Weight loss drugs and stomach paralysis: New findings

 Delayed gastric emptying, also known as gastroparesis, is a more common side effect of GLP-1s than other diabetes and weight loss treatments, according to new research.

Gastroparesis can range from mild symptoms to severe side effects, including refractory symptoms, the inability to orally consume nutrition and frequent hospital admissions. The most severe cases are known as stomach paralysis, and gastrointestinal clinicians have noticed a connection between the condition and GLP-1s. 

GLP-1s, or glucagon-like peptide-1 receptor agonists, are a drug class that helps diminish appetite and create a feeling of fullness. Most GLP-1 medications are approved for Type 2 diabetes, with a few indicated for chronic weight management and serious cardiovascular problems. 

In mid-2023, amid the increasing popularity of these therapies, medical professionals said GLP-1 patients were experiencing severe gastroparesis. Drugmakers are facing lawsuits over the reported side effect as surgeons wonder about the long-term effects of delayed gastric emptying. 

Epic Research, which internally reviews data on medical and public health matters, recently conducted two studies to quantify the rare side effect. 

In a review of 12 million diabetic patient records, researchers found delayed gastric emptying happened more often for those taking GLP-1s compared to those not prescribed these drugs. On the other hand, gallstones and ileus — in which the intestine temporarily cannot move waste — were less common symptoms among GLP-1 patients. 

Patients taking exenatide (Byetta, Bydureon), liraglutide (Saxenda, Victoza), dulaglutide (Trulicity), and semaglutide (Ozempic, Wegovy, Rybelsus) have a high likelihood of developing a gastrointestinal side effect, the research found. Those who are prescribed tirzepatide (Mounjaro, Zepbound) are less likely to experience GI issues than those not taking a GLP-1. 

In a different study, Epic Research analysts found that, among nondiabetic patients taking GLP-1s, there is a high likelihood of patients experiencing delayed gastric emptying, gallstones and ileus if they are taking liraglutide and semaglutide.

https://www.beckershospitalreview.com/glp-1s/weight-loss-drugs-and-stomach-paralysis-new-findings.html

Early-career physicians working temp roles to 'test drive' practice settings, survey finds

 Physicians and advanced practice providers are opting for the flexibility of temporary, locum tenens work in seek of improved job conditions and to relieve burnout, according to an April 23 survey conducted by AMN Healthcare. 

AMN, the largest provider of healthcare interim leadership and executive search services in the U.S., asked physicians, physician assistants and nurse practitioners who recently have worked locum tenens why they do so. 

The number one reason, according to 86% of respondents, was a better work schedule, followed closely by addressing feelings of burnout (80%). 

"During the COVID pandemic, healthcare professionals began to rethink how, when and where they work," Jeff Decker, president of AMN's physician solutions division, said in a news release. "Locum tenens offer relief from the long, inflexible work hours and onerous bureaucratic duties that often cause dissatisfaction and burnout among physicians and other healthcare providers."

Locum tenens providers also offer staffing flexibility for hospitals, health systems and other healthcare facilities amid ongoing workforce challenges. 

Despite survey respondents' positive feelings about locum tenens, many physicians, NPs and PAs said that they would return to permanent positions if conditions were right. Forty-five percent of respondents said they would stop working locum tenens and return to a permanent position if schedules, compensation and other practice conditions were favorable; 43% said they would stick to locum tenens. 

"Many physicians and other healthcare professionals feel they are being pushed from permanent positions by unsatisfactory work conditions," Mr. Decker said. "To get them back, employers should offer practice conditions that appeal to today’s providers."

The survey also suggests that physicians, NPs and PAs are choosing to work locum tenens earlier in their careers. 

Most respondents (81%) said they began working locum tenens either right out of training or in mid-career, while 19% began working locum tenens after retiring from full-time positions. By contrast, in 2016, only 64% of those surveyed began working locum tenens right after training or in mid-career, while 36% began after retirement. 

"Locum tenens is no longer an alternative just for healthcare providers in the twilight of their careers," Mr. Decker said. "Younger providers are working locum tenens as a way to ‘test drive’ practice settings or to opt out of practice environments that don't meet their needs."

The number of physicians working locum tenens is growing, from an estimated 26,000 in 2002 to more than 52,000 in 2024, reflecting an increasing diversity of practice styles, according to AMN. 

