Undo The Sun’s Damage To Your Skin

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It’s often said that our skin is our largest organ. Our brain or liver are the largest solid organs by mass (which one comes out on top will vary from person to person), our gut is the longest, and our lungs are the largest by surface area. But our skin is large, noticeable, and has a big impact on the rest of our health.

The sun is one of the main damaging factors for our skin; assorted toxins are also a major threat for many people, and once the skin barrier gets broken, it’s a field-day for bacteria.

So, what can we do about it?

Tretinoin: the skin’s rejuvenator

Tretinoin is also called retinoic acid, not to be mistaken for retinol, although they are both retinoids. Tretinoin is much stronger.

As for what it’s stronger at:

It’s usually prescribed for the treatment of sun-damage, acne, and wrinkles. Paradoxically, it works by inflaming the skin (and then making it better, and having done so, keeping it better).

In few words: it encourages your skin to speed up its life cycle, which means that cells die and are replaced sooner, which means the average age of skin cells will be considerably younger at any given time.

This is the same principle as we see at work when it comes to cellular apoptosis and autophagy in general, and specifically the same idea as we discussed when talking about senolytics, compounds that kill aging cells:

Fisetin: The Anti-Aging Assassin

About that paradoxical inflammation…

❝The topical use of tretinoin as an antiacne agent began almost a half century ago. Since that time it has been successfully used to treat comedonal and inflammatory acne.

Over the intervening years, the beneficial effects of tretinoin have grown from an understanding of its potent cornedolytie-related properties to an evolving appreciation of its antiinflammatory actions.

The topical use of clindamycin and tretinoin as a combination treatment modality that includes antibacterial, comedolytic, and antiinflammatoiy properties has proven to be a very effective therapy for treating the various stages of acne

It is now becoming increasingly clear that there may be good reasons for these observations.❞

~ Drs. Schmidt & Gans, lightly edited here for brevity

Read in full: Tretinoin: A Review of Its Anti-inflammatory Properties in the Treatment of Acne

Against damage by the sun

The older we get, the more likely sun damage is a problem than acne. And in the case of tretinoin,

❝In several well-controlled clinical trials, the proportion of patients showing improvement was significantly higher with 0.01 or 0.05% tretinoin cream than with placebo for criteria such as global assessment, fine and coarse wrinkling, pigmentation and roughness.

Improvements in the overall severity of photodamage were also significantly greater with tretinoin than with placebo.

Several placebo-controlled clinical studies have demonstrated that topical tretinoin has significant efficacy in the treatment of photodamaged skin. Improvements in subjective global assessment scores were recorded in:

49–100% of patients using once-daily 0.01% tretinoin,

68–100% of patients using 0.05% tretinoin, and

0–44% of patients using placebo.❞

~ Drs. Wagstaff & Noble

…which is quite compelling.

Read in full: Tretinoin: A Review of its Pharmacological Properties and Clinical Efficacy in the Topical Treatment of Photodamaged Skin

This is very well-established by now; here’s an old paper from when the mechanism of action was unknown (here in the current day, 17 mechanisms of action have been identified; beyond the scope of this article as we only have so much room, but it’s nice to see science building on science):

❝Tretinoin cream has been used extensively to reverse the changes of photoaging. It is the first topical therapy to undergo controlled clinical testing and proved to be efficacious. These results have been substantiated with photography, histopathologie examination, and skin surface replicas.

Tretinoin cream has an excellent safety record; a local cutaneous hypervitaminosis A reaction is the only common problem.❞

~ Dr. Goldfarb et al.

Read in full: Topical tretinoin therapy: Its use in photoaged skin

Is it safe?

For most people, when used as directed*, yes. However, it’s likely to irritate your skin at first, and that’s normal. If this persists more than a few weeks, or seems unduly severe, then you might want to stop and talk to your doctor again.

*See also: Scarring following inappropriate use of 0.05% tretinoin gel

(in the case of a young woman who used it 4x daily instead of 1x daily)

Want to try some?

Tretinoin is prescription-only, so speak with your doctor/pharmacist about that. Alternatively, retinal (not retinol) is the strongest natural alternative that works on the same principles; here’s an example product on Amazon 😎

Take care!

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  • Is thunderstorm asthma becoming more common?

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    When spring arrives, so do warnings about thunderstorm asthma. But a decade ago, most of us hadn’t heard of it.

    So where did thunderstorm asthma come from? Is it a new phenomenon?

    In 2016, the world’s most catastrophic thunderstorm asthma event took Melbourne by surprise. An increase in warnings and monitoring is partly a response to this.

    But there are also signs climate change may be exacerbating the likelihood of thunderstorm asthma, with more extreme weather, extended pollen seasons and a rise in Australians reporting hay fever.

    A landmark catastrophe

    The first time many Australians heard of thunderstorm asthma was in November 2016, when a major event rocked Melbourne.

    During a late night storm, an estimated 10,000 people were rushed to hospitals with severe asthma attacks. With thousands of calls on emergency lines, ambulances and emergency departments were unprepared to handle the rapid increase in people needing urgent medical care. Tragically, ten of those people died.

