CHEST Physician

While Kellie Lease Stecher, MD, was working as an ob.gyn. in Minneapolis, Minnesota, a patient confided in her a sexual assault allegation about one of Stecher’s male colleagues. Stecher shared the allegation with her supervisor, who told Stecher not to file a report and chose not to address the issue with the patient. Stecher weighed how to do the right thing: Should she speak up? What were the ethical and legal implications of speaking up vs staying silent?

After seeking advice from her mentors, Stecher felt it was her moral and legal duty to report the allegation to the Minnesota Medical Board. Once she did, her supervisor chastised her repeatedly for reporting the allegation. Stecher soon found herself in a hostile work environment where she was regularly singled out and silenced by her supervisor and colleagues.

“I got to a point where I felt like I couldn’t say anything at any meetings without somehow being targeted after the meeting. There was an individual who was even allowed to fat-shame me with no consequences,” Stecher said. “[Being bullied at work is] a struggle because you have no voice, you have no opportunities, and there’s someone who is intentionally making your life uncomfortable.”

Stecher’s experience is not unusual. Mistreatment is a common issue among healthcare workers, ranging from rudeness to bullying and harassment and permeating every level and specialty of the medical profession. A 2019 research review estimated that 26.3% of healthcare workers had experienced bullying and found bullying in healthcare to be associated with mental health problems such as burnout and depression, physical health problems such as insomnia and headaches, and physicians taking more sick leave.

The Medscape Physician Workplace Culture Report 2024 found similarly bleak results:

• 38% said workplace culture is declining.
• 70% don’t see a big commitment from employers for positive culture.
• 48% said staff isn’t committed to positive culture.

Toxicity’s ripple effects contribute to several issues in healthcare, including staffing shortages, physician attrition, inadequate leadership, and even suicide rates.

The irony, of course, is that most physicians enter the field to care for people. As individuals go from medical school to residency and on with the rest of their careers, they often experience a rude awakening.
 

It’s Everywhere

Noticing the prevalence of workplace bullying in the medical field, endocrinologist Farah Khan, MD, at UW Medicine in Seattle, Washington, decided to conduct a survey on the issue.

Khan collected 122 responses from colleagues, friends, and acquaintances in the field. When asked if they had ever been bullied in medicine, 68% of respondents said yes. But here’s the fascinating part: She tried to pinpoint one particular area or source of toxicity in the progression of a physician’s career — and couldn’t because it existed at all levels.

More than one third of respondents said their worst bullying experiences occurred in residency, while 30% said mistreatment was worst in medical school, and 24% indicated their worst experience had occurred once they became an attending.

The litany of experiences included being belittled, excluded, yelled at, criticized, shamed, unfairly blamed, threatened, sexually harassed, subjected to bigotry and slurs, and humiliated.

“What surprised me the most was how widespread this problem is and the many different layers of healthcare it permeates through, from operating room staff to medical students to hospital HR to residents and attendings,” Khan said of her findings.
 

Who Cares for the Caregivers?

When hematologist Mikkael Sekeres, MD, was in medical school, he seriously considered a career as a surgeon. Following success in his surgical rotations, he scrubbed in with a cardiothoracic surgeon who was well known for both his status as a surgeon and his fiery temper. Sekeres witnessed the surgeon yelling at whoever was nearby: Medical students, fellows, residents, operating room nurses.

“At the end of that experience, any passing thoughts I had of going into cardiothoracic surgery were gone,” Sekeres said. “Some of the people I met in surgery were truly wonderful. Some were unhappy people.”

He has clear ideas why. Mental health struggles that are all too common among physicians can be caused or exacerbated by mistreatment and can also lead a physician to mistreat others.

“People bully when they themselves are hurting,” Sekeres said. “It begs the question, why are people hurting? What’s driving them to be bullies? I think part of the reason is that they’re working really hard and they’re tired, and nobody’s caring for them. It’s hard to care for others when you feel as if you’re hurting more than they are.”

Gail Gazelle, MD, experienced something like this. In her case, the pressure to please and to be a perfect professional and mother affected how she interacted with those around her. While working as a hospice medical director and an academician and clinician at Harvard Medical School, Boston, Massachusetts, she found herself feeling exhausted and burnt out but simultaneously guilty for not doing enough at work or at home.

Guess what happened? She became irritable, lashing out at her son and not putting her best foot forward with coworkers or patients.

After trying traditional therapy and self-help through books and podcasts, Gazelle found her solution in life coaching. “I realized just how harsh I was being on myself and found ways to reverse that pattern,” she said. “I learned ways of regulating myself emotionally that I definitely didn’t learn in my training.”

Today, Gazelle works as a life coach herself, guiding physicians through common challenges of the profession — particularly bullying, which she sees often. She remembers one client, an oncologist, who was being targeted by a nurse practitioner she was training. The nurse practitioner began talking back to the oncologist, as well as gossiping and bad-mouthing her to the nurses in the practice. The nurses then began excluding the oncologist from their cafeteria table at lunchtime, which felt blatant in such a small practice.

A core component of Gazelle’s coaching strategy was helping the client reclaim her self-esteem by focusing on her strengths. She instructed the client to write down what went well that day each night rather than lying in bed ruminating. Such self-care strategies can not only help bullied physicians but also prevent some of the challenges that might cause a physician to bully or lash out at another in the first place.

Such strategies, along with the recent influx of wellness programs available in healthcare facilities, can help physicians cope with the mental health impacts of bullying and the job in general. But even life coaches like Gazelle acknowledge that they are often band-aids on the system’s deeper wounds. Bullying in healthcare is not an individual issue; at its core, it’s an institutional one.
 

Negative Hierarchies in Healthcare

When Stecher’s contract expired, she was fired by the supervisor who had been bullying her. Stecher has since filed a lawsuit, claiming sexual discrimination, defamation, and wrongful termination.

The medical field has a long history of hierarchy, and while this rigidity has softened over time, negative hierarchical dynamics are often perpetuated by leaders. Phenomena like cronyism and cliques and behaviors like petty gossip, lunchroom exclusion (which in the worst cases can mimic high school dynamics), and targeting can be at play in the healthcare workplace.

The classic examples, Stecher said, can usually be spotted: “If you threaten the status quo or offer different ideas, you are seen as a threat. Cronyism ... strict hierarchies ... people who elevate individuals in their social arena into leadership positions. Physicians don’t get the leadership training that they really need; they are often just dumped into roles with no previous experience because they’re someone’s golfing buddy.”

The question is how to get workplace culture momentum moving in a positive direction. When Gazelle’s clients are hesitant to voice concerns, she emphasizes doing so can and should benefit leadership, as well as patients and the wider healthcare system.

“The win-win is that you have a healthy culture of respect and dignity and civility rather than the opposite,” she said. “The leader will actually have more staff retention, which everybody’s concerned about, given the shortage of healthcare workers.”

And that’s a key incentive that may not be discussed as much: Talent drain from toxicity. The Medscape Workplace Culture Report asked about culture as it applies to physicians looking to join up. Notably, 93% of doctors say culture is important when mulling a job offer, 70% said culture is equal to money, and 18% ranked it as more important than money, and 46% say a positive atmosphere is the top priority.

Ultimately, it comes down to who is willing to step in and stand up. Respondents to Khan’s survey counted anonymous reporting systems, more supportive administration teams, and zero-tolerance policies as potential remedies. Gazelle, Sekeres, and Stecher all emphasize the need for zero-tolerance policies for bullying and mistreatment.

“We can’t afford to have things going on like this that just destroy the fabric of the healthcare endeavor,” Gazelle said. “They come out sideways eventually. They come out in terms of poor patient care because there are greater errors. There’s a lack of respect for patients. There’s anger and irritability and so much spillover. We have to have zero-tolerance policies from the top down.”

A version of this article appeared on Medscape.com.

While Kellie Lease Stecher, MD, was working as an ob.gyn. in Minneapolis, Minnesota, a patient confided in her a sexual assault allegation about one of Stecher’s male colleagues. Stecher shared the allegation with her supervisor, who told Stecher not to file a report and chose not to address the issue with the patient. Stecher weighed how to do the right thing: Should she speak up? What were the ethical and legal implications of speaking up vs staying silent?

After seeking advice from her mentors, Stecher felt it was her moral and legal duty to report the allegation to the Minnesota Medical Board. Once she did, her supervisor chastised her repeatedly for reporting the allegation. Stecher soon found herself in a hostile work environment where she was regularly singled out and silenced by her supervisor and colleagues.

“I got to a point where I felt like I couldn’t say anything at any meetings without somehow being targeted after the meeting. There was an individual who was even allowed to fat-shame me with no consequences,” Stecher said. “[Being bullied at work is] a struggle because you have no voice, you have no opportunities, and there’s someone who is intentionally making your life uncomfortable.”

Stecher’s experience is not unusual. Mistreatment is a common issue among healthcare workers, ranging from rudeness to bullying and harassment and permeating every level and specialty of the medical profession. A 2019 research review estimated that 26.3% of healthcare workers had experienced bullying and found bullying in healthcare to be associated with mental health problems such as burnout and depression, physical health problems such as insomnia and headaches, and physicians taking more sick leave.

The Medscape Physician Workplace Culture Report 2024 found similarly bleak results:

• 38% said workplace culture is declining.
• 70% don’t see a big commitment from employers for positive culture.
• 48% said staff isn’t committed to positive culture.

Toxicity’s ripple effects contribute to several issues in healthcare, including staffing shortages, physician attrition, inadequate leadership, and even suicide rates.

The irony, of course, is that most physicians enter the field to care for people. As individuals go from medical school to residency and on with the rest of their careers, they often experience a rude awakening.
 

It’s Everywhere

Noticing the prevalence of workplace bullying in the medical field, endocrinologist Farah Khan, MD, at UW Medicine in Seattle, Washington, decided to conduct a survey on the issue.

Khan collected 122 responses from colleagues, friends, and acquaintances in the field. When asked if they had ever been bullied in medicine, 68% of respondents said yes. But here’s the fascinating part: She tried to pinpoint one particular area or source of toxicity in the progression of a physician’s career — and couldn’t because it existed at all levels.

More than one third of respondents said their worst bullying experiences occurred in residency, while 30% said mistreatment was worst in medical school, and 24% indicated their worst experience had occurred once they became an attending.

The litany of experiences included being belittled, excluded, yelled at, criticized, shamed, unfairly blamed, threatened, sexually harassed, subjected to bigotry and slurs, and humiliated.

“What surprised me the most was how widespread this problem is and the many different layers of healthcare it permeates through, from operating room staff to medical students to hospital HR to residents and attendings,” Khan said of her findings.
 

Who Cares for the Caregivers?

When hematologist Mikkael Sekeres, MD, was in medical school, he seriously considered a career as a surgeon. Following success in his surgical rotations, he scrubbed in with a cardiothoracic surgeon who was well known for both his status as a surgeon and his fiery temper. Sekeres witnessed the surgeon yelling at whoever was nearby: Medical students, fellows, residents, operating room nurses.

“At the end of that experience, any passing thoughts I had of going into cardiothoracic surgery were gone,” Sekeres said. “Some of the people I met in surgery were truly wonderful. Some were unhappy people.”

He has clear ideas why. Mental health struggles that are all too common among physicians can be caused or exacerbated by mistreatment and can also lead a physician to mistreat others.

“People bully when they themselves are hurting,” Sekeres said. “It begs the question, why are people hurting? What’s driving them to be bullies? I think part of the reason is that they’re working really hard and they’re tired, and nobody’s caring for them. It’s hard to care for others when you feel as if you’re hurting more than they are.”

Gail Gazelle, MD, experienced something like this. In her case, the pressure to please and to be a perfect professional and mother affected how she interacted with those around her. While working as a hospice medical director and an academician and clinician at Harvard Medical School, Boston, Massachusetts, she found herself feeling exhausted and burnt out but simultaneously guilty for not doing enough at work or at home.

Guess what happened? She became irritable, lashing out at her son and not putting her best foot forward with coworkers or patients.

After trying traditional therapy and self-help through books and podcasts, Gazelle found her solution in life coaching. “I realized just how harsh I was being on myself and found ways to reverse that pattern,” she said. “I learned ways of regulating myself emotionally that I definitely didn’t learn in my training.”

Today, Gazelle works as a life coach herself, guiding physicians through common challenges of the profession — particularly bullying, which she sees often. She remembers one client, an oncologist, who was being targeted by a nurse practitioner she was training. The nurse practitioner began talking back to the oncologist, as well as gossiping and bad-mouthing her to the nurses in the practice. The nurses then began excluding the oncologist from their cafeteria table at lunchtime, which felt blatant in such a small practice.

A core component of Gazelle’s coaching strategy was helping the client reclaim her self-esteem by focusing on her strengths. She instructed the client to write down what went well that day each night rather than lying in bed ruminating. Such self-care strategies can not only help bullied physicians but also prevent some of the challenges that might cause a physician to bully or lash out at another in the first place.

Such strategies, along with the recent influx of wellness programs available in healthcare facilities, can help physicians cope with the mental health impacts of bullying and the job in general. But even life coaches like Gazelle acknowledge that they are often band-aids on the system’s deeper wounds. Bullying in healthcare is not an individual issue; at its core, it’s an institutional one.
 

Negative Hierarchies in Healthcare

When Stecher’s contract expired, she was fired by the supervisor who had been bullying her. Stecher has since filed a lawsuit, claiming sexual discrimination, defamation, and wrongful termination.

The medical field has a long history of hierarchy, and while this rigidity has softened over time, negative hierarchical dynamics are often perpetuated by leaders. Phenomena like cronyism and cliques and behaviors like petty gossip, lunchroom exclusion (which in the worst cases can mimic high school dynamics), and targeting can be at play in the healthcare workplace.

The classic examples, Stecher said, can usually be spotted: “If you threaten the status quo or offer different ideas, you are seen as a threat. Cronyism ... strict hierarchies ... people who elevate individuals in their social arena into leadership positions. Physicians don’t get the leadership training that they really need; they are often just dumped into roles with no previous experience because they’re someone’s golfing buddy.”

The question is how to get workplace culture momentum moving in a positive direction. When Gazelle’s clients are hesitant to voice concerns, she emphasizes doing so can and should benefit leadership, as well as patients and the wider healthcare system.

“The win-win is that you have a healthy culture of respect and dignity and civility rather than the opposite,” she said. “The leader will actually have more staff retention, which everybody’s concerned about, given the shortage of healthcare workers.”

And that’s a key incentive that may not be discussed as much: Talent drain from toxicity. The Medscape Workplace Culture Report asked about culture as it applies to physicians looking to join up. Notably, 93% of doctors say culture is important when mulling a job offer, 70% said culture is equal to money, and 18% ranked it as more important than money, and 46% say a positive atmosphere is the top priority.

Ultimately, it comes down to who is willing to step in and stand up. Respondents to Khan’s survey counted anonymous reporting systems, more supportive administration teams, and zero-tolerance policies as potential remedies. Gazelle, Sekeres, and Stecher all emphasize the need for zero-tolerance policies for bullying and mistreatment.

“We can’t afford to have things going on like this that just destroy the fabric of the healthcare endeavor,” Gazelle said. “They come out sideways eventually. They come out in terms of poor patient care because there are greater errors. There’s a lack of respect for patients. There’s anger and irritability and so much spillover. We have to have zero-tolerance policies from the top down.”

A version of this article appeared on Medscape.com.

While Kellie Lease Stecher, MD, was working as an ob.gyn. in Minneapolis, Minnesota, a patient confided in her a sexual assault allegation about one of Stecher’s male colleagues. Stecher shared the allegation with her supervisor, who told Stecher not to file a report and chose not to address the issue with the patient. Stecher weighed how to do the right thing: Should she speak up? What were the ethical and legal implications of speaking up vs staying silent?

After seeking advice from her mentors, Stecher felt it was her moral and legal duty to report the allegation to the Minnesota Medical Board. Once she did, her supervisor chastised her repeatedly for reporting the allegation. Stecher soon found herself in a hostile work environment where she was regularly singled out and silenced by her supervisor and colleagues.

“I got to a point where I felt like I couldn’t say anything at any meetings without somehow being targeted after the meeting. There was an individual who was even allowed to fat-shame me with no consequences,” Stecher said. “[Being bullied at work is] a struggle because you have no voice, you have no opportunities, and there’s someone who is intentionally making your life uncomfortable.”

Stecher’s experience is not unusual. Mistreatment is a common issue among healthcare workers, ranging from rudeness to bullying and harassment and permeating every level and specialty of the medical profession. A 2019 research review estimated that 26.3% of healthcare workers had experienced bullying and found bullying in healthcare to be associated with mental health problems such as burnout and depression, physical health problems such as insomnia and headaches, and physicians taking more sick leave.

The Medscape Physician Workplace Culture Report 2024 found similarly bleak results:

• 38% said workplace culture is declining.
• 70% don’t see a big commitment from employers for positive culture.
• 48% said staff isn’t committed to positive culture.

Toxicity’s ripple effects contribute to several issues in healthcare, including staffing shortages, physician attrition, inadequate leadership, and even suicide rates.

The irony, of course, is that most physicians enter the field to care for people. As individuals go from medical school to residency and on with the rest of their careers, they often experience a rude awakening.
 

It’s Everywhere

Noticing the prevalence of workplace bullying in the medical field, endocrinologist Farah Khan, MD, at UW Medicine in Seattle, Washington, decided to conduct a survey on the issue.

Khan collected 122 responses from colleagues, friends, and acquaintances in the field. When asked if they had ever been bullied in medicine, 68% of respondents said yes. But here’s the fascinating part: She tried to pinpoint one particular area or source of toxicity in the progression of a physician’s career — and couldn’t because it existed at all levels.

More than one third of respondents said their worst bullying experiences occurred in residency, while 30% said mistreatment was worst in medical school, and 24% indicated their worst experience had occurred once they became an attending.

The litany of experiences included being belittled, excluded, yelled at, criticized, shamed, unfairly blamed, threatened, sexually harassed, subjected to bigotry and slurs, and humiliated.

“What surprised me the most was how widespread this problem is and the many different layers of healthcare it permeates through, from operating room staff to medical students to hospital HR to residents and attendings,” Khan said of her findings.
 

Who Cares for the Caregivers?

When hematologist Mikkael Sekeres, MD, was in medical school, he seriously considered a career as a surgeon. Following success in his surgical rotations, he scrubbed in with a cardiothoracic surgeon who was well known for both his status as a surgeon and his fiery temper. Sekeres witnessed the surgeon yelling at whoever was nearby: Medical students, fellows, residents, operating room nurses.

“At the end of that experience, any passing thoughts I had of going into cardiothoracic surgery were gone,” Sekeres said. “Some of the people I met in surgery were truly wonderful. Some were unhappy people.”

He has clear ideas why. Mental health struggles that are all too common among physicians can be caused or exacerbated by mistreatment and can also lead a physician to mistreat others.

“People bully when they themselves are hurting,” Sekeres said. “It begs the question, why are people hurting? What’s driving them to be bullies? I think part of the reason is that they’re working really hard and they’re tired, and nobody’s caring for them. It’s hard to care for others when you feel as if you’re hurting more than they are.”

Gail Gazelle, MD, experienced something like this. In her case, the pressure to please and to be a perfect professional and mother affected how she interacted with those around her. While working as a hospice medical director and an academician and clinician at Harvard Medical School, Boston, Massachusetts, she found herself feeling exhausted and burnt out but simultaneously guilty for not doing enough at work or at home.

Guess what happened? She became irritable, lashing out at her son and not putting her best foot forward with coworkers or patients.

After trying traditional therapy and self-help through books and podcasts, Gazelle found her solution in life coaching. “I realized just how harsh I was being on myself and found ways to reverse that pattern,” she said. “I learned ways of regulating myself emotionally that I definitely didn’t learn in my training.”

Today, Gazelle works as a life coach herself, guiding physicians through common challenges of the profession — particularly bullying, which she sees often. She remembers one client, an oncologist, who was being targeted by a nurse practitioner she was training. The nurse practitioner began talking back to the oncologist, as well as gossiping and bad-mouthing her to the nurses in the practice. The nurses then began excluding the oncologist from their cafeteria table at lunchtime, which felt blatant in such a small practice.

