The median survival after a heart transplant is currently an astounding 13 years . Nevertheless, chronic rejection, 8% in the first year and 32% after 5 years may occur after transplantation, this may be due in part to poor compliance with immunosuppressive agents. FibonacciMD Compendium Heart Transplant- an unexpected success story by Justin Cole, M.D. and David Spielvogel, M.D. Heart transplant is a procedure indicated for severe, irreversible cardiac disease, often in relatively young patients. It consists of replacement of the de novo heart with a compatible donor allograft. Indications Indications for heart transplant include end-stage heart failure with objective, impaired functional capacity despite optimal medical management; recurrent, life-threatening arrhythmias refractory to medical therapy; intractable angina refractory to medicaltherapy and other interventions; primary cardiac tumors; and hypertrophic or restrictive cardiomyopathy not amenable to standard surgical intervention (i.e. myomectomy). Contraindications Contraindications for heart transplant include: severe, irreversible pulmonary hypertension; severe peripheral vascular disease; late-stage diabetes mellitus withorgan failure/irreversible organ damage; severe, irreversible liver, kidney, or pulmonary disease (but may be amenable to multi organ transplant [i.e. heart-kidney transplant]); active tobacco or illicit drug use; active infections; body mass index < 15 or > 40, or age> 70 years (relative contraindications). Heart Transplant Treatment and Recommended Follow-Up Before heart transplant, all patients must receive pneumococcal and influenza vaccinations (and hepatitis B vaccine, if not immune). Immediately following transplant, all patients must receive triple therapy consisting of glucocorticoids, calcineurin inhibitors, and antiproliferative agents. Patients are progressively weaned off glucocorticoids over 3-6 months. Prophylaxis should be immediately provided for Pneuomocystic carinii (with trimethoprim/sulfamethoxazole),herpes simplex virus (with acyclovir, valacyclovir), and oral candidiasis. Valganciclovir should be used in cytomegalovirus (CMV) -seropositive individuals. Acute graft rejection (humoral type)should be treated with high-dose intravenous (IV) corticosteroids with plasmapheresis and low-dose IV immunoglobulin. Acute graft rejection (cell-mediated type) should be treated with high-dose IV corticosteroids. Anti-thymocyte antibodies should be added if there is hemodynamic compromise and/or no improvement within the first days of steroid therapy. Cardiac allograft vasculopathy (CAV) is a common cause of chronic graft rejection.Treatment/prophylaxis includes statins, angiotensin-converting enzyme inhibitors, and calcium-channel blockers. Ganciclovir prophylaxis also helps prevent CAV progression secondary to CMV viral infection. Outcomes for advanced CAV are poor, and retransplantation is the only definitive treatment. Prognosis Median survival after heart transplant is ~13 years. Heart Transplant Complications Graft Rejection: Hyperacute graft rejection occurs within minutes to hours of heart transplant and is rare with current human leukocyte antigen and blood-typing techniques. Acute rejection may occur within weeks to years and is diagnosed by myocardial biopsy (usually performed on a regular basis). It may be caused by poor compliance with immunosuppressive agents. Chronic rejection occurs months to years after transplantation and leads to irreversible damage to the allograft, occurring in 8% in the first year and 32% after 5 years. Coronary angiography and/or Dobutamine stress echocardiography is often used to screen patients for allograft vasculopathy. Isolated right ventricular failure is more common than biventricular failure in heart transplant patients due to pulmonary hypertension. Most patients have a reversible component that resolves shortly after transplant. A fixed component may persist. Tricuspid regurgitation occurs in 19%-84% of all transplant patients. Patients can typically be managed conservatively with diuretics. Some degree of mitral regurgitation occurs in ~ 50% of all patients in the postoperative period and is typically asymptomatic. Hypotension occurs in some patients postoperatively secondary to systemic vasodilation. All of these patients should be worked up for possible sepsis. These patients may respond to alpha agonists. Sepsis is a major cause of early morbidity and mortality in the transplant patient, accounting for roughly 20% of deaths within the first year of surgery. More medical terminology in our BLOG and the Fibonacci Compendium www.FibonacciMD.app References Birati, EY, Rame JE. Post-heart transplant complication. CritCare Clin.2014;30:629-637. Initial post December 2020

Nodular Sclerosing Hodgkin Lymphoma and Mixed cellularity Hodgkin lymphoma FibonacciMD Compendium Nodular Sclerosing Hodgkin Lymphoma Microscopic image of a lymph node in a patient with Hodgkin's Disease (lymphoma), showing two Reed Sternberg cells in the same high power field. by Anurag Saraf, MD and Nancy Mills MD AKA Nodular Sclerosis Classical Hodgkin Lymphoma Nodular Sclerosing Hodgkin Lymphoma (NSHL) is the most common subtype of classical HL. Classical HL accounts for 95% of all HL (with Nodular Lymphocyte-Rich HL accounting for a majority of the remaining 5%). NSHL accounts for approximately 70% of all classical HL cases. NSHL presents commonly in younger patients (15-35 years old), occurs equally in males and females, and is commonly found in more affluent countries and patients with higher socioeconomic status. Signs and Symptoms NSHL most commonly presents with supradiaphragmatic lymphadenopathy, such as cervical and mediastinal lymph nodes, as well as lesions in the spleen, lung, liver, and bone marrow. Approximately 50% of patients present with bulky disease. Patients may present with what are called B symptoms (fevers, chills, night sweats) and diagnosis is commonly but not always at an early stage. Diagnostic Evaluation Diagnosis requires pathologic confirmation of disease. Microscopic hallmarks include collagen bands surrounding at least one nodule and Hodgkin Reed-Sternberg (HRS) cells with lacunar type morphology. Prognosis Prognosis of NSHL is generally good, with >90% survival at 5 years for early stage disease. Treatment often consists of chemotherapy, and advanced-disease is typically responsive to combination therapy with chemotherapy and radiation therapy. Patient who do not achieve complete remission with first-line therapy can typically be considered candidates for alternative chemotherapy regimens, targeted agents such as antibody-drug conjugate brentuximab, hematopoietic stem cell transplant or other cellular therapies, or immunotherapy such as PD-L1 inhibitors. Further Reading 1. Luca, et al. “Nodular Sclerosis Classical Hodgkin Lymphoma”, Pathology Outlines.com. (http://www.pathologyoutlines.com/topic/lymphomanonBnshl.html). 2. Gansler, et al. “Hodgkin lymphoma: A review and update on recent progress” CA: A Cancer Journal for Clinicians. (https://onlinelibrary.wiley.com/journal/15424863). Mixed cellularity Hodgkin lymphoma by Anurag Saraf, MD, and Nirmala Saraf, MD Mixed cellularity Hodgkin lymphoma (MCHL) is the second most common form of classical Hodgkin's lymphoma (HL). Classical HL accounts for 95% of all HL (with nodular lymphocyte-rich HL accounting for a majority of the remaining 5%). Further, nodular sclerosis HL accounts for most cases of classical HL, followed by MCHL, which accounts for ~20%-25% of classical HL cases. MCHL commonly presents in males, in patients affected with human immunodeficiency virus, and in individuals living in developing countries. The median age at diagnosis is 38 years. Signs and Symptoms MCHL commonly presents with peripheral lymphadenopathy, splenic and liver involvement, and supradiaphragmatic lymphadenopathy, especially cervical and mediastinal lymphadenopathy. Patients typically present with B symptoms (beta symptoms in those with lymphoma, lung cancer, and other cancers), such as fevers, chills, night sweats and unexplained weight loss. Diagnostic Evaluation Diagnosis of MCHL requires pathologic examination of tissue specimens. Reed-Sternberg tumor cells are typically seen in a background of a variety of inflammatory cells, including eosinophils, neutrophils, histiocytes, and plasma cells. Reed–Sternberg cells (lacunar histiocytes) are characteristic giant cells usually derived from B lymphocytes. They are multinucleated and contain pronounced eosinophilic inclusion-like nucleoli. These large clonal tumor cells typically stand out in the midst of normal B lymphocytes. Prognosis Prognosis of patients with MCHL is intermediate when compared with those having other HL diseases, as patients respond to therapy. However, they typically present at an advanced stage with abdominal or splenic involvement. Treatment often consists of chemotherapy, and advanced disease typically responds to combination therapy with chemotherapy and radiation therapy. More medical terminology on the FibonacciMD.app Compendium. References Carbone A, Gloghini A. Mixed cellularity classical Hodgkin lymphoma (MCcHL). Atlas Genet Cytogenet Oncol Haematol. 2017;21:98-102. Luca DC. Nodular sclerosis classical Hodgkin lymphoma. Pathology Outlines.com Web site. http://www.pathologyoutlines.com/topic/lymphomanonBnshl.html. Accessed June 4, 2019.