    This was the most catastrophic thunderstorm asthma event in recorded history and the first time deaths have ever occurred anywhere in the world.

    In response, the Victorian Department of Health implemented initiatives, including public awareness campaigns and improvements to health and emergency services, to be ready for future thunderstorm asthma events.

    A network of pollen monitoring stations was also set up across the state to gather data that helps to predict future events.

    A problem for decades

    While this event was unexpected, it wasn’t the first time we’d had thunderstorm asthma in Australia – we’ve actually known about it for decades.

    Melbourne reported its first instance of thunderstorm asthma back in 1984, only a year after this phenomenon was first discovered in Birmingham in the United Kingdom.

    Thunderstorm asthma has since been reported in other parts of Australia, including Canberra and New South Wales. But it is still most common in Melbourne. Compared to any other city (or country) the gap is significant: over a quarter of all known events worldwide have occurred in Melbourne.

    Why Melbourne?

    Melbourne’s location makes it a hotspot for these kinds of events. Winds coming from the north of Melbourne tend to be dry and hot as they come from deserts in the centre of Australia, while winds from the south are cooler as they come from the ocean.

    When hot and cool air mix above Melbourne, it creates the perfect conditions for thunderstorms to form.

    Northern winds also blow a lot of pollen from farmlands into the city, in particular grass pollen. This is not only the most common cause of seasonal hay fever in Melbourne but also a major trigger of thunderstorm asthma.

    Why grass pollen?

    There’s a particular reason grass pollen is the main culprit behind thunderstorm asthma in Australia. During storms there is a lot of moisture in the air. Grass pollen will absorb this moisture, making it swell up like a water balloon.

    If pollen absorbs too much water whilst airborne, it can burst or “rupture,” releasing hundreds of microscopic particles into the air that can be swept by powerful winds.

    Normally, when you breathe in pollen it gets stuck in your upper airway – for example, your nose and throat. This is what causes typical hay fever symptoms such as sneezing or runny nose.

    But the microscopic particles released from ruptured grass pollen are much smaller and don’t get stuck as easily in the upper airway. Instead, they can travel deep into your airways until they reach your lungs. This may trigger more severe symptoms, such as wheezing or difficulty breathing, even in people with no prior history of asthma.

    So who is at risk?

    You might think asthma is the biggest risk factor for thunderstorm asthma. In fact, the biggest risk factor is hay fever.

    Up to 99% of patients who went to the emergency department during the Melbourne 2016 event had hay fever, while a majority (60%) had no prior diagnosis of asthma.

    Every single person hospitalised was allergic to at least one type of grass pollen. All had a sensitivity to ryegrass.

    Is thunderstorm asthma becoming more common?

    Thunderstorm asthma events are rare, with just 26 events officially recorded worldwide.

    However there is evidence these events could become more frequent and severe in coming years, due to climate change. Higher temperatures and pollution could be making plants produce more pollen and pollen seasons last much longer.

    Extreme weather events, including thunderstorms, are also expected to become more common and severe.

    In addition, there are signs rates that hay fever may be increasing. The number of Australians reporting allergy symptoms have risen from 15% in 2008 to 24% in 2022. Similar trends in other countries has been linked to climate change.

    How can I prepare?

    Here are three ways you can reduce your risk of thunderstorm asthma:

    • stock up on allergy medication and set up an asthma action plan with your GP
    • check daily pollen forecasts for the estimated pollen level and risk of a thunderstorm asthma event in your local area
    • on days with high pollen or a high risk of thunderstorm asthma, spend less time outside or wear a surgical face mask to reduce your symptoms.

    Kira Morgan Hughes, PhD Candidate in Allergy and Asthma, School of Life and Environmental Sciences, Deakin University

    This article is republished from The Conversation under a Creative Commons license. Read the original article.

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  • Ovarian cancer is hard to detect. Focusing on these 4 symptoms can help with diagnosis

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    Ovarian cancers are often found when they are already advanced and hard to treat.

    Researchers have long believed this was because women first experienced symptoms when ovarian cancer was already well-established. Symptoms can also be hard to identify as they’re vague and similar to other conditions.

    But a new study shows promising signs ovarian cancer can be detected in its early stages. The study targeted women with four specific symptoms – bloating, abdominal pain, needing to pee frequently, and feeling full quickly – and put them on a fast track to see a specialist.

    As a result, even the most aggressive forms of ovarian cancer could be detected in their early stages.

    So what did the study find? And what could it mean for detecting – and treating – ovarian cancer more quickly?

    Ground Picture/Shutterstock

    Why is ovarian cancer hard to detect early?

    Ovarian cancer cannot be detected via cervical cancer screening (which used to be called a pap smear) and pelvic exams aren’t useful as a screening test.

    Current Australian guidelines recommend women get tested for ovarian cancer if they have symptoms for more than a month. But many of the symptoms – such as tiredness, constipation and changes in menstruation – are vague and overlap with other common illnesses.