A core component of Gazelle’s coaching strategy was helping the client reclaim her self-esteem by focusing on her strengths. She instructed the client to write down what went well that day each night rather than lying in bed ruminating. Such self-care strategies can not only help bullied physicians but also prevent some of the challenges that might cause a physician to bully or lash out at another in the first place.

Such strategies, along with the recent influx of wellness programs available in healthcare facilities, can help physicians cope with the mental health impacts of bullying and the job in general. But even life coaches like Gazelle acknowledge that they are often band-aids on the system’s deeper wounds. Bullying in healthcare is not an individual issue; at its core, it’s an institutional one.
 

Negative Hierarchies in Healthcare

When Stecher’s contract expired, she was fired by the supervisor who had been bullying her. Stecher has since filed a lawsuit, claiming sexual discrimination, defamation, and wrongful termination.

The medical field has a long history of hierarchy, and while this rigidity has softened over time, negative hierarchical dynamics are often perpetuated by leaders. Phenomena like cronyism and cliques and behaviors like petty gossip, lunchroom exclusion (which in the worst cases can mimic high school dynamics), and targeting can be at play in the healthcare workplace.

The classic examples, Stecher said, can usually be spotted: “If you threaten the status quo or offer different ideas, you are seen as a threat. Cronyism ... strict hierarchies ... people who elevate individuals in their social arena into leadership positions. Physicians don’t get the leadership training that they really need; they are often just dumped into roles with no previous experience because they’re someone’s golfing buddy.”

The question is how to get workplace culture momentum moving in a positive direction. When Gazelle’s clients are hesitant to voice concerns, she emphasizes doing so can and should benefit leadership, as well as patients and the wider healthcare system.

“The win-win is that you have a healthy culture of respect and dignity and civility rather than the opposite,” she said. “The leader will actually have more staff retention, which everybody’s concerned about, given the shortage of healthcare workers.”

And that’s a key incentive that may not be discussed as much: Talent drain from toxicity. The Medscape Workplace Culture Report asked about culture as it applies to physicians looking to join up. Notably, 93% of doctors say culture is important when mulling a job offer, 70% said culture is equal to money, and 18% ranked it as more important than money, and 46% say a positive atmosphere is the top priority.

Ultimately, it comes down to who is willing to step in and stand up. Respondents to Khan’s survey counted anonymous reporting systems, more supportive administration teams, and zero-tolerance policies as potential remedies. Gazelle, Sekeres, and Stecher all emphasize the need for zero-tolerance policies for bullying and mistreatment.

“We can’t afford to have things going on like this that just destroy the fabric of the healthcare endeavor,” Gazelle said. “They come out sideways eventually. They come out in terms of poor patient care because there are greater errors. There’s a lack of respect for patients. There’s anger and irritability and so much spillover. We have to have zero-tolerance policies from the top down.”

A version of this article appeared on Medscape.com.

A group of nurse practitioners (NPs) employed by the state of New York has sued the state, alleging that their employer has them doing the work of physicians but underpays them.

The New York State Civil Service Commission understates the job function of NPs, overstates their dependence on physicians, and inadequately pays them for their work, according to the complaint filed in the US District Court for the Northern District of New York.

The nurses claim the mistreatment is a consequence of the fact that “at least 80% of the state’s employed NPs are women.”

Michael H. Sussman, a Goshen, New York–based attorney for the nurses, said in an interview that New York NPs are increasingly being used essentially as doctors at state-run facilities, including prisons, yet the state has failed to adequately pay them.

The lawsuit comes after a decade-long attempt by NPs to attain equitable pay and the ability to advance their civil service careers, he said.

“New York state has not addressed the heart of the issue, which is that the classification of this position is much lower than other positions in the state which are not so female-dominated and which engage in very similar activities,” Sussman said.

The lawsuit claims that “the work of NPs is complex, equaling that of a medical specialist, psychiatrist, or clinical physician.”

A spokesman for the New York State Civil Service Commission declined comment, saying the department does not comment on pending litigation.
 

Novel Gender Discrimination Argument

Gender discrimination is a relatively new argument avenue in the larger equal work, equal pay debate, said Joanne Spetz, PhD, director of the Institute for Health Policy Studies at the University of California, San Francisco.

“This is the first time I’ve heard of [such] a case being really gender discrimination focused,” she said in an interview. “On one level, I think it’s groundbreaking as a legal approach, but it’s also limited because it’s focused on public, state employees.”

Spetz noted that New York has significantly expanded NPs’ scope of practice, enacting in 2022 legislation that granted NPs full practice authority. The law means NPs can evaluate, order, diagnose, manage treatments, and prescribe medications for patients without physician supervision.

“They are in a role where they are stepping back and saying, ‘Wait, why are [we] not receiving equal pay for equal work?’ ” Spetz said. “It’s a totally fair area for debate, especially because they are now authorized to do essentially equal work with a high degree of autonomy.”
 

Debate Over Pay Grade

The nurses’ complaint centers on the New York State Civil Service Commission’s classification for NPs, which hasn’t changed since 2006. NPs are classified at grade 24, and they have no possibility of internal advancement associated with their title, according to the legal complaint filed on September 17.

To comply with a state legislative directive, the commission in 2018 conducted a study of the NP classification but recommended against reclassification or implementing a career ladder. The study noted the subordinate role of NPs to physicians and the substantial difference between physician classification (entry at grade 34) and that of NPs, psychologists (grade 25), and pharmacists (grade 25).

The study concluded that higher classified positions have higher levels of educational attainment and licensure requirements and no supervision or collaboration requirements, according to the complaint.

At the time, groups such as the Nurse Practitioner Association and the Public Employees Federation (PEF) criticized the findings, but the commission stuck to its classification.

Following the NP Modernization Act that allowed NPs to practice independently, PEF sought an increase for NPs to grade 28 with a progression to grade 34 depending on experience.

“But to this date, despite altering the starting salaries of NPs, defendants have failed and refused to alter the compensation offered to the substantial majority of NPs, and each plaintiff remains cabined in a grade 24 with a discriminatorily low salary when compared with males in other job classifications doing highly similar functions,” the lawsuit contended.

Six plaintiffs are named in the lawsuit, all of whom are women and work for state agencies. Plaintiff Rachel Burns, for instance, works as a psychiatric mental health NP in West Seneca and is responsible for performing psychiatric evaluations for patients, diagnosis, prescribing medication, ordering labs, and determining risks. The evaluations are identical for a psychiatrist and require her to complete the same forms, according to the suit.

Another plaintiff, Amber Hawthorne Lashway, works at a correctional facility in Altona, where for many years she was the sole medical provider, according to the lawsuit. Lashway’s duties, which include diagnoses and treatment of inmates’ medical conditions, mirror those performed by clinical physicians, the suit stated.

The plaintiffs are requesting the court accept jurisdiction of the matter and certify the class they seek to represent. They are also demanding prospective pay equity and compensatory damages for the distress caused by “the long-standing discriminatory” treatment by the state.

The Civil Service Commission and state of New York have not yet responded to the complaint. Their responses are due on November 12.
 

Attorney: Case Impact Limited

Benjamin McMichael, PhD, JD, said the New York case is not surprising as more states across the country are granting nurses more practice autonomy. The current landscape tends to favor the nurses, he said, with about half of states now allowing NPs full practice authority.

“I think the [New York] NPs are correct that they are underpaid,” said McMichael, an associate professor of law and director of the Interdisciplinary Legal Studies Initiative at The University of Alabama in Tuscaloosa. “With that said, the nature of the case does not clearly lend itself to national change.”

The fact that the NP plaintiffs are employed by the state means they are using a specific set of laws to advance their cause, he said. Other NPs in other employment situations may not have access to the same laws.
 

A version of this article first appeared on Medscape.com.

A group of nurse practitioners (NPs) employed by the state of New York has sued the state, alleging that their employer has them doing the work of physicians but underpays them.

The New York State Civil Service Commission understates the job function of NPs, overstates their dependence on physicians, and inadequately pays them for their work, according to the complaint filed in the US District Court for the Northern District of New York.

The nurses claim the mistreatment is a consequence of the fact that “at least 80% of the state’s employed NPs are women.”

Michael H. Sussman, a Goshen, New York–based attorney for the nurses, said in an interview that New York NPs are increasingly being used essentially as doctors at state-run facilities, including prisons, yet the state has failed to adequately pay them.

The lawsuit comes after a decade-long attempt by NPs to attain equitable pay and the ability to advance their civil service careers, he said.

“New York state has not addressed the heart of the issue, which is that the classification of this position is much lower than other positions in the state which are not so female-dominated and which engage in very similar activities,” Sussman said.

The lawsuit claims that “the work of NPs is complex, equaling that of a medical specialist, psychiatrist, or clinical physician.”

A spokesman for the New York State Civil Service Commission declined comment, saying the department does not comment on pending litigation.
 

Novel Gender Discrimination Argument

Gender discrimination is a relatively new argument avenue in the larger equal work, equal pay debate, said Joanne Spetz, PhD, director of the Institute for Health Policy Studies at the University of California, San Francisco.

“This is the first time I’ve heard of [such] a case being really gender discrimination focused,” she said in an interview. “On one level, I think it’s groundbreaking as a legal approach, but it’s also limited because it’s focused on public, state employees.”

Spetz noted that New York has significantly expanded NPs’ scope of practice, enacting in 2022 legislation that granted NPs full practice authority. The law means NPs can evaluate, order, diagnose, manage treatments, and prescribe medications for patients without physician supervision.

“They are in a role where they are stepping back and saying, ‘Wait, why are [we] not receiving equal pay for equal work?’ ” Spetz said. “It’s a totally fair area for debate, especially because they are now authorized to do essentially equal work with a high degree of autonomy.”
 

Debate Over Pay Grade

The nurses’ complaint centers on the New York State Civil Service Commission’s classification for NPs, which hasn’t changed since 2006. NPs are classified at grade 24, and they have no possibility of internal advancement associated with their title, according to the legal complaint filed on September 17.

To comply with a state legislative directive, the commission in 2018 conducted a study of the NP classification but recommended against reclassification or implementing a career ladder. The study noted the subordinate role of NPs to physicians and the substantial difference between physician classification (entry at grade 34) and that of NPs, psychologists (grade 25), and pharmacists (grade 25).

The study concluded that higher classified positions have higher levels of educational attainment and licensure requirements and no supervision or collaboration requirements, according to the complaint.

At the time, groups such as the Nurse Practitioner Association and the Public Employees Federation (PEF) criticized the findings, but the commission stuck to its classification.

Following the NP Modernization Act that allowed NPs to practice independently, PEF sought an increase for NPs to grade 28 with a progression to grade 34 depending on experience.

“But to this date, despite altering the starting salaries of NPs, defendants have failed and refused to alter the compensation offered to the substantial majority of NPs, and each plaintiff remains cabined in a grade 24 with a discriminatorily low salary when compared with males in other job classifications doing highly similar functions,” the lawsuit contended.

Six plaintiffs are named in the lawsuit, all of whom are women and work for state agencies. Plaintiff Rachel Burns, for instance, works as a psychiatric mental health NP in West Seneca and is responsible for performing psychiatric evaluations for patients, diagnosis, prescribing medication, ordering labs, and determining risks. The evaluations are identical for a psychiatrist and require her to complete the same forms, according to the suit.

Another plaintiff, Amber Hawthorne Lashway, works at a correctional facility in Altona, where for many years she was the sole medical provider, according to the lawsuit. Lashway’s duties, which include diagnoses and treatment of inmates’ medical conditions, mirror those performed by clinical physicians, the suit stated.

The plaintiffs are requesting the court accept jurisdiction of the matter and certify the class they seek to represent. They are also demanding prospective pay equity and compensatory damages for the distress caused by “the long-standing discriminatory” treatment by the state.

The Civil Service Commission and state of New York have not yet responded to the complaint. Their responses are due on November 12.
 

Attorney: Case Impact Limited

Benjamin McMichael, PhD, JD, said the New York case is not surprising as more states across the country are granting nurses more practice autonomy. The current landscape tends to favor the nurses, he said, with about half of states now allowing NPs full practice authority.

“I think the [New York] NPs are correct that they are underpaid,” said McMichael, an associate professor of law and director of the Interdisciplinary Legal Studies Initiative at The University of Alabama in Tuscaloosa. “With that said, the nature of the case does not clearly lend itself to national change.”

The fact that the NP plaintiffs are employed by the state means they are using a specific set of laws to advance their cause, he said. Other NPs in other employment situations may not have access to the same laws.
 

A version of this article first appeared on Medscape.com.

A group of nurse practitioners (NPs) employed by the state of New York has sued the state, alleging that their employer has them doing the work of physicians but underpays them.

The New York State Civil Service Commission understates the job function of NPs, overstates their dependence on physicians, and inadequately pays them for their work, according to the complaint filed in the US District Court for the Northern District of New York.

The nurses claim the mistreatment is a consequence of the fact that “at least 80% of the state’s employed NPs are women.”

Michael H. Sussman, a Goshen, New York–based attorney for the nurses, said in an interview that New York NPs are increasingly being used essentially as doctors at state-run facilities, including prisons, yet the state has failed to adequately pay them.

The lawsuit comes after a decade-long attempt by NPs to attain equitable pay and the ability to advance their civil service careers, he said.

“New York state has not addressed the heart of the issue, which is that the classification of this position is much lower than other positions in the state which are not so female-dominated and which engage in very similar activities,” Sussman said.

The lawsuit claims that “the work of NPs is complex, equaling that of a medical specialist, psychiatrist, or clinical physician.”

A spokesman for the New York State Civil Service Commission declined comment, saying the department does not comment on pending litigation.
 

Novel Gender Discrimination Argument

Gender discrimination is a relatively new argument avenue in the larger equal work, equal pay debate, said Joanne Spetz, PhD, director of the Institute for Health Policy Studies at the University of California, San Francisco.

“This is the first time I’ve heard of [such] a case being really gender discrimination focused,” she said in an interview. “On one level, I think it’s groundbreaking as a legal approach, but it’s also limited because it’s focused on public, state employees.”

Spetz noted that New York has significantly expanded NPs’ scope of practice, enacting in 2022 legislation that granted NPs full practice authority. The law means NPs can evaluate, order, diagnose, manage treatments, and prescribe medications for patients without physician supervision.

“They are in a role where they are stepping back and saying, ‘Wait, why are [we] not receiving equal pay for equal work?’ ” Spetz said. “It’s a totally fair area for debate, especially because they are now authorized to do essentially equal work with a high degree of autonomy.”
 

Debate Over Pay Grade

The nurses’ complaint centers on the New York State Civil Service Commission’s classification for NPs, which hasn’t changed since 2006. NPs are classified at grade 24, and they have no possibility of internal advancement associated with their title, according to the legal complaint filed on September 17.

To comply with a state legislative directive, the commission in 2018 conducted a study of the NP classification but recommended against reclassification or implementing a career ladder. The study noted the subordinate role of NPs to physicians and the substantial difference between physician classification (entry at grade 34) and that of NPs, psychologists (grade 25), and pharmacists (grade 25).

The study concluded that higher classified positions have higher levels of educational attainment and licensure requirements and no supervision or collaboration requirements, according to the complaint.

At the time, groups such as the Nurse Practitioner Association and the Public Employees Federation (PEF) criticized the findings, but the commission stuck to its classification.

Following the NP Modernization Act that allowed NPs to practice independently, PEF sought an increase for NPs to grade 28 with a progression to grade 34 depending on experience.

“But to this date, despite altering the starting salaries of NPs, defendants have failed and refused to alter the compensation offered to the substantial majority of NPs, and each plaintiff remains cabined in a grade 24 with a discriminatorily low salary when compared with males in other job classifications doing highly similar functions,” the lawsuit contended.

Six plaintiffs are named in the lawsuit, all of whom are women and work for state agencies. Plaintiff Rachel Burns, for instance, works as a psychiatric mental health NP in West Seneca and is responsible for performing psychiatric evaluations for patients, diagnosis, prescribing medication, ordering labs, and determining risks. The evaluations are identical for a psychiatrist and require her to complete the same forms, according to the suit.

Another plaintiff, Amber Hawthorne Lashway, works at a correctional facility in Altona, where for many years she was the sole medical provider, according to the lawsuit. Lashway’s duties, which include diagnoses and treatment of inmates’ medical conditions, mirror those performed by clinical physicians, the suit stated.

The plaintiffs are requesting the court accept jurisdiction of the matter and certify the class they seek to represent. They are also demanding prospective pay equity and compensatory damages for the distress caused by “the long-standing discriminatory” treatment by the state.

The Civil Service Commission and state of New York have not yet responded to the complaint. Their responses are due on November 12.
 

Attorney: Case Impact Limited

Benjamin McMichael, PhD, JD, said the New York case is not surprising as more states across the country are granting nurses more practice autonomy. The current landscape tends to favor the nurses, he said, with about half of states now allowing NPs full practice authority.

“I think the [New York] NPs are correct that they are underpaid,” said McMichael, an associate professor of law and director of the Interdisciplinary Legal Studies Initiative at The University of Alabama in Tuscaloosa. “With that said, the nature of the case does not clearly lend itself to national change.”

The fact that the NP plaintiffs are employed by the state means they are using a specific set of laws to advance their cause, he said. Other NPs in other employment situations may not have access to the same laws.
 

A version of this article first appeared on Medscape.com.

Over the past few years, many states have attempted to address the ongoing shortage of healthcare workers by introducing new bills to increase the scope of practice for nurse practitioners (NPs) and physician assistants (PAs). The goal of each bill was to improve access to care, particularly for patients who may live in areas where it’s difficult to find a doctor.

In response, the American Medical Association (AMA) launched a targeted campaign to fight “scope creep.” Their goal was to gain the momentum necessary to block proposed legislation to modify or expand the practice authority of nonphysicians, including PAs. A spokesperson for the organization told this news organization that the AMA “greatly values and respects the contributions of PAs as important members of the healthcare team” but emphasized that they do not have the same “skill set or breadth of experience of physicians.”

As such, the AMA argued that expanded practice authority would not only dismantle physician-led care teams but also ultimately lead to higher costs and lower-quality patient care.

The AMA has since launched a large-scale advocacy effort to fight practice expansion legislation — and has a specific page on its website to highlight those efforts. In addition, they have authored model legislation, talking points for AMA members, and a widely read article in AMA News to help them in what they call a “fight for physicians.”

These resources have also been disseminated to the greater healthcare stakeholder community.

Marilyn Suri, PA-C, chief operating officer and senior executive for Advanced Practice Professional Affairs at Vincenzo Novara MDPA and Associates, a critical care pulmonary medicine practice in Miami, Florida, said she found the AMA’s campaign to be “very misleading.”

“PAs are created in the image of physicians to help manage the physician shortage. We are trained very rigorously — to diagnose illness, develop treatment plans, and prescribe medications,” she said. “We’re not trying to expand our scope. We are trying to eliminate or lessen barriers that prevent patients from getting access to care.”

Suri is not alone. Last summer, the American Academy of Physician Associates (AAPA) requested a meeting with the AMA to find ways for the two organizations to collaborate to improve care delivery — as well as find common ground to address issues regarding patient access to care. When the AMA did not respond, the AAPA sent a second letter in September 2024, reiterating their request for a meeting.

That correspondence also included a letter, signed by more than 8000 PAs from across the country, calling for an end to what the AAPA refers to as “damaging rhetoric,” as well as data from a recent survey of PAs regarding the fallout of AMA’s scope creep messaging.

Those survey results highlighted that the vast majority of PAs surveyed feel that the AMA is doing more than just attacking proposed legislation: They believe the association is negatively influencing patients’ understanding of PA qualifications, ultimately affecting their ability to provide care.

“The campaign is unintentionally harming patients by suggesting we are doing more than what we are trained to do,” said Elisa Hock, PA-C, a behavioral health PA in Texas. “And when you work in a place with limited resources, medically speaking — including limited access to providers — this kind of campaign is really detrimental to helping patients.”

Lisa M. Gables, CEO of the AAPA, said the organization is “deeply disappointed” in the AMA’s lack of response to their letters thus far — but remains committed to working with the organization to bring forward new solutions to address healthcare’s most pressing challenges.

“AAPA remains committed to pushing for modernization of practice laws to ensure all providers can practice medicine to the fullest extent of their training, education, and experience,” she said. “That is what patients deserve and want.”

