another push of the pandemic that had turned so many of us into open wounds. I was angry at everything: angry at the systemic failures of the government to act, angry at the individuals who treated COVID as a joke and angry at the disinformation that ushered in more death.

Every wave of COVID has been a special type of hell, but that August surge was much worse than those before it, as the summer of 2021 spiked to a boiling peak after a spring full of hope. This time we had the vaccine that should have put an end to all of it. The vaccine that I and so many health care workers had clung to like a lifeline for the first waves and the brutal winter was here, safe and effective—and largely ignored by patients that were first a trickle and then a torrent rushing into the emergency rooms, the medical surgical units, the intensive care unit, all gasping and dying and begging for a miracle, younger, sicker, crashing faster. Every death as devastating as it was preventable. Chart after chart told the same story: “COVID positive. Unvaccinated. Intubated, sedated, paralyzed. Prognosis is guarded in this critically ill patient.”

Eventually, that summer surge receded. By that, I mean that we occasionally had three or four open beds. My patients were all still sick, so sick. Many of them no longer had an active COVID infection, but their bodies had been so ravaged by the virus that they remained on breathing tubes as one organ system after another failed.

Whatever relief we felt at the slight lessening of pandemic pressure was short-lived: we already turned our eyes to the coming winter, to the holidays and the death at our heels. History repeats. My unit is full again. My co-workers and I are exhausted, angry and full of grief. The holidays brought with them another crush of death that will not reach a peak for weeks.

The medication room is a confessional for exhausted nurses and techs as we grapple with the awful deaths we witness and the understanding that the fatalities won’t stop, that the campaign of disinformation won and that many people won’t see COVID for the monster it is even when it stands shrieking in front of them. We seek solace in each other’s fury, in the knowledge that we don’t bear this anger and grief alone. Knowing that someone else sees and understands how bad things are brings a shred of peace. “Why are we even doing this?” my co-worker asked me in August, furious tears glistening in the corners of her eyes. We were both drenched in sweat and demoralized after another COVID admission that we knew would die in the hospital. “It’s been a year. I don’t want to do this anymore.” Just days after Christmas, the same co-worker grabbed my arm in silent support when I got choked up while giving her a report on a patient I moved mountains to try to save, both of us knowing that death was imminent.

I lost count of how many times I heard my colleagues say the words “I don’t want to do this anymore.”

I watched my co-workers develop post-traumatic stress disorder in real time, the shadows under their eyes deepening and the brilliant lights of their souls dimming under the onslaught of death. But the thing that damaged me more than anything else was knowing that we had a way out and didn’t take it. This sentiment has been echoed by many people that I work with, conservative and liberal alike, all of whom have seen the devastation that disinformation leaves in its wake. COVID is a hoax until someone you love is lying motionless in a hospital bed, half dead, being kept alive by an angry nurse, a tired respiratory therapist and a depressed physician.ADVERTISEMENT

For two years, medical workers around the globe have tried to spare others from paying the price of politicizing science and public health. Some people may have listened to us, and I hope that our warnings saved lives. Now, as the pandemic stretches into a second year and the desire to return to a normal life outweighs the recognition of what this disease is and what it does, the health care workers who take to social media and public forums to remind people that the pandemic rages on are treated with derision and hostility.

I have been in various forms of media discussing the pandemic, and while negative comments were always there, my last 15 minutes of fame in August was by far the most contentious. I wrote a thread on Twitter chronicling my first year as a nurse during the pandemic, and it went viral. As the comments (that I tried not to read) rolled in, I learned that I’m a fake, crisis actor. I’m getting paid to make COVID look worse than it is. I’m getting paid when my patients die. Just give them ivermectin. It’s that ventilator that kills them. Nurses and doctors are murderers. I wish I could say that these comments had no effect on me, but many of them, especially the ones accusing me and my colleagues of killing our patients, hit like a punch in the gut.