    This makes early detection a challenge. But it is crucial – a woman’s chances of surviving ovarian cancer are associated with how advanced the cancer is when she is diagnosed.

    If the cancer is still confined to the original site with no spread, the five-year survival rate is 92%. But over half of women diagnosed with ovarian cancer first present when the cancer has already metastatised, meaning it has spread to other parts of the body.

    If the cancer has spread to nearby lymph nodes, the survival rate is reduced to 72%. If the cancer has already metastasised and spread to distant sites at the time of diagnosis, the rate is only 31%.

    There are mixed findings on whether detecting ovarian cancer earlier leads to better survival rates. For example, a trial in the UK that screened more than 200,000 women failed to reduce deaths.

    That study screened the general public, rather than relying on self-reported symptoms. The new study suggests asking women to look for specific symptoms can lead to earlier diagnosis, meaning treatment can start more quickly.

    What did the new study look at?

    Between June 2015 and July 2022, the researchers recruited 2,596 women aged between 16 and 90 from 24 hospitals across the UK.

    They were asked to monitor for these four symptoms:

    • persistent abdominal distension (women often refer to this as bloating)
    • feeling full shortly after starting to eat and/or loss of appetite
    • pelvic or abdominal pain (which can feel like indigestion)
    • needing to urinate urgently or more often.

    Women who reported at least one of four symptoms persistently or frequently were put on a fast-track pathway. That means they were sent to see a gynaecologist within two weeks. The fast track pathway has been used in the UK since 2011, but is not specifically part of Australia’s guidelines.

    Some 1,741 participants were put on this fast track. First, they did a blood test that measured the cancer antigen 125 (CA125). If a woman’s CA125 level was abnormal, she was sent to do a internal vaginal ultrasound.

    What did they find?

    The study indicates this process is better at detecting ovarian cancer than general screening of people who don’t have symptoms. Some 12% of women on the fast-track pathway were diagnosed with some kind of ovarian cancer.

    A total of 6.8% of fast-tracked patients were diagnosed with high-grade serous ovarian cancer. It is the most aggressive form of cancer and responsible for 90% of ovarian cancer deaths.

    Out of those women with the most aggressive form, one in four were diagnosed when the cancer was still in its early stages. That is important because it allowed treatment of the most lethal cancer before it had spread significantly through the body.

    There were some promising signs in treating those with this aggressive form. The majority (95%) had surgery and three quarters (77%) had chemotherapy. Complete cytoreduction – meaning all of the cancer appears to have been removed – was achieved in six women out of ten (61%).

    It’s a promising sign that there may be ways to “catch” and target ovarian cancer before it is well-established in the body.

    What does this mean for detection?

    The study’s findings suggest this method of early testing and referral for the symptoms leads to earlier detection of ovarian cancer. This may also improve outcomes, although the study did not track survival rates.

    It also points to the importance of public awareness about symptoms.

    Clinicians should be able to recognise all of the ways ovarian cancer can present, including vague symptoms like general fatigue.

    But empowering members of the general public to recognise a narrower set of four symptoms can help trigger testing, detection and treatment of ovarian cancer earlier than we thought.

    This could also save GPs advising every woman who has general tiredness or constipation to undergo an ovarian cancer test, making testing and treatment more targeted and efficient.

    Many women remain unaware of the symptoms of ovarian cancer. This study shows recognising them may help early detection and treatment.

    Jenny Doust, Clinical Professorial Research Fellow, Australian Women and Girls’ Health Research Centre, The University of Queensland

    This article is republished from The Conversation under a Creative Commons license. Read the original article.

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  • Who will look after us in our final years? A pay rise alone won’t solve aged-care workforce shortages

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    Aged-care workers will receive a significant pay increase after the Fair Work Commission ruled they deserved substantial wage rises of up to 28%. The federal government has committed to the increases, but is yet to announce when they will start.

    But while wage rises for aged-care workers are welcome, this measure alone will not fix all workforce problems in the sector. The number of people over 80 is expected to triple over the next 40 years, driving an increase in the number of aged care workers needed.

    How did we get here?

    The Royal Commission into Aged Care Quality and Safety, which delivered its final report in March 2021, identified a litany of tragic failures in the regulation and delivery of aged care.

    The former Liberal government was dragged reluctantly to accept that a total revamp of the aged-care system was needed. But its weak response left the heavy lifting to the incoming Labor government.

    The current government’s response started well, with a significant injection of funding and a promising regulatory response. But it too has failed to pursue a visionary response to the problems identified by the Royal Commission.

    Action was needed on four fronts:

    • ensuring enough staff to provide care
    • building a functioning regulatory system to encourage good care and weed out bad providers
    • designing and introducing a fair payment system to distribute funds to providers and
    • implementing a financing system to pay for it all and achieve intergenerational equity.

    A government taskforce which proposed a timid response to the fourth challenge – an equitable financing system – was released at the start of last week.

    Consultation closed on a very poorly designed new regulatory regime the week before.