Click here to access the survey

https://www.beckershospitalreview.com/hospital-physician-relationships/early-career-physicians-working-temp-roles-to-test-drive-practice-settings-survey-finds.html

Hospitals see no respite from cost pressures

 Hospitals and health systems are at a crossroads of increasing demand for higher acuity care and deepening financial instability, caused by rising costs due to ongoing workforce shortages, severe fractures in the drugs and supplies supply chain and high levels of inflation, according to a May 2 report published by the American Hospital Association. 

While cost pressures have not let up in 2024, hospitals also have to contend with "inadequate increases" in reimbursement by CMS and increasing administrative burden due to "inappropriate" commercial payer practices, according to the report. 

"As this report clearly highlights, increased expenses, workforce challenges, and growing administrative burden are unsustainable and creating headwinds and obstacles that threaten access to care for millions of Americans,"AHA President and CEO Rick Pollack said. "The AHA urges Congress and the Administration to take action to strengthen hospitals and health systems and bolster access to care for all patients and communities."

Five things to know:

1. Costs of providing essential services. Hospitals often provide essential services — such as emergency care, behavioral healthcare, or labor and maternity services — that are not offered by other types of providers in the area — particularly in rural parts of America. Many of these services are resource intensive and costly to provide, and CMS payments for these services fall well below costs. 

The AHA found that Medicare paid 82 cents for every dollar hospitals spent on care for Medicare patients in 2022 — the most recent year for which data is available. Medicare underpayments to hospitals hit $99.2 billion in 2022, almost two and a half times the amount in 2012.

2. Administrative costs. Hospitals are dealing with significant growth in administrative costs due to "inappropriate practices" by commercial payers, including Medicare Advantage and Medicaid managed care plans, according to the AHA. Premiums have grown twice as fast as hospital prices, according to The Wall Street Journal, and commercial payers have overburdened hospitals with time-consuming and labor-intensive practices such as automatic claims denials and excessive prior authorization requirements. 

"Rarely, if ever, seen the kind of payer behavior that we've seen recently." Chicago-based CommonSpirit CFO Dan Morisette said during a Feb. 29 investor call. "Denials that are absolutely not in accordance with the contracts that we have, delayed payments where we need to go to arbitration and/or litigation to try to get paid for work that we're clearly entitled to. "The behavior overall has been egregious.

3. Drug costs. In 2023, hospitals spent $115 billion on drug expenses. One of the factors fueling this growth is drug companies imposing large price increases on existing drugs and introducing new drugs at record prices, according to the AHA. Last year, the median annual list price for a new drug was $300,000, a 35% increase over the previous year. While high drug prices pose significant challenges for hospitals and health systems, it is compounded by the fact that many of these same drugs are in shortage. The number of ongoing drug shortages in the U.S. is at its highest since 2001 — when the American Society of Health-System Pharmacists began tracking data. 

4. Supply costs. On average, supply costs comprise about 10.5% of a hospital's budget and accounted for a collective  $146.9 billion in 2023, increasing by $6.6 billion from the prior year, according to data from Strata Decision Technology. As technology evolves, hospitals need to buy new supplies, devices and equipment that meet clinical care standards and ensure high quality care. The upfront costs for critical equipment and device upgrades — such as cardiac magnetic resonance imaging — are expensive as well as the costs required for maintenance, upgrades and staff training. 

5. Labor costs. Between 2021 and 2023, hospital labor costs increased by more than $42.5 billion to $839 billion, accounting for nearly 60% of the average hospital’s expenses. Some hospitals continue to rely on expensive contract labor to fill gaps and maintain access to care, spending about $51.1 billion on contracted staff in 2023. Hospitals and health systems have invested more to attract and retain talent, with wage rates across all hospital jobs jumping by 10.1% during 2023, according to data from Lightcast. With a growing gap between supply and demand for healthcare workers over the next decade, the AHA expects labor costs to likely continue to be a challenge for hospitals.

https://www.beckershospitalreview.com/finance/hospitals-see-no-respite-from-cost-pressures.html

Resident-to-resident aggression common in assisted living

 One in six residents of assisted living facilities is subject to verbal, physical or other aggression by fellow residents in a typical month, and those suffering from dementia are most at risk, new research finds in the first large-scale study of the phenomenon.

Involving 930 residents of 14 licensed assisted living facilities in New York state, the study found incidents of resident-to-resident aggression, also called resident-to-resident elder mistreatment, were nearly as prevalent as they are in nursing homes. That was unexpected, since assisted living residents tend to be less impaired, more mobile and have more privacy than those in nursing homes.