Hock agreed. She told this news organization that the public is not always aware of what PAs can offer in terms of patient care. That said, she believes newer generations of physicians understand the value of PAs and the many skills they bring to the table.

“I’ve been doing this for 17 years, and it’s been an uphill battle, at times, to educate the public about what PAs can and can’t do,” she explained. “To throw more mud in the mix that will confuse patients more about what we do doesn’t help. Healthcare works best with a team-based approach. And that team has been and always will be led by the physician. We are aware of our role and our limitations. But we also know what we can offer patients, especially in areas like El Paso, where there is a real shortage of providers.”

With a growing aging population — and the physician shortage expected to increase in the coming decade — Suri hopes that the AMA will accept AAPA’s invitation to meet — because no one wins with this kind of healthcare infighting. In fact, she said patients will suffer because of it. She hopes that future discussions and collaborations can show providers and patients what team-based healthcare can offer.

“I think it’s important for those in healthcare to be aware that none of us work alone. Even physicians collaborate with other subspecialties, as well as nurses and other healthcare professionals,” said Suri. “[Physicians and PAs] need to take a collaborative approach. We need each other. PAs are not physicians. But, just like physicians, we are considered safe and trusted care providers because of our education and training. And we can increase access to care for patients tomorrow if we start working together.”

A version of this article appeared on Medscape.com.

Over the past few years, many states have attempted to address the ongoing shortage of healthcare workers by introducing new bills to increase the scope of practice for nurse practitioners (NPs) and physician assistants (PAs). The goal of each bill was to improve access to care, particularly for patients who may live in areas where it’s difficult to find a doctor.

In response, the American Medical Association (AMA) launched a targeted campaign to fight “scope creep.” Their goal was to gain the momentum necessary to block proposed legislation to modify or expand the practice authority of nonphysicians, including PAs. A spokesperson for the organization told this news organization that the AMA “greatly values and respects the contributions of PAs as important members of the healthcare team” but emphasized that they do not have the same “skill set or breadth of experience of physicians.”

As such, the AMA argued that expanded practice authority would not only dismantle physician-led care teams but also ultimately lead to higher costs and lower-quality patient care.

The AMA has since launched a large-scale advocacy effort to fight practice expansion legislation — and has a specific page on its website to highlight those efforts. In addition, they have authored model legislation, talking points for AMA members, and a widely read article in AMA News to help them in what they call a “fight for physicians.”

These resources have also been disseminated to the greater healthcare stakeholder community.

Marilyn Suri, PA-C, chief operating officer and senior executive for Advanced Practice Professional Affairs at Vincenzo Novara MDPA and Associates, a critical care pulmonary medicine practice in Miami, Florida, said she found the AMA’s campaign to be “very misleading.”

“PAs are created in the image of physicians to help manage the physician shortage. We are trained very rigorously — to diagnose illness, develop treatment plans, and prescribe medications,” she said. “We’re not trying to expand our scope. We are trying to eliminate or lessen barriers that prevent patients from getting access to care.”

Suri is not alone. Last summer, the American Academy of Physician Associates (AAPA) requested a meeting with the AMA to find ways for the two organizations to collaborate to improve care delivery — as well as find common ground to address issues regarding patient access to care. When the AMA did not respond, the AAPA sent a second letter in September 2024, reiterating their request for a meeting.

That correspondence also included a letter, signed by more than 8000 PAs from across the country, calling for an end to what the AAPA refers to as “damaging rhetoric,” as well as data from a recent survey of PAs regarding the fallout of AMA’s scope creep messaging.

Those survey results highlighted that the vast majority of PAs surveyed feel that the AMA is doing more than just attacking proposed legislation: They believe the association is negatively influencing patients’ understanding of PA qualifications, ultimately affecting their ability to provide care.

“The campaign is unintentionally harming patients by suggesting we are doing more than what we are trained to do,” said Elisa Hock, PA-C, a behavioral health PA in Texas. “And when you work in a place with limited resources, medically speaking — including limited access to providers — this kind of campaign is really detrimental to helping patients.”

Lisa M. Gables, CEO of the AAPA, said the organization is “deeply disappointed” in the AMA’s lack of response to their letters thus far — but remains committed to working with the organization to bring forward new solutions to address healthcare’s most pressing challenges.

“AAPA remains committed to pushing for modernization of practice laws to ensure all providers can practice medicine to the fullest extent of their training, education, and experience,” she said. “That is what patients deserve and want.”

Hock agreed. She told this news organization that the public is not always aware of what PAs can offer in terms of patient care. That said, she believes newer generations of physicians understand the value of PAs and the many skills they bring to the table.

“I’ve been doing this for 17 years, and it’s been an uphill battle, at times, to educate the public about what PAs can and can’t do,” she explained. “To throw more mud in the mix that will confuse patients more about what we do doesn’t help. Healthcare works best with a team-based approach. And that team has been and always will be led by the physician. We are aware of our role and our limitations. But we also know what we can offer patients, especially in areas like El Paso, where there is a real shortage of providers.”

With a growing aging population — and the physician shortage expected to increase in the coming decade — Suri hopes that the AMA will accept AAPA’s invitation to meet — because no one wins with this kind of healthcare infighting. In fact, she said patients will suffer because of it. She hopes that future discussions and collaborations can show providers and patients what team-based healthcare can offer.

“I think it’s important for those in healthcare to be aware that none of us work alone. Even physicians collaborate with other subspecialties, as well as nurses and other healthcare professionals,” said Suri. “[Physicians and PAs] need to take a collaborative approach. We need each other. PAs are not physicians. But, just like physicians, we are considered safe and trusted care providers because of our education and training. And we can increase access to care for patients tomorrow if we start working together.”

A version of this article appeared on Medscape.com.

Over the past few years, many states have attempted to address the ongoing shortage of healthcare workers by introducing new bills to increase the scope of practice for nurse practitioners (NPs) and physician assistants (PAs). The goal of each bill was to improve access to care, particularly for patients who may live in areas where it’s difficult to find a doctor.

In response, the American Medical Association (AMA) launched a targeted campaign to fight “scope creep.” Their goal was to gain the momentum necessary to block proposed legislation to modify or expand the practice authority of nonphysicians, including PAs. A spokesperson for the organization told this news organization that the AMA “greatly values and respects the contributions of PAs as important members of the healthcare team” but emphasized that they do not have the same “skill set or breadth of experience of physicians.”

As such, the AMA argued that expanded practice authority would not only dismantle physician-led care teams but also ultimately lead to higher costs and lower-quality patient care.

The AMA has since launched a large-scale advocacy effort to fight practice expansion legislation — and has a specific page on its website to highlight those efforts. In addition, they have authored model legislation, talking points for AMA members, and a widely read article in AMA News to help them in what they call a “fight for physicians.”

These resources have also been disseminated to the greater healthcare stakeholder community.

Marilyn Suri, PA-C, chief operating officer and senior executive for Advanced Practice Professional Affairs at Vincenzo Novara MDPA and Associates, a critical care pulmonary medicine practice in Miami, Florida, said she found the AMA’s campaign to be “very misleading.”

“PAs are created in the image of physicians to help manage the physician shortage. We are trained very rigorously — to diagnose illness, develop treatment plans, and prescribe medications,” she said. “We’re not trying to expand our scope. We are trying to eliminate or lessen barriers that prevent patients from getting access to care.”

Suri is not alone. Last summer, the American Academy of Physician Associates (AAPA) requested a meeting with the AMA to find ways for the two organizations to collaborate to improve care delivery — as well as find common ground to address issues regarding patient access to care. When the AMA did not respond, the AAPA sent a second letter in September 2024, reiterating their request for a meeting.

That correspondence also included a letter, signed by more than 8000 PAs from across the country, calling for an end to what the AAPA refers to as “damaging rhetoric,” as well as data from a recent survey of PAs regarding the fallout of AMA’s scope creep messaging.

Those survey results highlighted that the vast majority of PAs surveyed feel that the AMA is doing more than just attacking proposed legislation: They believe the association is negatively influencing patients’ understanding of PA qualifications, ultimately affecting their ability to provide care.

“The campaign is unintentionally harming patients by suggesting we are doing more than what we are trained to do,” said Elisa Hock, PA-C, a behavioral health PA in Texas. “And when you work in a place with limited resources, medically speaking — including limited access to providers — this kind of campaign is really detrimental to helping patients.”

Lisa M. Gables, CEO of the AAPA, said the organization is “deeply disappointed” in the AMA’s lack of response to their letters thus far — but remains committed to working with the organization to bring forward new solutions to address healthcare’s most pressing challenges.

“AAPA remains committed to pushing for modernization of practice laws to ensure all providers can practice medicine to the fullest extent of their training, education, and experience,” she said. “That is what patients deserve and want.”

Hock agreed. She told this news organization that the public is not always aware of what PAs can offer in terms of patient care. That said, she believes newer generations of physicians understand the value of PAs and the many skills they bring to the table.

“I’ve been doing this for 17 years, and it’s been an uphill battle, at times, to educate the public about what PAs can and can’t do,” she explained. “To throw more mud in the mix that will confuse patients more about what we do doesn’t help. Healthcare works best with a team-based approach. And that team has been and always will be led by the physician. We are aware of our role and our limitations. But we also know what we can offer patients, especially in areas like El Paso, where there is a real shortage of providers.”

With a growing aging population — and the physician shortage expected to increase in the coming decade — Suri hopes that the AMA will accept AAPA’s invitation to meet — because no one wins with this kind of healthcare infighting. In fact, she said patients will suffer because of it. She hopes that future discussions and collaborations can show providers and patients what team-based healthcare can offer.

“I think it’s important for those in healthcare to be aware that none of us work alone. Even physicians collaborate with other subspecialties, as well as nurses and other healthcare professionals,” said Suri. “[Physicians and PAs] need to take a collaborative approach. We need each other. PAs are not physicians. But, just like physicians, we are considered safe and trusted care providers because of our education and training. And we can increase access to care for patients tomorrow if we start working together.”

A version of this article appeared on Medscape.com.

SAN DIEGO — Chimeric antigen receptor (CAR) T-cell therapies offer the tantalizing prospect of dramatically altering the outcome of lung cancers, but there are many hurdles to treating patients with them, according to experts.

These hurdles include finding the right targets, minimizing the risks of the treatment, and reducing the enormous burdens getting these therapies places on patients.

“Precision immunotherapy,” or unleashing the immune system in a highly specific manner, “is obviously, in a way, a holy grail” in lung cancer, said Martin Forster, MD, PhD, who cochaired a session on the topic at the World Conference on Lung Cancer (WCLC) 2024.

He underlined, however, that “immunology is very complex, as is cancer biology,” and consequently, there are different avenues being explored, including CAR T-cell therapies, T-cell receptor therapies, and tumor-infiltrating lymphocytes, among others.

Antibody technology is also being harnessed to target chemotherapy, via antibody-drug conjugates, noted Forster, who is clinical lead of the early phase clinical trials programme at University College London in England.

Moreover, investigators are looking at combining various therapies, such as immune checkpoint inhibitors with T cell–engaging approaches.

He highlighted, however, that the ideal target for these approaches is something that is recognized by the immune system as being foreign, but is found within the cancer, “and you also want it ideally to be in all of the cancer cells.”

A good example is a clonal change, meaning an early evolutionary genetic alteration in the tumor that is present in all the cells, Forster said.
 

Identifying the Right Target

“One of the big challenges in all forms of targeted immunotherapy is around selecting the target and developing the right product for the right target,” Forster emphasized.

“This concept works really well in hematological malignancies” but is “proving to be more challenging to deliver within solid malignancies,” he added.

“The reason why so many lung tumors are resistant to immunotherapy is because they ‘re immunologically cold,” Roy Herbst, MD, PhD, Department of Medical Oncology, Yale Comprehensive Cancer Center, New Haven, Connecticut, said in an interview.

“There are no T cells in the tumor,” he explained, so it “doesn’t really matter how much you block checkpoint inhibitors, you still have to have a T cell in there in order to have effect.”

To overcome this problem CAR T-cell therapies are engineered to target a tumor, Herbst continued, but that “is a little hard in lung cancer because you need to have a unique antigen that’s on a lung tumor that’s not present on normal cells.”

Charu Aggarwal, MD, MPH, Leslye M. Heisler Associate Professor for Lung Cancer Excellence, Penn Medicine, Philadelphia, Pennsylvania, agreed, saying that there is “a lot of excitement with CAR T-cell therapies, and the promise of cure,” but “the biology is not as simple as we think.”

“For example, it’s not as simple as CD20 or CD19 targeting,” she said in an interview. “Most of the antigens that are being targeted in the solid tumor world, unfortunately, are also expressed on normal tissue. So there is always this potential for toxicity.”
 

A Question of Time

Another aspect of CAR T-cell therapy that is proving difficult is its delivery.

Forster outlined that the process involves first leukapheresis, in which T cells are obtained from a blood draw. These are then genetically modified to express chimeric antigen receptors before being multiplied in the laboratory and introduced to the patient.

This process can take several weeks, during which patients may require bridging treatment, such as chemotherapy or radiotherapy, to keep their cancer under control. “Sometimes, patients with solid tumors who are in later lines of therapy may not have the luxury of time to be able to wait for all of these steps,” Aggarwal said.

There is also the question of whether a bespoke treatment can be scaled up so that it can be delivered to more patients in a more timely manner.

“There are certainly lessons to be learned from use of off-the-shelf CAR T-cell products” in hematologic malignancies, she noted, “but we’re just not there yet in lung cancer.”
 

Life-Threatening Toxicities

To improve the chances of engraftment when the CAR T cells are introduced, patients will require prior lymphodepletion with chemotherapy.

This, Forster said, is a “relatively intensive part of treatment.” However, “if you just give immune cells to somebody, when the host body is already full of immune cells,” the CAR T cells are unlikely to engraft, and “so you need to create space for those cells to develop.”

“What you want is not an immediate effect” but rather an immune “memory” that will give an ongoing benefit, he underscored.

Many patients will need to stay in the hospital one or more nights “because when you bring T cells to a tumor, you get cytokine release syndrome [CRS],” Herbst said. This can cause hypotension, fever, and chills, similar to a viral response.

“So patients can get sick,” which in turn requires treatment and follow-up. That puts a “big burden on the health system” and is a major issue, Herbst said.

Patients are also at a risk for “significant neurotoxicity,” said session cochair Amy Moore, PhD, vice president of Global Engagement and Patient Partnerships, LUNGevity Foundation, Chicago. This, alongside CRS, “can be life threatening for our patients.”

Lengthy hospital stays also have a psychosocial impact on the patient and their quality of life, she emphasized, especially when they are treated in a center far away from family and loved ones.

“We’ve also heard anecdotally some reports recently of secondary malignancies” with CAR T cell and other therapies, and that’s something that needs to be monitored as more patients go on these treatments, she said.
 

‘At What Cost’ to Patients?

The difficulties faced by patients in receiving CAR T-cell therapy go far beyond the practicalities of generating the cells or the risks associated with lymphodepletion, however.

“These therapies are extraordinarily expensive,” although that has to be weighed against the cost of years of ongoing treatment with immunotherapy, Moore said.

Moreover, as CAR T-cell therapies are a “last resort” option, patients have to “exhaust all other treatments” before being eligible, she continued. There’s significant prior authorization challenges, which means patients “have to go through many hurdles before they can qualify for treatment with these therapies.”

This typically involves having numerous laboratory tests, which can add up to out-of-pocket expenses for patients often reaching tens of thousands of dollars, Moore said.

Another issue is that they must be administered in certified treatment centers, and there are a limited number of those in the United States, she added.

This increases the risk of heightening disparities, as patients are “forced to travel, seek lodging, and have meal expenses,” and the costs “are not trivial,” Moore underlined. “It can rack up quickly and mount to $10,000 or more.”

For physicians, there are difficulties in terms of the logistics of following up with those patients who need to be treated at centers on the other side of the country, uncertainties around reimbursement, and restrictions in terms of staff time and resources, among others.

“I’m as excited as you are at the science,” but it is the implementation that is at issue, Moore said. In other words, there is the offer of a cure with CAR T-cell therapy, but “at what cost?”

“For patients, these considerations are real and they’re significant” and “we have to ensure that what we’re doing is in service of people with cancer,” she emphasized.

No funding was declared. Aggarwal declared relationships with Genentech, Celgene, AstraZeneca, Daiichi Sankyo, Turning Point, Janssen, Pfizer, Lilly, Merck, Regeneron/Sanofi, Eisai, BeiGene, Boehringer Ingelheim, Blueprint Genetics, and Shionogi. Forster declared relationships with AstraZeneca, Boehringer Ingelheim, Merck, MSD, Achilles, Amgen, Bayer, Bristol-Myers Squibb, Celgene, EQRx, GSK, Immutep, Janssen, Merck, Oxford Vacmedix, PharmaMar, Roche, Takeda, Syncorp, Transgene, and Ultrahuman. Moore declared no relevant financial relationships.

A version of this article appeared on Medscape.com.

SAN DIEGO — Chimeric antigen receptor (CAR) T-cell therapies offer the tantalizing prospect of dramatically altering the outcome of lung cancers, but there are many hurdles to treating patients with them, according to experts.

These hurdles include finding the right targets, minimizing the risks of the treatment, and reducing the enormous burdens getting these therapies places on patients.

“Precision immunotherapy,” or unleashing the immune system in a highly specific manner, “is obviously, in a way, a holy grail” in lung cancer, said Martin Forster, MD, PhD, who cochaired a session on the topic at the World Conference on Lung Cancer (WCLC) 2024.

He underlined, however, that “immunology is very complex, as is cancer biology,” and consequently, there are different avenues being explored, including CAR T-cell therapies, T-cell receptor therapies, and tumor-infiltrating lymphocytes, among others.

Antibody technology is also being harnessed to target chemotherapy, via antibody-drug conjugates, noted Forster, who is clinical lead of the early phase clinical trials programme at University College London in England.

Moreover, investigators are looking at combining various therapies, such as immune checkpoint inhibitors with T cell–engaging approaches.

He highlighted, however, that the ideal target for these approaches is something that is recognized by the immune system as being foreign, but is found within the cancer, “and you also want it ideally to be in all of the cancer cells.”

A good example is a clonal change, meaning an early evolutionary genetic alteration in the tumor that is present in all the cells, Forster said.
 

Identifying the Right Target

“One of the big challenges in all forms of targeted immunotherapy is around selecting the target and developing the right product for the right target,” Forster emphasized.

“This concept works really well in hematological malignancies” but is “proving to be more challenging to deliver within solid malignancies,” he added.

“The reason why so many lung tumors are resistant to immunotherapy is because they ‘re immunologically cold,” Roy Herbst, MD, PhD, Department of Medical Oncology, Yale Comprehensive Cancer Center, New Haven, Connecticut, said in an interview.

“There are no T cells in the tumor,” he explained, so it “doesn’t really matter how much you block checkpoint inhibitors, you still have to have a T cell in there in order to have effect.”

To overcome this problem CAR T-cell therapies are engineered to target a tumor, Herbst continued, but that “is a little hard in lung cancer because you need to have a unique antigen that’s on a lung tumor that’s not present on normal cells.”

Charu Aggarwal, MD, MPH, Leslye M. Heisler Associate Professor for Lung Cancer Excellence, Penn Medicine, Philadelphia, Pennsylvania, agreed, saying that there is “a lot of excitement with CAR T-cell therapies, and the promise of cure,” but “the biology is not as simple as we think.”

“For example, it’s not as simple as CD20 or CD19 targeting,” she said in an interview. “Most of the antigens that are being targeted in the solid tumor world, unfortunately, are also expressed on normal tissue. So there is always this potential for toxicity.”
 

A Question of Time

Another aspect of CAR T-cell therapy that is proving difficult is its delivery.

Forster outlined that the process involves first leukapheresis, in which T cells are obtained from a blood draw. These are then genetically modified to express chimeric antigen receptors before being multiplied in the laboratory and introduced to the patient.

This process can take several weeks, during which patients may require bridging treatment, such as chemotherapy or radiotherapy, to keep their cancer under control. “Sometimes, patients with solid tumors who are in later lines of therapy may not have the luxury of time to be able to wait for all of these steps,” Aggarwal said.

