Tattoo care and removal; too much sitting; dialysis and hospice: Upstate Medical University's HealthLink on Air for Sunday, Dec. 17, 2023

Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," a dermatologist discusses how to take care of your tattoo.

Ramsay Farah, MD: ... When the skin is kind of in that fragile, healing state, you need to consider it a wound and treat it like a wound, which for the skin would mean covering it up, keeping it moist, et cetera. ...

Host Amber Smith: An exercise physiologist shares research linking excessive sitting to dementia.

Carol Sames, PhD: ... For people who sat more than 10 hours a day, their risk of developing dementia within the next seven years was 8% higher than if they sat fewer than 10 hours. So somehow 10 hours was a cutoff point where you saw a strong association. ...

Host Amber Smith: And we'll hear about dialysis at the end of life.

All that, and a visit from The Healing Muse. But first, the news.

This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith. On this week's show, we'll learn how long periods of sitting are linked to dementia. Then we'll look at what the end of life may be like for someone on kidney dialysis. But first, taking care of tattoos and what to consider if you want one removed.

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

A tattoo is art that some people use to assert their personal style, but it's also a bit of a medical procedure. The tattoo artist inserts ink beneath the skin using a needle.

Today, I'll talk with a doctor who specializes in skin care about what's important to consider about tattoos. Dr. Ramsay Farah is chief of dermatology at Upstate.

Welcome back to "HealthLink on Air," Dr. Farah.

Ramsay Farah, MD: Thank you. It's nice to be here.

Host Amber Smith: For the person who's thinking about getting a tattoo, let's talk about some of the things they need to decide beforehand. Are there areas of the skin on the body that ought to be avoided, either for medical or practical reasons?

Ramsay Farah, MD: I wouldn't say that physiologically there's a particular area of skin that needs to be avoided. I think all areas of skin can probably take receiving the tattoo ink. it's just that in terms of removal, if that ever becomes an issue in the future, there are certain areas that are more tricky to remove, or, I should say, certain areas that are less responsive to removal of tattoos.

And basically, the farther away you go from the heart and the less drainage there is of blood supply and lymphatic supply, the harder it is to get the tattoo to go away, even with laser therapy.

So, in particular, I would say around the feet or the ankles. I should say I've never really removed tattoos from the palms and soles, but I imagine, as I'm discussing with respect to the ankles, it would be difficult to remove it from that area.

Host Amber Smith: Are there pros and cons of getting a tattoo in a fleshy area versus a spot where the skin is thinner?

Ramsay Farah, MD: Again, I'm not a tattoo artist, so I can't comment on the pros and cons of inserting the tattoo pigment in those areas.

Off the top of my head, I would say it doesn't really matter much. What I will say is if there is an area that's kind of more over bone than over a fatty area, I think it would probably hurt more to get the tattoo in those areas, just like it would hurt more to remove the tattoos in those areas.

Host Amber Smith: I definitely want to talk to you more about tattoo removal, but before we get to that, in terms of getting a tattoo, people have to choose between black ink or colored ink. Does that make a difference in how hard it might be to remove later on?

Ramsay Farah, MD: It does. So the red ink is very hard to remove.

Paradoxically, the black ink, even though it's the darkest ink, is actually the easiest to remove. So I would say red ink is among the most difficult, and then, other shades of color become also more difficult to remove than black. So for example, blue and yellow and so forth. Those are harder to remove than the black, but probably easier to remove than the red.

The other issue with the red is that the chemicals that make up the red color tend to make for more allergies for people. So sometimes, if you get a lot of red ink and you're allergic to it, you can wind up getting an allergy in the areas of the red ink, even without removing the tattoo. So just generally speaking, allergic reactions, whether it's the red ink or other inks, is something to consider.

Host Amber Smith: Now, will the shape or the size of the tattoo change as a person's body changes over time?

Ramsay Farah, MD: I would say yes. And to the degree that there are changes in the skin surface area, either by weight gain or weight loss, or even sun damage and loss of elasticity, all of those will, of course, affect the way that the tattoo looks like.

So, I mean, if you imagine that the skin is like a parchment, and when you get the tattoo, the skin is young and the parchment is nice and tight and clean and all of that stuff, the tattoo is going to look far different than if the parchment has been aged for 30 years per se.

And so the outlines of the tattoo may become less distinct. The vibrancy of the colors may become less distinct. If you wind up getting sun damage and pigmentation from the sun and all of those changes associated with sun exposure, that overlay on top of the tattoo, again, that can change the way the tattoo looks. I would say that it's mostly about the vibrancy, and it's mostly about the sort of the division between tattooed skin and non-tattooed skin, the sharpness of the lines and of the artistic work. That potentially can change quite a bit over the years.