Hereditary Hemochromatosis diagnosis and treatment A review of Hereditary hemochromatosis, a disease resulting in an excess of iron stored in the body, potentially resulting in liver and other organ damage. FibonacciMD Compendium Excessive iron (stained blue with Perls Prussian blue) deposited in the cytoplasm of hepatocytes by David Payne, MD and David Kauvar, MD Hereditary hemochromatosis- homozygote or heterozygote, what is the difference? Hereditary hemochromatosis is one of the most common inherited disorders in individuals of which descent? Hereditary hemochromatosis (HH) is a disease resulting in an excess of iron stored in the body, potentially resulting in damage to the liver, pancreas, skin, heart, bones, and testes. The most common form stems from mutations in the homeostatic iron regulator (HFE) gene. It is inherited in an . . . Hereditary Hemochromatosis Signs and Symptoms Hemochromatosis is often discovered as an incidental finding on routine laboratory evaluation. The most common initial complaints for hemochromatosis are nonspecific and include fatigue, arthritis, and impotence. In the later stages of the disease, however, patients may suffer from a wide and variable array of disease manifestations, including heart failure, cirrhosis, hepatocellular carcinoma, diabetes, abdominal pain, and, more rarely, bronze skin. The disease tends to noticeably affect adults > 40 years of age. Women may have delayed onset before menopause, as menstruation causes iron loss. Diagnostic Evaluation of Hereditary Hemochromatosis Diagnosis of hemochromatosis depends on elevated iron stores and confirmation via testing for mutations in the HFE gene. Elevated ferritin ( men: >300 ng/mL; women: > 200 ng/mL) and/or elevated transferrin saturation ≥ 45% meet laboratory criteria for diagnosis. When testing for genetic mutations, the gene mutation is referred to as C282Y; as an autosomal recessive disease, it is a homozygous mutation in most patients. In the event of elevated ferritin and transferrin saturation and heterozygous C282Y status, referral to a gastroenterologist or hematologist for further workup, including liver biopsy, is warranted. Polycythemia may or may not be associated with hemochromatosis. Treatment Options The standard of care to treat hemochromatosis is phlebotomy, with the goal of reducing ferritin levels to normal levels (50-150 ng/mL). Depending on disease severity, phlebotomy schedule ranges from one or two 500-mL units of blood removed per week to one 500-mL unit of blood removed every 6 months. Use of iron supplements and vitamin-C supplements should be avoided. Efforts to reduce absorption include avoiding a heavy intake of iron-rich foods. Turmeric may help chelate iron from the body, and drinking coffee and especially tea may decrease absorption. However, in essentially all cases, phlebotomy remains necessary. The sequelae of hemochromatosis include diabetes mellitus, liver cirrhosis, hepatocellular carcinoma, and cardiomyopathy. Therefore, the treatment of severe hemochromatosis may require consultation from a multispecialty medical team. Prognosis Prognosis of hemochromatosis appears to be closely linked to development of liver cirrhosis. Prompt diagnosis and treatment may reverse or reduce the severity of diabetes, cardiomyopathy, and hepatic fibrosis, but cirrhosis cannot be reversed. If cirrhosis is present, mortality risk is greatly elevated (50% higher mortality risk over 5 years as compared with noncirrhotic hemochromatosis patients). Early detection and treatment can completely prevent any excess mortality caused by hemochromatosis. FibonacciMD.app Compendium (our medical encyclopedia) has over 6,000 medical terms and medications. References : PHOTO CREDIT: Jose Luis Calvo Brissot P Cavey T, Ropert M, Guggenbuhl P, Loréal O. Genetic hemochromatosis: pathophysiology, diagnostic and therapeutic management. Presse Med. 2017;46:e288-e295. Crownover B, Covey C. Hereditary hemochromatosis. Am Fam Physician. 2019;87:183-190. Milman N, Pedersen P, á Steig T, Byg K, Graudal N, Fenger K. Clinically overt hereditary hemochromatosis in Denmark 1948–1985: epidemiology, factors of significance for long-term survival, and causes of death in 179 patients. Ann Hematol. 2001;80:737-744. Asif S, Begemann M, Raza S. Polycythemia in Patients With Hereditary Hemochromatosis: Real or Myth? J Clin Med Res. 2019 Jun;11(6):422-427. doi: 10.14740/jocmr3816. Epub 2019 May 10. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6522237/ Choudhary C, Patel P, Bacon B, Gogia S. Hereditary Hemochromatosis (HH). American College of Gastroeneterology. Last updated September 2021. Kowdley K, Brown, K, Ahn, J, Sundaram, V. ACG Clinical Guideline: Hereditary Hemochroatosis. The American Journal of Gastroenterology. 2019;114(8):1202-1218. doi:10.14309/ajg.0000000000000315 Asberg A, Thorstensen K, Hveem K, Bjerve K. Hereditary hemochromatosis: the clinical significance of the S65C mutation. Genet Test. 2002;6(1):59-62. DOI: 10.1089/109065702760093933 initially published December 2, 2021

A Hearty and Nourishing Dish Featuring Toasty Farro and Roasted Sweetness Creative Cooking for the Health-Conscious Gourmet FibonacciRECIPES  | Culinary Medicine   Low-Fat | Low-Cholesterol | High Fiber  by Lori A. Smolin, PhD and Mary B Grosvenor, MS, RD This nourishing grain bowl features roasted sweet potatoes. Their natural sweetness pairs perfectly with the toasty, chewy farro. The green kale makes it as vibrant as it is delicious, The combination creates  a hearty, satisfying dish that balances earthy and sweet notes in every bite.  Ingredients 1 cup semi-pearled or regular farro 3.5 Tbsp Olive oil  1 medium onion, halved and cut in 1/8 th  inch wedges 2 large sweet potatoes, peeled and cut into ¾ inch cubes ½ tsp salt  ½ tsp ground cumin ½ tsp ground coriander ½ cup shelled, raw walnuts broken into small pieces ½ cup golden raisins 4 cups kale, stems removed and roughly chopped 1 large clove garlic, minced Additional seasonings:    Salt     Black pepper     Lemon juice  Instructions   In a medium saucepan, combine rinsed farro with 4 cups water. Bring to a boil. Cover and reduce heat to simmer until grain is tender, about 30 minutes. Drain any excess water and place farro in a large bowl to cool. While farro is cooking, preheat oven to 400°F.  Place walnuts and golden raisins on a baking sheet. Toast until walnuts begin to darken and raisins begin to plump, about 5 minutes. Check frequently as they can burn quickly. Remove from pan and set aside to cool. Toss onions with 1 Tbsp oil and  ¼ tsp salt. Place in a pile on the baking sheet and return to heated oven. Roast until browned, stirring often. Remove from pan and set aide to cool.  Toss the diced sweet potatoes with 1½ Tbsp oil, ¼ tsp salt, cumin, and coriander. Spread on the baking sheet and return to heated oven. Roast for about 20 minutes until browned, stirring halfway through.  Remove from pan and add to the bowl with the farro.  While potatoes are cooking, heat 1 Tbsp oil in a large skillet. Add kale and garlic and sauté until kale is wilted but still bright green.  Fold walnuts, raisins, onions, and kale into the farro sweet potato mixture.  Sprinkle with lemon juice, salt and pepper. Makes 6 one and a half cup servings  Nutrition Information per serving Calories 500, Fat 15.8g, Saturated fat 1.7g, Cholesterol 0 mg, Carbohydrate 76.5g, Fiber 14.2g, Protein 13.8g, Sodium 833mg, Potassium 780mg Notes:  If you don’t have farro, the recipe works well with brown rice, barley, or bulgur wheat.  It is delicious served either hot or cold You can freeze leftovers for up to 3 months Editor’s Note - Appropriate for a low saturated fat, low cholesterol, high fiber dietary regimen. Mary Recommends: As an Amazon Associate FibonacciMD earns from qualifying purchases. Ancient Grain Power: Stock up on Farro !  High in protein and fiber, this hearty, chewy grain supports digestive health and keeps you full longer. Shop Now on Amazon!  [ https://amzn.to/44i1cpE ]

Discover how private equity impacts healthcare quality and costs. This article covers LBOs, staffing shifts, and the facts behind hospital bankruptcies. ________________________________________________________________________________________________________ Go to our CME Site, Read Article,  Take Test ,  and Get FREE 🎓 CME Certificate with Valid Email We’ll send you occasional updates. Your email stays private—never sold or shared.  😇 ________________________________________________________________________________________________________ Private Equity in Healthcare What Are the Facts? by Stuart M. Caplen, MD   Over the past few decades, private equity (PE) firms in the U.S. have acquired hundreds of hospitals, thousands of physician practices, and numerous nursing homes, ambulatory surgery centers, and fertility clinics.[1]  What distinguishes PE from other for-profit healthcare owners is that PE firms generally aim to turn a profit by selling off assets within five to ten years.  Typical strategies to achieve this include decreasing staff, eliminating less profitable services, increasing prices, and attempting to increase patient volume.[1]   About 8.5% of all private hospitals are thought to be owned by private equity.[2]  Hospital-based medical practices are also purchased by PE firms, with one source reporting that by 2020, 40% of all emergency department physicians were working for PE-acquired firms.[3]  Estimates suggest that PE invested between $200 billion and $1 trillion in the U.S. healthcare industry over the last decade.[4,5]   A literature review of hospital waste-related costs in the U.S. healthcare system estimated wasteful overspending of $760 billion to $935 billion.[6]  The question is: Does PE entering the healthcare system reduce these over-expenditures using their management expertise, or are they predatory, taking profits and leaving behind a trail of increased debt or even bankruptcies? How Does Private Equity Make Money? Leveraged Buyouts (LBOs) To make the purchase, PE firms frequently use the acquired entity’s assets as collateral to obtain large loans, a process known as a leveraged buyout (LBO).  