    But the big news came at end of the week when the Fair Work Commission handed down a further determination on what aged-care workers should be paid, confirming and going beyond a previous interim determination.

    What did the Fair Work Commission find?

    Essentially, the commission determined that work in industries with a high proportion of women workers has been traditionally undervalued in wage-setting. This had consequences for both care workers in the aged-care industry (nurses and Certificate III-qualified personal-care workers) and indirect care workers (cleaners, food services assistants).

    Aged-care staff will now get significant pay increases – 18–28% increase for personal care workers employed under the Aged Care Award, inclusive of the increase awarded in the interim decision.

    Older person holding a stabilising bar
    The commission determined aged care work was undervalued.
    Shutterstock/Toa55

    Indirect care workers were awarded a general increase of 3%. Laundry hands, cleaners and food services assistants will receive a further 3.96% on the grounds they “interact with residents significantly more regularly than other indirect care employees”.

    The final increases for registered and enrolled nurses will be determined in the next few months.

    How has the sector responded?

    There has been no push-back from employer groups or conservative politicians. This suggests the uplift is accepted as fair by all concerned.

    The interim increases of up to 15% probably facilitated this acceptance, with the recognition of the community that care workers should be paid more than fast food workers.

    There was no criticism from aged-care providers either. This is probably because they are facing difficulty in recruiting staff at current wage rates. And because government payments to providers reflect the actual cost of aged care, increased payments will automatically flow to providers.

    When the increases will flow has yet to be determined. The government is due to give its recommendations for staging implementation by mid-April.

    Is the workforce problem fixed?

    An increase in wages is necessary, but alone is not sufficient to solve workforce shortages.

    The health- and social-care workforce is predicted to grow faster than any other sector over the next decade. The “care economy” will grow from around 8% to around 15% of GDP over the next 40 years.

    This means a greater proportion of school-leavers will need to be attracted to the aged-care sector. Aged care will also need to attract and retrain workers displaced from industries in decline and attract suitably skilled migrants and refugees with appropriate language skills.

    Nursing students practise their skills
    Aged care will need to attract workers from other sectors.
    nastya_ph/Shutterstock

    The caps on university and college enrolments imposed by the previous government, coupled with weak student demand for places in key professions (such as nursing), has meant workforce shortages will continue for a few more years, despite the allure of increased wages.

    A significant increase in intakes into university and vocational education college courses preparing students for health and social care is still required. Better pay will help to increase student demand, but funding to expand place numbers will ensure there are enough qualified staff for the aged-care system of the future. The Conversation

    Stephen Duckett, Honorary Enterprise Professor, School of Population and Global Health, and Department of General Practice and Primary Care, The University of Melbourne

    This article is republished from The Conversation under a Creative Commons license. Read the original article.

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  • The Powerful Constraints on Medical Care in Catholic Hospitals Across America

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    Nurse midwife Beverly Maldonado recalls a pregnant woman arriving at Ascension Saint Agnes Hospital in Maryland after her water broke. It was weeks before the baby would have any chance of survival, and the patient’s wishes were clear, she recalled: “Why am I staying pregnant then? What’s the point?” the patient pleaded.

    But the doctors couldn’t intervene, she said. The fetus still had a heartbeat and it was a Catholic hospital, subject to the “Ethical and Religious Directives for Catholic Health Care Services” that prohibit or limit procedures like abortion that the church deems “immoral” or “intrinsically evil,” according to its interpretation of the Bible.

    “I remember asking the doctors. And they were like, ‘Well, the baby still has a heartbeat. We can’t do anything,’” said Maldonado, now working as a nurse midwife in California, who asked them: “What do you mean we can’t do anything? This baby’s not going to survive.”

    The woman was hospitalized for days before going into labor, Maldonado said, and the baby died.

    Ascension declined to comment for this article.

    The Catholic Church’s directives are often at odds with accepted medical standards, especially in areas of reproductive health, according to physicians and other medical practitioners.

    The American College of Obstetricians and Gynecologists’ clinical guidelines for managing pre-labor rupture of membranes, in which a patient’s water breaks before labor begins, state that women should be offered options, including ending the pregnancy.

    Maldonado felt her patient made her wishes clear.

    “Under the ideal medical practice, that patient should be helped to obtain an appropriate method of terminating the pregnancy,” said Christian Pettker, a professor of obstetrics, gynecology, and reproductive sciences at the Yale School of Medicine, who helped author the guidelines.

    He said, “It would be perfectly medically appropriate to do a termination of pregnancy before the cessation of cardiac activity, to avoid the health risks to the pregnant person.”

    “Patients are being turned away from necessary care,” said Jennifer Chin, an OB-GYN at UW Medicine in Seattle, because of the “emphasis on these ethical and religious directives.”

    They can be a powerful constraint on the care that patients receive at Catholic hospitals, whether emergency treatment when a woman’s health is at risk, or access to birth control and abortions.