Host Amber Smith: Is it safe for people with rosacea or acne or eczema to get tattoos?

Ramsay Farah, MD: They can. I mean, if you're talking about them getting a tattoo on the face, I think their face would almost certainly be more reactive, but people with rosacea, I don't think it's going to matter much if they get a tattoo on their arms.

So if we're talking about the face, then yes, I think there would be quite a bit more reaction and potentially more problems in that area, but not if it's at distant sites from the activity of the rosacea.

Host Amber Smith: You talked a little about the allergic reaction possibility. Are there other risks associated with tattoos, and how often do you hear about people that have bad outcomes?

Ramsay Farah, MD: So I would say that the worst outcome, so to speak, it tends to be related to people not liking the tattoo once it's on their skin, for various reasons. Maybe it wasn't quite what they expected, or they didn't review in detail with the artist exactly what was going to be part of the artistic tattoo, the endeavor.

And so they're kind of surprised because they say, "Oh, that's not really what I had in mind." That's far more common, I would say, in all honesty, than some of the physiologic problems I see. I would say that I see allergies, I wouldn't say commonly, but I see them, and that manifests kind of as bumps within the area of the tattoo.

You know, whenever you do anything on the skin that's somewhat invasive, and I would say the application of tattoo ink through a needle would constitute an invasive procedure, there's always the risk of hypertrophic scarring, or forming a scar, as a result of that trauma. I wouldn't say that I see that often, but potentially that can occur.

And then, of course, you have to consider that you're inserting something into the skin. So you want to make sure that the place where you're getting this procedure follows sterile or near-sterile technique, that there's no contamination of the instruments, there's as little chance of possible of getting a bloodborne disease like hepatitis through cross-contamination of equipment and things like that.

So I would say there's the allergy issue, there's the scar issue, and there's the infectious disease issue as the things to consider physiologically. And then just make sure you review with the tattoo artist exactly what's going on your skin and where, so you're not taken by surprise when it happens.

Host Amber Smith: Tattoo artists send people home with a dressing covering a new tattoo. What's the purpose of covering that?

Ramsay Farah, MD: It's probably because they would consider the area that is just recently tattooed to sort of be a fresh wound, right? Because the skin has been compromised through the needle to get the tattoo ink. There's a lot of physiology going on with wound healing and inflammation and so forth. And when the skin is kind of in that fragile, healing state, you need to consider it a wound and treat it like a wound, which for the skin would mean covering it up, keeping it moist, et cetera, until that inflammatory phase of the healing is over, and the skin is less fragile, and then therefore can be exposed to the environment, without any risk of infection or harm.

Host Amber Smith: So the skin may be sort of reddish or feel warm or itchy afterward, and that might be normal?

Ramsay Farah, MD: Yeah, sure. It could be, again, from the trauma of the needle insertion and then all of the inflammation that ensues afterwards. It can cause it to be a little tender, a little bit red, possibly a little bit warm. Sure, all of that's possible.

Host Amber Smith: Are there any ointments to use or anything to avoid with a new tattoo?

Ramsay Farah, MD: I would probably use very bland ointments, things that have very little chance of making people allergic. So Vaseline or Aquaphor, these are kind of moisturizing ointments. I would probably stay away from things like oils, and especially like nut-based oils or even aloe vera, because all of those materials, while they can in certain settings be soothing, that's true, but many people can also be allergic and sensitive to them. So I would use something that's less likely to cause that, just plain old Vaseline, Aquaphor, something very bland, but something that can moisturize.

Host Amber Smith: Now, once a tattoo is no longer new, what kinds of care do people need to follow, going forward?

Is there anything they can do to keep their tattoo from fading or drying out?

Ramsay Farah, MD: I would say, and this is not necessarily from a specific source that I'm getting, I'm just kind of speaking off the top of my head, the more you take care of your skin in that area, and the more you keep your skin physiologically normal, so using sunscreens, using moisturizers, not letting your skin get too dry, those kinds of general measures that you would follow for general skin health, I think would probably contribute to keeping your tattoo as vibrant as possible for as long as possible.

I must say, people, when they come to me for their tattoos, they kind of want them off, so I'm usually not engaged in a discussion about how you can lengthen the longevity of your tattoo.

On the contrary, they come to me and say, "I want this off. What can I do?" So that's more my area of expertise. But I think it's, probably correct to say that the more you keep your skin healthy, with all of what that entails, the more likely that your tattoo is going to remain kind of as young looking as possible.

