Internal Medicine

Elizabeth Cerceo, MD, on How to Address Health Care’s Impact on Climate Change – MD Magazine

The health care industry accounts for approximately 5% of total greenhouse gas and toxic air emissions, coming primarily from the United States and contributing directly to the ongoing climate crisis.1

Given the health care sectors notable contributions to climate change, mitigation and adaptation efforts fall heavily on physicians and key stakeholders, a topic Elizabeth Cerceo, MD, associate internal medicine program director and director of environmental health in the division of hospital medicine at Cooper University Health Care, discussed in her session at the 2024 American College of Physicians (ACP) Internal Medicine Meeting in Boston.

Specifically, she referenced the importance of leveraging direct patient education, noting Health care providers, health care professionals, whether it's nurses, physicians, we are all very trusted messengers by the public, so when they hear a message that comes from us about climate-related health factors or impacts of climate change, they will listen to us much more than they'll listen to politicians or other places where they may be hearing messages.

Although Cerceo described how physicians generally like to be fully educated on a topic before they discuss it with their patients, she said the strength of the current data should make health care providers feel empowered and like opening up that conversation will ultimately benefit the patient, regardless of how up-to-date you are on the most recent climate-related information.

Beyond ensuring that physicians themselves are educated on climate change and its link to health care, Cerceo also emphasized the importance of educating trainees and perhaps other physicians who may not yet be aware of or well-versed on the health consequences associated with climate change.

New research is coming down the pike fast and furious, she added. We're seeing studies where you can demonstrate the path of physiologic linkages. We don't just have correlation, association studies anymore, but we have that more foundational data that shows that these are real effects that are happening, and we can demonstrate why.

Despite the mounting body of evidence supporting the growing climate crisis, Cerceo explained that patients receptiveness toward climate-related topics when discussing their health tends to depend on how the conversation is framed. Beyond counseling her patients on the need to be careful about their exposure to certain environmental factors like air pollution, she also described the importance of providing them with tangible things they should be doing or a linkage that appeals to their direct experiences.

Although Cerceo described the expansion of the conversation and research surrounding climate change as encouraging, she was also careful to note that it is not enough, saying Things really need to accelerate, and we need to keep our foot on the gas pedal. Now is not the time to sit back and think, oh, you know, there's been a few positive steps, let's rest on our accolades It has to be all physicians recognizing the inter-linkages between us and our environment, and that we need to be mindful of this and incorporating it into our daily practice.

Reference:

1. Eckelman MJ, Huang K, Lagasse R, et al. Health Care Pollution And Public Health Damage In The United States: An Update. Health Affairs. https://doi.org/10.1377/hlthaff.2020.01247

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Elizabeth Cerceo, MD, on How to Address Health Care's Impact on Climate Change - MD Magazine

Internal Medicine

Dual-Tasking: Spotlighting the Impacts on Individuals with Dementia – MD Magazine

Ryan Langston

Credit: Geriatric Assessment, Intervention, & Technologies Laboratory (GAIT Lab)

Dual-tasking among adults living with dementia is more sensitive to the detection of impairments in these individuals gait, posture, and functional mobility compared to single-task assessments, according to recent findings in Dual-tasks and dementia severity impact postural stability and gait among people living with dementia in residential care facilities: A cross sectional pilot study.1

This research was presented by Ryan Langston from the Medical College of Georgia at Augusta University, at the 2024 American College of Physicians (ACP) Internal Medicine Meeting in Boston, Massachusetts. Langston and colleagues additionally noted in their findings presented at ACP that dual-tasking performance interference may be affected by individuals dementia severity.

Prior to their description of their new data, the research team suggested that individuals who live with dementia are known to have mobility and cognition which is relatively worse than individuals who do not live with dementia. They also added that dementia tends to increase such individuals fall risk, basing their information on the study The Lived Experience of Healthcare Workers in Preventing Falls in Community Dwelling Individuals with Dementia.2

In the study cited, it had been noted that combining physical and cognitive strategies was not widely practiced as part of a falls prevention strategy, and that this approach has potential benefits but was highlighted as being complex and needs to be person-centered.2 Such findings highlight the importance of fall risk awareness and its connection to dementia.