A PE firm typically assumes only part of the responsibility for the loan and, for example, taking responsibility for just 25% of the loan, leaving the healthcare entity responsible for the remaining 75%.  This increased debt load raises the risk of bankruptcy for the acquired entity while allowing the private equity firm to minimize its own financial risk.[1]  The use of leveraged buyouts for business acquisitions has been found to increase the ten-year bankruptcy rate of target firms by tenfold compared to controls (20% compared to 2%).[7]   Sale-Leaseback Transactions In addition, the hospital or healthcare entity’s land and buildings are commonly sold to a REIT (real estate investment trust), in a sale-leaseback transaction, providing the PE firm with immediate cash.  The healthcare facility must then lease back its land and buildings, which increases its debt burden due to rental costs.[8]  The PE firm is not required to reinvest all the proceeds from the property sale to benefit the healthcare entity and may take a portion as profit.  These transactions effectively turn part of the acquisition into a profitable real estate deal.  One study found that, over a two-year period, assets owned by PE-acquired hospitals decreased by 24% compared to control hospitals.[9]  Another, more recent study reported that 25% of hospitals that participated in REIT sale-leaseback transactions closed or declared bankruptcy compared to 4% of control hospitals. Additionally, there was a 31% decrease in the fixed assets of hospitals involved in REIT transactions compared to the control group.[10]  Management Fees PE firms may also charge management fees to the acquired healthcare entity.[11] Related-Party Transactions In some cases, “related-party transactions” can increase PE profits.  After acquisition, the healthcare entity may be required to purchase services from another company owned by the PE firm regardless of cost or quality.  One example would be the mandated use of a PE-owned debt collection company.[3]   Increased Charges PE-acquired hospitals have been found to raise charges more than control hospitals.  In a study of over 500 physician practices purchased by private equity firms from 2016 to 2020, charges increased by an average of 20%.[12]  Another systematic review found a consistent pattern of increased costs to patients and insurers following PE acquisition of healthcare entities.[13]  Selling the Entity or Walking Away If the PE firm can make the healthcare entity profitable, it can potentially sell it at a profit.  If bankruptcy occurs, the PE firm may walk away with substantial earnings already extracted, leaving vendors, other debtors, the REIT, and the community the entity previously served, to deal with the fallout.  Surprise Billing Previously, one major attraction of owning in-hospital physician groups was the ability to engage in balance-billing.  For example, PE-owned anesthesia or emergency medicine groups would go out-of-network with commercial insurers, even if the hospital they worked at was in-network.  This allowed the groups to charge patients any amount they chose and then balance-bill the patients for the difference between their charges and the insurer’s reimbursement.  This practice, commonly known as “surprise billing”, provoked widespread patient anger and in 2022, the No Surprises Act  was enacted by Congress, which prohibited such billing practices.  Following the law’s passage, several large PE-owned emergency department physician staffing firms filed for bankruptcy, claiming the legislation had negatively affected their revenue.[14,15,16,17,18]     Does Private Equity Improve or Worsen Healthcare?  A study compared PE-acquired hospitals to hospitals acquired by other entities (typically another medical center), as well as a group of non-acquired hospitals used as controls.  The researchers found that over an eight-year period the PE-acquired hospitals were more likely to succeed financially than both the non-PE-acquired hospitals and the controls.[4] The same study also reported that the number of core workers (doctors, nurses, and pharmacists) in the PE-acquired hospitals decreased by 15% compared to controls in the first four years after acquisition.  However, in the following four years, core staffing in PE-acquired hospitals increased and ended up only being 5% lower than the control hospitals.  By contrast, non-PE-acquired hospitals had a 24% drop in core personnel in the first four years, which became a 25% drop in comparison to the control group over the subsequent four years.[4] Compared to control hospitals, PE-acquired hospitals reduced administrative positions by 14%-16% over eight years, while no reduction occurred in non-PE-acquired hospitals.[4]  Over the eight-year period, total employment decreased by 8% at PE-acquired hospitals versus a 4%-5% decrease in non-PE acquired hospitals.[4]  According to this study, it appears that regardless of which type of entity purchases a hospital, core staffing will decrease.  However, in a PE-acquired hospital, administrative staff are reduced to a much greater degree, resulting in a lesser overall drop in core personnel compared to non-PE-acquired hospitals.[4] The authors did not find any differences in 30-day mortality for myocardial infarction or hospital-acquired pneumonia between PE-acquired hospitals and non-PE-acquired hospitals, though heart failure mortality rates were slightly higher in non-PE-acquired hospitals.  There was a small increase in the 30-day pneumonia readmission rate in PE-acquired hospitals.  No changes were observed in the percentage of Medicaid patients at either PE- or non-PE-acquired hospitals, suggesting that the hospitals did not increasingly cater to wealthier patients after acquisition.[4]  A different study looking at REIT-acquired hospitals found no significant differences in the 30-day mortality rate or 30-day hospital readmission rate for patients with acute myocardial infarction, congestive heart failure, or pneumonia compared to non-REIT-acquired hospitals.[10]   Another analysis reported that PE-acquired hospitals performed significantly better on pneumonia and acute myocardial infarction quality measures than control hospitals.[19] However, these relatively positive findings from the above studies contrast with other published studies. A study of Medicare data revealed that PE acquisition was associated with a 25% increase in hospital-acquired conditions, such as increased falls and central intravenous line infections.  Post PE acquisition, there was a 27% increase in patient falls and central line-associated infections rose 38% (despite 16% fewer central lines being placed), compared to the incidence before the PE firm took over.  There were no significant differences found in the rates of pressure ulcers, surgical infections, deep vein thromboses, or catheter associated urinary tract infections pre- and post-PE acquisition.[20] A review of nursing home data between 2000 and 2017, reported that, depending on which statistical method was used, there was a 2% to 11% increase in short-term mortality in PE-owned nursing homes despite accepting lower risk patients.  The authors documented multiple changes in clinical and operational factors that may help explain the increased mortality, such as declines in measures of patient well-being, nurse staffing, and compliance with care standards in PE-owned nursing homes.  They also reported that there was a 77% increase in facility building lease payments and a 224% increase in interest payments after PE acquisition.[21]  A recent study of differences in staffing and mortality in emergency departments (EDs) and intensive care units (ICUs) between PE-owned facilities and controls, reported that ED salary expenditures decreased 18.2% and ICU salary expenditures decreased 15.9% in PE-owned hospitals.  ED patient deaths increased by 13.4% after PE acquisition.  By contrast, the non-PE-owned hospitals studied experienced decreased ED mortality.  ICU mortality did not increase, but patient transfers to other institutions rose by 4.2% from PE-owned EDs and 10.6% from PE-owned ICUs.  These results suggest that fewer services may have been offered at PE-acquired hospitals, requiring more transfers of sicker patients.  The authors suggested that decreased ICU staffing may have been a contributor to increased ED holding times, which have been associated with worsened healthcare outcomes.[22,23] Actual Cases of Private Equity Acquisition that Led to Bankruptcy Theoretically, private equity can supply needed cash and possibly better management to a troubled hospital or other healthcare entity.  However, there have been instances where the PE firm enriched itself while increasing the debt of the acquired institution to the point of bankruptcy.  Not all PE acquisitions end in bankruptcy, but two illustrative examples in which this occurred are highlighted below. Steward Healthcare Steward Healthcare serves as a cautionary tale.  As described in a report by the Private Equity Stakeholders Project , Steward Health Care is a multi-state hospital system that was owned by PE firm Cerberus Capital Management from 2010 to 2020.  Steward was formed in 2010 when Cerberus purchased Caritas Christi, a nonprofit six-hospital Catholic healthcare system in Massachusetts.[11]  Massachusetts regulators imposed conditions on the transaction including a five-year monitoring period for Steward following the transaction.  In 2016, after its monitoring period ended, Steward, which had purchased more hospitals by then, sold the real estate of five of its Massachusetts hospitals and mortgaged four more hospitals to Medical Properties Trust (MPT), a REIT.  This transaction generated $1.2 billion, $484 million of which was paid to Cerberus Capital’s funds as dividends.[11]  The hospitals either no longer owned their real estate or had new mortgages and were then required to pay millions of dollars in lease or mortgage payments.  