Host Amber Smith: So what's involved? If someone regrets their tattoo, and they want it removed, how can that be done?

Ramsay Farah, MD: One could probably find various methods that have been described on the internet, but I would kind of stay away from all of them. I think the laser tattoo removal is probably the safest method and the method that has the most scientific study behind it.

I've seen lots of scarring and some pretty bad aftereffects of some very bizarre kind of home remedies that have been recommended. So I would definitely stick with the laser tattoo removal as the preferred method of treatment. And what I would say to people is, you should find a physician who does this, who's familiar with lasers and has done laser tattoo removal and get a consult, because, probably the reality, process, of getting your tattoo taken off is different than what people think. They may think, "Oh, I'll just go in a couple of times, get the tattoos zapped, and it'll be gone, and my skin will be completely normal after that."

And unfortunately, that's not the case.

I mean, there's a lot to consider, and it's a pretty long process, to be honest. It's not one or two treatments.

Host Amber Smith: Does it matter if it's a recent tattoo or if it's a tattoo from decades ago? Are they equally challenging to remove?

Ramsay Farah, MD: So that's a good question, and I'm not sure we have a great answer for that.

The thinking used to be that if the tattoo is very old, that means over the years the body has tried to kind of degrade the tattoo and sort of break up the tattoo, and therefore the tattoo would be easier to remove with lasers. More recently, there's been a suggestion that actually if it's a very fresh tattoo, and the ink hasn't sort of gotten a chance to settle in as much into the skin, that that might be easier.

So I don't know exactly what the right answer is. I guess what I would say from my experience that they're equally challenging. they will both take a large number of treatments, over many, many months. So I don't know what the answer is, but I think they're both hard on a practical level.

Host Amber Smith: Does it cost more to remove a tattoo than it probably did to get it in the first place?

Ramsay Farah, MD: I would say, as a general rule, yes. To be honest with you, I don't know what the going rates are for getting a tattoo. And the going rates for removal of a tattoo can also vary from practice to practice, the type of laser that is offered in the practice. So, I can't give you a definite answer. I can just kind of give you a general gestalt (overview).

I think it's going to cost more to remove the tattoo than to get it, if, for nothing else, the number of treatments that are required to remove the tattoo, whereas getting a tattoo is basically one and done.

Host Amber Smith: Upstate's "HealthLink on Air" has to take a short break, but we'll be back shortly with more about tattoo care from Dr. Ramsay Farah.

Welcome back to "HealthLink on Air." This is your host, Amber Smith, talking with Upstate's chief of dermatology, Dr. Ramsay Farah, about tattoo care.

So once it's removed, and I understand it may be more than one visit to get it removed, will there be any sort of, like, a ghostly image of it left on the body, or will it be invisible?

Ramsay Farah, MD: That depends a lot on the tattoo, the colors, the location, and to a certain extent, the technique used. And so the answer is there are really, I would say, three possibilities of what can happen when you start the process of tattoo removal.

The first possibility is that the best you can do is just fade the tattoo, such that people will look at it, it will look very faded, but they can still make out that a tattoo was there. I don't think that happens very often to be honest with you, but it is possible. So that's one possibility.

The other possibility is that the tattoo can be almost completely gone, but some tattoo pigment remains in the skin, maybe it's even sort of caught in a little microscopic scar that could develop as the process continues. And so, what that means is that the tattoo, the area of the tattoo, might look, like, a little smudgy or even a little dirty. People might look at that area and say, "Hmm, what is that? Is that like a birthmark? I can't tell what that is, but there's something on the skin." So that's another possibility.

And then the third possibility is that the tattoo is completely removed and the skin looks completely normal, and that's obviously the home run, and that's what we aim to get.

And then there is a fourth possibility. The fourth possibility is that the tattoo is completely removed, but in the process of removing it and all of that physiology that takes effect after the tattoo is zapped with the laser and the healing and the number of treatments that are done, you can leave microscopic scarring in the skin, which you can't see with the naked eye, other than it looks a little white. And that is called ghosting. So basically you remove the tattoo, but you leave a whitish outline of the tattoo, and that is also a possibility.

Now, that tends to be more common in darker-skinned individuals, so someone like from a Mediterranean or Southern European background, it's more likely to occur in that setting than someone who's of Northern European descent and has very, very white skin. Now, if that happens, that ghosting happens, there are some lasers you can use to try and blend that in somewhat, although it may not be perfect.