In another cited study, Langston and colleagues noted that the research had indicated that dual-tasking had the potential to be utilized for screening fall risk, though they highlighted that additional evidence may be necessary.3 This study had highlighted gait changes during dual-task testing and their link with future risk of falling, adding that the association was shown to be stronger than the same link for conditions which were single-task conditions.

The investigators set out to assess and compare the impacts of single-task and dual-task conditions on subjects functional mobility, gait, and posture, specifically looking at participants who had been living with all-cause dementia and living in residential care facilities. Additionally, the study aimed to assess how the severity of dementia might influence performance and interference in dual-task scenarios.

The research team had used Montreal Cognitive Assessment (MoCA) score assessments for dementia. A score on the MoCA assessment of 26 or below is considered to be an indicator of the presence of cognitive impairment.4

As stated previously, among adults with dementia, dual-tasking was shown by the team to be more sensitive to the impairment detection as far as subjects gait, functional mobility, and posture compared to single-task.1 They also noted that several responses during dual-tasks had been higher among subjects with moderate-to-severe dementia compared to mild dementia, including the following:

The investigators also concluded in their research that dual-tasking may be necessary for consideration in evaluations routinely made on individuals living with dementia, the purpose being to monitor any declines in cognitive abilities. Additionally, dual-tasking could help to identify adults with impairment increases in their gait, functional mobility, and posture.

References

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Dual-Tasking: Spotlighting the Impacts on Individuals with Dementia - MD Magazine

Internal Medicine

What We Would Be If We Weren’t Doctors – Medpage Today

In this video, Mikhail Varshavski, DO -- who goes by "Dr. Mike" on social media -- asks 20 physicians what their alternate career path would be. Let us know what yours would be in the comments!

Following is a partial transcript of the video (note that errors are possible):

Varshavski: I asked 20 doctors to tell me what they would do for work if they weren't a doctor. I'll go first. Obviously a detective. Right now, instead of solving crimes, I'm solving complex medical cases. I'm no Dr. House, but I may be a Sherlock Holmes in my past life.

Alok Patel, MD: How's it going? I'm Dr. Alok Patel. I'm a pediatric hospitalist, so if a child is hospitalized, count on me to coordinate care. I like action, mystery, suspense, believing that my work is making a difference. Put that together, I think I'd be working with the FBI or the CIA. Maybe forensic science, global anti-terrorism, or missing and endangered children. I'm not really sure, but in general fighting crime.

Siobhan Deshauer, MD: Hi, I'm Dr. Siobhan Deshauer, also known as Violin MD. I'm an internal medicine and rheumatology specialist. In medicine, I really love digging into mystery cases and looking at problems from different angles. If I wasn't a doctor or a violinist, then I'd probably be an investigative journalist.

Jake Goodman, MD: What's up everyone? My name is Jake Goodman and I'm a psychiatry resident doctor in my third year of residency training. Fun fact, I actually graduated from the College of Agriculture and Environmental Sciences at the University of Georgia, which means that I took classes in botany, horticulture, herbs, and medicinal plants, and I'm a huge plant dad. This is one of my favorite plants right now. Her name is Ava. I found her as an avocado seed in a trash can and grew her into this beautiful plant right here. One man's trash is another man's avocado seed that they turn into a friend. If I wasn't a doctor, I'd probably be a botanist.

Alok Kanojia, MD: My name is Alok Kanojia, but the internet knows me as Dr. K. I'm a psychiatrist, which means that I'm a medical doctor that focuses on the mind. If I wasn't a medical doctor, chances are I would have become a monk, and that's actually what I ended up doing for a long time. I spent 7 years studying to become a monk and then decided to go to medical school. I was fascinated with the mind to begin with and I think that the Eastern monks, like yogis and Buddhist monks, have a really, really interesting perspective on the mind which medical science could learn a lot from.