The results point to a need to train staff on how to recognize potentially harmful aggression and intervene, and for clearer policy guidance on how facilities should address the issue. The researchers are currently testing a training program they developed, "Improving Resident Relationships in Long-Term Care," which they said has helped reduce injuries in nursing homes.

"Interpersonal aggression is common in assisted living facilities and staff are inadequately trained to deal with it," said Karl Pillemer, the Hazel E. Reed Professor of Psychology in Cornell's College of Human Ecology (CHE) and professor of gerontology in medicine at Weill Cornell Medicine.

"Residents are vulnerable to psychological distress and physical injury from other residents, and that's something we need to take very seriously."

Pillemer is the first author of "Estimated Prevalence of Resident-to-Resident Aggression in Assisted Living," published May 3 in JAMA Network Open.

Co-investigators were Dr. Mark Lachs, co-chief of geriatrics and palliative medicine at Weill Cornell Medicine and NewYork-Presbyterian/Weill Cornell Medical Center and the Irene and Roy Psaty Distinguished Professor of Clinical Medicine at Weill Cornell Medicine; and Jeanne Teresi, assistant professor of medical sciences at Columbia University Irving Medical Center and co-director of the Columbia University Stroud Center for Aging Studies.

Over 800,000 people live in more than 30,600 assisted living facilities in the U.S., according to the American Health Care Association, numbers that are expected to grow with an aging population. Most facilities provide competent, compassionate care, Pillemer said, but resident-to-resident aggression can be a compromising factor.

In the most extensive study of the problem in nursing homes, members of the research team found that 1 in 5 residents had experienced aggressive interactions in the prior 30 days. Shifting their focus to assisted living settings, the researchers visited a randomly selected group of larger, licensed facilities in New York—eight upstate and six in New York City, Westchester County and Long Island—between 2018 and 2022.

They interviewed staff, residents and caregivers, and reviewed incident reports and medical records, inquiring about 22 forms of aggression by residents over the previous 30 days—totals that would likely be higher on an annual basis.

The results revealed a monthly prevalence of resident-to-resident aggression of 15.2%, with verbal (11.2%) the most common—events that could include screaming, trying to scare someone or boss them around, or use of racist language.

Physical aggression—such as hitting, kicking, grabbing, spitting or throwing things—affected 4.4% of the study sample. Sexual aggression—saying sexual things, doing sexual things in front of someone, or touching in a sexual manner—affected 0.8%, and "other" behavior 7.5%. The categories were not mutually exclusive: A verbal altercation, for example, could escalate into a physical one.

Any of those interactions could have serious consequences for a frail population, the researchers said. A shove could cause a fall that permanently limits mobility. Verbal attacks could make residents feel afraid and vulnerable.

"In geriatrics, even minor incidents, physical or emotional, can get you into trouble," Lachs said. "You can't weather physical or verbal insults the way you can when you're younger, and they really do reduce the quality of life in these environments."

The study found that, as in nursing homes, the risk of interpersonal aggression was highest in memory care units serving residents with dementia, including Alzheimer's disease—a prevalence of 22.5% compared to 10.3% in other units. Dementia may be associated with aggressive behaviors, the researchers said, and residents afflicted with it are concentrated in contained environments.

That finding is significant, the researchers said, given that assisted living facilities are increasingly housing people with memory disorders.

The data also showed higher risk for residents with better mobility, vision and hearing—those with more opportunity to get into harm's way, or to interfere with a neighbor.

In addition to anticipating and responding to such conflicts, the researchers said, facility staff should work to identify root causes. Residents might lash out because they are in pain, depressed or struggling with medication—even because they are bored.

"It requires a concerted effort to understand why the behaviors are occurring and how to treat them," Pillemer said.

In addition to Pillemer, Lachs and Teresi, the study involved nine other co-authors affiliated with Weill Cornell Medicine, Columbia University and CHE's Bronfenbrenner Center for Translational Research.

More information: Pillemer K et al, Estimated Prevalence of Resident-to-Resident Aggression in Assisted Living. JAMA Network Open (2024). DOI: 10.1001/jamanetworkopen.2024.9668. jamanetwork.com/journals/jaman … /fullarticle/2818241

https://medicalxpress.com/news/2024-05-resident-aggression-common.html

Compounds produced by gut bacteria can treat inflammation

 Researchers at the University of Toronto have found naturally occurring compounds in the gut that can be harnessed to reduce inflammation and other symptoms of digestive issues. This can be achieved by binding the compounds to an important, but poorly understood, nuclear receptor.