So you can have a fading, you can have a smudging, you can have a ghosting, or you can have it gone completely with no residual whatsoever.

Host Amber Smith: Well, if it goes as planned, and the skin returns to normal, does the hair grow back? Does it return to like what it used to be before the tattoo?

Ramsay Farah, MD: Yes. I mean, if all goes well, then it would go back to what it was before the tattoo. The hair should grow back again because the depths of the penetration and so forth of the laser may not quite be where the hair follicle is to get rid of the hair. There's always a little bit of a chance of that, by the way. But generally, alopecia, or hair loss, is not much of an issue, and most people don't necessarily have tattoos in hair-bearing areas, unless women choose to tattoo their eyebrows. But even in that setting, even though the hair growth may be slowed, the hair generally does come back. So it's not really a hair-removal procedure.

Host Amber Smith: Well, if you remove a tattoo from someone's body, and then they decide they want to get a new one, would they be recommended to get it in the same place, or would you tell them to avoid that area?

Ramsay Farah, MD: Generally, I tell them to avoid the area. So even though visually it looks like it's perfectly normal, right, if all goes well in that fourth scenario, I think if you biopsy the skin and look at it under the microscope, you're going to see some changes in the structure of the skin. There's just too much energy kind of zapped into the skin and too much inflammation over and over and over again to remove a tattoo, in my opinion, to make the skin there completely normal.

So, as a general rule, I would tell them to maybe avoid that area.

But I do sometimes have people come and say, "You know, remove this part of the tattoo. Don't remove the whole thing, just this part that I don't like. And then I'm going to have another tattoo kind of done over it." So they come and ask me to remove it as much as possible, so then they can camouflage the area they didn't like with yet another tattoo.

And people do that, and I haven't heard from them that something terrible has happened with that strategy, but it's just that the more you traumatize the skin, the less the skin is likely to remain completely normal.

Host Amber Smith: I guess some people put a tattoo to kind of camouflage a mole. Does the mole change colors; does it accept the ink? Or does it stay as a mole?

Ramsay Farah, MD: It kind of depends what the tattoo artist does. If they ink around the mole, then the mole won't necessarily change color.

If they put ink over the mole and deposit the ink even above some of the mole cells, then potentially it could change color and could kind of look weird and be sort of a diagnostic challenge for the physician looking at it. What is that? That's an unusual morphology (form), an unusual color. So it makes ambiguity enter into an arena that is already ambiguous enough.

I mean, mole checks are hard enough on their own, without having to add these other factors to complicate it.

Host Amber Smith: Well, as tattoos seem to be getting more popular with people, and some people have many, many tattoos covering a lot of their body, if they had a tattoo over a mole or other skin blemishes, how would you be able to, or would you be able to, do a skin cancer screening if they're covered?

Ramsay Farah, MD: Yeah, so that's a very good question. And actually there have been some studies that have shown that moles in the area of tattoos can be sufficiently camouflaged that sometimes if they turn malignant, it's more difficult to recognize them.

So that is true, and what I do when someone comes in for a skin exam and they've got a tattoo, a large one, I turn my light on, I turn my magnifiers on, and I look very, very carefully within the tattoo to see if I can identify a mole. And then if I can, I use my dermatoscope, which is a device that can make me see even more.

So I'm very careful when examining skin that has been tattooed, for that reason. Now, the other question I think that you asked is: Can you remove a tattoo if there's a mole there? And the answer is yes, but do we know exactly what all of that energy does to the mole that's there?

I mean, I don't know that anyone knows for sure. I haven't really seen any studies that would suggest that the lasers will make a mole turn into cancer. and I don't think that that's probably true. The question is whether there was a mole there that would have turned to cancer anyway happens to be in an area of a tattoo. That's a more difficult question and a more difficult mole to identify.

The other thing I'll comment is, if people come in with a -- I'll call it like a bathing-trunk tattoo, something really large, like over their chest or their entire arm, I wouldn't be able to remove that in one sitting because, again, there's a lot of biology that's activated with these treatments. There's a lot of inflammation, and people can actually wind up feeling sick if I do way too much of a surface area.

So for someone with a very large tattoo, I kind of do it piecemeal. I do a certain section at one sitting and another section at another sitting. But I wouldn't do the whole thing because they can actually get systemic effects of feeling joint pains and muscle aches, and almost like they have a flu or a virus.

Host Amber Smith: That's very interesting to know. Dr. Farah, I thank you so much for making time for this interview.

Ramsay Farah, MD: My pleasure. Thanks for asking me to speak.