I’ve received multiple death threats and refuse to publicly identify my hospital to protect both myself and my co-workers. I see how easy it would be for someone who believes these conspiracy theories to act on their misguided rage. I saw a video on TikTok showing a man on security camera, apparently trying to get into the intensive care unit, threatening the nurses and doctors who he says killed his friend. “Why are you killing people with your treatment?” he demands. He states that he has been studying the routines of the nurses and that he has a gun at home. My in-person experiences with individuals who would threaten nurses physically or sue a hospital to force them to administer ivermectin or hydroxychloroquine, have been small but not zero. Each has left me angry and unsettled, at a total loss to understand how anyone could think that we wouldn’t end this misery in a heartbeat if we could.

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Most patients and their families are kind, lovely people who are enduring something horrible, gracious in their sadness and understanding of how hard we fight to save the person they love. They vastly outnumber the small but vocal group who believe that we are choosing not to save their loved ones. “I know you’re moving heaven and earth for her,” a husband told me once, tears in his eyes. “I know you’re trying.”

I became a nurse because I want to help people. I don’t want to watch them die these horrible, preventable deaths, shift after shift and year after year. No health care worker does. Every time I speak publicly about COVID, it’s to beg people to listen to us so that they don’t have to learn the hard way, but the longer the pandemic drags on, the more I feel that I’m shouting into an abyss.ADVERTISEMENT

Medical workers are tired, we’ve been tired, but we keep showing up for the same simple reason most of us sought out this field in the first place: we want to help people. We have borne witness to immense pain and want to ease it, to bring life back into places of darkness and suffering. We’re not heroes or angels or any of the other things that well-meaning people call us. We are just human beings who are not immune to the pressure, grief and relentless crush of misery this pandemic causes.

Everyone has a breaking point. Many health care workers have been driven close to ours, not just because of COVID itself but because of all the ugly things that humanity—particularly in the United States—has revealed about itself in our response to COVID. An exodus of nurses began before the pandemic, created by impossible workloads and uncaring employers, and it will continue so long as selfishness and profit are valued above human life. Now the Centers for Disease Control and Prevention has released new guidelines that decrease the amount of time health care workers should isolate with COVID, which increases our risk of exposure. I expect these standards will fuel the next wave of exits. For two years we have sacrificed, broken our hearts and our bodies for a country that views us as an acceptable loss, yet more and more is asked of us by organizations that lack the spine for the mask and vaccine mandates that could bring us out of this hell. We are canaries in a coal mine.

Despite all this, all the complicated emotions and experiences that come with being a health care worker, people will always be drawn to the fields of nursing and medicine. Despite all of it, I’m glad I became a nurse.

There is always light, even in this unrelenting dark. The human condition has always been dogged by misery, genocide, colonialism, pandemics and petty wars; yet there is always beauty in small things. I remind myself of this when I feel overwhelmed by all the terrible things in the world, by the amount of death that I’ve seen since I became a nurse in July of 2020. I feel that dark tugging at me like a riptide, a constant crush of all the love that has nowhere to go and the grief that could swallow the world, and I feel the bravery and goodness of the people staring back into the abyss with me. After two years the death and darkness threaten to swallow us whole, and yet I look to my co-workers standing battered but steadfast against each wave of death, and I find courage to face it myself. This is what it is to be a nurse: facing that darkness and telling it that you are not afraid.

Severity of menopausal symptoms impacts cognitive performance

The cognitive performance of women was sensitive to the severity of their menopausal symptoms, particularly depression and sexual dysfunction, according to a cross-sectional study published in Menopause.

The study included 404 women aged 40 to 65 years (mean age, 50.78 years) living in the rural areas of district Rupnagar, Punjab, India, according to Mankamal Kaur, MSc, a research scholar, and Maninder Kaur, PhD, chair and assistant professor, both of the department of anthropology at Panjab University in Chandigarh, India.