The gut microbiome hosts bacteria that produce compounds as by-products of feeding on our digestive remnants. The compounds can bind to nuclear receptors, which help transcribe DNA to produce proteins and non-coding RNA segments.

By identifying which microbial by-products can be leveraged to regulate receptors, researchers hope to tap into their potential to treat disease.

"We conducted an unbiased screen of small molecules across the human gut microbiome," said Jiabao Liu, first author on the study and research associate at U of T's Donnelly Centre for Cellular and Biomolecular Research. "We found that these molecules act similarly to artificial compounds that are currently being used to regulate the constitutive androstane receptor, otherwise known as CAR. This makes them viable candidates for drug development."

The study was recently published in the journal Nature Communications.

CAR plays a critical role in regulating the breakdown, uptake and removal of foreign substances in the liver, including drugs. It is also involved in intestinal inflammation.

"One of the challenges with studying CAR is that there isn't a useful compound that binds to both the human and mouse versions of the receptor—the latter being necessary for research and disease modeling prior to testing on people," said Henry Krause, principal investigator on the study and professor of molecular genetics at the Donnelly Centre and the Temerty Faculty of Medicine. "Prior efforts focused on developing molecules with strong binding and activation capability. This has resulted in synthetic regulators that over-activate the receptor, which can lead to unintended outcomes. The natural compounds that we discovered don't cause this issue."

Two of the compounds found in the metabolite screen were diindolylmethane (DIM) and diindolylethane (DIE). While DIM has been previously identified from sampling the human gut, DIE has not. This study is the first time DIE has been detected in the human microbiome.

The two compounds regulated CAR in both the human and mouse liver. They were also found to match the effectiveness of an artificial human CAR regulator called CITCO.

A promising finding for future research on CAR regulation was that neither compound produced side effects, like liver enlargement, in mice. This means that DIM and DIE can be used to study CAR function and regulation in mice, where the findings can be applied to humans.

"This receptor plays a role in diabetes, fatty liver disease and small intestine ulcerative colitis," said Liu. "We could potentially treat all of these issues with the two natural compounds we found that already exist in the human gut."

More information: Jiabao Liu et al, Diindoles produced from commensal microbiota metabolites function as endogenous CAR/Nr1i3 ligands, Nature Communications (2024). DOI: 10.1038/s41467-024-46559-3

https://medicalxpress.com/news/2024-05-compounds-gut-bacteria-inflammation.html

Inulin fiber may trigger intestinal inflammation

 Inulin, a type of fiber found in certain plant-based foods and fiber supplements, causes inflammation in the gut and exacerbates inflammatory bowel disease in a preclinical model, according to a new study by Weill Cornell Medicine investigators. The surprising findings could pave the way for therapeutic diets that may help ease symptoms and promote gut health. 

The study, published March 20 in the Journal of Experimental Medicine, shows that inulin, which is found in foods such as garlic, leeks and sunchoke, as well as commonly used fiber supplements and foods with added fiber, stimulates microbes in the gut to release bile acids that increase the production of molecules that promote intestinal inflammation.

One such protein, IL-33, causes immune cells called group 2 innate lymphoid cells (ILC2s) to become activated, triggering an excessive immune response similar to an allergic reaction. That excessive immune response then exacerbates intestinal damage and symptoms in an animal model of inflammatory bowel disease.

Dietary fiber, including inulin, is considered an essential part of a healthy diet for most people. Gut microbes turn inulin and other types of dietary fiber into short-chain fatty acids that turn on immune cells called regulatory T cells, which help reduce inflammation and have other beneficial effects throughout the body. This led to a remarkable rise in use of dietary fiber as an additive in both foods and supplements, and purified inulin or inulin-rich chicory root is often the main source of the fiber.

"Inulin is now everywhere, from clinical trials to prebiotic sodas," said lead author Mohammad Arifuzzaman, a postdoctoral associate at Weill Cornell Medicine. He and his colleagues expected that inulin would also have protective effects in inflammatory bowel disease. But they found just the opposite. 

Feeding inulin to mice in the context of a model of inflammatory bowel disease increased the production of certain bile acids by specific groups of gut bacteria. The increased bile acids boosted the production of an inflammatory protein called IL-5 by ILC2s. The ILC2s also failed to produce a tissue-protecting protein called amphiregulin.

In response to these changes, the immune system promotes the production of immune cells called eosinophils, which further ramp up inflammation and tissue damage. Previously, a 2022 study by the same team of investigators showed that this flood of eosinophils may help protect against parasite infections. However, in the inflammatory bowel disease model, this chain reaction exacerbated intestinal inflammation, weight loss and other symptoms like diarrhea. 