When Cerberus acquired the initial six-hospital chain in 2010, Steward was $475 million in debt; by the end of 2014, total liabilities exceeded $1.4 billion.[11]  In 2017, with financing assistance from MPT, Steward rapidly expanded to a 37-hospital system operating in ten states and became the largest for-profit private hospital operator in the U.S.[11]  More sale-leaseback deals followed.[10]  Many Steward hospitals were financially struggling as Cerberus began to make its exit in 2020.[11]  In 2023, as Steward reportedly missed rent payments, faced increased complaints of patient care issues and unpaid vendor bills, it took on $600 million in new debt to refinance existing obligations.[11]  Between 2018 and 2024, Steward closed six hospitals, resulting in the layoffs of at least 2,650 workers and reduced community access to care.  Steward also reportedly cut unprofitable service lines at some of their hospitals, such as obstetrics, behavioral health, and cancer care.[11] In May 2024, Steward Health Care filed for Chapter 11 bankruptcy, reporting over $9 billion in liabilities.  Of this, $6.6 billion were long-term lease liabilities owed to MPT, $290 million were unpaid wages to employees, and nearly $1 billion were unpaid debts to vendors and suppliers.[11]  Before the bankruptcy filing, the healthcare system was sold to a new set of owners who allegedly paid themselves a final $111 million dividend.[11]  Cerberus reportedly made $800 million in total in the decade it owned Steward.[11]  In the year since Steward’s bankruptcy filing, five more former Steward hospitals in Massachusetts, Florida, and Ohio have closed and laid off approximately 2,400 workers.[24]  Prospect Medical Holdings Prospect Medical Holdings (PMH), a 16-hospital PE-owned chain, declared bankruptcy in 2025.  It was owned by the PE firm Leonard Green & Partners (LGP).[25]  In 2022, in Connecticut, Yale New Haven Health agreed to take over three Prospect Hospitals for $435 million.[26]  It was reported in the news, based on court filings, that after further investigation, “Yale New Haven Health sued to get out of buying the hospitals, citing “severe” neglect of facilities that included failure to maintain basic cybersecurity standards, missed payments to vendors and numerous regulatory violations.”[25,27]  An arbitration agreement following Prospect’s bankruptcy and counter-suit against Yale, cost Yale $45 million to negate the deal.[28]  A U.S. Senate Budget Committee investigation officially reported that one of its key findings was: “Despite gross financial and operational mismanagement of its hospitals, LGP took home $424 million of the $645 million that PMH paid out in dividends and preferred stock redemption during LGP’s majority ownership,—in addition to over $13 million in fees—that left PMH in severe financial distress.  In order to pay out these distributions, PMH was forced to take on hundreds of millions of dollars in debt, eventually leading to PMH running out of cash and defaulting on its loans.”[29] What Can Be Done to Prevent Private Equity Excesses?  While a struggling healthcare system may benefit from new management and a cash infusion, the structure of PE acquisitions can allow firms to extract excessive profits while dramatically increasing the system’s debt, sometimes pushing it toward bankruptcy. The Private Equity Stakeholder Project has suggested some legislative changes to prevent excessive private equity profiteering in the future.[11] Create a robust set of change-of-ownership regulations for healthcare facilities that give states authority to approve or deny transactions based on multiple factors, including cost and market share, long-term access to quality healthcare for the community, and preservation of jobs and collective bargaining rights. Require full financial transparency of licensed hospital operators and their investors, including  private equity firms, real estate investment trusts (REITs), and other shareholders. Require that acute care hospital operators offer a minimum set of clinical services. Give states authority to put hospitals in receivership in the event of mismanagement by their owners. Bar hospital investors from paying themselves debt-funded dividends from healthcare systems (also called dividend recapitalizations) or dividends from real estate sales.  Investors should be able to prove that any dividends paid to the PE firm can be funded without impacting the short- or long-term financial viability of the hospital/healthcare system. Ban or place limits on sale-leasebacks and similar types of real estate transactions involving hospital property, for all types of hospitals. Establish joint and several liability for corporate owners and investors of hospital systems for both operations and real estate, so that if a hospital is sued, the controlling corporate entities could also be held liable. (In joint and several liability, parties can be held individually to pay the amount of the total judgment if another defendant is unable to.)  Place limits on management fees. Summary Private equity firms have developed strategies to generate substantial income from healthcare entities using leveraged buyouts, sale-leaseback deals for land and property, and management fees.  This has encouraged heavy PE investment in this sector.  These financial strategies can produce significant returns regardless of whether the healthcare entity succeeds or fails, sometimes leaving hospitals over-leveraged and vulnerable to bankruptcy.   Interestingly, one study found that both PE- and non-PE-acquired hospitals reduced core clinical staffing compared to controls, which may have potential negative effects on both clinical outcomes and on patient satisfaction.  However, four-to-eight years post-acquisition, core staff levels in PE-acquired hospitals had improved, while reductions persisted in non-PE-acquired hospitals.  Administrative positions were reduced only in PE-acquired facilities.   Evidence on the impact of PE ownership on healthcare quality is mixed, but some research has found worsened health outcomes in PE-acquired healthcare entities.  It may be likely that some PE firms prioritize improving quality and turning the investment around while others extract massive profits, decrease staffing, and cut essential community services while driving the entity towards bankruptcy.   PE ownership of healthcare entities such as nursing homes and physician practices has been associated with increased charges to patients, insurance companies, and Medicare.     When PE acquires a hospital or other healthcare entity, stakeholder priorities shift, and the needs of the PE firm may outweigh the needs of the local community.  Real-world cases presented in this article highlight the potential risks when financial extraction by the owners may threaten the long-term viability of a hospital system. It is likely that PE investments in healthcare will continue given how profitable ownership has proved to be.  It is incumbent on legislators and regulators to ensure that the potential excesses that have occurred in the past are limited by better oversight, regulation, and legislation.  ✅ Earn Free CME Credit for Reading This Article on Our CME Site Eligible for 0.5 PRA Category 1 Credit Click the button below to complete the course and take a short quiz. A valid email is required to send your certificate. We’ll send you occasional updates. Your email stays private—never sold or shared.  😇 Take Test As an Amazon Associate FibonacciMD earns from qualifying purchases. The Philips HeartStart Home AED  is the only defibrillator available over-the-counter without a prescription, specifically designed for use by ordinary people in extraordinary moments. This Value Package  provides a comprehensive, out-of-the-box solution to ensure you are fully prepared for a cardiac emergency at home. 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Understanding hospice and palliative care eligibility, timing, care models, and outcomes to improve serious illness and end-of-life decision-making. ________________________________________________________________________________________________________ Go to our CME Site, Read Article , Take Test , and Get FREE 🎓 CME Certificate with Valid Email We’ll send you occasional updates. Your email stays private—never sold or shared.  😇 ________________________________________________________________________________________________________ Hospice and Palliative Care Are They Different? by Stuart M. Caplen, MD   Stuart M. Caplen, MD  Palliative medicine is specialized medical care for people with serious or life-limiting illnesses.  Hospice focuses on end-of-life care for patients with a life expectancy of six months or less and often incorporates palliative care.  This article reviews the history, structure, and effectiveness of both models of care. History The hospice movement originated in London, England, in 1967, when Dame Cicely Saunders founded St. Christopher’s Hospice.  Drawing on her experience as a social worker, nurse, and later a physician, Dame Cicely Saunders observed significant untreated pain and suffering in patients approaching the end of life, which led to the development of modern hospice care.  She discovered and popularized the concept that regularly scheduled opioid doses can provide effective pain relief while allowing patients to remain alert and responsive.[1] In 1974, after visiting and working with Dr. Saunders, Florence Wald, an American nurse, founded the first hospice in the United States in Branford, Connecticut.  Congress authorized the hospice benefit in 1981, with Medicare reimbursement beginning in 1983.[1]  Dr. Balfour Mount, who was a surgical oncologist at the Royal Victoria Hospital in Montreal, Canada, coined the term “palliative care” to avoid negative connotations of the word “hospice” in French-speaking Quebec.  In France, hospices were traditionally run by religious orders that provided food and shelter for the destitute, sick, and elderly.   The first hospital-based palliative care program in the United States was established in 1985 at the Wayne State University School of Medicine in Detroit, Michigan.