    More and more women are running into barriers to obtaining care as Catholic health systems have aggressively acquired secular hospitals in much of the country. Four of the 10 largest U.S. hospital chains by number of beds are Catholic, according to federal data from the Agency for Healthcare Research and Quality. There are just over 600 Catholic general hospitals nationally and roughly 100 more managed by Catholic chains that place some religious limits on care, a KFF Health News investigation reveals.

    Maldonado’s experience in Maryland came just months before the Supreme Court’s ruling in 2022 to overturn Roe v. Wade, a decision that compounded the impact of Catholic health care restrictions. In its wake, roughly a third of states have banned or severely limited access to abortion, creating a one-two punch for women seeking to prevent pregnancy or to end one. Ironically, some states where Catholic hospitals dominate — such as Washington, Oregon, and Colorado — are now considered medical havens for women in nearby states that have banned abortion.

    KFF Health News analyzed state-level birth data to discover that more than half a million babies are born each year in the U.S. in Catholic-run hospitals, including those owned by CommonSpirit Health, Ascension, Trinity Health, and Providence St. Joseph Health. That’s 16% of all hospital births each year, with rates in 10 states exceeding 30%. In Washington, half of all babies are born at such hospitals, the highest share in the country.

    “We had many instances where people would have to get in their car to drive to us while they were bleeding, or patients who had had their water bags broken for up to five days or even up to a week,” said Chin, who has treated patients turned away by Catholic hospitals.

    Physicians who turned away patients like that “were going against evidence-based care and going against what they had been taught in medical school and residency,” she said, “but felt that they had to provide a certain type of care — or lack of care — just because of the strength of the ethical and religious directives.”

    Following religious mandates can be dangerous, Chin and other clinicians said.

    When a patient has chosen to end a pregnancy after the amniotic sac — or water — has broken, Pettker said, “any delay that might be added to a procedure that is inevitably going to happen places that person at risk of serious, life-threatening complications,” including sepsis and organ infection.

    Reporters analyzed American Hospital Association data as of August and used Catholic Health Association directories, news reports, government documents, and hospital websites and other materials to determine which hospitals are Catholic or part of Catholic systems, and gathered birth data from state health departments and hospital associations. They interviewed patients, medical providers, academic experts, advocacy organizations, and attorneys, and reviewed hundreds of pages of court and government records and guidance from Catholic health institutions and authorities to understand how the directives affect patient care.

    Nationally, nearly 800,000 people have only Catholic or Catholic-affiliated birth hospitals within an hour’s drive, according to KFF Health News’ analysis. For example, that’s true of 1 in 10 North Dakotans. In South Dakota, it’s 1 in 20. When care is more than an hour away, academic researchers often define the area as a hospital desert. Pregnant women who must drive farther to a delivery facility are at higher risk of harm to themselves or their fetus, research shows.

    Many Americans don’t have a choice — non-Catholic hospitals are too far to reach in an emergency or aren’t in their insurance networks. Ambulances may take patients to a Catholic facility without giving them a say. Women often don’t know that hospitals are affiliated with the Catholic Church or that they restrict reproductive care, academic research suggests.

    And, in most of the country, state laws shield at least some hospitals from lawsuits for not performing procedures they object to on religious grounds, leaving little recourse for patients who were harmed because care was withheld. Thirty-five states prevent patients from suing hospitals for not providing abortions, including 25 states where abortion remains broadly legal. About half of those laws don’t include exceptions for emergencies, ectopic pregnancies, or miscarriages. Sixteen states prohibit lawsuits against hospitals for refusing to perform sterilization procedures.

    “It’s hard for the ordinary citizen to understand, ‘Well, what difference does it make if my hospital is bought by this other big health system, as long as it stays open? That’s all I care about,’” said Erin Fuse Brown, who is the director of the Center for Law, Health & Society at Georgia State University and an expert in health care consolidation. Catholic directives also ban medical aid in dying for terminally ill patients.

    People “may not realize that they’re losing access to important services, like reproductive health [and] end-of-life care,” she said.

    ‘Our Faith-Based Health Care Ministry’

    After the Supreme Court ended the constitutional right to abortion in June 2022, Michigan resident Kalaina Sullivan wanted surgery to permanently prevent pregnancy.

    Michigan voters in November that year enshrined the right to abortion under the state constitution, but the state’s concentration of Catholic hospitals means people like Sullivan sometimes still struggle to obtain reproductive health care.

    Because her doctor worked for the Catholic chain Trinity Health, the nation’s fourth-largest hospital system, she had the surgery with a different doctor at North Ottawa Community Health System, an independent hospital near the shores of Lake Michigan.

    Less than two months later, that, too, became a Catholic hospital, newly acquired by Trinity.

    To mark the transition, Cory Mitchell, who at the time was the mission leader of Trinity Health Muskegon, stood before his new colleagues and offered a blessing.

    “The work of your hands is what makes our faith-based health care ministry possible,” he said, according to a video of the ceremony Trinity Health provided to KFF Health News. “May these hands continue to bring compassion, compassion and healing, to all those they touch.”