The most common menopausal symptoms among late postmenopausal women include depression (67%), sexual dysfunction (67.8%) and somatic symptoms (63.5%).
Kaur M, et al. Menopause. 2021;doi:10.1097/GME.0000000000001910.

With a mean age at menarche of 14.89 ± 0.08 years and at menopause of 47.24 ± 0.32 years, 107 of the participants were premenopausal, 90 were perimenopausal, 92 were early menopausal and 115 were late menopausal according to WHO criteria.

Also, 83.4% were married, and 93.8% did not have any kind of private or government job. In terms of education, 22.5% were illiterate, 37.6% had primary to middle school education, 32.2% had a high school degree and 7.7% were graduates or postgraduates.

The women were evaluated according to the Greene Climacteric Scale, which evaluates 21 menopausal symptoms across psychological, somatic, vasomotor and sexual interest classifications.

Depression (67%), somatic (63.5%) and sexual dysfunction (67.8%) were highest among late postmenopausal women. Anxiety (58.7%) and vasomotor symptoms (59.8%) were highest among early postmenopausal women.

Also, the women completed a 30-point Hindi version of the Mini-Mental State Examination (MMSE) to gauge their global cognitive performance across its orientation to time and place, registration, attention and calculation, recall, and language and visuo-spatial ability subdomains.

Women with severe menopausal symptoms had significantly lower mean values for orientation (8.11 vs. 8.9; P < .001), registration (2.77 vs. 2.91; P < .001), attention (4.31 vs. 4.48; P < .01), recall (2.26 vs. 2.53, P < .05) and language/visio-spatial skills (7.13 vs. 7.91, P < .001) than women with mild symptoms.

In a univariate linear regression analysis, the severity of each menopausal symptom was negatively and significantly associated with global cognitive scores, the researchers said.

In the multivariate linear regression analysis, though, only severe depression and greater intensity of sexual dysfunction had a negative and significant association with MMSE scores.

After adjusting for age and marital and educational status, the researchers found that severe depression and sexual dysfunction were the only symptoms with a significant association with overall cognitive performance.

Severe vasomotor symptoms were not predictors of cognitive performance in all the cognitive domains on the MMSE scale except for attention, and once the researchers adjusted for covariates in the model, its significance was lost as well. No significant association was observed between somatic symptoms and cognitive performance either.

Although more longitudinal and cross-sectional studies of large population-based samples could clarify these associations, the researchers said, they believe their results can help rural services address these issues and help many women.



Stephanie S. Faubion, MD, MBA, FACP, NCMP, IF)

Stephanie Faubion, MD, MBA

The study showed a link between cognitive performance and the severity of menopause symptoms in a cohort of midlife women in rural India. The finding of cognitive changes in women during the menopause transition is not new.

Many women describe “brain fog” during the menopause transition, and this may relate to a number of factors, including sleep disruption related to menopause (insomnia, night sweats), mood disorders and life stressors.

Sleep disorders unrelated to menopause are also more prevalent in midlife and include restless leg syndrome and obstructive sleep apnea, which can contribute to daytime fatigue and cognitive changes.

Life stressors potentially resulting in sleep disruption and contributing to poorer cognitive performance include caretaking, relationship discord, financial stressors and other factors.

We also know that the menopause transition is a period of vulnerability in terms of mood, and mood disorders can certainly result in poorer cognitive performance.

Whether cognitive changes that occur in midlife are transient remains unclear. In contrast to findings of the Study of Women’s Health Across the Nation (SWAN), a recent study by Maki et al showed that cognitive declines in menopause may be persistent in women with multiple risk factors for cognitive dysfunction, including those with low income, low education, mental health disorders and high trauma exposure — factors that may be more prevalent in rural populations in India.