[1] What Is Hospice Care? Hospice is a health care delivery system for patients at the end of life.  By statute, hospice is specifically limited to patients with a prognosis of six months or less to live and, in the U.S., is covered as a benefit by Medicare, Medicaid, and most private insurance companies.[1] Hospice is both a philosophy and a system of care delivery and is not limited to a specific location. There are four levels of hospice care: Routine hospice care can occur at home, nursing home, or in an assisted living facility.   Inpatient hospice care  is used to treat acute symptoms or emergencies that cannot be managed in another setting.  It provides short-term clinical support in a hospital, hospice facility, or skilled nursing home.   Continuous care  is used for crisis management for a hospice patient, such as terminal agitation or severe pain, to support continued management of the patient at home.  It typically provides nursing care for eight to 24 hours a day and homemaker or hospice aide services may supplement the nursing care.[2] Respite care  provides temporary relief for the hospice patient’s primary caregiver(s).  Respite care can be provided for up to five days[3] in a hospital, hospice facility, or more commonly in a long-term care facility to provide the caregiver(s) with some rest before they resume home care.[1] Although hospice care may last up to six months, one study reported that 32.4% of patients in hospice die within seven days and 10.5% live more than 180 days.  These statistics highlight the challenge physicians face to accurately predict life expectancy.  Given that nearly one-third of hospice patients die within one week of enrollment, these findings suggest underuse of hospice services and indicate that earlier referral may be beneficial.[4]  How Is a Patient Determined to Be Eligible for Hospice? Hospice eligibility requires the following three criteria to be met: Two physicians must certify that the patient is terminally ill. The patient or surrogate must elect comfort-focused care rather than curative treatment for the underlying terminal disease. The patient or surrogate must sign a statement electing the hospice benefit.[1] The Centers for Medicare & Medicaid Services have specific criteria and documentation requirements to establish hospice eligibility and to ensure coverage, which can be accessed at this link. [5]   Hospice care requires recertification by the hospice physician after the initial 90-day benefit period, again after an additional 90 days, and every 60 days thereafter.  If a patient’s prognosis improves during hospice care and estimated life expectancy becomes more than six months, the patient can then be discharged from hospice.  It has been reported that about 6.7% of hospice patients do improve enough to be discharged.[1] Hospice care usually involves a multidisciplinary team that typically includes physicians, nurses, therapists, home health aides, social workers, bereavement counselors, and chaplains.  Hospice services are often more intensive during initial evaluation period, as well as in the final two weeks of life when the patient may require additional supportive care.  Medicare permits increased benefits during those periods.[1]   Bereavement resources are also available to the patient’s family for one year following the patient’s death as part of hospice care.[1]  Hospice Ratings  Medicare has compiled comparative quality ratings for hospices, which are publicly available at this website.   The Office of the Inspector General issued a report on hospice care in 2019 and determined that 18% were considered poor performers.  Deficiencies found included: Providing fewer services than required Failing to address individual needs Inadequate supervision or training of aides  Failing to monitor medications  Failing to assess pain  Failing to update comprehensive assessments on a regular basis Failing to obtain criminal background checks or ensuring staff had proper credentials  Failing to effectively manage pain  Failing to properly treat severe wounds  Failing to provide volunteer services (all hospices are required to use volunteers)  Failing to notify the physician of worsening or new symptoms  Lack of required contracts with inpatient facilities, as required by regulation[6]  Palliative care Palliative care has been defined as care that supports patients with serious illness by relieving pain and other symptoms, improving quality of life, and aligning treatment with the values and goals of patients and their families. Palliative care should be offered early in the course of treatment for a serious illness and can be delivered in various health care settings, including at home, in nursing homes, long-term acute-care facilities, hospitals, and outpatient clinics.[7]  Unlike hospice care, palliative care is not limited to end-of-life care and may be provided at any stage of a serious illness which negatively impacts quality of life or daily function, and/or places a significant burden on caregivers.[1]   Palliative care is an interdisciplinary model that can vary by geographic region, setting (inpatient or outpatient), and disease being treated.  Examples of illnesses that might be approved for palliative care but not hospice include chronic respiratory, renal, cardiac, or neurodegenerative diseases.  Palliative care consists of eight core domains (also called components).  The structure and processes  - Personnel on the interdisciplinary team and definition of how assessment and care will occur.  Physical - Assessment and treatment of concerning symptoms and planning of the patient’s care.   Psychological  - Assessment and treatment of psychological or psychiatric issues in the person with severe or terminal disease. Social  - Assessment of social support needs of the patient and family. Spiritual  - Assessment of spiritual and religious needs and support needed  Cultural  - Assessment of how cultural influences will affect how care will be delivered.  End-of-Life - Focusing on how care and support will be provided in the period near end of life.  Ethical and Legal  -  Planning for surrogate decision-making, advance directives, and legal and ethical issues at the end-of-life.[1,8] Palliative care requires collaboration with patients, families, or surrogates.  Decision-making preferences exist along a spectrum, ranging from patient- or family-directed decision-making to shared decision-making and, in select situations, physician-directed decision-making.  Providers must assess which approach is most appropriate for each patient and family.[1] How Effective is Palliative and Hospice Care? Substantial evidence supports the effectiveness of palliative and hospice care.[1]  In one study, institution of a palliative care program reduced hospital admissions by 34%, reduced costs by approximately $12,000 per patient in the last three months of life, and increased median hospice length of stay by 24 days, compared to patients not receiving palliative care.[9]  A large systematic review reported statistically significant improvements in both patient and caregiver outcomes associated with palliative care such as quality of life and symptom reduction for cancer, congestive heart failure, and chronic obstructive pulmonary disease.  Palliative care also significantly reduced hospital use resulting in cost savings.[10]  Another study reported that patients with cancer who were in hospice for two months or more had improved quality-of-life scores compared to those who were in hospice one week or less, suggesting that early referral of patients to hospice may be advantageous.[11] Early initiation of palliative care was associated with improved survival of cancer patients in several studies.[12,13] One of the key strengths of hospice and palliative care is the opportunity for communication and discussing end-of-life issues with patients and family.[10,11]  One report noted that at an average of four months prior to death only 37% of advanced cancer patients had participated in end-of-life discussions.  When end-of-life conversations had occurred, patients reported better quality of life, received less aggressive medical care near death, and were referred earlier to hospice.  In addition, when end-of-life issues were not discussed, bereaved caregivers experienced worse quality of life, more regret, and were at higher risk of developing a major depressive disorder a median of 6.5 months later.[11] How Many Patients Require Palliative Care but Don’t Receive It? The World Health Organization (WHO) estimates that worldwide, 56.8 million people, including 25.7 million in the last year of life, are in need of palliative care.  The majority of adults in need of palliative care have chronic diseases such as cardiovascular diseases (38.5%), cancer (34%), chronic respiratory diseases (10.3%), AIDS (5.7%), and diabetes (4.6%).  Other conditions that may require palliative care include kidney failure, chronic liver disease, multiple sclerosis, Parkinson’s disease, dementia and other neurological diseases, rheumatoid arthritis, congenital anomalies, and drug-resistant tuberculosis.[14]   The WHO identifies four issues that prevent palliative care from reaching more people.   Lack of awareness among policymakers, health professionals, and the public about what palliative care is, and the benefits it can offer patients and health systems. Cultural and social barriers, including beliefs about death and dying. Misconceptions about palliative care, such as that it is only for patients with cancer or for the last weeks of life. Misconceptions that improving access to opioid analgesia will lead to increased substance abuse.[14] Palliative Care in the U.S.  In the U.S., it is estimated that 13 million adults and 700,000 children who could benefit from palliative care do not receive it.[15]   Hospital palliative care programs have expanded substantially over the years.  As of 2022, 84% of U.S. hospitals with fifty or more beds reported a palliative care team, up from 67% in 2015 and 7% in 2001.  