    Trinity Health declined to answer detailed questions about its merger with North Ottawa Community Health System and the ethical and religious directives. “Our commitment to high-quality, compassionate care means informing our patients of all appropriate care options, and trusting and supporting our physicians to make difficult and medically necessary decisions in the best interest of their patients’ health and safety,” spokesperson Jennifer Amundson said in an emailed statement. “High-quality, safe care is critical for the women in our communities and in cases where a non-critical service is not available at our facility, the physician will transfer care as appropriate.”

    Leaders in Catholic-based health systems have hammered home the importance of the church’s directives, which are issued by the U.S. Conference of Catholic Bishops, all men, and were first drafted in 1948. The essential view on abortion is as it was in 1948. The last revision, in 2018, added several directives addressing Catholic health institution acquisitions or mergers with non-Catholic ones, including that “whatever comes under control of the Catholic institution — whether by acquisition, governance, or management — must be operated in full accord with the moral teaching of the Catholic Church.”

    “While many of the faithful in the local church may not be aware of these requirements for Catholic health care, the local bishop certainly is,” wrote Sister Doris Gottemoeller, a former board member of the Bon Secours Mercy Health system, in a 2023 Catholic Health Association journal article. “In fact, the bishop should be briefed on a regular basis about the hospital’s activities and strategies.”

    Now, for care at a non-Catholic hospital, Sullivan would need to travel nearly 30 miles.

    “I don’t see why there’s any reason for me to have to follow the rules of their religion and have that be a part of what’s going on with my body,” she said.

    Risks Come With Religion

    Nathaniel Hibner, senior director of ethics at the Catholic Health Association, said the ethical and religious directives allow clinicians to provide medically necessary treatments in emergencies. In a pregnancy crisis when a person’s life is at risk, “I do not believe that the ERDs should restrict the physician in acting in the way that they see medically indicated.”

    “Catholic health care is committed to the health of all women and mothers who enter into our facilities,” Hibner said.

    The directives permit care to cure “a proportionately serious pathological condition of a pregnant woman” even if it would “result in the death of the unborn child.” Hibner demurred when asked who defines what that means and when such care is provided, saying, “for the most part, the physician and the patients are the ones that are having a conversation and dialogue with what is supposed to be medically appropriate.”

    It is common for practitioners at any hospital to consult an ethics board about difficult cases — such as whether a teenager with cancer can decline treatment. At Catholic hospitals, providers must ask a board for permission to perform procedures restricted by the religious directives, clinicians and researchers say. For example, could an abortion be performed if a pregnancy threatened the mother’s life?

    How and when an ethics consultation occurs depends on the hospital, Hibner said. “That ethics consultation can be initiated by anyone involved in the direct care of that situation — the patient, the surrogate of that patient, the physician, the nurse, the social worker all have the ability to request a consultation,” he said. When asked whether a consultation with an ethics board can occur without a request, he said “sometimes it could.”

    How strictly directives are followed can depend on the hospital and the views of the local bishop.

    “If the hospital has made a difficult decision about a critical pregnancy or an end-of-life care situation, the bishop should be the first to know about it,” Gottemoeller wrote.

    In an interview, Gottemoeller said that even when pregnancy termination decisions are made on sound ethical grounds, not informing the bishop puts him in a bad position and hurts the church. “If there’s a possibility of it being misunderstood, or misinterpreted, or criticized,” Gottemoeller said, the bishop should understand what happened and why “before the newspapers call him and ask him for an opinion.”

    “And if he has to say, ‘Well, I think you made a mistake,’ well, all right,” she said. “But don’t let him be blindsided. I mean, we’re one church and the bishop has pastoral concern over everything in his diocese.”

    Katherine Parker Bryden, a nurse midwife in Iowa who works for MercyOne, said she regularly tells pregnant patients that the hospital cannot perform tubal sterilization surgery, to prevent future pregnancies, or refer patients to other hospitals that do. MercyOne is one of the largest health systems in Iowa. Nearly half of general hospitals in the state are Catholic or Catholic-affiliated — the highest share among all states.

    The National Catholic Bioethics Center, an ethics authority for Catholic health institutions, has said that referrals for care that go against church teaching would be “immoral.”

    “As providers, you’re put in this kind of moral dilemma,” Parker Bryden said. “Am I serving my patients or am I serving the archbishop and the pope?”

    In response to questions, MercyOne spokesperson Eve Lederhouse said in an email that its providers “offer care and services that are consistent with the guidelines of a Catholic health system.”

    Maria Rodriguez, an OB-GYN professor at Oregon Health & Science University, said that as a resident in the early 2000s at a Catholic hospital she was able to secure permission — what she calls a “pope note” — to sterilize some patients with conditions such as gestational diabetes.

    Annie Iriye, a retired OB-GYN in Washington state, said that more than a decade ago she sought permission to administer medication to hasten labor for a patient experiencing a second-trimester miscarriage at a Catholic hospital. She said she was told no because the fetus had a heartbeat. The patient took 10 hours to deliver — time that would have been cut by half, Iriye said, had she been able to follow her own medical training and expertise. During that time, she said, the patient developed an infection.