Anthony Youn, MD: My name is Dr. Anthony Youn and I'm a board-certified plastic surgeon. If I weren't a doctor, I would be an unemployed rock star. Back when I was younger and going through my residency training, I was in a band and we kind of toured locally. We played a lot of gigs and we made a little bit of money. But the problem is that we were really not that good. I was a three-chord warrior and we pretty much maxed out what we could do in this field of rock and roll. You'd probably see me performing at the bar at the Holiday Inn Express outside the Boise Airport.

Ed Hope, MBBS: Hello, my name is Ed Hope. I'm a doctor working in the emergency department over in the U.K. If I wasn't a doctor, I would want to be a musician. I actually paid a lot of my way through medical school by busking on the weekends. On the surface, you might think the two are pretty different, but they are not a million miles away. You have to study the theory, there is a big practical element involved, and ultimately you can have a huge positive impact on people's lives. Lying heavy in the sky, woo.

Benjamin Winters, DDS: Hi, my name is Dr. Winters a.k.a. The Bentist online, and I am an orthodontist. Dentistry and orthodontics has a lot of art-related things. In fact, dentistry is a lot like being a sculptor, painter, and artist. That being said, as much as I love art, I would probably rather use these hands to play video games actually. I've played video games my entire life, and if I could, I'd probably be a professional video game player or a streamer.

Dana Brems, DPM: I'm Dr. Dana Brems and I'm a podiatrist, which is a foot and ankle specialist and surgeon. When I was a kid, I always wanted to be an artist because I love putting things together and being creative.

Karan Rajan, MBBS: If I wasn't a doctor, I have always thought I'd probably be a chef because I like eating food and I like traveling, so maybe a food critic maybe. But if I was a chef, I can see lots of parallels between surgery and cooking. I mean, for starters you need to know the recipe, the steps of the operation. You can't burn your meat. You need to please people and you can't pick things up after being dropped on the floor.

John W. Patton III, MD: What up? My name is Dr. John Patton, Doc JP3, and I'm a board-certified anesthesiologist and a regional anesthesia and acute pain medicine specialist. A lot of people don't know this about me, but I love to cook. I think it's the alpha personality inside me that makes me believe I could be a Michelin chef. I just love the experience and the artistic nature, and to be able to take people on a culinary journey every single night would be a lot of fun. Anesthesiologist by day, chef by night. Doc JP3 chef day cuisine. Love it.

Danielle Jones, MD: I'm Dr. Danielle Jones -- some of you may know me as MDJ -- and I am an ob/gyn. That means I take care of anything having to do with periods, pregnancy, and the female reproductive tract. Honestly, I am so glad I get to do this job because I love being an obstetrician and gynecologist, but if I wasn't, I think I could see myself as a politician or maybe a public health professional. Maybe in another life, even a professional skier would have been fun.

Benjamin Schmidt, MD: Hi, I'm Dr. Benjamin Schmidt, also known as Doc Schmidt, and I'm a GI doctor, which means that I specialize in gastroenterology. Now, I'm not sure if this is even an entire job by itself, but if I wasn't a doctor, I would love to edit movie trailers. I love the idea of trying to synthesize down a whole movie into a couple of minutes and finding cool new songs to get people excited about the movie. Plus, you get to see most of the footage from movies way in advance, so that would be pretty cool too.

Brian Boxer Wachler, MD: Hi, I am Dr. Brian Boxer Wachler and I'm an eye surgeon a.k.a. ophthalmologist. If I wasn't a doctor, I would probably be a film director because I loved making movies when I was in high school and college. As a matter of fact, I made a feature-length Batman movie, an hour-long one, that we screened on campus at UCLA [University of California Los Angeles]. And yes, I was running around in tights.

Ricky Brown, MD: My name is Ricky Brown and I'm a board-certified plastic surgeon in Scottsdale, Arizona. What would I be if I wasn't a plastic surgeon? I think I'd be a voice actor. I'd probably crush that.

Rena Malik, MD: Hi, I'm Dr. Rena Malik, urologist and pelvic surgeon, and a urologist is essentially a surgical and medical doctor of the genitourinary tract. If I wasn't a medical doctor, I'd probably be the CEO of a company. My superpower is being organized. It's what helps me take care of patients and do everything else I do. If I wasn't a medical doctor, I'd probably be organizing a whole bunch of people in a company somewhere.