The study by Kaur and Kaur, however, highlights the importance of screening for potentially modifiable factors in individual women, such as sleep issues, mood disorders and bothersome menopause symptoms. But it also underscores the importance of addressing the more difficult societal level issues of the effects of poverty and trauma on health and quality of life.Stephanie Faubion, MD, MBADirector, Mayo Clinic Center for Womens HealthMedical Director, the North American Menopause Society

Aromatherapy may reduce anxiety, pain in oculoplastic surgery

In patients who had oculoplastic surgery with monitored anesthesia sedation, aromatherapy may be associated with less anxiety and pain, according to a presenter at the American Academy of Ophthalmology meeting.

“Aromatherapy has been shown to reduce preoperative anxiety, and its effectiveness has also been shown in ophthalmic procedures, namely cataract surgery, in reducing anxiety,” Michael Chang, MD, said in the presentation. “However, to the best of our knowledge, no studies on the effects of aromatherapy on patients undergoing oculoplastic surgeries have been studied, and therefore this is the main role of our current study.”


In a non-masked, placebo-controlled prospective study, Chang and colleagues randomly assigned 60 patients who underwent oculoplastic surgery with monitored anesthesia care sedation at Ruby Memorial Hospital, West Virginia, between August 2018 and November 2020 to the aromatherapy group or the control group.

A cotton pad was attached to participants’ gowns preoperatively; 32 patients had a lavender-, bergamot- or orange-infused pad, and 28 patients had a sham pad. The Spielberger State-Trait Anxiety Inventory scale was used to measure preoperative anxiety traits and preoperative and postoperative anxiety states, and the visual analogue scale was used to measure anxiety and pain, according to the poster.

There were no significant differences in procedure type between the control and aromatherapy groups, with the most common procedures being ptosis repair, lesion excision and lateral tarsal strip. Thirteen patients had multiple procedures.

Compared with the control group, patients in the aromatherapy group had better anxiety and pain scores postoperatively.

“[Of] patients who received aromatherapy, the majority of them had improved postoperative anxiety, whereas if you looked at the control group, more patients compared to the aromatherapy group had increased postoperative anxiety,” Chang said.

Patients in the aromatherapy group also spent less time in the post-anesthesia care unit, which could financially benefit surgical centers, Chang said. Analysis of midazolam and dexmedetomidine use revealed neither was a significant contributor to outcomes.

“In conclusion, aromatherapy can be a safe treatment, but in addition, preoperative use of aromatherapy can have a synergistic effect with intraoperative anesthetics to reduce both pain and anxiety,” Chang said.

IV magnesium fails to decrease asthma exacerbation severity in children

IV magnesium for children with moderate-to-severe asthma exacerbations was associated with increased exacerbation severity and risk for hospitalization without any acceleration in resolution, according to observational study results.

National Heart, Lung, and Blood Institute expert guidelines recommend considering IV magnesium (IV-Mg) for children with moderate-to-severe asthma exacerbations who don’t completely respond to systemic corticosteroid (CCS) and inhaled albuterol, Donald H. Arnold, MD, MPH, professor of pediatrics and director of pediatric emergency medicine research at Monroe Carell Jr. Children’s Hospital at Vanderbilt, and colleagues wrote, adding, however, that a Cochrane systematic review of randomized trials showed varying study results among children treated with IV-Mg


Donald H. Arnold

“Moreover, recent studies showed that IV-Mg is typically administered late in the ED course, and most children are hospitalized after receiving IV-Mg,” they added. “Yet despite limited evidence for the safety and efficacy of IV-Mg in children, the use of IV-Mg increased in the United States over the past decade.”

Thus, Arnold and colleagues conducted a secondary analysis of a prospective, observational cohort to evaluate whether IV-Mg administered early in the ED decreased exacerbation severity, hospitalizations and time to spacing of inhaled albuterol to 4 hours or more.

The analysis included data from 933 children aged 5 to 17 years with acute moderate or severe asthma exacerbations in an urban tertiary children’s hospital ED between April 2008 and February 2013.