Host Amber Smith: My guest has been Dr. Ramsay Farah. He's the chief of dermatology at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."

Host Amber Smith: No matter how much you exercise, if you sit all day at work, that's sedentary behavior. Next on Upstate's "HealthLink on Air."

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

People who sit for long hours at work and at home have a greater risk of developing dementia than people who don't sit for long hours. That's according to recent research published in the Journal of the American Medical Association, and it's in line with other recent research that is focused on the dangers of sitting.

Here with me to help us understand what this may mean is Dr. Carol Sames. She's an exercise physiologist at Upstate, where she teaches students in physical therapy and in physician assistant studies. Welcome back to "HealthLink on Air," Dr. Sames.

Carol Sames, PhD: Thanks so much, Amber. Glad to be here.

Host Amber Smith: Now, this study sounds a little bit alarming, but I don't want to overreact. Have you had a chance to look this over?

Carol Sames, PhD: Yes, and actually it's in line with a lot of research that is now starting to come out in an attempt to look at the association between sedentary lifestyle and later-life onset of dementia.

Host Amber Smith: And so the authors are from credible institutions, and they worked with good quality data?

Carol Sames, PhD: Yeah. The authors here were from UCLA, University of Arizona and University of Grenoble in France. And they were basically looking at the United Kingdom Biobank, and this is a data set that's been going on for a long period of time. They started following people and, essentially, seeing what happens to them as they get older.

And so they took a subset of that data, and it was about 49,000 adults. And these adults were all over the age of 60 years old. And they did not have a diagnosis of dementia. They were living in England, Scotland or Wales. And they had been wearing what we call an accelerometer, which is just an activity monitor on their wrist. And they had had that on their wrist 24 hours a day for a seven-day span.

So, in terms of sample size, very robust. And the accelerometer data is better quality, it's more accurate and reliable than, say, giving me a questionnaire and asking me how much activity do I do, because we know that people tend to exaggerate what they're doing, and by wearing this accelerometer, it pretty much doesn't lie.

Host Amber Smith: So did the researchers show a strong association between sedentary behavior and increased risk of dementia?

Carol Sames, PhD: It was interesting what they found. They actually found this nonlinear association, so up to 9.5 to 10 hours of sedentary time in a day. They actually didn't find an association between sedentary behavior anddementia. But, at 10 hours and greater, there was a very strong relationship. In fact, the risk greatly increased for the development of dementia. For people who sat more than 10 hours a day, their risk of developing dementia within the next seven years was 8% higher than if they sat fewer than 10 hours. So somehow 10 hours was a cutoff point where you saw a strong association.

Host Amber Smith: Was there also an association between physical activity and lower rates of dementia? Did they look at it that way, too?

Carol Sames, PhD: So interestingly, what they did is, when they were looking at the data, they controlled for physical activity. So, they didn't want that to be a variable that could impact the results, so they controlled for it. However, when they looked back on the data, they found that even in individuals who were active, if they sat more than 10 hours a day, they had an increased risk of dementia. So to say that physical activity was protective, they could not make that claim if people were sitting more than 10 hours a day.

So it wasn't protective. If I got up and walked this morning, and then I've decided that I'm going to sit for the next 11 hours, it didn't end up adding any benefit.

Host Amber Smith: That's really interesting. Was there anything besides activity level that may have accounted for the lower or higher rates of dementia in the people they studied?

Carol Sames, PhD: Right now the whole concept of trying to determine cause of dementia ... this study was looking at an association, so it's not causal. So we really don't know the exact mechanisms. Clearly, when we are active, from a physical activity standpoint, we get increased blood flow. To be able to say precisely what is going on when we are inactive for 10 hours or more in a day, it's difficult to be able to say, what are the exact mechanisms? And so that's really where the research needs to go. We also know from a physical activity standpoint that physical activity reduces inflammation and insulin resistance. And that in turn can lead, with higher levels of inflammation and insulin resistance, we have an increased risk of cardiovascular disease and Type 2 diabetes and obesity. So, there is an interplay there, but I think the take-home message here is, by being active, I'm not protected if I sit for long periods of time in a day, so 10 hours or more, and this was cumulative time, so this wasn't one bout of 10 hours or more. This was waking hours, 10 hours of accumulated sedentary time.

Host Amber Smith: This is Upstate's "HealthLink on Air" with your host, Amber Smith. I'm talking with Dr. Carol Sames. She's an exercise physiologist at Upstate, and she teaches students in physical therapy and in physician assistant studies.

Let's talk about how activity or the lack of activity in the human body may influence dementia risk. When we're active and our hearts are pumping and blood is flowing more quickly through our body, how does that affect the development of dementia? Do we know?