Sanjay Juneja, MD: My name is Dr. Sanjay Juneja. I'm a hematologist and medical oncologist basically specializing in blood disorders as well as cancers and how to treat them. If I wasn't a doctor, I'd be a teacher. It's not just because doctor stands for teacher in Latin, but I really enjoy being able to make sense of something or make someone appreciate how something works. It would probably be physics or chemistry.

Antonio Webb, MD: Hi, my name is Dr. Antonio Webb. I'm an orthopedic spine surgeon here in San Antonio, Texas. I would probably do something in real estate. I have a passion for real estate and buying residential properties, and hopefully commercial properties in the future, buying a property and renting it out or rehabbing it and reselling it. If I wasn't a spine surgeon, I would be a real estate investor.

Varshavski: You know, I'm not only a doctor, but also professional boxer and Air Force pilot. Click here to see me fly an F16 with the U.S. Air Force Thunderbirds. And as always, stay happy and healthy.

Mike Varshavski, DO, is a board-certified family physician and social media influencer with more than 11 million subscribers.

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What We Would Be If We Weren't Doctors - Medpage Today

Internal Medicine

Scientists unveil new remote-controlled ‘pillbot’ a microrobot that you can swallow for early disease detection – Good Good Good

Internal medicine has advanced in leaps and bounds throughout the 19th and 20th century, as doctors implemented X-rays, endoscopes, ultrasounds, and MRIs into daily care.

But checking the human body for cysts, tumors, and other predictors for a range of diseases is not an easy undertaking and often involves multiple referrals, appointments, and health insurance hoops.

Physician scientist Vivek Kumbhari, chairman of Gastroenterology at the Mayo Clinic, explained a common scenario that he encounters at his clinic.

A patient, whos generally in good health, comes to see me because they have abdominal pain, and I suspect its coming from the stomach. Now, I need to precisely understand what the problem is, but I cant just pop my head in and take a look, Kumbhari said in a TED Talk in Vancouver earlier this week.

Despite that patient sitting right in front of me, I have to ask them to go back home and come back to the hospital on another occasion, so I can put them to sleep with anesthesia, insert a long tube with a camera at the tip through the mouth and into the stomach, Kumbhari continued.

This is an endoscopy, a relatively expensive and invasive procedure and were on a mission to do better.

That same mission is one that engineer Alex Luebke has been undertaking for years. Luebke comes from a long background in astronautics and aeronautics, but in the last decade hes turned his attention inward to the human body.

Like Kumbhari, Luebke imagines a future that forgoes anesthesia and expensive procedures, one where a patient could come in with an issue and be taken care of right then and there, and possibly be diagnosed in the same sitting. A future thats possible with a microrobot named PillBot.

PillBot is a small wireless robot that is remotely controlled, and it swims around in three dimensions in a water-filled human stomach, Luebke said in the same TED Talk, where they debuted the new invention.

The PillBot is outfitted with a data transceiver, a lithium battery, a camera that can capture a live video feed, three pump-jet thrusters that allow it to move, and miniscule LED lights because of course, Luebke explains, the inside of the human body is quite dark.

The first model of the PillBot was enormous, approaching a football in size.

Over the course of five years, Luebke and his team worked on getting the microrobot smaller and smaller. Todays model is no bigger than a multivitamin, but its still equipped with all the necessary circuitry and tools.

Kumbhari explained that the PillBot can be remotely operated by a game controller, tablet, or smartphone. He piloted the PillBot in a small aquarium tank to show how it operates, but then he and Luebke took the presentation one step further.

We developed PillBot to allow for direct visualization of internal organs, anywhere and any time, Kumbhari teased. This is our goal: be anywhere in the world, whether youre at home sitting on your couch, visiting space, or right here on stage at TED.

Right on cue, Luebke swallowed PillBot with a smile, and downed it with a swig of water.

Within seconds, the microrobot entered Luebkes stomach, and a live feed was streamed on stage as Kumbhari maneuvered it with his controller.

Im carefully moving around, looking for changes in surface architecture that might represent an ulcer, or a cancer, or any other pathology, Kumbhari explained. And Im able to get very similar views as I would if I used a conventional endoscope.