Currently, 96% of all hospitals with 300 or more beds have a palliative care team.[15] However, availability of palliative care is lower in for-profit hospitals (49%) and rural hospitals (34%).  In 2024, there were 19,920 clinicians across all disciplines in the U.S. with specialty certification in hospice and palliative care.  This equates to 2.86 prescribers (physicians, advanced practice nurses, and physician assistants) per 100,000 population, which is far below most other medical specialties.  According to the Center to Advance Palliative Care, this is insufficient to meet the estimated demand.   In the U.S., there are reportedly geographic differences in a patient’s ability to access and receive quality palliative care as well as varying state support for clinician education.  The Center to Advance Palliative Care has created a state-by-state rating system which can be accessed here .[16] Pain Management in Palliative Care  Pain management is a key component of palliative care, with opioids and other adjuvant medications and treatments frequently required to decrease pain and suffering.   The WHO Three-step Analgesic Ladder [17] A full discussion of the subject of pain relief in patients requiring palliative care is beyond the scope of this learning activity, but some suggested resources include: The American Society of Clinical Oncology Guidelines  [18] and The WHO Guidelines for the Pharmacological and Radiotherapeutic Management of Cancer Pain in Adults and Adolescents .[17]   Summary Hospice is a care model intended for patients in the final six months of life who have chosen comfort-focused care rather than disease-directed treatment.  Palliative care is a multidisciplinary approach that addresses pain and other symptoms, psychosocial needs, and patient values and treatment preferences at any stage of serious illness and may be provided alongside curative or life-extending therapies.  Hospice care most commonly includes palliative care, and both models may care for patients in the home, in a long-term nursing facility, in a hospice facility, or in a hospital.  Hospice and palliative care have been shown to decrease end-of-life costs, reduce hospital admissions, improve quality of life, possibly improve survival in some cases, improve communication, and support family members both during the illness and after the patient dies.  Despite these benefits, hospice referrals often occur late in the disease course, thereby limiting their potential impact. Within the United States and globally, millions of patients who could benefit from palliative care lack access to these services.  In the U.S., there are regional differences in the ability to receive palliative care services, and an insufficient number of specialty-certified clinicians to meet demand.  Author’s note: Thank you to Theodor Feigelman, MD for editing this article. ✅ Earn Free CME Credit for Reading this Article on Our CME Site Eligible for 0.5 PRA Category 1 Credit Click the button below to complete the course and take a short quiz. A valid email is required to send your certificate. We’ll send you occasional updates. Your email stays private—never sold or shared.  😇 Take Test As an Amazon Associate FibonacciMD earns from qualifying purchases. Adjustable laptop table  [ https://amzn.to/3NYGky7 ] Medical rolling stool with back support [ https://amzn.to/3Z9HSb9 ] References If you liked this CME/article, you may also enjoy reading "Private Equity in Healthcare" You may also find these other FibonacciMedicine CME articles interesting: Mirror Therapy for Phantom Limb Pain and Stroke Small Intestinal Bacterial Overgrowth. What Is SIBO, and How Is It Diagnosed and Treated? Communication Issues in Healthcare: Its Relation to Malpractice Risk, and How to Communicate More Effectively All CME articles here .

References for CME Article " Hospice and Palliative Care — Are They Different? " References [1] E. Tatum PE and Sarah S. Mills SS. Hospice and Palliative Care. Medical Clinics of North America. Volume 104, Issue 3. Retrieved from: https://www.medical.theclinics.com/article/S0025-7125(20)30001-8/abstract [2] Continuous Home Care in the Medicare Hospice Benefit. National Hospice and Palliative Care Organization, Revised Mar 2021, Retrieved from: https://allianceforcareathome.org/wp-content/uploads/CHC_Compliance_guide.pdf [3] Managing Medicare Hospice Respite Care Compliance for Hospice Providers. National Alliance for Care at Home. Revised July 2021.  Retrieved from: https://allianceforcareathome.org/wp-content/uploads/Respite_Tip_sheet.pdf [4] Wachterman MW, Marcantonio ER, Davis RB, McCarthy EP: Association of hospice agency profit status with patient diagnosis, location of care, and length of stay. JAMA 2011;305:472–479. Retrieved from: https://pmc.ncbi.nlm.nih.gov/articles/PMC3142476/ [5] Hospice – Determining Terminal Status. Centers for Medicare & Medicaid Services. Last updated 11/07/2023. Retrieved from: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=33393&ver=9&keyword=hospice&keywordType=starts&areaId=all&docType=NCA,CAL,NCD,MEDCAC,TA,MCD,6,3,5,1,F,P&contractOption=all&sortBy=relevance&bc=1 [6] Hospice Deficiencies Pose Risks to Medicare Beneficiaries. HHS Office of the Inspector General. 07/03/2019. Retrieved from: https://oig.hhs.gov/reports/all/2019/hospice-deficiencies-pose-risks-to-medicare-beneficiaries/ https://www.canhr.org/wp-content/uploads/2022/10/2019_OIG_Report-Hospice_Deficiencies.pdf [7] Dying in America-Improving Quality and Honoring Individual Preferences Near the End of Life. National Academies Press; 2015. Retrieved from: https://doi.org/10.17226/18748 [8] National Consensus Project for Quality Palliative Care. Clinical Practice Guidelines for Quality Palliative Care, 4th edition. Richmond, VA: National Coalition for Hospice and Palliative Care; 2018. Retrieved from: https://www.nationalcoalitionhpc.org/wp-content/uploads/2020/07/NCHPC-NCPGuidelines_4thED_web_FINAL.pdf [9] Lustbader D, Mudra M, Romano C, et al. The impact of a home-based palliative care program in an accountable care organization. J Palliat Med 2017;20(1). Retrieved from: https://www.liebertpub.com/doi/10.1089/jpm.2016.0265 [10] Singer AE et al. Populations and Interventions for Palliative and End-of-Life Care: A Systematic Review. Journal of Palliative Medicine. Volume 19, Number 9, 2016. Retrieved from: https://pmc.ncbi.nlm.nih.gov/articles/PMC5011630/pdf/jpm.2015.0367.pdf [11] Wright AA et al. Associations Between End-of-Life Discussions, Patient Mental Health, Medical Care Near Death, and Caregiver Bereavement Adjustment. JAMA. 2008;300(14):1665–1673. Retrieved from: https://jamanetwork.com/journals/jama/fullarticle/182700 [12] Bakitas, Marie A et al. "Early versus delayed initiation of concurrent palliative oncology care: patient outcomes in the ENABLE III randomized controlled trial." Journal of clinical oncology 33.13 (2015): 1438-1445. Retrieved from: https://pmc.ncbi.nlm.nih.gov/articles/PMC4404422/pdf/zlj1438.pdf [13] Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 2010;363(8):733–42. Retrieved from: https://www.nejm.org/doi/full/10.1056/NEJMoa1000678 [14] Palliative care. World Health Organization. 5 August 2020. Retrieved from: https://www.who.int/news-room/fact-sheets/detail/palliative-care [15] Palliative Care Facts and Stats.  Center to Advance Palliative Care. Retrieved from: https://www.capc.org/documents/download/665/#:~:text=%E2%80%A2%20At%20least%2013%2C000%2C000%20adults%20and%20nearly,illness%2C%20and%20could%20benefit%20from%20palliative%20care [16] America’s Readiness to Meet the Needs of People with Serious Illness- 2024 Serious Illness Scorecard: A State-By-State Look at Palliative Care Capacity. Center to Advance Palliative Care. August 2024. Retrieved from: https://scorecard.capc.org/ [17] Who Guidelines for the Pharmacological and Radiotherapeutic Management of Cancer Pain in Adults and Adolescents. WHO, 2018 Retrieved from: https://iris.who.int/server/api/core/bitstreams/809a021b-e75c-4f9c-b002-6fb13bf1a0f5/content [18] Paice JA et al. Use of Opioids for Adults With Pain From Cancer or Cancer Treatment: ASCO Guideline. J Clin Oncol 41:914-930. December 5, 2022. Retrieved from: https://ascopubs.org/doi/pdfdirect/10.1200/JCO.22.02198 CME article: " Hospice and Palliative Care — Are They Different? "

Pumpkin gingerbread - yum - it's even vegan! Creative Cooking for the Health-Conscious Gourmet FibonacciRECIPES  | Culinary Medicine      by Lori A. Smolin, PhD  and Mary B Grosvenor, MS, RD Enjoy a new twist on gingerbread. Add pumpkin puree. The pumpkin enhances the flavor and consistency and takes the place of eggs in the recipe, creating a tasty vegan option.   Mary Recommends As an Amazon Associate FibonacciMD earns from qualifying purchases. Rectangular Baking Bread Loaf Pan , 9.5 x 5 [ https://amzn.to/4kqWQ6a ] Ingredients 1½  cups whole-wheat pastry flour  2 tsp baking powder ½ tsp baking soda 2 tsp ground ginger 1 ½ tsp cinnamon ¼ tsp nutmeg ¼ tsp cloves ½ tsp salt 1 cup canned pumpkin puree  ½ cup canola oil 1/3 cup unsulfured molasses ½ cup packed dark brown sugar 1 tsp vanilla extract ¼ cup soymilk or other plant-based milk Instructions Preheat oven to 350 °F. Grease and flour an 8.5 X 4.5” loaf pan. In a medium bowl mix flour, baking powder, baking soda, ginger, cinnamon, nutmeg, cloves, and salt. In a large bowl whisk together pumpkin puree, oil, molasses, brown sugar, vanilla, and soymilk. Slowly add dry ingredients to the wet, stirring until evenly incorporated. Transfer batter to loaf pan. Bake for 45 minutes or until a toothpick comes out clean. Cool for at least 15 minutes before serving Makes 12 slices  Nutrition information per slice Calories 215, Total Fat 9.2g, Saturated Fat 0.7g, Cholesterol 6 mg, Total Carbohydrate 30g, Dietary fiber 2.8g, Protein 2g, Potassium 256mg, Sodium 225 mg Authors’ Note:  Whole wheat pastry flour used was Bob’s Red Mill Editor’s Note: This recipe is appropriate for a low-cholesterol, low saturated fat, vegan dietary regimen. It also provides a good source of fiber.