    Iriye and Chin were part of an effort by reproductive rights groups and medical organizations that pushed for a state law to protect physicians if they act against Catholic hospital restrictions. The bill, which Washington enacted in 2021, was opposed by the Washington State Hospital Association, whose membership includes multiple large Catholic health systems.

    State lawmakers in Oregon in 2021 enacted legislation that beefed up powers to reject health care mergers if they would reduce access to the types of care constrained by Catholic directives. The hospital lobby has sued to block the statute. Washington state lawmakers introduced similar legislation last year, which the hospital association opposes.

    Hibner said Catholic hospitals are committed to instituting systemic changes that improve maternal and child health, including access to primary, prenatal, and postpartum care. “Those are the things that I think rural communities really need support and advocacy for,” he said.

    Maldonado, the nurse midwife, still thinks of her patient who was forced to stay pregnant with a baby who could not survive. “To feel like she was going to have to fight to have an abortion of a baby that she wanted?” Maldonado said. “It was just horrible.”

    KFF Health News data editor Holly K. Hacker contributed to this report.

    Click to open the methodology Methodology

    By Hannah Recht

    KFF Health News identified areas of the country where patients have only Catholic hospital options nearby. The “Ethical and Religious Directives for Catholic Health Care Services” — which are issued by the U.S. Conference of Catholic Bishops, all men — dictate how patients receive reproductive care at Catholic health facilities. In our analysis, we focused on hospitals where babies are born.

    We constructed a national database of hospital locations, identified which ones are Catholic or Catholic-affiliated, found how many babies are born at each, and calculated how many people live near those hospitals.

    Hospital Universe

    We identified hospitals in the 50 states and the District of Columbia using the American Hospital Association database from August 2023. We removed hospitals that had closed or were listed more than once, added hospitals that were not included, and corrected inaccurate or out-of-date information about ownership, primary service type, and location. We excluded federal hospitals, such as military and Indian Health Service facilities, because they are not open to everyone.

    Catholic Affiliation

    To identify Catholic hospitals, we used the Catholic Health Association’s member directory. We also counted as Catholic a handful of hospitals that are not part of this voluntary membership group but explicitly follow the Ethical and Religious Directives, according to their mission statements, websites, or promotional materials.

    We also tracked Catholic-affiliated hospitals: those that are owned or managed by a Catholic health system, such as CommonSpirit Health or Trinity Health, and are influenced by the religious directives but do not necessarily adhere to them in full. To identify Catholic-affiliated hospitals, we consulted health system and hospital websites, government documents, and news reports.

    We combined both Catholic and Catholic-affiliated hospitals for analysis, in line with previous research about the influence of Catholic directives on health care.

    Births

    To determine the share of births that occur at Catholic or Catholic-affiliated hospitals, we gathered the latest annual number of births by hospital from state health departments. Where recent data was not publicly available, we submitted records requests for the most recent complete year available.

    The resulting data covered births in 2022 for nine states and D.C., births in 2021 for 23 states, births in 2020 for nine states, and births in 2019 for one state. We used data from the 2021 American Hospital Association survey, the latest available at the time of analysis, for the eight remaining states that did not provide birth data in response to our requests. A small number of hospitals have recently opened or closed labor and delivery units. The vast majority of the rest record about the same number of births each year. This means that the results would not be substantially different if data from 2023 were available.

    We used this data to calculate the number of babies born in Catholic and Catholic-affiliated hospitals, as well as non-Catholic hospitals by state and nationally.

    We used hospitals’ Catholic status as of August 2023 in this analysis. In 10 cases where the hospital had already closed, we used Catholic status at the time of the closure.

    Because our analysis focuses on hospital care, we excluded births that occurred in non-hospital settings, such as homes and stand-alone birth centers, as well as federal hospitals.

    Several states suppressed data from hospitals with fewer than 10 births due to privacy restrictions. Because those numbers were so low, this suppression had a negligible effect on state-level totals.

    Drive-Time Analysis

    We obtained hospitals’ geographic coordinates based on addresses in the AHA dataset using HERE’s geocoder. For addresses that could not be automatically geocoded with a high degree of certainty, we verified coordinates manually using hospital websites and Google Maps.

    We calculated the areas within 30, 60, and 90 minutes of travel time from each birth hospital that was open in August 2023 using tools from HERE. We included only hospitals that had 10 or more births as a proxy for hospitals that have labor and delivery units, or where births regularly occur.

    The analysis focused on the areas with hospitals within an hour’s drive. Researchers often define hospital deserts as places where one would have to drive an hour or more for hospital care. (For example: [1] “Disparities in Access to Trauma Care in the United States: A Population-Based Analysis,” [2] “Injury-Based Geographic Access to Trauma Centers,” [3] “Trends in the Geospatial Distribution of Inpatient Adult Surgical Services Across the United States,” [4] “Access to Trauma Centers in the United States.”)