Kumbhari went on to say that the experience could be further enhanced if he were to use an augmented reality headset for 3D visualization or the assistance of artificial intelligence for early detection of abnormalities.

Fortunately for Alex, from this brief review, everything is looking normal here, Kumbhari said. Though if there were a problem, being able to show and discuss this with Alex in real time, elevates his understanding of himself.

As for extraction or retrieval after the procedure? No need. Kumbhari explained that PillBot would then take its natural course through and out of the body, likely without Luebke even knowing when it passes.

This robot was designed for the stomach, but the entire body needs this capability, Kumbhari said. Parts of the body, such as the colon, the heart, and the brain should be made accessible through specialized robots that are just as easy to use.

Luebke jumped in to build on Kumbharis statement, saying that PillBot was only the beginning.

Future and emerging adaptations for PillBot include lab-on-chip capabilities that would allow doctors to analyze material from within the body, sensors to monitor disease regression, and the potential to cauterize incisions and inject medicine without invasive procedures.

Ive dreamt of the day when I could explore the inside of the human body with robots, Kumbhari said. Recognizing that it would be an inflection point on my ability to help people live longer and healthier lives.

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Scientists unveil new remote-controlled 'pillbot' a microrobot that you can swallow for early disease detection - Good Good Good

Internal Medicine

American College of Physicians issues clinical recommendations for newer pharmacological treatments of adults with … – InvestorsObserver

Reviews evidence of newer medications, recommends adding to metformin

BOSTON , April 19, 2024 /PRNewswire/ --The American College of Physicians (ACP) today released an update of its 2017 guideline with clinical recommendations for the use of newer pharmacological treatments of adults with Type 2 diabetes. The clinical guideline is based on the best available evidence for effectiveness, comparative benefits and harms, consideration of patients' values and preferences, and costs. Newer Pharmacological Treatments in Adults with Type 2 Diabetes: A Clinical Guideline from the American College of Physicians was published today in Annals of Internal Medicine .

In the updated clinical guideline, ACP recommends adding a sodium-glucose cotransporter-2 (SGLT-2) inhibitor or glucagon-like peptide-1 (GLP-1) agonist to metformin and lifestyle interventions in patients with Type 2 diabetes and inadequate glycemic control. Use SGLT-2 inhibitor to reduce the risk of all-cause mortality, major adverse cardiovascular events, progression of chronic kidney disease, and hospitalization due to congestive heart failure or use GLP-1 agonist to reduce the risk of all-cause mortality, major adverse cardiovascular events, and stroke.

ACP, however, recommends against adding a dipeptidyl peptidase-4 (DPP-4) inhibitor to metformin and lifestyle modifications in adults with Type 2 diabetes and inadequate glycemic control because high-certainty evidence showed that adding a DPP-4 inhibitor does not reduce morbidity or all-cause mortality.

"As additional pharmacological treatments become available for the treatment of Type 2 diabetes, it's critical for us to examine their effectiveness, the harms and benefits as well as costs in order to provide the best treatment for our patients," said Carolyn J. Crandall , M.D., MS, MACP, Chair, Guidelines Committee. "Adding a second medication to metformin for patients with inadequate glycemic controlmay provide additional benefits but the added benefit on important clinical outcomes may be minimal in relation to the high cost, particularly for the more expensive, newer medications."

This clinical guideline is based on a systematic review of the effectiveness and harms of newer pharmacological treatments for Type 2 diabetes.ACP prioritized the following outcomes, which were evaluated using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach: all-cause mortality, major adverse cardiovascular events, myocardial infarction, stroke, hospitalization for congestive heart failure, progression of chronic kidney disease, serious adverse events, and severe hypoglycemia. Weight loss, as measured by percentage of participants who achieved at least 10% total body weight loss, was a prioritized outcome, but data were insufficient for network meta-analysis and not rated with GRADE.

The updated ACP guideline did not look at the effects of treatment for glycemic control, though this is a common treatment goal. It is known that all included treatments can improve glycemic control in adults with Type 2 diabetes. Instead, the guideline focuses on clinical benefit outcomes, such as whether the treatments improve cardiovascular outcomes.