Carol Sames, PhD: The exact mechanism is not quite known. However, we have enough research to send us in the right direction. So we know that individuals who are more active, they have less inflammation, they have less insulin resistance. And so that's beneficial.

We also know that physical activity is associated with some changes in the brain areas. One is the hippocampus, and that's important for memory formation and learning. That's a tertiary way of looking at how activity can be helpful for brain. We also know that physical activity increases this factor called brain-derived neutrotrophic factor, and that is responsible for formation of neurons. And neurons are our brain cells. So, we have an idea of what physical activity can do. But to make that jump from physical activity to dementia, we have sedentary time kind of influencing that interaction.

Host Amber Smith: So, what is most important to know about what sitting all day does to our body in general and our dementia risk in particular?

Carol Sames, PhD: Well, clearly, the way we were put together and designed, we're not supposed to sit for long periods of time in terms of an accumulation of sedentary time.

So I think really that the take-home message here is that we need to be active. We need to move around. It doesn't necessarily mean that it has to be vigorous activity, but that we cannot sit for long periods of time. And, maybe if we're not sure, we might want to start tracking our sitting behavior. Sometimes we might get caught up in, if we're working, we're sitting in meetings for periods of time, and 10 hours sounds like it's a lot. But maybe when we start to record that, we realize that maybe it's not as much as we think, or we get engaged in some TV binge-watching, and the next thing you know, five hours has gone by.

So I think really the bottom line is that we need to be moving more and trying, maybe, strategies such as when I'm on the phone, I'm walking around. Is that possible? Can I have a walking meeting, if I'm working? Can I do things that incorporate movement into, maybe, activities that were more sedentary? If I want to listen to a podcast, maybe I should, if I can, take a walk or walk around my home. So try to reduce that cumulative sedentary time.

Host Amber Smith: Well, a lot of people are faithful with working out every day, morning or evening, but then they have jobs where they do have to pretty much sit all day, or that's what they are doing. Short of being able to find more active careers -- I mean, you're talking about walking when you're on the phone and -- are there other things like standing desks? Does it matter if you're, like, standing in front of the computer versus sitting? And are there different ways of sitting that might be less bad for you?

Carol Sames, PhD: So standing desks can be very helpful. But when you stand ... the cutoff in terms of level of moderate activity, standing is a little bit below moderate activity. And nobody has really looked at standing without any associated movement. Like, there isn't any strong research on that. But certainly, standing at least will require a little bit more blood flow than sitting.

Some people I know that sit will sit on a stability ball, one of those round balls that kind of require you to stabilize. So instead of just sitting in, say, my LazyBoy rocker-recliner, which I don't have to really do much, sitting on a stability ball is going to require me to have some movement, but again, it's not hitting that threshold for moderate activity. So I think we don't really know how protective that is.

We're going to see in the next couple of years a lot of research, because this whole idea that sedentary behavior is a separate risk than physical activity is somewhat troubling because we've always said we need to exercise, we need to engage in physical activity, but we're seeing that that is not as protective as we thought, if we end up sitting for long periods of time in the day.

Host Amber Smith: Well, here's another thing that surprises me. You're calling my behavior, actually, sedentary. I would never think of myself as sedentary. But if I sit all day for work, by definition of this study, at least, I mean, I've got sedentary behavior. And so do many office workers. So, what's the takeaway for us?

Carol Sames, PhD: I think the takeaway for us is really that we need to try to engage in more activity, less sitting time while we're awake. And it is a different mindset because I know personally I've always felt that I'm hitting the guidelines, I'm exercising, I'm good. And from the standpoint of all the benefits associated with activity -- and there are many -- we're getting those.

But in terms of dementia risk, maybe not. So maybe that changes the way I think about when I'm not at work. What am I doing at home? Am I trying to be engaged with a little bit more activity? Maybe my idea of working and sitting for eight hours and then coming home and binge-watching something for four hours, once in a while could be good, but maybe I don't want to make that a daily pattern.

Host Amber Smith: Well, this has been very enlightening. I appreciate your time, Dr. Sames.

Carol Sames, PhD: Thank you very much.

Host Amber Smith: My guest has been exercise physiologist Carol Sames, who teaches physician assistant and physical therapist students at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."

Next on Upstate's "HealthLink on Air," a look at hospice and dialysis.

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

Today we'll be talking about people with end-stage kidney disease and when and how they may go into hospice care. My guest, Dr. Ayorinde Soipe, agreed to talk about a study he led recently that examined these trends in the United States.