There is also the question of whether a bespoke treatment can be scaled up so that it can be delivered to more patients in a more timely manner.

“There are certainly lessons to be learned from use of off-the-shelf CAR T-cell products” in hematologic malignancies, she noted, “but we’re just not there yet in lung cancer.”
 

Life-Threatening Toxicities

To improve the chances of engraftment when the CAR T cells are introduced, patients will require prior lymphodepletion with chemotherapy.

This, Forster said, is a “relatively intensive part of treatment.” However, “if you just give immune cells to somebody, when the host body is already full of immune cells,” the CAR T cells are unlikely to engraft, and “so you need to create space for those cells to develop.”

“What you want is not an immediate effect” but rather an immune “memory” that will give an ongoing benefit, he underscored.

Many patients will need to stay in the hospital one or more nights “because when you bring T cells to a tumor, you get cytokine release syndrome [CRS],” Herbst said. This can cause hypotension, fever, and chills, similar to a viral response.

“So patients can get sick,” which in turn requires treatment and follow-up. That puts a “big burden on the health system” and is a major issue, Herbst said.

Patients are also at a risk for “significant neurotoxicity,” said session cochair Amy Moore, PhD, vice president of Global Engagement and Patient Partnerships, LUNGevity Foundation, Chicago. This, alongside CRS, “can be life threatening for our patients.”

Lengthy hospital stays also have a psychosocial impact on the patient and their quality of life, she emphasized, especially when they are treated in a center far away from family and loved ones.

“We’ve also heard anecdotally some reports recently of secondary malignancies” with CAR T cell and other therapies, and that’s something that needs to be monitored as more patients go on these treatments, she said.
 

‘At What Cost’ to Patients?

The difficulties faced by patients in receiving CAR T-cell therapy go far beyond the practicalities of generating the cells or the risks associated with lymphodepletion, however.

“These therapies are extraordinarily expensive,” although that has to be weighed against the cost of years of ongoing treatment with immunotherapy, Moore said.

Moreover, as CAR T-cell therapies are a “last resort” option, patients have to “exhaust all other treatments” before being eligible, she continued. There’s significant prior authorization challenges, which means patients “have to go through many hurdles before they can qualify for treatment with these therapies.”

This typically involves having numerous laboratory tests, which can add up to out-of-pocket expenses for patients often reaching tens of thousands of dollars, Moore said.

Another issue is that they must be administered in certified treatment centers, and there are a limited number of those in the United States, she added.

This increases the risk of heightening disparities, as patients are “forced to travel, seek lodging, and have meal expenses,” and the costs “are not trivial,” Moore underlined. “It can rack up quickly and mount to $10,000 or more.”

For physicians, there are difficulties in terms of the logistics of following up with those patients who need to be treated at centers on the other side of the country, uncertainties around reimbursement, and restrictions in terms of staff time and resources, among others.

“I’m as excited as you are at the science,” but it is the implementation that is at issue, Moore said. In other words, there is the offer of a cure with CAR T-cell therapy, but “at what cost?”

“For patients, these considerations are real and they’re significant” and “we have to ensure that what we’re doing is in service of people with cancer,” she emphasized.

No funding was declared. Aggarwal declared relationships with Genentech, Celgene, AstraZeneca, Daiichi Sankyo, Turning Point, Janssen, Pfizer, Lilly, Merck, Regeneron/Sanofi, Eisai, BeiGene, Boehringer Ingelheim, Blueprint Genetics, and Shionogi. Forster declared relationships with AstraZeneca, Boehringer Ingelheim, Merck, MSD, Achilles, Amgen, Bayer, Bristol-Myers Squibb, Celgene, EQRx, GSK, Immutep, Janssen, Merck, Oxford Vacmedix, PharmaMar, Roche, Takeda, Syncorp, Transgene, and Ultrahuman. Moore declared no relevant financial relationships.

A version of this article appeared on Medscape.com.

SAN DIEGO — Chimeric antigen receptor (CAR) T-cell therapies offer the tantalizing prospect of dramatically altering the outcome of lung cancers, but there are many hurdles to treating patients with them, according to experts.

These hurdles include finding the right targets, minimizing the risks of the treatment, and reducing the enormous burdens getting these therapies places on patients.

“Precision immunotherapy,” or unleashing the immune system in a highly specific manner, “is obviously, in a way, a holy grail” in lung cancer, said Martin Forster, MD, PhD, who cochaired a session on the topic at the World Conference on Lung Cancer (WCLC) 2024.

He underlined, however, that “immunology is very complex, as is cancer biology,” and consequently, there are different avenues being explored, including CAR T-cell therapies, T-cell receptor therapies, and tumor-infiltrating lymphocytes, among others.

Antibody technology is also being harnessed to target chemotherapy, via antibody-drug conjugates, noted Forster, who is clinical lead of the early phase clinical trials programme at University College London in England.

Moreover, investigators are looking at combining various therapies, such as immune checkpoint inhibitors with T cell–engaging approaches.

He highlighted, however, that the ideal target for these approaches is something that is recognized by the immune system as being foreign, but is found within the cancer, “and you also want it ideally to be in all of the cancer cells.”

A good example is a clonal change, meaning an early evolutionary genetic alteration in the tumor that is present in all the cells, Forster said.
 

Identifying the Right Target

“One of the big challenges in all forms of targeted immunotherapy is around selecting the target and developing the right product for the right target,” Forster emphasized.

“This concept works really well in hematological malignancies” but is “proving to be more challenging to deliver within solid malignancies,” he added.

“The reason why so many lung tumors are resistant to immunotherapy is because they ‘re immunologically cold,” Roy Herbst, MD, PhD, Department of Medical Oncology, Yale Comprehensive Cancer Center, New Haven, Connecticut, said in an interview.

“There are no T cells in the tumor,” he explained, so it “doesn’t really matter how much you block checkpoint inhibitors, you still have to have a T cell in there in order to have effect.”

To overcome this problem CAR T-cell therapies are engineered to target a tumor, Herbst continued, but that “is a little hard in lung cancer because you need to have a unique antigen that’s on a lung tumor that’s not present on normal cells.”

Charu Aggarwal, MD, MPH, Leslye M. Heisler Associate Professor for Lung Cancer Excellence, Penn Medicine, Philadelphia, Pennsylvania, agreed, saying that there is “a lot of excitement with CAR T-cell therapies, and the promise of cure,” but “the biology is not as simple as we think.”

“For example, it’s not as simple as CD20 or CD19 targeting,” she said in an interview. “Most of the antigens that are being targeted in the solid tumor world, unfortunately, are also expressed on normal tissue. So there is always this potential for toxicity.”
 

A Question of Time

Another aspect of CAR T-cell therapy that is proving difficult is its delivery.

Forster outlined that the process involves first leukapheresis, in which T cells are obtained from a blood draw. These are then genetically modified to express chimeric antigen receptors before being multiplied in the laboratory and introduced to the patient.

This process can take several weeks, during which patients may require bridging treatment, such as chemotherapy or radiotherapy, to keep their cancer under control. “Sometimes, patients with solid tumors who are in later lines of therapy may not have the luxury of time to be able to wait for all of these steps,” Aggarwal said.

There is also the question of whether a bespoke treatment can be scaled up so that it can be delivered to more patients in a more timely manner.

“There are certainly lessons to be learned from use of off-the-shelf CAR T-cell products” in hematologic malignancies, she noted, “but we’re just not there yet in lung cancer.”
 

Life-Threatening Toxicities

To improve the chances of engraftment when the CAR T cells are introduced, patients will require prior lymphodepletion with chemotherapy.

This, Forster said, is a “relatively intensive part of treatment.” However, “if you just give immune cells to somebody, when the host body is already full of immune cells,” the CAR T cells are unlikely to engraft, and “so you need to create space for those cells to develop.”

“What you want is not an immediate effect” but rather an immune “memory” that will give an ongoing benefit, he underscored.

Many patients will need to stay in the hospital one or more nights “because when you bring T cells to a tumor, you get cytokine release syndrome [CRS],” Herbst said. This can cause hypotension, fever, and chills, similar to a viral response.

“So patients can get sick,” which in turn requires treatment and follow-up. That puts a “big burden on the health system” and is a major issue, Herbst said.

Patients are also at a risk for “significant neurotoxicity,” said session cochair Amy Moore, PhD, vice president of Global Engagement and Patient Partnerships, LUNGevity Foundation, Chicago. This, alongside CRS, “can be life threatening for our patients.”

Lengthy hospital stays also have a psychosocial impact on the patient and their quality of life, she emphasized, especially when they are treated in a center far away from family and loved ones.

“We’ve also heard anecdotally some reports recently of secondary malignancies” with CAR T cell and other therapies, and that’s something that needs to be monitored as more patients go on these treatments, she said.
 

‘At What Cost’ to Patients?

The difficulties faced by patients in receiving CAR T-cell therapy go far beyond the practicalities of generating the cells or the risks associated with lymphodepletion, however.

“These therapies are extraordinarily expensive,” although that has to be weighed against the cost of years of ongoing treatment with immunotherapy, Moore said.

Moreover, as CAR T-cell therapies are a “last resort” option, patients have to “exhaust all other treatments” before being eligible, she continued. There’s significant prior authorization challenges, which means patients “have to go through many hurdles before they can qualify for treatment with these therapies.”

This typically involves having numerous laboratory tests, which can add up to out-of-pocket expenses for patients often reaching tens of thousands of dollars, Moore said.

Another issue is that they must be administered in certified treatment centers, and there are a limited number of those in the United States, she added.

This increases the risk of heightening disparities, as patients are “forced to travel, seek lodging, and have meal expenses,” and the costs “are not trivial,” Moore underlined. “It can rack up quickly and mount to $10,000 or more.”

For physicians, there are difficulties in terms of the logistics of following up with those patients who need to be treated at centers on the other side of the country, uncertainties around reimbursement, and restrictions in terms of staff time and resources, among others.

“I’m as excited as you are at the science,” but it is the implementation that is at issue, Moore said. In other words, there is the offer of a cure with CAR T-cell therapy, but “at what cost?”

“For patients, these considerations are real and they’re significant” and “we have to ensure that what we’re doing is in service of people with cancer,” she emphasized.

No funding was declared. Aggarwal declared relationships with Genentech, Celgene, AstraZeneca, Daiichi Sankyo, Turning Point, Janssen, Pfizer, Lilly, Merck, Regeneron/Sanofi, Eisai, BeiGene, Boehringer Ingelheim, Blueprint Genetics, and Shionogi. Forster declared relationships with AstraZeneca, Boehringer Ingelheim, Merck, MSD, Achilles, Amgen, Bayer, Bristol-Myers Squibb, Celgene, EQRx, GSK, Immutep, Janssen, Merck, Oxford Vacmedix, PharmaMar, Roche, Takeda, Syncorp, Transgene, and Ultrahuman. Moore declared no relevant financial relationships.

A version of this article appeared on Medscape.com.

VIENNA — Artificial Intelligence (AI) can assist doctors in assessing and diagnosing respiratory illnesses in infants and children, according to two new studies presented at the European Respiratory Society (ERS) 2024 Congress.

Researchers can train artificial neural networks (ANNs) to detect lung disease in premature babies by analyzing their breathing patterns while they sleep. “Our noninvasive test is less distressing for the baby and their parents, meaning they can access treatment more quickly, and may also be relevant for their long-term prognosis,” said Edgar Delgado-Eckert, PhD, adjunct professor in the Department of Biomedical Engineering at The University of Basel, Switzerland, and a research group leader at the University Children’s Hospital, Switzerland.

Manjith Narayanan, MD, a consultant in pediatric pulmonology at the Royal Hospital for Children and Young People, Edinburgh, and honorary senior clinical lecturer at The University of Edinburgh, United Kingdom, said chatbots such as ChatGPT, Bard, and Bing can perform as well as or better than trainee doctors when assessing children with respiratory issues. He said chatbots could triage patients more quickly and ease pressure on health services.
 

Chatbots Show Promise in Triage of Pediatric Respiratory Illnesses

Researchers at The University of Edinburgh provided 10 trainee doctors with less than 4 months of clinical experience in pediatrics with clinical scenarios that covered topics such as cystic fibrosis, asthma, sleep-disordered breathing, breathlessness, chest infections, or no obvious diagnosis. 

The trainee doctors had 1 hour to use the internet, although they were not allowed to use chatbots to solve each scenario with a descriptive answer. 

Each scenario was also presented to the three large language models (LLMs): OpenAI’s ChatGPT, Google’s Bard, and Microsoft’s Bing.

Six pediatric respiratory experts assessed all responses, scoring correctness, comprehensiveness, usefulness, plausibility, and coherence on a scale of 0-9. They were also asked to say whether they thought a human or a chatbot generated each response.

ChatGPT scored an average of 7 out of 9 overall and was believed to be more human-like than responses from the other chatbots. Bard scored an average of 6 out of 9 and was more “coherent” than trainee doctors, but in other respects, it was no better or worse than trainee doctors. Bing and trainee doctors scored an average of 4 out of 9. The six pediatricians reliably identified Bing and Bard’s responses as nonhuman.

“Our study is the first, to our knowledge, to test LLMs against trainee doctors in situations that reflect real-life clinical practice,” Narayanan said. “We did this by allowing the trainee doctors to have full access to resources available on the internet, as they would in real life. This moves the focus away from testing memory, where LLMs have a clear advantage.”

Narayanan said that these models could help nurses, trainee doctors, and primary care physicians triage patients quickly and assist medical professionals in their studies by summarizing their thought processes. “The key word, though, is “assist.” They cannot replace conventional medical training yet,” he told Medscape Medical News. 

The researchers found no obvious hallucinations — seemingly made-up information — with any of the three LLMs. Still, Narayanan said, “We need to be aware of this possibility and build mitigations.”

Hilary Pinnock, ERS education council chair and professor of primary care respiratory medicine at The University of Edinburgh who was not involved in the research, said seeing how widely available AI tools can provide solutions to complex cases of respiratory illness in children is exciting and worrying at the same time. “It certainly points the way to a brave new world of AI-supported care.” 

“However, before we start to use AI in routine clinical practice, we need to be confident that it will not create errors either through ‘hallucinating’ fake information or because it has been trained on data that does not equitably represent the population we serve,” she said.
 

AI Predicts Lung Disease in Premature Babies

Identifying bronchopulmonary dysplasia (BPD) in premature babies remains a challenge. Lung function tests usually require blowing out on request, which is a task babies cannot perform. Current techniques require sophisticated equipment to measure an infant’s lung ventilation characteristics, so doctors usually diagnose BPD by the presence of its leading causes, prematurity and the need for respiratory support.

Researchers at the University of Basel in Switzerland trained an ANN model to predict BPD in premature babies.

The team studied a group of 139 full-term and 190 premature infants who had been assessed for BPD, recording their breathing for 10 minutes while they slept. For each baby, 100 consecutive regular breaths, carefully inspected to exclude sighs or other artifacts, were used to train, validate, and test an ANN called a Long Short-Term Memory model (LSTM), which is particularly effective at classifying sequential data such as tidal breathing.

Researchers used 60% of the data to teach the network how to recognize BPD, 20% to validate the model, and then fed the remaining 20% of the data to the model to see if it could correctly identify those babies with BPD.

The LSTM model classified a series of flow values in the unseen test data set as belonging to a patient diagnosed with BPD or not with 96% accuracy.

“Until recently, this need for large amounts of data has hindered efforts to create accurate models for lung disease in infants because it is so difficult to assess their lung function,” Delgado-Eckert said. “Our research delivers, for the first time, a comprehensive way of analyzing infants’ breathing and allows us to detect which babies have BPD as early as 1 month of corrected age.”

The study presented by Delgado-Eckert received funding from the Swiss National Science Foundation. Narayanan and Pinnock reported no relevant financial relationships. 
 

A version of this article appeared on Medscape.com.

VIENNA — Artificial Intelligence (AI) can assist doctors in assessing and diagnosing respiratory illnesses in infants and children, according to two new studies presented at the European Respiratory Society (ERS) 2024 Congress.

Researchers can train artificial neural networks (ANNs) to detect lung disease in premature babies by analyzing their breathing patterns while they sleep. “Our noninvasive test is less distressing for the baby and their parents, meaning they can access treatment more quickly, and may also be relevant for their long-term prognosis,” said Edgar Delgado-Eckert, PhD, adjunct professor in the Department of Biomedical Engineering at The University of Basel, Switzerland, and a research group leader at the University Children’s Hospital, Switzerland.

Manjith Narayanan, MD, a consultant in pediatric pulmonology at the Royal Hospital for Children and Young People, Edinburgh, and honorary senior clinical lecturer at The University of Edinburgh, United Kingdom, said chatbots such as ChatGPT, Bard, and Bing can perform as well as or better than trainee doctors when assessing children with respiratory issues. He said chatbots could triage patients more quickly and ease pressure on health services.
 

Chatbots Show Promise in Triage of Pediatric Respiratory Illnesses

Researchers at The University of Edinburgh provided 10 trainee doctors with less than 4 months of clinical experience in pediatrics with clinical scenarios that covered topics such as cystic fibrosis, asthma, sleep-disordered breathing, breathlessness, chest infections, or no obvious diagnosis. 

The trainee doctors had 1 hour to use the internet, although they were not allowed to use chatbots to solve each scenario with a descriptive answer. 

Each scenario was also presented to the three large language models (LLMs): OpenAI’s ChatGPT, Google’s Bard, and Microsoft’s Bing.

Six pediatric respiratory experts assessed all responses, scoring correctness, comprehensiveness, usefulness, plausibility, and coherence on a scale of 0-9. They were also asked to say whether they thought a human or a chatbot generated each response.

ChatGPT scored an average of 7 out of 9 overall and was believed to be more human-like than responses from the other chatbots. Bard scored an average of 6 out of 9 and was more “coherent” than trainee doctors, but in other respects, it was no better or worse than trainee doctors. Bing and trainee doctors scored an average of 4 out of 9. The six pediatricians reliably identified Bing and Bard’s responses as nonhuman.

“Our study is the first, to our knowledge, to test LLMs against trainee doctors in situations that reflect real-life clinical practice,” Narayanan said. “We did this by allowing the trainee doctors to have full access to resources available on the internet, as they would in real life. This moves the focus away from testing memory, where LLMs have a clear advantage.”

Narayanan said that these models could help nurses, trainee doctors, and primary care physicians triage patients quickly and assist medical professionals in their studies by summarizing their thought processes. “The key word, though, is “assist.” They cannot replace conventional medical training yet,” he told Medscape Medical News. 

The researchers found no obvious hallucinations — seemingly made-up information — with any of the three LLMs. Still, Narayanan said, “We need to be aware of this possibility and build mitigations.”

Hilary Pinnock, ERS education council chair and professor of primary care respiratory medicine at The University of Edinburgh who was not involved in the research, said seeing how widely available AI tools can provide solutions to complex cases of respiratory illness in children is exciting and worrying at the same time. “It certainly points the way to a brave new world of AI-supported care.” 

“However, before we start to use AI in routine clinical practice, we need to be confident that it will not create errors either through ‘hallucinating’ fake information or because it has been trained on data that does not equitably represent the population we serve,” she said.
 

AI Predicts Lung Disease in Premature Babies

Identifying bronchopulmonary dysplasia (BPD) in premature babies remains a challenge. Lung function tests usually require blowing out on request, which is a task babies cannot perform. Current techniques require sophisticated equipment to measure an infant’s lung ventilation characteristics, so doctors usually diagnose BPD by the presence of its leading causes, prematurity and the need for respiratory support.

Researchers at the University of Basel in Switzerland trained an ANN model to predict BPD in premature babies.

The team studied a group of 139 full-term and 190 premature infants who had been assessed for BPD, recording their breathing for 10 minutes while they slept. For each baby, 100 consecutive regular breaths, carefully inspected to exclude sighs or other artifacts, were used to train, validate, and test an ANN called a Long Short-Term Memory model (LSTM), which is particularly effective at classifying sequential data such as tidal breathing.

Researchers used 60% of the data to teach the network how to recognize BPD, 20% to validate the model, and then fed the remaining 20% of the data to the model to see if it could correctly identify those babies with BPD.