ACP guidelines emphasize shared decision-making, recognizing that each patient's needs and circumstances are unique. ACP encourages physicians to consider individual patient characteristics like age, comorbidities, and personal preferences when discussing a treatment plan for Type 2 diabetes.SGLT-2s and GLP-1s are costly, but lower cost options (like sulfonylureas) were inferior in reducing all-cause mortality and morbidity.There are currently no generic formulations for GLP-1s and SGLT-2.

TheACP clinical guideline is published with an accompanying visual clinical guideline where a person can interact and visualize the data supporting these recommendations.

About the American College of Physicians The American College of Physicians is the largest medical specialty organization in the United States with members in more than 145 countries worldwide. ACP membership includes 161,000 internal medicine physicians, related subspecialists, and medical students. Internal medicine physicians are specialists who apply scientific knowledge and clinical expertise to the diagnosis, treatment, and compassionate care of adults across the spectrum from health to complex illness. Follow ACP on X , Facebook , Instagram and LinkedIn .

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Family Medicine

Letters to the editor: ‘I wonder if the main stumbling block might be doctors themselves.’ The right to a family doctor, plus … – The Globe and Mail

Place blame

Re A young life in Gaza, shattered (Opinion, April 6): The account of Nada and her family in Gaza is a tragedy.

It is a tragedy for that family. Equally it is a tragedy because there are thousands of innocent Palestinian families just like Nadas who have similar experiences, cannot get wounds healed or access health care, have lost their homes, family members and futures.

But Nada is not alone in not forgiving. Many people outside of Gaza will not forgive, either.

Roger Emsley Delta, B.C.

The life of Nada before Oct. 7, 2023, as a student with a bright future living a fairly prosperous life in a modern apartment in Gaza City, is contrasted to her present nightmarish existence. Its shocking.

However, I fail to comprehend who she blames. Had the events of Oct. 7 not occurred, there would be no grudge to bear.

David Sacoransky Toronto

Re Why should Indigenous Canadians not be entitled to the same rights as other Canadians? (Opinion, April 6): Ask First Nations if they signed on to the Charter. If the answer is no, then deference should be given to Indigenous peoples determining their own path.

The Charter is characterized as an altruistic, unchangeable, perfect set of rights for all peoples. But it is interpreted, and I would not presume that to be done in the best manner for another group, especially First Nations.

Supreme Court Justice Malcolm Rowe, as the only dissenter on this point, seems to have got it right.

Jason New Foothills County, Alta.

First Nations that successfully negotiate self-government treaties should be free to bring themselves under the jurisdiction of the Charter.

But one of the purposes of Section 25 seems to be ensuring that the constitutional underpinnings adopted by a First Nation are of its choosing, not necessarily reflective of the values of its colonizers. In other words, the Charter cannot be used to invalidate or detract from the rights of Indigenous peoples, even when those rights are different from Canadians. (The right to an Indigenous fishery comes to mind.)

Why should First Nations not be entitled to the same rights as Canadians? Canadians do not have the right, for example, to govern Quebec when they live in British Columbia. More importantly, a First Nation may decide it wants a different type of rights-and-freedoms regime.

Does colonialism keep us from seeing that possibility?

Brenda Taylor Surrey, B.C.

Re Its time for Canadians to have the right to a family doctor (Opinion, April 6): I would vote for any party committed to implementing primary health care that mirrors the structure of public education systems. However, I wonder if the main stumbling block might be doctors themselves.

It would mean abandoning family practices as sole proprietorships. All physicians would become civil servants. There would be greater accountability for patient loads and hours worked. Team-based models would be required, not optional.

On the other hand, it would address a common complaint among family doctors that, as small business owners, they spend too much time on administration. It would mean more time with patients.

But would they give up the power that accompanies running the show? I would hope so, for the greater good.

Michael Brooks Burlington, Ont.

Kudos to doctor Jane Philpott for her interesting idea. Her model might contribute to solving unnecessary waiting times and rationing Canadian experiences related to failures of primary care governance.