In translational patient-based studies, the team also analyzed human tissue, blood and stool samples from Weill Cornell Medicine's Jill Roberts Institute for Research in Inflammatory Bowel Disease Live Cell Bank. This analysis revealed that patients with inflammatory bowel disease, like the mice fed inulin, had higher levels of bile acids in their blood and stool and excessive levels of eosinophils in their intestine compared with people without the condition.

The results suggest that the inflammation cascade similar to that in the mice fed inulin is already primed in humans with inflammatory bowel disease, and dietary uptake of inulin may further exacerbate the disease.

These unexpected discoveries may help explain why high-fiber diets often exacerbate inflammatory bowel disease in patients. It may also help scientists develop therapeutic diets to reduce symptoms and gut damage in patients with inflammatory bowel disease or related conditions.

New therapies are urgently needed for these increasingly common gut conditions. Existing biologic therapies can increase the risk of developing infections or autoimmune diseases, which cause the immune system to attack the body. 

"The present study shows that not all fibers are the same in how they influence the microbiota and the body's immune system," said senior author David Artis, director of the Jill Roberts Institute for Research in Inflammatory Bowel Disease and director of the Friedman Center for Nutrition and Inflammation at Weill Cornell Medicine.

"These findings could have broader implications for the delivery of precision nutrition to individual patients to promote their overall health based on their unique symptoms, microbiota composition and dietary needs."

More information: Mohammad Arifuzzaman et al, Dietary fiber is a critical determinant of pathologic ILC2 responses and intestinal inflammation, Journal of Experimental Medicine (2024). DOI: 10.1084/jem.20232148

https://medicalxpress.com/news/2024-05-common-fiber-trigger-bowel-inflammation.html

California Bill Would Give Black Applicants An Edge In Getting Occupational Licenses

 by Sophie Li via The Epoch Times,

California lawmakers are considering a bill that would give preference to African American applicants seeking occupational licenses, for such professions as teaching, nursing, counseling, electrical work and others, especially those who are descendants of slaves.

Assemblyman Mike Gipson, author of AB 2862, said the state’s licensing process poses barriers for African Americans seeking employment, particularly in terms of wage disparities and access to leadership or managerial positions.

“There has been historical longstanding deficiencies and internal barriers … [for] African Americans seeking professional work, and by prioritizing their applications, we are bridging the gap of professional inequities of under representation and under compensation,” Mr. Gipson said in a bill analysis.

Under current law, only veterans are eligible for such prioritization.

Mr. Gipson argued in the analysis that if such priority can be granted to veterans, similar standards should be applicable to African-American applicants.

“If expediting licensure for veterans does not discriminate, then perhaps prioritizing African American applicants also is not discriminatory,” his statement reads.

“Nor would a preference for African American applicants violate the equal protection clause of the California Constitution any more than the existing preference for veterans.”

Supporters of the bill, including the Greater Sacramento Urban League and the California African American Chamber of Commerce, said the legislation addresses historical injustices and “promotes equity and provides opportunities for economic advancement within our community.”

However, opponents say it is “unconstitutional” and lacks legal backing.

The Pacific Legal Foundation, a public interest law firm, argues in a statement that both the U.S. and California Constitutions guarantee citizens equal protection under the law, prohibiting the government from treating citizens differently based on race, ancestry, or other protected categories.

The law firm suggested if the bill were to become law, it would probably not hold up against legal challenges, referencing the Supreme Court’s ruling in Students for Fair Admissions v. Harvard last summer. The court deemed the consideration of an applicant’s race as a factor in admissions decisions unconstitutional.

They argued that while the constitution allows the government to use race to remedy instances of past discrimination, the bill doesn’t cite any specific California laws that exclude African Americans or that were drafted with the intention of excluding workers needing redress.

Additionally, they said that introducing race as a factor in the licensing process would exacerbate barriers for many Californians seeking to enter the workforce, particularly low-income workers, who already face numerous challenges.

The law firm also pointed out that the representation of minority groups within industries often varies, suggesting that prioritizing one group over others would fail to address the root of the problem.

They argued that if the state were to do so, it should reduce barriers to licensure for all Californians.

The bill, which will now be heard in the Assembly’s Appropriations Committee, passed the Assembly’s Business and Professions Committee on a 13–2 vote last week.

If ultimately passed, it would go into effect on Jan. 1, 2029.

https://www.zerohedge.com/political/california-bill-would-give-black-applicants-edge-getting-occupational-licenses