The LSTM model classified a series of flow values in the unseen test data set as belonging to a patient diagnosed with BPD or not with 96% accuracy.

“Until recently, this need for large amounts of data has hindered efforts to create accurate models for lung disease in infants because it is so difficult to assess their lung function,” Delgado-Eckert said. “Our research delivers, for the first time, a comprehensive way of analyzing infants’ breathing and allows us to detect which babies have BPD as early as 1 month of corrected age.”

The study presented by Delgado-Eckert received funding from the Swiss National Science Foundation. Narayanan and Pinnock reported no relevant financial relationships. 
 

A version of this article appeared on Medscape.com.

VIENNA — Artificial Intelligence (AI) can assist doctors in assessing and diagnosing respiratory illnesses in infants and children, according to two new studies presented at the European Respiratory Society (ERS) 2024 Congress.

Researchers can train artificial neural networks (ANNs) to detect lung disease in premature babies by analyzing their breathing patterns while they sleep. “Our noninvasive test is less distressing for the baby and their parents, meaning they can access treatment more quickly, and may also be relevant for their long-term prognosis,” said Edgar Delgado-Eckert, PhD, adjunct professor in the Department of Biomedical Engineering at The University of Basel, Switzerland, and a research group leader at the University Children’s Hospital, Switzerland.

Manjith Narayanan, MD, a consultant in pediatric pulmonology at the Royal Hospital for Children and Young People, Edinburgh, and honorary senior clinical lecturer at The University of Edinburgh, United Kingdom, said chatbots such as ChatGPT, Bard, and Bing can perform as well as or better than trainee doctors when assessing children with respiratory issues. He said chatbots could triage patients more quickly and ease pressure on health services.
 

Chatbots Show Promise in Triage of Pediatric Respiratory Illnesses

Researchers at The University of Edinburgh provided 10 trainee doctors with less than 4 months of clinical experience in pediatrics with clinical scenarios that covered topics such as cystic fibrosis, asthma, sleep-disordered breathing, breathlessness, chest infections, or no obvious diagnosis. 

The trainee doctors had 1 hour to use the internet, although they were not allowed to use chatbots to solve each scenario with a descriptive answer. 

Each scenario was also presented to the three large language models (LLMs): OpenAI’s ChatGPT, Google’s Bard, and Microsoft’s Bing.

Six pediatric respiratory experts assessed all responses, scoring correctness, comprehensiveness, usefulness, plausibility, and coherence on a scale of 0-9. They were also asked to say whether they thought a human or a chatbot generated each response.

ChatGPT scored an average of 7 out of 9 overall and was believed to be more human-like than responses from the other chatbots. Bard scored an average of 6 out of 9 and was more “coherent” than trainee doctors, but in other respects, it was no better or worse than trainee doctors. Bing and trainee doctors scored an average of 4 out of 9. The six pediatricians reliably identified Bing and Bard’s responses as nonhuman.

“Our study is the first, to our knowledge, to test LLMs against trainee doctors in situations that reflect real-life clinical practice,” Narayanan said. “We did this by allowing the trainee doctors to have full access to resources available on the internet, as they would in real life. This moves the focus away from testing memory, where LLMs have a clear advantage.”

Narayanan said that these models could help nurses, trainee doctors, and primary care physicians triage patients quickly and assist medical professionals in their studies by summarizing their thought processes. “The key word, though, is “assist.” They cannot replace conventional medical training yet,” he told Medscape Medical News. 

The researchers found no obvious hallucinations — seemingly made-up information — with any of the three LLMs. Still, Narayanan said, “We need to be aware of this possibility and build mitigations.”

Hilary Pinnock, ERS education council chair and professor of primary care respiratory medicine at The University of Edinburgh who was not involved in the research, said seeing how widely available AI tools can provide solutions to complex cases of respiratory illness in children is exciting and worrying at the same time. “It certainly points the way to a brave new world of AI-supported care.” 

“However, before we start to use AI in routine clinical practice, we need to be confident that it will not create errors either through ‘hallucinating’ fake information or because it has been trained on data that does not equitably represent the population we serve,” she said.
 

AI Predicts Lung Disease in Premature Babies

Identifying bronchopulmonary dysplasia (BPD) in premature babies remains a challenge. Lung function tests usually require blowing out on request, which is a task babies cannot perform. Current techniques require sophisticated equipment to measure an infant’s lung ventilation characteristics, so doctors usually diagnose BPD by the presence of its leading causes, prematurity and the need for respiratory support.

Researchers at the University of Basel in Switzerland trained an ANN model to predict BPD in premature babies.

The team studied a group of 139 full-term and 190 premature infants who had been assessed for BPD, recording their breathing for 10 minutes while they slept. For each baby, 100 consecutive regular breaths, carefully inspected to exclude sighs or other artifacts, were used to train, validate, and test an ANN called a Long Short-Term Memory model (LSTM), which is particularly effective at classifying sequential data such as tidal breathing.

Researchers used 60% of the data to teach the network how to recognize BPD, 20% to validate the model, and then fed the remaining 20% of the data to the model to see if it could correctly identify those babies with BPD.

The LSTM model classified a series of flow values in the unseen test data set as belonging to a patient diagnosed with BPD or not with 96% accuracy.

“Until recently, this need for large amounts of data has hindered efforts to create accurate models for lung disease in infants because it is so difficult to assess their lung function,” Delgado-Eckert said. “Our research delivers, for the first time, a comprehensive way of analyzing infants’ breathing and allows us to detect which babies have BPD as early as 1 month of corrected age.”

The study presented by Delgado-Eckert received funding from the Swiss National Science Foundation. Narayanan and Pinnock reported no relevant financial relationships. 
 

A version of this article appeared on Medscape.com.

ORLANDO — It’s important for pediatricians not only to understand the causes and effects of climate change but also to know how to discuss this issue with families and make risk-based adjustments to their clinical practice based on the individual health and circumstances of each patient. That’s one of the key messages delivered at the annual meeting of the American Academy of Pediatrics (AAP) by Elizabeth C. Matsui, MD, MHS, professor of population health and pediatrics and director of the Center for Health and Environment Education and Research at the University of Texas at Austin Dell Medical School. 

“Even though climate change has been here and has been affecting health already for a while, it’s just really impossible to ignore right now,” she told attendees in a session focused on climate change impacts on allergies and asthma. “The challenge is connecting the dots between something that is much larger, or feels much larger, than the patient and the family that’s in front of you.” 

The reality, however, is that climate change is now impacting patients’ health on an individual level, and pediatricians have a responsibility to understand how that’s happening and to help their families prepare for it. 

“From the perspective of someone who went into medicine to practice and take care of the individual patient, I think it has been more difficult to connect those dots, and for the people in this room, it’s our job to connect those dots,” Matsui said. She also acknowledged that many of the solutions are frustratingly limited to the policy level and challenging to implement, “but it doesn’t mean that we can’t make a difference for the patients who are in front of us.” 

Charles Moon, MD, a pediatrician and Pediatric Environmental Health Fellow at the Children’s Environmental Health Center, Icahn School of Medicine at Mount Sinai, New York City, found the talk particularly helpful in providing information about both the broader issue and what it means on a local practice level. 

“The biggest takeaway is that more people and more pediatricians are tuning in to this issue and realizing the dangers,” Moon said. “It’s clear that a larger community is forming around this, and I think we are at the cusp where more and more people will be coming in. We are really focusing on taking all the data and trying to figure out solutions. I think the solutions orientation is the most important part.” 
 

Understanding the Big Picture

Matsui opened with a general discussion of the human causes of climate change and the effects on a global scale presently and in the future. For example, over the past 800,000 years, carbon dioxide levels have never been above 300 ppm, but they surpassed that threshold in 1911 and have reached 420 ppm today. The trapping of heat in Earth’s atmosphere caused by the increase in carbon dioxide and other greenhouse gases is leading to multiple phenomena that impact health, such as longer growing seasons; increased droughts, heat waves, and wildfire seasons; and higher temperatures. These changes, in turn, affect allergens and asthma.

Children are particularly vulnerable to climate change impacts because they have a higher risk for developing asthma, allergic disease, and infections, Matsui said. Childhood is a critical period for lung and immune development, and the Environmental Protection Agency’s 2023 Climate Change and Children’s Health and Well-Being report projects that an increase of 2° C in global warming will result in an additional 34,500 pediatric asthma cases and 228,000 allergic rhinitis cases per year, driven largely by predicted increases in ozone and 2.5-µm particulate matter. The report also forecasts an increase in 6240 asthma emergency department visits and 332 additional respiratory hospitalizations per year. 

“We know that these associations that we see between climate change exposures and poor respiratory health outcomes in kids are biologically plausible,” Matsui said. “They’re not just correlation without causation. A lot of the mechanisms for how air pollution, allergies, and other factors directly affect the lungs of the airway epithelium have been worked out.” 
 

An Increase in Allergens and Viral Infections

Pediatricians should prepare for anticipated growth in allergens and viral infections. The longer growing seasons mean that pollen seasons will also lengthen. Meanwhile, higher concentrations of carbon dioxide cause individual plants to produce more pollen. 

“As the winters get warmer, mice that might not be able to survive during the winter are surviving, and mice reproduce at a very rapid rate,” she said. “The increase in moisture means that dust mites, which absorb their water — they drink by absorbing humidity that’s in the air — will be present in higher concentrations, and their range will expand.”

Fungal and mold exposures are also increasing, not just outdoors but also indoors, “and there are all sorts of allergic and respiratory health consequences of fungal exposure,” Matsui said. As hurricanes and flooding increase, storm damage can also make indoor environments more conducive to fungal and mold growth. 

Extreme weather from climate change also affects infrastructure. “When there’s healthcare infrastructure disruption and other infrastructure disruption, it adds to the challenge,” she said. “It compounds all the other threat to health from climate change, so this overall problem of climate change and health is multidimensional and very complicated.”

Then there’s the impact of climate change on respiratory viruses, which are a major driver of asthma exacerbations, Matsui said. The greater variability in daytime temperatures affects environmental reservoirs, transmission patterns, geographical ranges, and seasonality of various respiratory pathogens. The prevalence of respiratory syncytial virus infections, for example, increases during humid periods. 

“This is coupled with the fact that the projected increases in air pollution increase susceptibility to respiratory virus infections,” Matsui said. “In fact, climate change and air pollution are inextricably linked.” 
 

Climate Change and Air Pollution

Climate disruption creates extreme weather patterns that then lead to worsening air quality due to high temperatures; heavier precipitation; and more forest fires, droughts, dust storms, thunderstorms, hurricanes, stagnation events, and other extreme weather. Matsui shared a map showing the substantial increase in days with stagnant air since 1973. During stagnation events, air pollution builds up in the atmosphere because of a stable air mass that remains over a region for several days, with low-level winds and no precipitation. 

The pollutants can then contribute to rising temperatures. Black carbon particulate matter released from the burning of forests and other biomass absorbs more solar radiation, further contributing to temperature increases. Data from the National Bureau of Economic Research has shown that the US made big strides in reducing air pollution from 2009 through 2016, but it began to reverse in 2016 as severe weather events picked up. 

Pediatricians need to be cognizant of the synergistic effect of these different impacts as well. “We oftentimes talk about these problems in a silo, so we may talk about air pollution and health effects, or allergens and health effects, or heat and health effects, but all of these interact with each other and further compound the health effects,” compared to just one of them in isolation, Matsui said.

For example, air pollution increases sensitivity to allergen exposure and increases reaction severity, which disrupts the immune tolerance to allergens. “Heat and air pollution also interact, and the combination of the two is more deadly than either one alone,” she said. 

Air pollution from wildfire smoke is also more toxic to the lungs than air pollution from other sources, so if there’s wildfire-based air pollution, the impact on respiratory hospitalizations is significantly greater. Even in places that would not otherwise be at risk for wildfires, the threat remains of air pollution from more distant fires, as New York City experienced from Canadian wildfires last year. 

“This is a problem that is not just isolated to the parts of the world where the wildfires are located,” Matsui said.

Moon, who practices in New York City, said he really appreciated Matsui’s perspectives and nuanced advice as a subspecialist “because it’s obvious that the way we deliver healthcare is going to have to change based on climate change.” He hopes to see more subspecialists from other pediatric areas getting involved in looking at climate impacts and providing nuanced advice about changing clinical care similar to the examples Matsui provided. 

Air pollution can also be deadly, as a landmark case in the United Kingdom revealed a few years ago when the court ruled that a child’s death from an asthma attack was directly due to air pollution. In addition to causing worse asthma symptoms and exacerbations, air pollution also adds to the risk of developing asthma and impedes lung growth, all of which disproportionately affects disadvantaged and minoritized communities, she said. 
 

Greater Impact on Disadvantaged Populations

Matsui called attention to the equity implications of climate change impacts on health. 

“If you have a community that does not have the infrastructure and access to resources, and that same community has a prevalence of asthma that is double that of their more advantaged and white counterparts, then the impacts of climate change are going to be amplified even more,” she said.

For example, a 2019 study found that the biggest predictor of the location of ragweed plants has to do with vacant lots and demolition of housing. Ragweed plants being more common in neighborhoods with vacant lots will disproportionately affect disadvantaged neighborhoods, she said. Another study found in Baltimore that mouse allergens — specifically urine — were a bigger cause of asthma in low-income children than were cockroach allergens. 

“It’s important to consider context,” including age, gender and social and behavioral context, she said. “We as pediatricians know that children are particularly vulnerable, and what happens to them has an effect across the lifespan.” 

Furthermore, pediatricians are aware that disadvantaged and minoritized communities lack infrastructure; often live in areas with greater air pollution; often have heat islands in their communities without protection, such as tree canopy; and may be at greater flooding risk. “Poverty is also associated with increased vulnerability” because of poorer housing and infrastructure, less education, less access to care, more preexisting health conditions and greater discrimination, she said.
 

Three Cornerstone Interventions

Interventions fall into three main buckets, Matsui said: mitigation, adaption, and resilience. 

“Mitigation means reducing greenhouse gas and air pollution production and trying to enhance sinks for greenhouse gases,” she said. Mitigation strategies primarily occur at the policy level, with improved regulation, treaties, and market-based approaches, such as carbon tax and cap and trade. 

Adaptation includes actions that lessen the impact on health and environment, such as infrastructure changes and implementation of air conditioning. Examples of climate change adaptation strategies also mostly come from policy but largely at state and local levels, where individual pediatricians have a greater voice and influence. These can include changes in urban planning to address heat islands, flooding risk, and public transportation’s contribution to air pollution and climate change. It can also include changes in housing regulation and policy and investments in healthcare, such as expanded Medicaid and health insurance and investing in disaster planning and readiness. 

“Resilience is a more holistic concept,” Matsui said, “which advocates for system-wide, multilevel changes and involves a range of strategies to enhance social, human, natural, physical, and financial capacities.”
 

What Pediatricians Can Do

Pediatricians have an important role to play when it comes to climate change and health impacts. 

“The first step is sort of understanding the complexity of climate change in terms of its potential health effects, but also being prepared to talk with our patients and their families about it,” Matsui said. “The second step is advocacy.” She drew attention to the February policy statement in Pediatrics that discusses precisely the ways in which pediatricians can leverage their expertise and credibility. 

“Pediatricians are ideal advocates with whom to partner and uplift youth and community voices working to advance zero-carbon energy policy and climate justice,” she said. “There are many opportunities to advocate for climate solution policies at the local, state, national, and even international level.” 

These roles can include educating elected officials and health insurance entities about the risks that climate change poses to allergies, asthma, and child health more broadly, as well as the benefits of local solutions, including improved air quality, tree canopy, and green space. “There are lots of opportunities to engage with the community, including speaking at public hearings, serving as an expert testimony, and writing letters to the editor,” she said. 

The impact of these efforts can be further maximized by working with other healthcare professionals. Lori Byron, MD, a pediatrician from Red Lodge, Montana, who heads the AAP Chapter Climate Advocates program, noted during Q&A that every AAP chapter in the country has climate advocates. She added that the AAP is the first medical board to have climate modules in their maintenance of certification specifically designed to incorporate climate change education into well visits.
 

Adjusting Clinical Care

Meanwhile, in patient care, Matsui acknowledged it can be frustrating to think about what a massive impact climate has and simultaneously challenging to engage families in discussions about it. However, a wide range of resources are available that can be provided to patients. 

“For a patient in front of you, being informed and prepared to talk about it is the first step to being able to assess their climate change risk and provide tailored guidance,” she said. Tailored guidance takes into account the child’s specific health situation and the risks they’re most likely to encounter, such as wildfire smoke, air pollution, longer pollen seasons, environmental allergens, or disruption of infrastructure. 

“If I am seeing a patient with asthma who is allergic to a particular pollen, I can anticipate that pollen may be present in higher levels of the future, and that the season for that pollen may be longer,” Matsui said. “So if I’m thinking about allergen immunotherapy for that patient, future risk may be something that would push the conversation and the shared decision-making” from possible consideration to more serious consideration, depending on the child’s age. 

“Another example is a patient with asthma, thinking about wildfire risk and having them prepared, because we know from data that wildfire air pollution is going to be worse for that child than pollution from other sources, and there are ways for them to be prepared,” Matsui said. For instance, having an HVAC system with a high-grade air filter (at least a MERV 13) will filter the air better if a wildfire causes smoke to descend over an area. Portable, less expensive HEPA filters are also an option if a family cannot upgrade their system, and wearing an N95 or N95-equivalent mask can also reduce the impact of high air pollution levels. 

An example of thinking about the impact of potential infrastructure disruption could be ensuring patients have enough of all their medications if they’re close to running out. “It’s important for them to always have think about their medications and get those refills ahead of a storm,” she said.
 

Additional Resources 

Understanding that pediatricians may not have time to discuss all these issues or have broader conversations about climate change during visits, Matsui highlighted the AAP website of resources on climate change. In addition to resources for pediatricians, such as a basic fact sheet about climate change impacts on children’s health and the technical report that informed the policy statement, the site has multiple resources for families:

• Climate Change Impact: Safeguarding Your Family’s Health and Well-being (video), How to Talk With Children About Climate Change, Climate Change & Children’s Health: AAP Policy Explained, Climate Checkup for Children’s Health: Little Changes With Big Impact, How Climate Change Can Make Children Sick: What Parents Need to Know, Climate Change & Wildfires: Why Kids Are Most at Risk, Climate Change, Extreme Weather & Children: What Families Need to Know, Extreme Heat & Air Pollution: Health Effects on Babies & Pregnant People, and

The following resources can also be helpful to pediatricians and/or families:

• Ready.gov, AirNow, Patient Exposure and the Air Quality Index, Protecting Vulnerable Patient Populations from Climate Hazards: A Referral Guide for Health Professionals from the US Department of Health and Human Services, Low Income Home Energy Assistance Program (LIHEAP), Weatherization Assistance Program, and the Disaster Supplemental Nutrition Assistance Program (D-SNAP)

In some states, Medicaid will provide or cover the cost of air conditioning and/or air filters.

The presentation did not involve external funding. Drs. Matsui and Moon had no disclosures. 
 

A version of this article first appeared on Medscape.com.

ORLANDO — It’s important for pediatricians not only to understand the causes and effects of climate change but also to know how to discuss this issue with families and make risk-based adjustments to their clinical practice based on the individual health and circumstances of each patient. That’s one of the key messages delivered at the annual meeting of the American Academy of Pediatrics (AAP) by Elizabeth C. Matsui, MD, MHS, professor of population health and pediatrics and director of the Center for Health and Environment Education and Research at the University of Texas at Austin Dell Medical School. 

“Even though climate change has been here and has been affecting health already for a while, it’s just really impossible to ignore right now,” she told attendees in a session focused on climate change impacts on allergies and asthma. “The challenge is connecting the dots between something that is much larger, or feels much larger, than the patient and the family that’s in front of you.” 

The reality, however, is that climate change is now impacting patients’ health on an individual level, and pediatricians have a responsibility to understand how that’s happening and to help their families prepare for it. 

“From the perspective of someone who went into medicine to practice and take care of the individual patient, I think it has been more difficult to connect those dots, and for the people in this room, it’s our job to connect those dots,” Matsui said. She also acknowledged that many of the solutions are frustratingly limited to the policy level and challenging to implement, “but it doesn’t mean that we can’t make a difference for the patients who are in front of us.” 