Many Canadian public schools are successful, partly because they have parent-teacher associations and other elements of local participation and governance.

Several years ago, the Nova Scotia Co-operative Council suggested a series of local health co-operatives, governed and managed by local boards. They would have maintained the principle of universality and negotiated salaries and revenue with members, staff and governments.

Unfortunately, both the federal and provincial governments rejected the idea. They preferred to continue the failing model of centralized governance and management.

David Zitner MD, Halifax

The year I was president of the Ontario College of Family Physicians, the provincial government introduced family health teams.

As a member of a team, I witnessed the excitement as medical students watched the renaissance of our specialty. We attracted many young, talented family physicians. The percentage of students choosing this career increased dramatically.

But that was almost 20 years ago. Subsequent governments felt teams were too expensive and a moratorium resulted. Now students mainly see overwhelmed physicians working in non-teams. Recent government announcements have added a small number of new teams that will hardly undo the damage of years of complacency.

Our residency matching process witnessed an abrupt decrease in those choosing family medicine. Teams cannot exist without a physician or nurse practitioner to lead them.

Although I applaud doctor Jane Philpotts ideas, it may well be that our governments have done too little, too late.

Val Rachlis MD, Toronto

As a family physician of 40 years, I appreciate doctor Jane Philpotts eloquent call to action.

The research of doctor Barbara Starfield has shown that investment in primary care was associated with improved system quality, equity and efficiency. Yet in Canada, there is inadequate financial support for primary care practices which provide access to the health system, preventive care, diagnosis and management of disease.

In my role of training future physicians, I hear them speak of their moral dilemma regarding family practice. They want to serve their communities, yet worry about the double debt from medical training and running private offices, as the costs of these have risen sharply.

We should redesign the system together, to meet the urgent needs of our population. Who will have the courage to fund primary care adequately?

Cleo Mavriplis MD Ottawa

Re No kids? No problem: How Canadas child-free and cash-rich couples are spending their time and money (Report on Business, April 6): The people presented all seem solely focused on themselves.

Does the money saved let them support charities? Does the additional leisure time let them become more engaged in their communities?

Are these choices good for Canada? Are these the citizens of the future?

Perhaps immigration is the cure to find people who really care.

Grant Swanson Oakville, Ont.

Fyodor Dostoevsky writes that the soul is healed by being with children. I guess that is one type of healing which DINKs mostly sacrifice.

Paul Thiessen Vancouver

..................................................................................................................................

Letters to the Editor should be exclusive to The Globe and Mail. Include your name, address and daytime phone number. Keep letters to 150 words or fewer. Letters may be edited for length and clarity. To submit a letter by e-mail, click here: letters@globeandmail.com

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Letters to the editor: 'I wonder if the main stumbling block might be doctors themselves.' The right to a family doctor, plus ... - The Globe and Mail

Family Medicine

Who Is Daily Caller Host Ben Shapiros Wife? Let’s Meet Mor – Distractify

Ben Shapiro is all about family values, and he practices what he preaches.

Like many influencers who lean toward the right, Ben Shapiro spends much of his time extolling the virtues of having a traditional family. Its only natural, then, for people who both like and dislike Ben to wonder who his wife and family are.

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Ben is one of the best-known influencers on the right, and although he frequently gets made fun of for his political takes and commentary by those on the left, it seems he has been happily married for quite some time. Heres what we know about Bens wife and family.

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Bens wife is Mor Shapiro, previously Mor Toledano. Mor is of Moroccan descent and was born and raised Herzliya, a city located near Tel Aviv in Israel, in 1988. Her parents moved to the U.S. when she was 12 and she obtained U.S. citizenship.

Mor is a family medicine doctor and she previously worked at the Family Medicine Residency Program at Kaiser Foundation Hospital in Fontana, Calif.

Perhaps somewhat ironically, Mor focuses on womens health and advocates for awareness around diseases that affect women, specifically. Her advocacy doesnt explicitly conflict with her husbands worldview and philosophies, but for many, issues like abortion, which Ben strongly opposes, are also a question of womens health. Regardless, it seems that Mor and Ben have been able to reconcile whatever beliefs they might not share.