Exacerbations included cough, dyspnea, wheezing and/or chest pain as well as the need for CCS and inhaled albuterol treatments as determined by the clinical team and the Acute Asthma Intensity Research Score (AAIRS), a 0- to 16-point scale, with 16 indicating the most severe cases.

The researchers measured and recorded relevant variables before treatment and 2 and 4 hours after administration of CCS, if the participant was still in the ED. Clinicians considered use of 75 mg/kg IV-Mg if the patient showed insufficient response to CCS and inhaled albuterol after 20 minutes.

A change in AAIRS after 2 hours of ED-administered treatment served as the primary outcome.

According to the study, 301 of the participants (median age, 8.1 years; 57% Black; 67% boys) had an AAIRS of 7 or greater before treatment and were still in the ED 2 hours after treatment began. Of them, 84 (28%) received IV magnesium (IV-Mg) treatment.

IV-Mg treatment appeared associated with a 2-hour increase in AAIRS score based on the study’s propensity score (PS)-adjusted multivariable regression model ( coefficient = 0.98; 95% CI, 0.2-1.77), which denoted increased exacerbations.

Also, patients who received IV-Mg during the first 2 hours of treatment had a 5.8-fold (95% CI, 2.8-11.9) greater odds of hospitalization in the PS-adjusted multivariable regression model. In the inverse probability of treatment weighting multivariable regression model, the odds were 6.8 times greater (95% CI, 3.6-12.9).

There also was no difference in time to albuterol of every 4 hours or more among hospitalized patients (HR = 1.2; 95% CI, 0.8-1.8) in the PS covariate-adjusted Cox proportional hazards model, indicating that IV-Mg did not accelerate exacerbation resolution.

Further, the researchers found an association between IV-Mg treatment and an approximately one-point increase in exacerbation severity on the validated AAIRS. Typically, a decrease of two or more points is clinically meaningful for decisions to deescalate treatment.

The researchers called this one-point increase in clinical severity cause for concern that IV-Mg treatment may be deleterious for children who are experiencing moderate-to-severe asthma exacerbations.

“Although IV-Mg is generally safe and well-tolerated, the results of this observational study of real-world use of IV-Mg indicate that it is associated with increased exacerbation severity and hospitalizations and does not accelerate clinical improvement in hospitalized patients,” they wrote. “In the absence of a randomized controlled trial powered to examine important outcomes, there is insufficient evidence to support the use of IV-Mg for moderate and severe acute asthma exacerbations in children.”



 Jennifer Namazy, MD)

Jennifer Namazy, MD

For years, magnesium sulfate has been used in the care of acute asthma exacerbations among both children and adults. As an inexpensive treatment available in most hospitals, it is thought to have minimal adverse effects. It is the recommended treatment for children aged older than 4 years who present with severe asthma exacerbations. In fact, a meta-analysis of five studies found that treatment with magnesium sulfate was effective in preventing hospitalizations in children with acute asthma.

The study by Arnold and colleagues is significant, then, because it suggests further studies should assess the safety and efficacy of this treatment in both adults and children. This therapy did not lead to a reduction in rescue medication and was associated with an increased risk for severe exacerbation. The fact that it did not reduce the need of rescue medication is counterintuitive to why we use magnesium sulfate in the first place, which is because it leads to relaxation of bronchial smooth muscle.

Studies have been conflicting in this area. Another randomized trial comparing magnesium sulfate with placebo in children who were wheezing and unresponsive to bronchodilators found no difference between the two groups in reduction of respiratory distress. I agree with Arnold and colleagues that its relative safety and tolerability should not alone advocate its use.

Further studies are needed to assess its efficacy in reductions of moderate-to-severe asthma exacerbations. A large randomized controlled trial comparing magnesium sulfate with placebo looking at outcomes such as symptom improvement, lung function improvement, exacerbation reduction and hospitalizations is warranted.Jennifer Namazy, MDScripps Clinic Medical Group