Charles Moon, MD, a pediatrician and Pediatric Environmental Health Fellow at the Children’s Environmental Health Center, Icahn School of Medicine at Mount Sinai, New York City, found the talk particularly helpful in providing information about both the broader issue and what it means on a local practice level. 

“The biggest takeaway is that more people and more pediatricians are tuning in to this issue and realizing the dangers,” Moon said. “It’s clear that a larger community is forming around this, and I think we are at the cusp where more and more people will be coming in. We are really focusing on taking all the data and trying to figure out solutions. I think the solutions orientation is the most important part.” 
 

Understanding the Big Picture

Matsui opened with a general discussion of the human causes of climate change and the effects on a global scale presently and in the future. For example, over the past 800,000 years, carbon dioxide levels have never been above 300 ppm, but they surpassed that threshold in 1911 and have reached 420 ppm today. The trapping of heat in Earth’s atmosphere caused by the increase in carbon dioxide and other greenhouse gases is leading to multiple phenomena that impact health, such as longer growing seasons; increased droughts, heat waves, and wildfire seasons; and higher temperatures. These changes, in turn, affect allergens and asthma.

Children are particularly vulnerable to climate change impacts because they have a higher risk for developing asthma, allergic disease, and infections, Matsui said. Childhood is a critical period for lung and immune development, and the Environmental Protection Agency’s 2023 Climate Change and Children’s Health and Well-Being report projects that an increase of 2° C in global warming will result in an additional 34,500 pediatric asthma cases and 228,000 allergic rhinitis cases per year, driven largely by predicted increases in ozone and 2.5-µm particulate matter. The report also forecasts an increase in 6240 asthma emergency department visits and 332 additional respiratory hospitalizations per year. 

“We know that these associations that we see between climate change exposures and poor respiratory health outcomes in kids are biologically plausible,” Matsui said. “They’re not just correlation without causation. A lot of the mechanisms for how air pollution, allergies, and other factors directly affect the lungs of the airway epithelium have been worked out.” 
 

An Increase in Allergens and Viral Infections

Pediatricians should prepare for anticipated growth in allergens and viral infections. The longer growing seasons mean that pollen seasons will also lengthen. Meanwhile, higher concentrations of carbon dioxide cause individual plants to produce more pollen. 

“As the winters get warmer, mice that might not be able to survive during the winter are surviving, and mice reproduce at a very rapid rate,” she said. “The increase in moisture means that dust mites, which absorb their water — they drink by absorbing humidity that’s in the air — will be present in higher concentrations, and their range will expand.”

Fungal and mold exposures are also increasing, not just outdoors but also indoors, “and there are all sorts of allergic and respiratory health consequences of fungal exposure,” Matsui said. As hurricanes and flooding increase, storm damage can also make indoor environments more conducive to fungal and mold growth. 

Extreme weather from climate change also affects infrastructure. “When there’s healthcare infrastructure disruption and other infrastructure disruption, it adds to the challenge,” she said. “It compounds all the other threat to health from climate change, so this overall problem of climate change and health is multidimensional and very complicated.”

Then there’s the impact of climate change on respiratory viruses, which are a major driver of asthma exacerbations, Matsui said. The greater variability in daytime temperatures affects environmental reservoirs, transmission patterns, geographical ranges, and seasonality of various respiratory pathogens. The prevalence of respiratory syncytial virus infections, for example, increases during humid periods. 

“This is coupled with the fact that the projected increases in air pollution increase susceptibility to respiratory virus infections,” Matsui said. “In fact, climate change and air pollution are inextricably linked.” 
 

Climate Change and Air Pollution

Climate disruption creates extreme weather patterns that then lead to worsening air quality due to high temperatures; heavier precipitation; and more forest fires, droughts, dust storms, thunderstorms, hurricanes, stagnation events, and other extreme weather. Matsui shared a map showing the substantial increase in days with stagnant air since 1973. During stagnation events, air pollution builds up in the atmosphere because of a stable air mass that remains over a region for several days, with low-level winds and no precipitation. 

The pollutants can then contribute to rising temperatures. Black carbon particulate matter released from the burning of forests and other biomass absorbs more solar radiation, further contributing to temperature increases. Data from the National Bureau of Economic Research has shown that the US made big strides in reducing air pollution from 2009 through 2016, but it began to reverse in 2016 as severe weather events picked up. 

Pediatricians need to be cognizant of the synergistic effect of these different impacts as well. “We oftentimes talk about these problems in a silo, so we may talk about air pollution and health effects, or allergens and health effects, or heat and health effects, but all of these interact with each other and further compound the health effects,” compared to just one of them in isolation, Matsui said.

For example, air pollution increases sensitivity to allergen exposure and increases reaction severity, which disrupts the immune tolerance to allergens. “Heat and air pollution also interact, and the combination of the two is more deadly than either one alone,” she said. 

Air pollution from wildfire smoke is also more toxic to the lungs than air pollution from other sources, so if there’s wildfire-based air pollution, the impact on respiratory hospitalizations is significantly greater. Even in places that would not otherwise be at risk for wildfires, the threat remains of air pollution from more distant fires, as New York City experienced from Canadian wildfires last year. 

“This is a problem that is not just isolated to the parts of the world where the wildfires are located,” Matsui said.

Moon, who practices in New York City, said he really appreciated Matsui’s perspectives and nuanced advice as a subspecialist “because it’s obvious that the way we deliver healthcare is going to have to change based on climate change.” He hopes to see more subspecialists from other pediatric areas getting involved in looking at climate impacts and providing nuanced advice about changing clinical care similar to the examples Matsui provided. 

Air pollution can also be deadly, as a landmark case in the United Kingdom revealed a few years ago when the court ruled that a child’s death from an asthma attack was directly due to air pollution. In addition to causing worse asthma symptoms and exacerbations, air pollution also adds to the risk of developing asthma and impedes lung growth, all of which disproportionately affects disadvantaged and minoritized communities, she said. 
 

Greater Impact on Disadvantaged Populations

Matsui called attention to the equity implications of climate change impacts on health. 

“If you have a community that does not have the infrastructure and access to resources, and that same community has a prevalence of asthma that is double that of their more advantaged and white counterparts, then the impacts of climate change are going to be amplified even more,” she said.

For example, a 2019 study found that the biggest predictor of the location of ragweed plants has to do with vacant lots and demolition of housing. Ragweed plants being more common in neighborhoods with vacant lots will disproportionately affect disadvantaged neighborhoods, she said. Another study found in Baltimore that mouse allergens — specifically urine — were a bigger cause of asthma in low-income children than were cockroach allergens. 

“It’s important to consider context,” including age, gender and social and behavioral context, she said. “We as pediatricians know that children are particularly vulnerable, and what happens to them has an effect across the lifespan.” 

Furthermore, pediatricians are aware that disadvantaged and minoritized communities lack infrastructure; often live in areas with greater air pollution; often have heat islands in their communities without protection, such as tree canopy; and may be at greater flooding risk. “Poverty is also associated with increased vulnerability” because of poorer housing and infrastructure, less education, less access to care, more preexisting health conditions and greater discrimination, she said.
 

Three Cornerstone Interventions

Interventions fall into three main buckets, Matsui said: mitigation, adaption, and resilience. 

“Mitigation means reducing greenhouse gas and air pollution production and trying to enhance sinks for greenhouse gases,” she said. Mitigation strategies primarily occur at the policy level, with improved regulation, treaties, and market-based approaches, such as carbon tax and cap and trade. 

Adaptation includes actions that lessen the impact on health and environment, such as infrastructure changes and implementation of air conditioning. Examples of climate change adaptation strategies also mostly come from policy but largely at state and local levels, where individual pediatricians have a greater voice and influence. These can include changes in urban planning to address heat islands, flooding risk, and public transportation’s contribution to air pollution and climate change. It can also include changes in housing regulation and policy and investments in healthcare, such as expanded Medicaid and health insurance and investing in disaster planning and readiness. 

“Resilience is a more holistic concept,” Matsui said, “which advocates for system-wide, multilevel changes and involves a range of strategies to enhance social, human, natural, physical, and financial capacities.”
 

What Pediatricians Can Do

Pediatricians have an important role to play when it comes to climate change and health impacts. 

“The first step is sort of understanding the complexity of climate change in terms of its potential health effects, but also being prepared to talk with our patients and their families about it,” Matsui said. “The second step is advocacy.” She drew attention to the February policy statement in Pediatrics that discusses precisely the ways in which pediatricians can leverage their expertise and credibility. 

“Pediatricians are ideal advocates with whom to partner and uplift youth and community voices working to advance zero-carbon energy policy and climate justice,” she said. “There are many opportunities to advocate for climate solution policies at the local, state, national, and even international level.” 

These roles can include educating elected officials and health insurance entities about the risks that climate change poses to allergies, asthma, and child health more broadly, as well as the benefits of local solutions, including improved air quality, tree canopy, and green space. “There are lots of opportunities to engage with the community, including speaking at public hearings, serving as an expert testimony, and writing letters to the editor,” she said. 

The impact of these efforts can be further maximized by working with other healthcare professionals. Lori Byron, MD, a pediatrician from Red Lodge, Montana, who heads the AAP Chapter Climate Advocates program, noted during Q&A that every AAP chapter in the country has climate advocates. She added that the AAP is the first medical board to have climate modules in their maintenance of certification specifically designed to incorporate climate change education into well visits.
 

Adjusting Clinical Care

Meanwhile, in patient care, Matsui acknowledged it can be frustrating to think about what a massive impact climate has and simultaneously challenging to engage families in discussions about it. However, a wide range of resources are available that can be provided to patients. 

“For a patient in front of you, being informed and prepared to talk about it is the first step to being able to assess their climate change risk and provide tailored guidance,” she said. Tailored guidance takes into account the child’s specific health situation and the risks they’re most likely to encounter, such as wildfire smoke, air pollution, longer pollen seasons, environmental allergens, or disruption of infrastructure. 

“If I am seeing a patient with asthma who is allergic to a particular pollen, I can anticipate that pollen may be present in higher levels of the future, and that the season for that pollen may be longer,” Matsui said. “So if I’m thinking about allergen immunotherapy for that patient, future risk may be something that would push the conversation and the shared decision-making” from possible consideration to more serious consideration, depending on the child’s age. 

“Another example is a patient with asthma, thinking about wildfire risk and having them prepared, because we know from data that wildfire air pollution is going to be worse for that child than pollution from other sources, and there are ways for them to be prepared,” Matsui said. For instance, having an HVAC system with a high-grade air filter (at least a MERV 13) will filter the air better if a wildfire causes smoke to descend over an area. Portable, less expensive HEPA filters are also an option if a family cannot upgrade their system, and wearing an N95 or N95-equivalent mask can also reduce the impact of high air pollution levels. 

An example of thinking about the impact of potential infrastructure disruption could be ensuring patients have enough of all their medications if they’re close to running out. “It’s important for them to always have think about their medications and get those refills ahead of a storm,” she said.
 

Additional Resources 

Understanding that pediatricians may not have time to discuss all these issues or have broader conversations about climate change during visits, Matsui highlighted the AAP website of resources on climate change. In addition to resources for pediatricians, such as a basic fact sheet about climate change impacts on children’s health and the technical report that informed the policy statement, the site has multiple resources for families:

• Climate Change Impact: Safeguarding Your Family’s Health and Well-being (video), How to Talk With Children About Climate Change, Climate Change & Children’s Health: AAP Policy Explained, Climate Checkup for Children’s Health: Little Changes With Big Impact, How Climate Change Can Make Children Sick: What Parents Need to Know, Climate Change & Wildfires: Why Kids Are Most at Risk, Climate Change, Extreme Weather & Children: What Families Need to Know, Extreme Heat & Air Pollution: Health Effects on Babies & Pregnant People, and

The following resources can also be helpful to pediatricians and/or families:

• Ready.gov, AirNow, Patient Exposure and the Air Quality Index, Protecting Vulnerable Patient Populations from Climate Hazards: A Referral Guide for Health Professionals from the US Department of Health and Human Services, Low Income Home Energy Assistance Program (LIHEAP), Weatherization Assistance Program, and the Disaster Supplemental Nutrition Assistance Program (D-SNAP)

In some states, Medicaid will provide or cover the cost of air conditioning and/or air filters.

The presentation did not involve external funding. Drs. Matsui and Moon had no disclosures. 
 

A version of this article first appeared on Medscape.com.

ORLANDO — It’s important for pediatricians not only to understand the causes and effects of climate change but also to know how to discuss this issue with families and make risk-based adjustments to their clinical practice based on the individual health and circumstances of each patient. That’s one of the key messages delivered at the annual meeting of the American Academy of Pediatrics (AAP) by Elizabeth C. Matsui, MD, MHS, professor of population health and pediatrics and director of the Center for Health and Environment Education and Research at the University of Texas at Austin Dell Medical School. 

“Even though climate change has been here and has been affecting health already for a while, it’s just really impossible to ignore right now,” she told attendees in a session focused on climate change impacts on allergies and asthma. “The challenge is connecting the dots between something that is much larger, or feels much larger, than the patient and the family that’s in front of you.” 

The reality, however, is that climate change is now impacting patients’ health on an individual level, and pediatricians have a responsibility to understand how that’s happening and to help their families prepare for it. 

“From the perspective of someone who went into medicine to practice and take care of the individual patient, I think it has been more difficult to connect those dots, and for the people in this room, it’s our job to connect those dots,” Matsui said. She also acknowledged that many of the solutions are frustratingly limited to the policy level and challenging to implement, “but it doesn’t mean that we can’t make a difference for the patients who are in front of us.” 

Charles Moon, MD, a pediatrician and Pediatric Environmental Health Fellow at the Children’s Environmental Health Center, Icahn School of Medicine at Mount Sinai, New York City, found the talk particularly helpful in providing information about both the broader issue and what it means on a local practice level. 

“The biggest takeaway is that more people and more pediatricians are tuning in to this issue and realizing the dangers,” Moon said. “It’s clear that a larger community is forming around this, and I think we are at the cusp where more and more people will be coming in. We are really focusing on taking all the data and trying to figure out solutions. I think the solutions orientation is the most important part.” 
 

Understanding the Big Picture

Matsui opened with a general discussion of the human causes of climate change and the effects on a global scale presently and in the future. For example, over the past 800,000 years, carbon dioxide levels have never been above 300 ppm, but they surpassed that threshold in 1911 and have reached 420 ppm today. The trapping of heat in Earth’s atmosphere caused by the increase in carbon dioxide and other greenhouse gases is leading to multiple phenomena that impact health, such as longer growing seasons; increased droughts, heat waves, and wildfire seasons; and higher temperatures. These changes, in turn, affect allergens and asthma.

Children are particularly vulnerable to climate change impacts because they have a higher risk for developing asthma, allergic disease, and infections, Matsui said. Childhood is a critical period for lung and immune development, and the Environmental Protection Agency’s 2023 Climate Change and Children’s Health and Well-Being report projects that an increase of 2° C in global warming will result in an additional 34,500 pediatric asthma cases and 228,000 allergic rhinitis cases per year, driven largely by predicted increases in ozone and 2.5-µm particulate matter. The report also forecasts an increase in 6240 asthma emergency department visits and 332 additional respiratory hospitalizations per year. 

“We know that these associations that we see between climate change exposures and poor respiratory health outcomes in kids are biologically plausible,” Matsui said. “They’re not just correlation without causation. A lot of the mechanisms for how air pollution, allergies, and other factors directly affect the lungs of the airway epithelium have been worked out.” 
 

An Increase in Allergens and Viral Infections

Pediatricians should prepare for anticipated growth in allergens and viral infections. The longer growing seasons mean that pollen seasons will also lengthen. Meanwhile, higher concentrations of carbon dioxide cause individual plants to produce more pollen. 

“As the winters get warmer, mice that might not be able to survive during the winter are surviving, and mice reproduce at a very rapid rate,” she said. “The increase in moisture means that dust mites, which absorb their water — they drink by absorbing humidity that’s in the air — will be present in higher concentrations, and their range will expand.”

Fungal and mold exposures are also increasing, not just outdoors but also indoors, “and there are all sorts of allergic and respiratory health consequences of fungal exposure,” Matsui said. As hurricanes and flooding increase, storm damage can also make indoor environments more conducive to fungal and mold growth. 

Extreme weather from climate change also affects infrastructure. “When there’s healthcare infrastructure disruption and other infrastructure disruption, it adds to the challenge,” she said. “It compounds all the other threat to health from climate change, so this overall problem of climate change and health is multidimensional and very complicated.”

Then there’s the impact of climate change on respiratory viruses, which are a major driver of asthma exacerbations, Matsui said. The greater variability in daytime temperatures affects environmental reservoirs, transmission patterns, geographical ranges, and seasonality of various respiratory pathogens. The prevalence of respiratory syncytial virus infections, for example, increases during humid periods. 

“This is coupled with the fact that the projected increases in air pollution increase susceptibility to respiratory virus infections,” Matsui said. “In fact, climate change and air pollution are inextricably linked.” 
 

Climate Change and Air Pollution

Climate disruption creates extreme weather patterns that then lead to worsening air quality due to high temperatures; heavier precipitation; and more forest fires, droughts, dust storms, thunderstorms, hurricanes, stagnation events, and other extreme weather. Matsui shared a map showing the substantial increase in days with stagnant air since 1973. During stagnation events, air pollution builds up in the atmosphere because of a stable air mass that remains over a region for several days, with low-level winds and no precipitation. 

The pollutants can then contribute to rising temperatures. Black carbon particulate matter released from the burning of forests and other biomass absorbs more solar radiation, further contributing to temperature increases. Data from the National Bureau of Economic Research has shown that the US made big strides in reducing air pollution from 2009 through 2016, but it began to reverse in 2016 as severe weather events picked up. 

Pediatricians need to be cognizant of the synergistic effect of these different impacts as well. “We oftentimes talk about these problems in a silo, so we may talk about air pollution and health effects, or allergens and health effects, or heat and health effects, but all of these interact with each other and further compound the health effects,” compared to just one of them in isolation, Matsui said.

For example, air pollution increases sensitivity to allergen exposure and increases reaction severity, which disrupts the immune tolerance to allergens. “Heat and air pollution also interact, and the combination of the two is more deadly than either one alone,” she said. 

Air pollution from wildfire smoke is also more toxic to the lungs than air pollution from other sources, so if there’s wildfire-based air pollution, the impact on respiratory hospitalizations is significantly greater. Even in places that would not otherwise be at risk for wildfires, the threat remains of air pollution from more distant fires, as New York City experienced from Canadian wildfires last year. 

“This is a problem that is not just isolated to the parts of the world where the wildfires are located,” Matsui said.

Moon, who practices in New York City, said he really appreciated Matsui’s perspectives and nuanced advice as a subspecialist “because it’s obvious that the way we deliver healthcare is going to have to change based on climate change.” He hopes to see more subspecialists from other pediatric areas getting involved in looking at climate impacts and providing nuanced advice about changing clinical care similar to the examples Matsui provided. 

Air pollution can also be deadly, as a landmark case in the United Kingdom revealed a few years ago when the court ruled that a child’s death from an asthma attack was directly due to air pollution. In addition to causing worse asthma symptoms and exacerbations, air pollution also adds to the risk of developing asthma and impedes lung growth, all of which disproportionately affects disadvantaged and minoritized communities, she said. 
 

Greater Impact on Disadvantaged Populations

Matsui called attention to the equity implications of climate change impacts on health. 

“If you have a community that does not have the infrastructure and access to resources, and that same community has a prevalence of asthma that is double that of their more advantaged and white counterparts, then the impacts of climate change are going to be amplified even more,” she said.

For example, a 2019 study found that the biggest predictor of the location of ragweed plants has to do with vacant lots and demolition of housing. Ragweed plants being more common in neighborhoods with vacant lots will disproportionately affect disadvantaged neighborhoods, she said. Another study found in Baltimore that mouse allergens — specifically urine — were a bigger cause of asthma in low-income children than were cockroach allergens. 

“It’s important to consider context,” including age, gender and social and behavioral context, she said. “We as pediatricians know that children are particularly vulnerable, and what happens to them has an effect across the lifespan.” 