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Ben has tried to keep many of the details about his family life private, but he has been open about how much love and support he gets from his loved ones. Ben and Mor have four children together, and although Ben celebrates his childrens births on social media, he doesnt share much else from his family. All of his children are still young, and all of them still live at home.

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Ben was born in Los Angeles to an Ashkenazi Jewish family. His family converted to Orthodox Judaism when he was nine years old, and he still practices Judaism to this day. As may be expected given who his wife is and his own political views, Ben has been an outspoken supporter of Israel throughout the ongoing war in Gaza following the Oct. 7, 2023, attack.

Few commentators of any political valence have faced more backlash than Ben, and that backlash has helped make him one of the best-known right-wing commentators in the world. Although Ben says outrageous things in part to earn the ire of his political opponents, there are also aspects of Bens identity that are less directly related to their political views.

Given how firmly held Ben's political stances are, and how uninterested he often seems in actually changing his views, it seems unlikely that Ben is actually going to win over new supporters. The people who love him will continue to do so, and those who find him outrageous will continue to be outraged by him.

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Who Is Daily Caller Host Ben Shapiros Wife? Let's Meet Mor - Distractify

Endocrinology

No Link Between GLP-1 Drugs and Suicide, Says European Regulator – Medpage Today

The European Medicines Agency (EMA) found no evidence to support a causal link between GLP-1 receptor agonists and suicidal thoughts, a committee said on Friday following a 9-month review.

An investigation was launched in July 2023 over reports of suicidal ideation and self-harm thoughts and actions not previously reported in any clinical trials. The investigation was extended again last November when the committee requested more postmarketing data from the drugmakers.

But after reviewing the totality of evidence from non-clinical studies, clinical trials, and post-marketing surveillance data, the committee said that an update to the product information is not warranted.

"The marketing authorization holders for these medicines will continue to monitor these events closely, including any new publications, as part of their pharmacovigilance activities and report any new evidence on this issue in their Periodic Safety Update Reports (PSURs)," the committee noted.

This more definitive conclusion comes on the heels of the FDA's preliminary evaluation of the issue, which was released in January.

At that time, the FDA said that while it "cannot definitively rule out that a small risk may exist," its preliminary evaluation did not suggest a causal link. "We will communicate our final conclusions and recommendations after we complete our review or have more information to share," the agency wrote in its safety communication.

The EMA's conclusion was based on the recent Nature Medicine study of 240,618 patients who had overweight or obesity taking semaglutide (Ozempic, Rybelsus, Wegovy). Interestingly, there was a significantly lower risk of suicidal ideation among these patients compared with those on non-GLP-1 anti-obesity medications (0.11% vs 0.43%; HR 0.27, 95% CI 0.20-0.36).

This study also looked at 1,572,885 patients with type 2 diabetes on semaglutide, who had a significantly lower risk of suicidal ideation compared with patients taking other anti-diabetes medications (0.13% vs 0.36%; HR 0.36, 95% CI 0.25-0.53).

In addition, the review included an analysis that the EMA conducted independently that compared type 2 diabetes patients on a GLP-1 receptor agonist with those on an SGLT2 inhibitor, but no results were reported.

The EMA's announcement was exclusive to agents in the GLP-1 receptor agonist class currently approved in Europe -- semaglutide, liraglutide (Victoza, Saxenda), liraglutide/insulin degludec (Xultophy), dulaglutide (Trulicity), exenatide (Byetta, Bydureon BCise), lixisenatide (Adlyxin), and lixisenatide/insulin glargine (Soliqua). It didn't include FDA-approved tirzepatide (Mounjaro, Zepbound), a dual GIP/GLP-1 receptor agonist. These agents have indications for the treatment of type 2 diabetes, obesity, or both.

If you or someone you know is considering suicide, call or text 988 or go to the 988 Suicide and Crisis Lifeline website.

Kristen Monaco is a senior staff writer, focusing on endocrinology, psychiatry, and nephrology news. Based out of the New York City office, shes worked at the company since 2015.

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No Link Between GLP-1 Drugs and Suicide, Says European Regulator - Medpage Today