Creative Cooking for the Health-Conscious Gourmet FibonacciRECIPES  | Culinary Medicine   by Mary B Grosvenor, MS, RD  and Lori A. Smolin, PhD   Ring in a healthier new year or toast another celebration with this pretty, flavorful, bubbly drink that skips the alcohol. Add sugared cranberries for a stunning vibrant red garnish.  Ingredients For sugared cranberries: ½ cup water 1 cup white sugar ½ cup fresh cranberries For mock champagne: 6 oz apple juice, chilled 12 oz sparkling water Instructions Prepare sugared cranberries  (best to prepare a day ahead) Combine water with ½ cup of sugar in a small saucepan.  Warm on medium heat stirring until the mixture starts to simmer and the sugar is dissolved. Remove from heat and let cool slightly. Stir in the fresh cranberries and let set for 5 minutes. Remove the cranberries and place in a single layer on cooling rack over parchment paper.  Air dry for at least 20 minutes. They should be tacky but not wet. Pour the remaining ½ cup sugar onto a plate and spoon on the cranberries a few at a time, rotating until coated .  Remove sugared cranberries and place on a lined baking sheet. Dry for at least 30 minutes.  They can be stored at room temperature in a sealed container for 2-3 days. Prepare mock champagne: Combine apple juice and sparkling water in a pitcher. Divide between 4 glasses. Garnish with sugared cranberries.  Makes 4 (4.5 oz) servings Nutrition information per serving Calories 35, Total Fat 0 g, Saturated Fat 0g, Cholesterol 0mg, Total Carbohydrate 9g, Dietary fiber 0.3g, Protein 0.1g, Potassium 50mg, Sodium 10mg You might be interested in reading " Dry January and Beyond" by Mary B Grosvenor, MS, RD  and   Lori A Smolin, PhD   Mary Recommends As an Amazon Associate FibonacciMD earns from qualifying purchases. Looking to extend Dry January—or go alcohol-free all year? The Art of Mixology Mocktails  recipe book delivers creative, alcohol-free drinks—from sparkling mocktails to fruit-forward blends—perfect for Dry January and beyond. [ https://amzn.to/4qiyaim ] Mocktail Party : 75 Plant-Based, Non-Alcoholic Mocktail Recipes for Every Occasion by Diana Licalzi, Kerry Benson, et al. [ https://amzn.to/455j7jF ] Mocktail Hour : 70 Sips for Anytime Delights and Hangover-Free Nights by Callie Gullickson [ https://amzn.to/4pEWrhw ]

Creative Cooking for the Health-Conscious Gourmet FibonacciRECIPES  | Culinary Medicine   by Mary B Grosvenor, MS, RD   Waldorf salad is classic American dish. It originated at the end of the 19 th  century as a signature dish served at the Waldorf Hotel in New York City. The original relied on apples, celery and mayonnaise but it has been updated many times. This version replaces the mayonnaise with walnut oil thus reducing the amount of saturated fat in the dish. It is a great winter salad because it does not rely on summer greens, but rather uses fruits, vegetables and nuts that are available in the winter. The crunch of apples, celery and walnuts gives way to the sweet of the cranberries with the tang of the vinegar-based dressing.  Ingredients 2 large red apples ½ cup celery, diced ½ cup roughly chopped walnuts ¼ cup dried cranberries 2 scallions 2 tsp walnut oil 1/4 tsp black pepper ½ tsp salt 2 tsp apple cider vinegar 1 tsp honey 1 Tbsp lime juice Instructions Toast walnuts in a fry pan on medium heat for about 3 minutes until they darken slightly, remove from pan and let cool. Dice the apples, with skins.  Combine the apples, celery, dried cranberries and walnuts and mix. Cut the green part of the scallions into thin rings. Make the dressing by combining the scallions, vinegar, walnut oil, honey, lime juice, salt, and pepper. Pour the dressing over the salad and stir. Serve immediately or refrigerate covered until service.  Makes 5 one-half cup servings Nutrition information per serving Calories 160, Total Fat 9g, Saturated Fat 0.9g, Cholesterol 0 mg, Total Carbohydrate 18g, Dietary fiber 3.4g, Protein 2g, Potassium 190mg, Sodium 240mg Author’s Note Refrigerating this salad for 2 to 4 hours before service allows the flavors to blend. Editor’s Note This recipe is appropriate for a low saturated fat, low cholesterol, and low carbohydrate  dietary regimen.  And it is a good source of fiber. Mary Recommends: As an Amazon Associate FibonacciMD earns from qualifying purchases. This versatile Large Glass Salad Bowl Set  features a 5.7 L decorative bowl  and a multipurpose wood lid , providing the perfect all-in-one solution for thoroughly mixing  your Waldorf salad and creating an elegant table presentation . [ https://amzn.to/45z49CN ]

A healthy, vegan version of traditional Bierocks. Recipe made with plant-based ground beef and fresh cabbage—a quick, 130-calorie meal perfect for low-cholesterol diets. Creative Cooking for the Health-Conscious Gourmet FibonacciRECIPES  | Culinary Medicine   by Mary B Grosvenor, MS, RD and Lori A. Smolin, PhD   Traditional bierocks are dough pockets stuffed with seasoned ground beef, onions, and cabbage. This version uses a plant-based beef substitute to create a vegan version of this traditional Eastern European food. Using a premade frozen dough makes this a quick and easy meal or snack.  Ingredients 12 frozen dinner roll dough balls 2 tsp olive oil 1 cup diced onion ½ tsp salt ½ tsp black pepper ½ tsp apple cider vinegar ¼ tsp smoked paprika 1 cup Gardein™ Plant-Based Ground Be'f  (or other plant-based beef alternative) 2 cups shredded green cabbage Instructions Prepare the dough – start about 30 minutes before the rest of the recipe  Spray cookie sheet with cooking spray Place frozen roll dough balls on the sprayed cookie sheet. Spray a sheet of plastic wrap with cooking spray and place it over the dough balls. Let thaw in a warm spot for 30 minutes to an hour. Once the dough is softened, flatten the balls on a lightly floured surface. Then stretch each to form a circle about 5 inches in diameter. Return to cookie sheet and cover.  Prepare the filling Preheat the oven to 350 degrees. Sauté diced onion in olive oil until translucent, about 5 minutes. Add salt, pepper, vinegar, and smoked paprika and continue to sauté for another 1 to 2 minutes. Add beef alternative and continue to cook over low heat for another 5 minutes. Stir in shredded cabbage and cook covered for 2 minutes. Remove lid and simmer uncovered on low heat for another 5 minutes until cabbage is soft Remove from heat and let cool to room temperature.  As they may have shrunk, stretch each dough circle again to 5 inches. Spoon 2-3 Tbsp of filling onto the center of the dough circle, fold in half and crimp edges to seal.  Place crimped rolls back on cookie sheet and bake for 18 to 20 minutes. Remove from oven and cool on rack for a few minutes before serving. Any bierocks that are not consumed within 1-2 hours can be refrigerated for 3 days or frozen for 3 months. Makes 12 bierocks Nutrition facts   per bierocks Calories 130, Total Fat 2.8g, Saturated Fat 0g, Cholesterol 0mg,  Total Carbohydrate 20g, Dietary fiber 2.2g, Protein 5g, Potassium 166mg,  Sodium 375mg Notes You can also use bread dough (frozen or homemade) for this recipe using about 1 ounce of dough per bierock. Pillsbury Grands! Southern Homestyle Biscuits also work well and do not require thawing. But they may contain milk so are not vegan. If using Impossible or Beyond beef alternatives, you may need to thaw the “meat” first, crumble it into the pan and increase the cooking time to 7 to 10 minutes. Editor’s note:  This recipe is appropriate for a low cholesterol, low saturated fat, vegan dietary regimen. It is a relatively low fat and low carb recipe with some fiber contribution (close to the accepted standards).  Mary Recommends As an Amazon Associate FibonacciMD earns from qualifying purchases. Pick up the Gardein Ultimate Plant-Based Ground Be'f  on Amazon to use as the perfect protein-packed filling for our savory new Vegan Bierocks recipe! [ https://amzn.to/4bZKNKO ]