Furthermore, pediatricians are aware that disadvantaged and minoritized communities lack infrastructure; often live in areas with greater air pollution; often have heat islands in their communities without protection, such as tree canopy; and may be at greater flooding risk. “Poverty is also associated with increased vulnerability” because of poorer housing and infrastructure, less education, less access to care, more preexisting health conditions and greater discrimination, she said.
 

Three Cornerstone Interventions

Interventions fall into three main buckets, Matsui said: mitigation, adaption, and resilience. 

“Mitigation means reducing greenhouse gas and air pollution production and trying to enhance sinks for greenhouse gases,” she said. Mitigation strategies primarily occur at the policy level, with improved regulation, treaties, and market-based approaches, such as carbon tax and cap and trade. 

Adaptation includes actions that lessen the impact on health and environment, such as infrastructure changes and implementation of air conditioning. Examples of climate change adaptation strategies also mostly come from policy but largely at state and local levels, where individual pediatricians have a greater voice and influence. These can include changes in urban planning to address heat islands, flooding risk, and public transportation’s contribution to air pollution and climate change. It can also include changes in housing regulation and policy and investments in healthcare, such as expanded Medicaid and health insurance and investing in disaster planning and readiness. 

“Resilience is a more holistic concept,” Matsui said, “which advocates for system-wide, multilevel changes and involves a range of strategies to enhance social, human, natural, physical, and financial capacities.”
 

What Pediatricians Can Do

Pediatricians have an important role to play when it comes to climate change and health impacts. 

“The first step is sort of understanding the complexity of climate change in terms of its potential health effects, but also being prepared to talk with our patients and their families about it,” Matsui said. “The second step is advocacy.” She drew attention to the February policy statement in Pediatrics that discusses precisely the ways in which pediatricians can leverage their expertise and credibility. 

“Pediatricians are ideal advocates with whom to partner and uplift youth and community voices working to advance zero-carbon energy policy and climate justice,” she said. “There are many opportunities to advocate for climate solution policies at the local, state, national, and even international level.” 

These roles can include educating elected officials and health insurance entities about the risks that climate change poses to allergies, asthma, and child health more broadly, as well as the benefits of local solutions, including improved air quality, tree canopy, and green space. “There are lots of opportunities to engage with the community, including speaking at public hearings, serving as an expert testimony, and writing letters to the editor,” she said. 

The impact of these efforts can be further maximized by working with other healthcare professionals. Lori Byron, MD, a pediatrician from Red Lodge, Montana, who heads the AAP Chapter Climate Advocates program, noted during Q&A that every AAP chapter in the country has climate advocates. She added that the AAP is the first medical board to have climate modules in their maintenance of certification specifically designed to incorporate climate change education into well visits.
 

Adjusting Clinical Care

Meanwhile, in patient care, Matsui acknowledged it can be frustrating to think about what a massive impact climate has and simultaneously challenging to engage families in discussions about it. However, a wide range of resources are available that can be provided to patients. 

“For a patient in front of you, being informed and prepared to talk about it is the first step to being able to assess their climate change risk and provide tailored guidance,” she said. Tailored guidance takes into account the child’s specific health situation and the risks they’re most likely to encounter, such as wildfire smoke, air pollution, longer pollen seasons, environmental allergens, or disruption of infrastructure. 

“If I am seeing a patient with asthma who is allergic to a particular pollen, I can anticipate that pollen may be present in higher levels of the future, and that the season for that pollen may be longer,” Matsui said. “So if I’m thinking about allergen immunotherapy for that patient, future risk may be something that would push the conversation and the shared decision-making” from possible consideration to more serious consideration, depending on the child’s age. 

“Another example is a patient with asthma, thinking about wildfire risk and having them prepared, because we know from data that wildfire air pollution is going to be worse for that child than pollution from other sources, and there are ways for them to be prepared,” Matsui said. For instance, having an HVAC system with a high-grade air filter (at least a MERV 13) will filter the air better if a wildfire causes smoke to descend over an area. Portable, less expensive HEPA filters are also an option if a family cannot upgrade their system, and wearing an N95 or N95-equivalent mask can also reduce the impact of high air pollution levels. 

An example of thinking about the impact of potential infrastructure disruption could be ensuring patients have enough of all their medications if they’re close to running out. “It’s important for them to always have think about their medications and get those refills ahead of a storm,” she said.
 

Additional Resources 

Understanding that pediatricians may not have time to discuss all these issues or have broader conversations about climate change during visits, Matsui highlighted the AAP website of resources on climate change. In addition to resources for pediatricians, such as a basic fact sheet about climate change impacts on children’s health and the technical report that informed the policy statement, the site has multiple resources for families:

• Climate Change Impact: Safeguarding Your Family’s Health and Well-being (video), How to Talk With Children About Climate Change, Climate Change & Children’s Health: AAP Policy Explained, Climate Checkup for Children’s Health: Little Changes With Big Impact, How Climate Change Can Make Children Sick: What Parents Need to Know, Climate Change & Wildfires: Why Kids Are Most at Risk, Climate Change, Extreme Weather & Children: What Families Need to Know, Extreme Heat & Air Pollution: Health Effects on Babies & Pregnant People, and

The following resources can also be helpful to pediatricians and/or families:

• Ready.gov, AirNow, Patient Exposure and the Air Quality Index, Protecting Vulnerable Patient Populations from Climate Hazards: A Referral Guide for Health Professionals from the US Department of Health and Human Services, Low Income Home Energy Assistance Program (LIHEAP), Weatherization Assistance Program, and the Disaster Supplemental Nutrition Assistance Program (D-SNAP)

In some states, Medicaid will provide or cover the cost of air conditioning and/or air filters.

The presentation did not involve external funding. Drs. Matsui and Moon had no disclosures. 
 

A version of this article first appeared on Medscape.com.

Higher concentrations of specific volatile organic compounds (VOCs) in daycare centers were significantly associated with an increased risk for wheezing in children who attended these centers, based on data from more than 500 children.

“There is an increasing concern about of the role of Indoor Air Quality (IAQ) in development of respiratory disorders like asthma, especially in children whose immune system is under development, and they are more vulnerable to the effects of poor air quality,” lead author Ioannis Sakellaris, PhD, of Université Paris-Saclay, Villejuif, France, said in an interview. However, the effects of specific pollutants on the health of young children in daycare settings has not been examined, he said. 

In a presentation at the European Respiratory Society Congress, Sakellaris reviewed data from the French CRESPI cohort study, an epidemiological study of the impact of exposures to disinfectants and cleaning products on workers and children in daycare centers in France.

The study population included 532 children (47.4% girls) with a mean age of 22.3 months (aged 3 months to 4 years) in 106 daycare centers. A total of 171 children reportedly experienced at least one episode of wheezing since birth. 

A total of 67 VOCs were measured during one day, and concentrations were studied in four categories based on quartiles. The researchers evaluated three child wheezing outcomes based on parental questionnaires: Ever wheeze since birth, recurrent wheeze (≥ 3 times since birth), and ever wheeze with inhaled corticosteroid use. The researchers adjusted for factors including child age and parental smoking status and education level.

Overall, ever wheezing was significantly associated with higher concentrations of 1,2,4-trimethylbenzene (odds ratio [OR] for Q4 vs Q1, 1.56; P = .08 for trend), 1-methoxy-2-propylacetate (OR, 1.62; P = .01), decamethylcyclopentasiloxane (OR, 2.12; P = .004), and methylisobutylcetone (OR, 1.85; P < .001).

The results emphasize the significant role of IAQ in respiratory health, said Sakellaris. “Further efforts to reduce pollutant concentrations and limit sources are needed,” he said. In addition, more studies on the combined effect of multiple VOCs are necessary for a deeper understanding of the complex relations between IAQ and children’s respiratory health, he said.
 

Pay Attention to Indoor Pollutants

“Since the COVID-19 pandemic, the use of cleaning products and disinfectants has exploded,” Alexander S. Rabin, MD, of the University of Michigan, Ann Arbor, Michigan, said in an interview. Although many of these cleaning agents contain chemicals, including VOCs, that are known respiratory irritants, little is known about the relationship between VOCs and children’s respiratory outcomes in daycare settings, said Rabin, who was not involved in the study.

“I was struck by the wide array of VOCs detected in daycare settings,” Rabin said. However, the relationship to childhood wheeze was not entirely surprising as the VOCs included the known irritants benzene and toluene, he added.

The results suggest that exposure to VOCs, not only in cleaning agents but also building materials and other consumer products in daycare settings, may be associated with an increased risk for wheeze in children, said Rabin. 

However, “it is important to know more about confounding variables, including concurrent rates of respiratory infection that are common among children,” said Rabin. “As the authors highlight, further work on the compound effects of multiple pollutants would be of interest. Lastly, it would be helpful to clearly identify the most common sources of VOCs that place children at greatest risk for wheeze, so that appropriate steps can be taken to mitigate risk,” he said.

The original CRESPI cohort study was supported by ANSES, ADEME, Fondation de France, and ARS Ile-de-France. Sakellaris and Rabin had no financial conflicts to disclose.
 

A version of this article appeared on Medscape.com.

Higher concentrations of specific volatile organic compounds (VOCs) in daycare centers were significantly associated with an increased risk for wheezing in children who attended these centers, based on data from more than 500 children.

“There is an increasing concern about of the role of Indoor Air Quality (IAQ) in development of respiratory disorders like asthma, especially in children whose immune system is under development, and they are more vulnerable to the effects of poor air quality,” lead author Ioannis Sakellaris, PhD, of Université Paris-Saclay, Villejuif, France, said in an interview. However, the effects of specific pollutants on the health of young children in daycare settings has not been examined, he said. 

In a presentation at the European Respiratory Society Congress, Sakellaris reviewed data from the French CRESPI cohort study, an epidemiological study of the impact of exposures to disinfectants and cleaning products on workers and children in daycare centers in France.

The study population included 532 children (47.4% girls) with a mean age of 22.3 months (aged 3 months to 4 years) in 106 daycare centers. A total of 171 children reportedly experienced at least one episode of wheezing since birth. 

A total of 67 VOCs were measured during one day, and concentrations were studied in four categories based on quartiles. The researchers evaluated three child wheezing outcomes based on parental questionnaires: Ever wheeze since birth, recurrent wheeze (≥ 3 times since birth), and ever wheeze with inhaled corticosteroid use. The researchers adjusted for factors including child age and parental smoking status and education level.

Overall, ever wheezing was significantly associated with higher concentrations of 1,2,4-trimethylbenzene (odds ratio [OR] for Q4 vs Q1, 1.56; P = .08 for trend), 1-methoxy-2-propylacetate (OR, 1.62; P = .01), decamethylcyclopentasiloxane (OR, 2.12; P = .004), and methylisobutylcetone (OR, 1.85; P < .001).

The results emphasize the significant role of IAQ in respiratory health, said Sakellaris. “Further efforts to reduce pollutant concentrations and limit sources are needed,” he said. In addition, more studies on the combined effect of multiple VOCs are necessary for a deeper understanding of the complex relations between IAQ and children’s respiratory health, he said.
 

Pay Attention to Indoor Pollutants

“Since the COVID-19 pandemic, the use of cleaning products and disinfectants has exploded,” Alexander S. Rabin, MD, of the University of Michigan, Ann Arbor, Michigan, said in an interview. Although many of these cleaning agents contain chemicals, including VOCs, that are known respiratory irritants, little is known about the relationship between VOCs and children’s respiratory outcomes in daycare settings, said Rabin, who was not involved in the study.

“I was struck by the wide array of VOCs detected in daycare settings,” Rabin said. However, the relationship to childhood wheeze was not entirely surprising as the VOCs included the known irritants benzene and toluene, he added.

The results suggest that exposure to VOCs, not only in cleaning agents but also building materials and other consumer products in daycare settings, may be associated with an increased risk for wheeze in children, said Rabin. 

However, “it is important to know more about confounding variables, including concurrent rates of respiratory infection that are common among children,” said Rabin. “As the authors highlight, further work on the compound effects of multiple pollutants would be of interest. Lastly, it would be helpful to clearly identify the most common sources of VOCs that place children at greatest risk for wheeze, so that appropriate steps can be taken to mitigate risk,” he said.

The original CRESPI cohort study was supported by ANSES, ADEME, Fondation de France, and ARS Ile-de-France. Sakellaris and Rabin had no financial conflicts to disclose.
 

A version of this article appeared on Medscape.com.

Higher concentrations of specific volatile organic compounds (VOCs) in daycare centers were significantly associated with an increased risk for wheezing in children who attended these centers, based on data from more than 500 children.

“There is an increasing concern about of the role of Indoor Air Quality (IAQ) in development of respiratory disorders like asthma, especially in children whose immune system is under development, and they are more vulnerable to the effects of poor air quality,” lead author Ioannis Sakellaris, PhD, of Université Paris-Saclay, Villejuif, France, said in an interview. However, the effects of specific pollutants on the health of young children in daycare settings has not been examined, he said. 

In a presentation at the European Respiratory Society Congress, Sakellaris reviewed data from the French CRESPI cohort study, an epidemiological study of the impact of exposures to disinfectants and cleaning products on workers and children in daycare centers in France.

The study population included 532 children (47.4% girls) with a mean age of 22.3 months (aged 3 months to 4 years) in 106 daycare centers. A total of 171 children reportedly experienced at least one episode of wheezing since birth. 

A total of 67 VOCs were measured during one day, and concentrations were studied in four categories based on quartiles. The researchers evaluated three child wheezing outcomes based on parental questionnaires: Ever wheeze since birth, recurrent wheeze (≥ 3 times since birth), and ever wheeze with inhaled corticosteroid use. The researchers adjusted for factors including child age and parental smoking status and education level.

Overall, ever wheezing was significantly associated with higher concentrations of 1,2,4-trimethylbenzene (odds ratio [OR] for Q4 vs Q1, 1.56; P = .08 for trend), 1-methoxy-2-propylacetate (OR, 1.62; P = .01), decamethylcyclopentasiloxane (OR, 2.12; P = .004), and methylisobutylcetone (OR, 1.85; P < .001).

The results emphasize the significant role of IAQ in respiratory health, said Sakellaris. “Further efforts to reduce pollutant concentrations and limit sources are needed,” he said. In addition, more studies on the combined effect of multiple VOCs are necessary for a deeper understanding of the complex relations between IAQ and children’s respiratory health, he said.
 

Pay Attention to Indoor Pollutants

“Since the COVID-19 pandemic, the use of cleaning products and disinfectants has exploded,” Alexander S. Rabin, MD, of the University of Michigan, Ann Arbor, Michigan, said in an interview. Although many of these cleaning agents contain chemicals, including VOCs, that are known respiratory irritants, little is known about the relationship between VOCs and children’s respiratory outcomes in daycare settings, said Rabin, who was not involved in the study.

“I was struck by the wide array of VOCs detected in daycare settings,” Rabin said. However, the relationship to childhood wheeze was not entirely surprising as the VOCs included the known irritants benzene and toluene, he added.

The results suggest that exposure to VOCs, not only in cleaning agents but also building materials and other consumer products in daycare settings, may be associated with an increased risk for wheeze in children, said Rabin. 

However, “it is important to know more about confounding variables, including concurrent rates of respiratory infection that are common among children,” said Rabin. “As the authors highlight, further work on the compound effects of multiple pollutants would be of interest. Lastly, it would be helpful to clearly identify the most common sources of VOCs that place children at greatest risk for wheeze, so that appropriate steps can be taken to mitigate risk,” he said.

The original CRESPI cohort study was supported by ANSES, ADEME, Fondation de France, and ARS Ile-de-France. Sakellaris and Rabin had no financial conflicts to disclose.
 

A version of this article appeared on Medscape.com.

A strategy developed by Canadian researchers for encouraging older patients with insomnia to wean themselves from sleeping pills and improve their sleep through behavioral techniques is effective, data suggest. If proven helpful for the millions of older Canadians who currently rely on nightly benzodiazepines (BZDs) and non-BZDs (colloquially known as Z drugs) for their sleep, it might yield an additional benefit: Reducing resource utilization.

“We know that cognitive behavioral therapy for insomnia (CBTI) works. It’s recommended as first-line therapy because it works,” study author David Gardner, PharmD, professor of psychiatry at Dalhousie University in Halifax, Nova Scotia, Canada, told this news organization.

“We’re sharing information about sleeping pills, information that has been embedded with behavior-change techniques that lead people to second-guess or rethink their long-term use of sedative hypnotics and then bring that information to their provider or pharmacist to discuss it,” he said.

The results were published in JAMA Psychiatry.
 

Better Sleep, Fewer Pills

Dr. Gardner and his team created a direct-to-patient, patient-directed, multicomponent knowledge mobilization intervention called Sleepwell. It incorporates best practice– and guideline-based evidence and multiple behavioral change techniques with content and graphics. Dr. Gardner emphasized that it represents a directional shift in care that alleviates providers’ burden without removing it entirely.

To test the intervention’s effectiveness, Dr. Gardner and his team chose New Brunswick as a location for a 6-month, three-arm, open-label, randomized controlled trial; the province has one of the highest rates of sedative use and an older adult population that is vulnerable to the serious side effects of these drugs (eg, cognitive impairment, falls, and frailty). The study was called Your Answers When Needing Sleep in New Brunswick (YAWNS NB).

Eligible participants were aged ≥ 65 years, lived in the community, and had taken benzodiazepine receptor agonists (BZRAs) for ≥ 3 nights per week for 3 or more months. Participants were randomly assigned to a control group or one of the two intervention groups. The YAWNS-1 intervention group (n = 195) received a mailed package containing a cover letter, a booklet outlining how to stop sleeping pills, a booklet on how to “get your sleep back,” and a companion website. The YAWNS-2 group (n = 193) received updated versions of the booklets used in a prior trial. The control group (n = 192) was assigned treatment as usual (TAU).

A greater proportion of YAWNS-1 participants discontinued BZRAs at 6 months (26.2%) and had dose reductions (20.4%), compared with YAWNS-2 participants (20.3% and 14.4%, respectively) and TAU participants (7.5% and 12.8%, respectively). The corresponding numbers needed to mail to achieve an additional discontinuation was 5.3 YAWNS-1 packages and 7.8 YAWNS-2 packages.

At 6 months, BZRA cessation was sustained a mean 13.6 weeks for YAWNS-1, 14.3 weeks for YAWNS-2, and 16.9 weeks for TAU.

Sleep measures also improved with YAWNS-1, compared with YAWNs-2 and TAU. Sleep onset latency was reduced by 26.1 minutes among YAWNS-1 participants, compared with YAWNS-2 (P < .001), and by 27.7 minutes, compared with TAU (P < .001). Wake after sleep onset increased by 4.1 minutes in YAWNS-1, 11.1 minutes in YAWNS-2, and 7.5 minutes in TAU.

Although all participants underwent rigorous assessment before inclusion, less than half of participants receiving either intervention (36% in YAWNS-1 and 43% in YAWNS-2) contacted their provider or pharmacist to discuss BZD dose reductions. This finding may have resulted partly from limited access because of the COVID-19 pandemic, according to the authors.
 

A Stepped-Care Model

The intervention is intended to help patients “change their approach from sleeping pills to a short-term CBTI course for long-term sleep benefits, and then speak to their provider,” said Dr. Gardner.

He pointed to a post-study follow-up of the study participants’ health providers, most of whom had moderate to extensive experience deprescribing BZRAs, which showed that 87.5%-100% fully or nearly fully agreed with or supported using the Sleepwell strategy and its content with older patients who rely on sedatives.

“Providers said that deprescribing is difficult, time-consuming, and often not a productive use of their time,” said Dr. Gardner. “I see insomnia as a health issue well set up for a stepped-care model. Self-help approaches are at the very bottom of that model and can help shift the initial burden to patients and out of the healthcare system.”

Poor uptake has prevented CBTI from demonstrating its potential, which is a challenge that Charles M. Morin, PhD, professor of psychology at Laval University in Quebec City, Quebec, Canada, attributes to two factors. “Clearly, there aren’t enough providers with this kind of expertise, and it’s not always covered by public health insurance, so people have to pay out of pocket to treat their insomnia,” he said.