Welcome to "HealthLink on Air," Dr. Soipe.

Ayorinde Soipe, MD: Thank you, Amber. It's a pleasure to be here today.

Host Amber Smith: I understand you accessed the United States Renal Data System database for this work, and that contains data for 3.4 million patients. How did you choose the 800,000 whose data was used for this study?

Ayorinde Soipe, MD: So the, United States Renal Data System, called USRDS for short, has clinical and demographic information for patients with kidney failure and who are on chronic dialysis across the United States.

The database was initially created in 1989. And as at the time when we did our study, the database contained 3.4 million patients with kidney failure across the U.S. who are on dialysis. So to arrive at our analytic sample of 800,000 patients. What we did was that we utilized a statistical software called SAS to identify patients who had died between the years 2012 and 2019.

The reason why we chose 2012 was because earlier on in the year, in the 2000s, some studies had been done in this field, but despite the changes in the landscape of hospital utilization across the U.S., there was no updates. There was no recent studies that had updated those findings, so we decided to use 2012 as a cutoff.

And then we also used 2019 as the other cutoff just because the data from USRDS for 2020 upwards was still being prepared, so we focused our analysis between 2012 and 2019, and we came around to the 800,000 patients for the study.

Host Amber Smith: So of the patients in your study, how many had a history of hospice enrollment?

Ayorinde Soipe, MD: What our studies showed was that approximately 218,000 patients, which was 27% of our analytic sample, had the history of hospice enrollment.

Host Amber Smith: We should probably describe what hospice enrollment is for listeners.

Ayorinde Soipe, MD: Yeah, for sure. So hospice is the type of care that emphasizes comfort and quality of life among patients with advanced illnesses.

So it's not uncommon for us to see patients who have very serious illnesses to be referred to experts that are called palliative care experts, whereby the coordination of the patient's care can be aligned with the patient's goals of being comfortable when they eventually decide to go into hospice. So hospice helps these patients to have a more comfortable end of life.

Host Amber Smith: Now, can these patients be on dialysis when they're in hospice? And I should ask you to please describe what dialysis is.

Ayorinde Soipe, MD: Dialysis, by definition, is an intervention, is a kind of treatment, whereby excess water and toxins in the blood are being removed by passing the blood through a machine -- this is the dialysis machine -- and then returning the blood back to the patients.

So this is done for patients whose kidneys have failed and who cannot perform these functions naturally anymore. By extension, any patient who has now reached this stage of being dialysis dependent are said to have reached end-stage renal disease. Current policies by the CMS, the Centers for Medicare and Medicaid Services, is that patients who have a primary diagnosis of end-stage renal disease and who choose hospice would not be able to get dialysis.

So that's the policy. So it's like you have make a choice if you want to go into hospice,you have to forego dialysis. So patients who are in hospice currently, based on CMS policies, cannot at the same time be getting dialysis. But I need to mention that there are some efforts currently being trialed, being explored, by CMS to try and break this barrier.

So there are efforts underway, but those are not policies yet.

Host Amber Smith: So let me ask you, if someone with end-stage renal disease suddenly stops taking dialysis, I guess I'm wondering, I know that dialysis is essential, but is it comforting as well? Will they be in pain without it?

Ayorinde Soipe, MD: Absolutely.

Patients who have become dialysis-dependent, who need dialysis to survive just because their kidneys have failed. They're not able to clean their blood. They're not able to get rid of the excess water in their blood. Eventually, all these things kind of accumulate in them, especially the toxins and the fluid.

So they become what we call fluid overloaded, meaning that they have too much water in them, and then this fluid overload leads to them having challenges with breathing. So they become short of breath, they can't breathe, and eventually this can lead to a lot of discomfort. So patients who are receiving dialysis definitely benefit more by the dialysis helping them clean their blood, and also getting rid of the excess water in their system, compared to somebody who's not receiving dialysis, which can be a little bit uncomfortable.

Host Amber Smith: So maybe the policies need to keep up with this, it sounds like.

Ayorinde Soipe, MD: Certainly, for sure, especially if we're talking about patients who are seriously ill, who are dialysis dependent, we need to be able to let them have a choice If they want to go into hospice, and they want to keep doing dialysis, mainly because hospice's role is to make them comfortable, to have good quality of life. If they have to forgo that modality that gives them some comfort, then we are not really doing the best for them, in that sense.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking to Dr. Ayorinde Soipe, an internal medicine resident at Upstate.

Now in your study, how many of the people died on dialysis and how many died in hospice when they were not on dialysis?