Explore the bizarre and true history of the tobacco smoke enema, an 18th-century resuscitation technique that paved the way for modern CPR and inspired a famous foul-mouthed idiom. by Stuart M. Caplen, MD     John Woodall’s Enema Fumosum (Smoke Enema) In 1585, Sir Walter Raleigh reportedly first brought tobacco from Virginia to England and colonial tobacco later grew to become a booming export business.  Native Americans used tobacco as medicine and are thought to have been the first practitioners of tobacco smoke enemas.  Word of this treatment eventually made its way from the American colonies to England.  The first described use of the procedure for medical treatment occurred in the 1600s, by John Woodall (1570-1643), in his book The Surgeon’s Mate .  Woodall was the first Surgeon-General of the East India Company.  Tobacco was known to be a stimulant and irritant, and warm tobacco smoke was thought to be useful for various medicinal purposes. The Institution In 1745, physician Richard Mead is credited as the first person to write about using tobacco smoke enemas for resuscitation of drowning victims.  In 1774, physicians William Hawes and Thomas Cogan founded The Institution for Affording Immediate Relief to Persons Apparently Dead, from Drowning  in London, England.  This organization later became   the  Royal Humane Society, which still exists today as a charity that grants awards for acts of bravery in saving human life and for the restoration of life by resuscitation.   The Institution initially consisted of 34 volunteers who purchased boats and equipment for rescuing drowning victims and placed resuscitation kits along the Thames River.  They also created receiving houses where drowning victims could be cared for.  Aiming to save these victims, the Institute paid a reward to anyone who rescued a recently drowned victim or immediately brought them to the Institute for resuscitation.  Paintings Commissioned by the Royal Humane Society in 1787 to Demonstrate a Successful Resuscitation from Drowning and Promote the Practice However, the leaders of The Institution were strong proponents of the resuscitative powers of tobacco smoke to restart respiration due to its warming and stimulating qualities.  Reportedly, Dr. Cogan wrote, “It is not only the admission of a kindly warmth into the internal parts of the body which in all cases must prove advantageous, but its stimulus connected with its warmth seems admirably adapted to excite irritability and to restore the suspended or languid peristaltic motion of the intestines.” How Was It Performed?  Tobacco Smoke Enema Resuscitation Kit with Bellows from 1774 In Paris, in 1746, one of the earliest recorded instances of the practice involved a woman who was a drowning victim.  She was pulled from the water unconscious.  A sailor advised her husband to light a pipe filled with tobacco and insert the stem of the pipe into his wife’s rectum.  He then covered the bowl with paper that had holes pricked into it and blew into the lit end of the pipe, forcing smoke into her colon.  She reportedly awoke after the fifth puff.  Success stories such as this one spread widely and led to more credence for the procedure.  In London, if medical assistants from The Institution were at the scene of a drowning, they would attempt to warm the victim, insert a rectal tube, and blow tobacco smoke down the tube.  This was unsafe for the rescuer because the tube lacked a check valve to prevent fluid from flowing back up, potentially transmitting deadly diseases to the  rescuer.  With time, more sophisticated tubes, nozzles, and eventually, bellows were used for tobacco smoke enemas.  Mouth-to-mouth resuscitation at the time was generally avoided due to contagion fears, but bellows were used sometimes to inflate the lungs for resuscitation in drownings.  It was thought that tobacco smoke inserted rectally was more effective for resuscitation than smoke blown into the mouth and lungs.   Use Spreads to Other Ailments Tobacco smoke enemas became a popular treatment in Europe for many conditions, including headaches, respiratory failure, colds, abdominal pain, typhoid fever, and cholera.  The Procedure Becomes Discredited, but Lives on in Popular Culture Some physicians began questioning the effectiveness of the tobacco smoke enema and its use ended around 1811.  The final blow for the procedure came when English scientist Benjamin Brodie, while performing animal experiments, discovered that the nicotine in tobacco smoke was toxic to the heart.  It is believed that after the tobacco smoke enema was discredited as a therapeutic procedure and regarded as useless, the terms “blowing smoke” or “blowing smoke up your arse (ass)” started gaining popularity as idioms meaning insincere flattery or misleading information. As an Amazon Associate FibonacciMD earns from qualifying purchases. The Philips HeartStart Home AED  is the only defibrillator available over-the-counter without a prescription, specifically designed for use by ordinary people in extraordinary moments. This Value Package  provides a comprehensive, out-of-the-box solution to ensure you are fully prepared for a cardiac emergency at home. [ https://amzn.to/4qhJPNQ ] You may enjoy reading these other FibonacciMedicine articles about other forms of popular medical quackery in the past. The History of the “Whale Cure” for Rheumatism The History of “Snake Oil” and “Snake Oil Salesmen” Benjamin Franklin, Mesmerism, and the First Use of Placebos in Science The Dancing Plague of 1518 The History of Leeches in Medicine and the Era of the “Leech Mania” This is the fascinating story behind the face used on CPR manikins. The Story of the Most “Kissed” Face in the World References Duffin CJ. John Woodall (1570-1643) of the East India Company. Topics in the History of Medicine. 2021; Volume 1: 6-24. Retrieved from: file:///C:/Users/stuar/Downloads/Duffin2021JohnWoodall1570-1643oftheEastIndiaCompany.pdf Lawrence I.  Saving lives with a puff of smoke? Science Museum. 25 April 2019. Retrieved from: https://blog.sciencemuseum.org.uk/saving-lives-with-a-puff-of-smoke/ Haynes S. Special feature: Tobacco smoke enemas. BCMJ, vol. 54, No. 10, December 2012. https://bcmj.org/special-feature/special-feature-tobacco-smoke-enemas Bamji, A. Blowing Smoke Up Your Arse: Drowning, Resuscitation, and Public Health in Eighteenth-Century Venice. Bulletin of the History of Medicine, 94 (1). pp. 29-63. 2020. Retrieved from https://pubmed.ncbi.nlm.nih.gov/32362593/ https://eprints.whiterose.ac.uk/id/eprint/149881/10/Bamji%20-%20Main%20document%20-%20Drowning%20FINAL%2BFIGURES.pdf Justin. Medical History: The Exciting True Story of Blowing Smoke Up One’s Arse. Natures Poisons. Retrieved from: https://naturespoisons.com/2014/07/29/the-exciting-history-of-blowing-smoke-up-ones-arse-tobacco-smoke-enema/ McCrary-Ruiz-Esparza E. Before Modern CPR, There Were Tobacco-Smoke Enemas. Discover. Oct 9, 2023. Retrieved from: https://www.discovermagazine.com/before-modern-cpr-there-were-tobacco-smoke-enemas-45447 Patowary K. When ‘Blowing Smoke Up Your Ass’ Was a Real Thing. Amusing Planet.  Oct 15, 2018. Retrieved from: https://www.amusingplanet.com/2018/10/when-blowing-smoke-up-your-ass-was-real.html Boulton T.  When Doctors Literally “Blew Smoke Up Your Arse”. Today I Found Out. May 19, 2014. Retrieved from: https://www.todayifoundout.com/index.php/2014/05/origin-expression-blow-smoke-ass/ Royal Humane Society. 2025. Retrieved from: https://royalhumanesociety.org.uk/about-us/the-royal-humane-society/ Images- The Wellcome Collection https://wellcomecollection.org/collections , and Science Museum Group. Retrieved from: https://collection.sciencemuseumgroup.org.uk/objects/co140739/tobacco-resuscitator-kit-england-1785