    We combined the drive-time areas to see which areas of the United States have only Catholic or Catholic-affiliated birth hospitals nearby, both Catholic and non-Catholic, non-Catholic only, or none. We then joined these areas to the 2021 census block group shapefile from IPUMS NHGIS and removed water bodies using the U.S. Geological Survey’s National Hydrography Dataset to calculate the percentage of each census block group that falls within each hospital access category. We calculated the number of people in each area using the 2021 “American Community Survey” block group population totals. For example, if half of a block group’s land area had access to only Catholic or Catholic-affiliated hospitals, then half of the population was counted in that category.

    KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

    Subscribe to KFF Health News’ free Morning Briefing.

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  • How To Clean Your Brain (Glymphatic Health Primer)

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    That’s not a typo! The name “glymphatic system” was coined by the Danish neuroscientist Dr. Maiken Nedergaard, and is a nod to its use of glial cells to do a similar job to that of the peripheral lymphatic system—but this time, in the CNS. Today, we have Dr. Jin Sung to tell us more:

    Brainwashing (but not like that)

    The glymphatic system may sound like a boring job, but so does “sanitation worker” in a city—yet the city would grind to a messy halt very very quickly without them. Same goes for your brain.

    Diseases that are prevalent when this doesn’t happen the way it should include Alzheimer’s (beta-amyloid clearance) and Parkinson’s (alpha-synuclein clearance) amongst others.

    Things Dr. Sung recommends for optimal glymphatic function include: sleep (7–9 hours), exercise (30–45 minutes daily), hydration (half your bodyweight in pounds, in ounces, so if your body weighs 150 lbs, that means 75 oz of water), good posture (including the use of good ergonomics, e.g. computer monitor at right height, car seat correct, etc), stress reduction (reduces inflammatory cytokines), getting enough omega-3 (the brain needs certain fats to work properly, and this is the one most likely to see a deficit), vagal stimulation (methods include humming, gargling, and gagging—please note we said vagal stimulation; easy to misread at a glance!), LED light therapy, and fasting (intermittent or prolonged).

    For more on each of these, including specific tips, enjoy:

    Click Here If The Embedded Video Doesn’t Load Automatically!

    Want to learn more?

    You might also like to read:

    Take care!

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  • Train For The Event Of Your Life!

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    Mobility As A Sporting Pursuit

    As we get older, it becomes increasingly important to treat life like a sporting event. By this we mean:

    As an “athlete of life”, there are always events coming up for which we need to train. Many of these events will be surprise tests!

    Such events/tests might include:

    • Not slipping in the shower and breaking a hip (or worse)
    • Reaching an item from a high shelf without tearing a ligament
    • Getting out of the car at an awkward angle without popping a vertebra
    • Climbing stairs without passing out light-headed at the top
    • Descending stairs without making it a sled-ride-without-a-sled

    …and many more.

    Train for these athletic events now

    Not necessarily this very second; we appreciate you finishing reading first. But, now generally in your life, not after the first time you fail such a test; it can (and if we’re not attentive: will) indeed happen to us all.

    With regard to falling, you might like to revisit our…

    Fall Special

    …which covers how to not fall, and to not injure yourself if you do.

    You’ll also want to be able to keep control of your legs (without them buckling) all the way between standing and being on the ground.

    Slav squats or sitting squats (same exercise, different names, amongst others) are great for building and maintaining this kind of strength and suppleness:

    (Click here for a refresher if you haven’t recently seen Zuzka’s excellent video explaining how to do this, especially if it’s initially difficult for you, “The Most Anti-Aging Exercise”)

    this exercise is, by the way, great for pretty much everything below the waist!

    You will also want to do resistance exercises to keep your body robust:

    Resistance Is Useful! (Especially As We Get Older)

    And as for those shoulders? If it is convenient for you to go swimming, then backstroke is awesome for increasing and maintaining shoulder mobility (and strength).

    If swimming isn’t a viable option for you, then doing the same motion with your arms, while standing, will build the same flexibility. If you do it while holding a small weight (even just 1kg is fine, but feel free to increase if you so wish and safely can) in each hand will build the necessary strength as you go too.

    As for why even just 1kg is fine: read on

    About that “and strength”, by the way…

    Stretching is not everything. Stretching is great, but mobility without strength (in that joint!) is just asking for dislocation.

    You don’t have to be built like the Terminator, but you do need to have the structural integrity to move your body and then a little bit more weight than that (or else any extra physical work could be enough to tip you to breaking point) without incurring damage from the strain. So, it needs to not be a strain! See again, the aforementioned resistance exercises.

    That said, even very gentle exercise helps too; see for example the impact of walking on osteoporosis:

    Living near green spaces linked to higher bone density and lower osteoporosis risk

    and…

    Walking vs Osteoporosis

    So you don’t have to run marathons—although you can if you want:

    Marathons in Mid- and Later-Life

    …to keep your hips and more in good order.

    Want to test yourself now?

    Check out:

    Building & Maintaining Mobility

    Take care!

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