Ayorinde Soipe, MD: Our study used the database, as we said, the United States Renal Data System, which is a database that contains information for patients across the U.S. who are on dialysis.

So by definition, any patient who is in that database needs to be on dialysis. Then for our own study, what we did was then to now identify those who died between 2012 and 2019. So that now narrowed down our sample size to 800,000 patients. So now, talking about those who discontinue dialysis, without going to hospice, among our analysis, what we showed was that approximately 66,000 patients who died between 2012 and 2019, this was about 8% of our sample size, did not actually go into hospice even after stopping dialysis. So this is a unique subset of patients that our study was the very first to actually elucidate, was the first to show that every year from 2012 to 2019, there's a specific proportion of patients who stop dialysis but still do not go into hospice.

So what could be responsible for this trend? There needs to be some other factors playing in the background that's keeping these patients from going to hospice, even after stopping dialysis. This is something that is worthy of looking into.

Host Amber Smith: So do you have any theories for what some of those things might be that would prevent them from entering hospice?

Ayorinde Soipe, MD: Historically, the major barrier that has been identified as what is causing people from using hospice is the CMS policies. But as I said, even when patients stop dialysis, they still don't go into hospice. So there have to be other factors in the background that's keeping them. This could be just a theory: It could be maybe secondary to lack of knowledge among providers on the benefits that hospice will give to these patients. Or it could be secondary to some cultural or demographic barriers that need to be explored more, that need more efforts to try and ameliorate. So for sure, this is an area that needs to be further explored so that we can really identify what's keeping those subsets of patients from going to hospice even when they stop dialysis.

Host Amber Smith: Can I ask you to compare what death is like for someone with end-stage renal disease if they are enrolled in hospice versus if they're not?

Ayorinde Soipe, MD: The main goal of hospice is to make the patient comfortable at the end of life. And when patients are in hospice, they are able to receive different kind of modalities of treatment that will make them comfortable, to make their breathing comfortable, to make their pain comfortable. When the patient who's on not on dialysis is dying, it could be secondary to a lot of toxins building up in their blood. It could be secondary to a lot of water building up in that system whereby they can't breathe very well anymore. If they don't receive hospice treatments, the dying process might be a little bit more uncomfortable compared to somebody who's in hospice, who receives other modalities to help them with their breathing, to help them with their pain.

And going further, if somebody is now in hospice and is able to even get dialysis when in hospice, this even helps better because what that will do is that you'll be able to manage their symptoms. You'll be able to help them breathe even more by giving them some form of comfort in terms of dialysis. So the dying process in a patient who is in hospice, compared to a patient who's not in hospice, is definitely different. Hospice helps our patients be comfortable, meet their goals of care, so that they can enjoy a little bit more at the end of life.

Host Amber Smith: Well, Dr. Soipe, I appreciate you making time for this interview and telling us about your research.

Ayorinde Soipe, MD: Thank you so much, Amber. It's been a pleasure to be here today.

Host Amber Smith: My guest has been Upstate internal medicine resident Dr. Ayorinde Soipe. I'm Amber Smith for Upstate's "HealthLink on Air."

And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.

Deirdre Neilen, PhD: Gloria Heffernan recently published "Exploring Poetry of Presence." The poem she sent us, "Call Button," praises the work of hospital nurses.

"Call Button"

She is matter-of-fact

as she carries the bed pan

to the toilet, empties it,

peels off the latex gloves,

fixes my sheet.

Please don't apologize, she says,

Young enough to be my daughter.

Attentive to details I can't begin to discern.

Solving problems I don't even know I have.

And then on to her other eleven patients --

to their bedpans and IVs,

stained sheets and unasked questions.

Some cogent enough to say thank you,

others already retreating into silence.

The woman two doors down

howls long into the night,

Help me.

And so she does.

Again and again,

until the woman wears herself out

and falls asleep.

At 3:00 am the nurse wakes me again

to check my vitals.

Sorry to bother you, she says,

Please don't apologize, I reply.

She records my numbers,

pats my arm and says good-night.

Two doors down,

the woman moans again.

Help me.

The nurse hears the call and goes,

Her footsteps rhythmic

as a beating heart.

Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York.

Next week on "HealthLink on Air," all about low back pain and the neuromodulators that may offer relief.

If you missed any of today's show, or for more information on a variety of health, science and medical topics, visit our website at healthlinkonair.org.

Upstate's "HealthLink on Air" is produced by Jim Howe, with sound engineering by Bill Broeckel.

This is your host, Amber Smith, thanking you for listening.