“Overall, I think that this was a very nice study, well conducted, with an impressive sample size,” said Dr. Morin, who was not involved in the study. “The results are quite encouraging, telling us that even when older adults have used sleep medications for an average of 10 years, it’s still possible to reduce the medication. But this doesn’t happen alone. People need to be guided in doing that, not only to decrease medication use, but they also need an alternative,” he said.

Dr. Morin questioned how many patients agree to start with a low intensity. “Ideally, it should be a shared decision paradigm, where the physician or whoever sees the patient first presents the available options and explains the pluses and minuses of each. Some patients might choose medication because it’s a quick fix,” he said. “But some might want to do CBTI, even if it takes more work. The results are sustainable over time,” he added.

The study was jointly funded by the Public Health Agency of Canada and the government of New Brunswick as a Healthy Seniors Pilot Project. Dr. Gardner and Dr. Morin reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

A strategy developed by Canadian researchers for encouraging older patients with insomnia to wean themselves from sleeping pills and improve their sleep through behavioral techniques is effective, data suggest. If proven helpful for the millions of older Canadians who currently rely on nightly benzodiazepines (BZDs) and non-BZDs (colloquially known as Z drugs) for their sleep, it might yield an additional benefit: Reducing resource utilization.

“We know that cognitive behavioral therapy for insomnia (CBTI) works. It’s recommended as first-line therapy because it works,” study author David Gardner, PharmD, professor of psychiatry at Dalhousie University in Halifax, Nova Scotia, Canada, told this news organization.

“We’re sharing information about sleeping pills, information that has been embedded with behavior-change techniques that lead people to second-guess or rethink their long-term use of sedative hypnotics and then bring that information to their provider or pharmacist to discuss it,” he said.

The results were published in JAMA Psychiatry.
 

Better Sleep, Fewer Pills

Dr. Gardner and his team created a direct-to-patient, patient-directed, multicomponent knowledge mobilization intervention called Sleepwell. It incorporates best practice– and guideline-based evidence and multiple behavioral change techniques with content and graphics. Dr. Gardner emphasized that it represents a directional shift in care that alleviates providers’ burden without removing it entirely.

To test the intervention’s effectiveness, Dr. Gardner and his team chose New Brunswick as a location for a 6-month, three-arm, open-label, randomized controlled trial; the province has one of the highest rates of sedative use and an older adult population that is vulnerable to the serious side effects of these drugs (eg, cognitive impairment, falls, and frailty). The study was called Your Answers When Needing Sleep in New Brunswick (YAWNS NB).

Eligible participants were aged ≥ 65 years, lived in the community, and had taken benzodiazepine receptor agonists (BZRAs) for ≥ 3 nights per week for 3 or more months. Participants were randomly assigned to a control group or one of the two intervention groups. The YAWNS-1 intervention group (n = 195) received a mailed package containing a cover letter, a booklet outlining how to stop sleeping pills, a booklet on how to “get your sleep back,” and a companion website. The YAWNS-2 group (n = 193) received updated versions of the booklets used in a prior trial. The control group (n = 192) was assigned treatment as usual (TAU).

A greater proportion of YAWNS-1 participants discontinued BZRAs at 6 months (26.2%) and had dose reductions (20.4%), compared with YAWNS-2 participants (20.3% and 14.4%, respectively) and TAU participants (7.5% and 12.8%, respectively). The corresponding numbers needed to mail to achieve an additional discontinuation was 5.3 YAWNS-1 packages and 7.8 YAWNS-2 packages.

At 6 months, BZRA cessation was sustained a mean 13.6 weeks for YAWNS-1, 14.3 weeks for YAWNS-2, and 16.9 weeks for TAU.

Sleep measures also improved with YAWNS-1, compared with YAWNs-2 and TAU. Sleep onset latency was reduced by 26.1 minutes among YAWNS-1 participants, compared with YAWNS-2 (P < .001), and by 27.7 minutes, compared with TAU (P < .001). Wake after sleep onset increased by 4.1 minutes in YAWNS-1, 11.1 minutes in YAWNS-2, and 7.5 minutes in TAU.

Although all participants underwent rigorous assessment before inclusion, less than half of participants receiving either intervention (36% in YAWNS-1 and 43% in YAWNS-2) contacted their provider or pharmacist to discuss BZD dose reductions. This finding may have resulted partly from limited access because of the COVID-19 pandemic, according to the authors.
 

A Stepped-Care Model

The intervention is intended to help patients “change their approach from sleeping pills to a short-term CBTI course for long-term sleep benefits, and then speak to their provider,” said Dr. Gardner.

He pointed to a post-study follow-up of the study participants’ health providers, most of whom had moderate to extensive experience deprescribing BZRAs, which showed that 87.5%-100% fully or nearly fully agreed with or supported using the Sleepwell strategy and its content with older patients who rely on sedatives.

“Providers said that deprescribing is difficult, time-consuming, and often not a productive use of their time,” said Dr. Gardner. “I see insomnia as a health issue well set up for a stepped-care model. Self-help approaches are at the very bottom of that model and can help shift the initial burden to patients and out of the healthcare system.”

Poor uptake has prevented CBTI from demonstrating its potential, which is a challenge that Charles M. Morin, PhD, professor of psychology at Laval University in Quebec City, Quebec, Canada, attributes to two factors. “Clearly, there aren’t enough providers with this kind of expertise, and it’s not always covered by public health insurance, so people have to pay out of pocket to treat their insomnia,” he said.

“Overall, I think that this was a very nice study, well conducted, with an impressive sample size,” said Dr. Morin, who was not involved in the study. “The results are quite encouraging, telling us that even when older adults have used sleep medications for an average of 10 years, it’s still possible to reduce the medication. But this doesn’t happen alone. People need to be guided in doing that, not only to decrease medication use, but they also need an alternative,” he said.

Dr. Morin questioned how many patients agree to start with a low intensity. “Ideally, it should be a shared decision paradigm, where the physician or whoever sees the patient first presents the available options and explains the pluses and minuses of each. Some patients might choose medication because it’s a quick fix,” he said. “But some might want to do CBTI, even if it takes more work. The results are sustainable over time,” he added.

The study was jointly funded by the Public Health Agency of Canada and the government of New Brunswick as a Healthy Seniors Pilot Project. Dr. Gardner and Dr. Morin reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

A strategy developed by Canadian researchers for encouraging older patients with insomnia to wean themselves from sleeping pills and improve their sleep through behavioral techniques is effective, data suggest. If proven helpful for the millions of older Canadians who currently rely on nightly benzodiazepines (BZDs) and non-BZDs (colloquially known as Z drugs) for their sleep, it might yield an additional benefit: Reducing resource utilization.

“We know that cognitive behavioral therapy for insomnia (CBTI) works. It’s recommended as first-line therapy because it works,” study author David Gardner, PharmD, professor of psychiatry at Dalhousie University in Halifax, Nova Scotia, Canada, told this news organization.

“We’re sharing information about sleeping pills, information that has been embedded with behavior-change techniques that lead people to second-guess or rethink their long-term use of sedative hypnotics and then bring that information to their provider or pharmacist to discuss it,” he said.

The results were published in JAMA Psychiatry.
 

Better Sleep, Fewer Pills

Dr. Gardner and his team created a direct-to-patient, patient-directed, multicomponent knowledge mobilization intervention called Sleepwell. It incorporates best practice– and guideline-based evidence and multiple behavioral change techniques with content and graphics. Dr. Gardner emphasized that it represents a directional shift in care that alleviates providers’ burden without removing it entirely.

To test the intervention’s effectiveness, Dr. Gardner and his team chose New Brunswick as a location for a 6-month, three-arm, open-label, randomized controlled trial; the province has one of the highest rates of sedative use and an older adult population that is vulnerable to the serious side effects of these drugs (eg, cognitive impairment, falls, and frailty). The study was called Your Answers When Needing Sleep in New Brunswick (YAWNS NB).

Eligible participants were aged ≥ 65 years, lived in the community, and had taken benzodiazepine receptor agonists (BZRAs) for ≥ 3 nights per week for 3 or more months. Participants were randomly assigned to a control group or one of the two intervention groups. The YAWNS-1 intervention group (n = 195) received a mailed package containing a cover letter, a booklet outlining how to stop sleeping pills, a booklet on how to “get your sleep back,” and a companion website. The YAWNS-2 group (n = 193) received updated versions of the booklets used in a prior trial. The control group (n = 192) was assigned treatment as usual (TAU).

A greater proportion of YAWNS-1 participants discontinued BZRAs at 6 months (26.2%) and had dose reductions (20.4%), compared with YAWNS-2 participants (20.3% and 14.4%, respectively) and TAU participants (7.5% and 12.8%, respectively). The corresponding numbers needed to mail to achieve an additional discontinuation was 5.3 YAWNS-1 packages and 7.8 YAWNS-2 packages.

At 6 months, BZRA cessation was sustained a mean 13.6 weeks for YAWNS-1, 14.3 weeks for YAWNS-2, and 16.9 weeks for TAU.

Sleep measures also improved with YAWNS-1, compared with YAWNs-2 and TAU. Sleep onset latency was reduced by 26.1 minutes among YAWNS-1 participants, compared with YAWNS-2 (P < .001), and by 27.7 minutes, compared with TAU (P < .001). Wake after sleep onset increased by 4.1 minutes in YAWNS-1, 11.1 minutes in YAWNS-2, and 7.5 minutes in TAU.

Although all participants underwent rigorous assessment before inclusion, less than half of participants receiving either intervention (36% in YAWNS-1 and 43% in YAWNS-2) contacted their provider or pharmacist to discuss BZD dose reductions. This finding may have resulted partly from limited access because of the COVID-19 pandemic, according to the authors.
 

A Stepped-Care Model

The intervention is intended to help patients “change their approach from sleeping pills to a short-term CBTI course for long-term sleep benefits, and then speak to their provider,” said Dr. Gardner.

He pointed to a post-study follow-up of the study participants’ health providers, most of whom had moderate to extensive experience deprescribing BZRAs, which showed that 87.5%-100% fully or nearly fully agreed with or supported using the Sleepwell strategy and its content with older patients who rely on sedatives.

“Providers said that deprescribing is difficult, time-consuming, and often not a productive use of their time,” said Dr. Gardner. “I see insomnia as a health issue well set up for a stepped-care model. Self-help approaches are at the very bottom of that model and can help shift the initial burden to patients and out of the healthcare system.”

Poor uptake has prevented CBTI from demonstrating its potential, which is a challenge that Charles M. Morin, PhD, professor of psychology at Laval University in Quebec City, Quebec, Canada, attributes to two factors. “Clearly, there aren’t enough providers with this kind of expertise, and it’s not always covered by public health insurance, so people have to pay out of pocket to treat their insomnia,” he said.

“Overall, I think that this was a very nice study, well conducted, with an impressive sample size,” said Dr. Morin, who was not involved in the study. “The results are quite encouraging, telling us that even when older adults have used sleep medications for an average of 10 years, it’s still possible to reduce the medication. But this doesn’t happen alone. People need to be guided in doing that, not only to decrease medication use, but they also need an alternative,” he said.

Dr. Morin questioned how many patients agree to start with a low intensity. “Ideally, it should be a shared decision paradigm, where the physician or whoever sees the patient first presents the available options and explains the pluses and minuses of each. Some patients might choose medication because it’s a quick fix,” he said. “But some might want to do CBTI, even if it takes more work. The results are sustainable over time,” he added.

The study was jointly funded by the Public Health Agency of Canada and the government of New Brunswick as a Healthy Seniors Pilot Project. Dr. Gardner and Dr. Morin reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

BOSTON — With the remarkable advances made in therapy over the past decade, many patients with cystic fibrosis (CF) can expect to survive into their 50s and even well beyond. But as patients with CF live longer, they are increasingly likely to develop complications such as cardiovascular diseases (CVDs) that beset many older adults. And as evidence from a new study suggests, there is an increasing need for cardiovascular screening and specialized cardiac care for these patients.

Among more than 83,000 patients with CF hospitalized for any reason from 2016 through 2021, less than 1% of patients had a cardiac cause listed, but in unadjusted analyses, these patients had a more than twofold risk for in-hospital death than those with CF hospitalized for other causes, reported Adnan Bhat, MD, assistant professor of hospital medicine at the University of Florida, Gainesville.

Although the excess mortality was no longer statistically significant in analyses adjusted for potential confounding factors, the data highlight a trend that requires further exploration, he said during an oral abstract session at the annual meeting of the American College of Chest Physicians (CHEST).

“There’s a trend for people with cystic fibrosis admitted for cardiac causes to have a higher in-hospital mortality and increased rate of discharge to nursing facilities, especially for patients admitted for heart failure. The clinical implication is that there is an increased need to start screening for cardiovascular risk factors,” he said.
 

National Database Sample

Bhat and colleagues conducted a retrospective study using the National Inpatient Sample database to identify all hospitalizations among patients with CF in the United States from 2016 through 2021.

They included all hospitalizations with a principal diagnosis code for atrial fibrillation, heart failure, or myocardial infarction.

Of 83,250 total hospitalizations during the study period, 415 (0.5%) were for primary cardiac causes. These included 170 hospitalizations for atrial fibrillation, 95 for heart failure, and 150 for myocardial infarction.

Patients hospitalized for cardiac causes had a higher mean age (59.5 vs 34.5 years) and more comorbidities than patients hospitalized for other causes. These comorbidities included hyperlipidemia, chronic kidney disease, obesity, and a family history of coronary artery disease.

In all, 5% of patients hospitalized for cardiac cause died in hospital, compared with 2% of patients hospitalized for other reasons (P = .044).

However, in logistic regression analyses adjusting for age, sex, and race, this difference was no longer significant.

Similarly, an unadjusted analysis showed that patients with cardiac disease were twice as likely to be discharged to a nursing facility (8% vs 4%, respectively), but this difference too disappeared in adjusted analyses.

The risk for in-hospital mortality appeared to be highest among those patients with a primary diagnosis of heart failure, who had an 11% rate of in-hospital death, compared with 2% among patients with CF hospitalized for other causes.

The total number of deaths was too small, however, to allow for regression analysis, Bhat said.

Nonetheless, taken together, the data indicate a trend toward increased mortality from cardiovascular causes among older patients with CF, as well as the need for further research into the cardiovascular health of these patients, Bhat concluded.
 

Better Nutrition, Higher Risk

In an interview, Yuqing A. Gao, MD, from the Santa Monica Pulmonary Sleep Clinic in California, who was not involved in the study, commented that with the advent of elexacaftor/tezacaftor/ivacaftor modulator therapy, patients with CF tend to have increases in body mass index and improved nutritional intake and absorption, which in turn could increase hyperlipidemia and other factors that might in turn contribute to increased CVD risk.

“It’s really an interesting area of research, and there’s hope that this will bring more focus on how to better screen [for CVD risk] because that’s something that’s very much not known at this time,” she said.

Gao was co-moderator for the session where Bhat presented the data. Bhat did not report a study funding source. Bhat and Gao reported no relevant financial relationships.

A version of this article appeared on Medscape.com.

BOSTON — With the remarkable advances made in therapy over the past decade, many patients with cystic fibrosis (CF) can expect to survive into their 50s and even well beyond. But as patients with CF live longer, they are increasingly likely to develop complications such as cardiovascular diseases (CVDs) that beset many older adults. And as evidence from a new study suggests, there is an increasing need for cardiovascular screening and specialized cardiac care for these patients.

Among more than 83,000 patients with CF hospitalized for any reason from 2016 through 2021, less than 1% of patients had a cardiac cause listed, but in unadjusted analyses, these patients had a more than twofold risk for in-hospital death than those with CF hospitalized for other causes, reported Adnan Bhat, MD, assistant professor of hospital medicine at the University of Florida, Gainesville.

Although the excess mortality was no longer statistically significant in analyses adjusted for potential confounding factors, the data highlight a trend that requires further exploration, he said during an oral abstract session at the annual meeting of the American College of Chest Physicians (CHEST).

“There’s a trend for people with cystic fibrosis admitted for cardiac causes to have a higher in-hospital mortality and increased rate of discharge to nursing facilities, especially for patients admitted for heart failure. The clinical implication is that there is an increased need to start screening for cardiovascular risk factors,” he said.
 

National Database Sample

Bhat and colleagues conducted a retrospective study using the National Inpatient Sample database to identify all hospitalizations among patients with CF in the United States from 2016 through 2021.

They included all hospitalizations with a principal diagnosis code for atrial fibrillation, heart failure, or myocardial infarction.

Of 83,250 total hospitalizations during the study period, 415 (0.5%) were for primary cardiac causes. These included 170 hospitalizations for atrial fibrillation, 95 for heart failure, and 150 for myocardial infarction.

Patients hospitalized for cardiac causes had a higher mean age (59.5 vs 34.5 years) and more comorbidities than patients hospitalized for other causes. These comorbidities included hyperlipidemia, chronic kidney disease, obesity, and a family history of coronary artery disease.

In all, 5% of patients hospitalized for cardiac cause died in hospital, compared with 2% of patients hospitalized for other reasons (P = .044).

However, in logistic regression analyses adjusting for age, sex, and race, this difference was no longer significant.

Similarly, an unadjusted analysis showed that patients with cardiac disease were twice as likely to be discharged to a nursing facility (8% vs 4%, respectively), but this difference too disappeared in adjusted analyses.

The risk for in-hospital mortality appeared to be highest among those patients with a primary diagnosis of heart failure, who had an 11% rate of in-hospital death, compared with 2% among patients with CF hospitalized for other causes.

The total number of deaths was too small, however, to allow for regression analysis, Bhat said.

Nonetheless, taken together, the data indicate a trend toward increased mortality from cardiovascular causes among older patients with CF, as well as the need for further research into the cardiovascular health of these patients, Bhat concluded.
 

Better Nutrition, Higher Risk

In an interview, Yuqing A. Gao, MD, from the Santa Monica Pulmonary Sleep Clinic in California, who was not involved in the study, commented that with the advent of elexacaftor/tezacaftor/ivacaftor modulator therapy, patients with CF tend to have increases in body mass index and improved nutritional intake and absorption, which in turn could increase hyperlipidemia and other factors that might in turn contribute to increased CVD risk.

“It’s really an interesting area of research, and there’s hope that this will bring more focus on how to better screen [for CVD risk] because that’s something that’s very much not known at this time,” she said.

Gao was co-moderator for the session where Bhat presented the data. Bhat did not report a study funding source. Bhat and Gao reported no relevant financial relationships.

A version of this article appeared on Medscape.com.

BOSTON — With the remarkable advances made in therapy over the past decade, many patients with cystic fibrosis (CF) can expect to survive into their 50s and even well beyond. But as patients with CF live longer, they are increasingly likely to develop complications such as cardiovascular diseases (CVDs) that beset many older adults. And as evidence from a new study suggests, there is an increasing need for cardiovascular screening and specialized cardiac care for these patients.

Among more than 83,000 patients with CF hospitalized for any reason from 2016 through 2021, less than 1% of patients had a cardiac cause listed, but in unadjusted analyses, these patients had a more than twofold risk for in-hospital death than those with CF hospitalized for other causes, reported Adnan Bhat, MD, assistant professor of hospital medicine at the University of Florida, Gainesville.

Although the excess mortality was no longer statistically significant in analyses adjusted for potential confounding factors, the data highlight a trend that requires further exploration, he said during an oral abstract session at the annual meeting of the American College of Chest Physicians (CHEST).

“There’s a trend for people with cystic fibrosis admitted for cardiac causes to have a higher in-hospital mortality and increased rate of discharge to nursing facilities, especially for patients admitted for heart failure. The clinical implication is that there is an increased need to start screening for cardiovascular risk factors,” he said.
 

National Database Sample

Bhat and colleagues conducted a retrospective study using the National Inpatient Sample database to identify all hospitalizations among patients with CF in the United States from 2016 through 2021.

They included all hospitalizations with a principal diagnosis code for atrial fibrillation, heart failure, or myocardial infarction.

Of 83,250 total hospitalizations during the study period, 415 (0.5%) were for primary cardiac causes. These included 170 hospitalizations for atrial fibrillation, 95 for heart failure, and 150 for myocardial infarction.

Patients hospitalized for cardiac causes had a higher mean age (59.5 vs 34.5 years) and more comorbidities than patients hospitalized for other causes. These comorbidities included hyperlipidemia, chronic kidney disease, obesity, and a family history of coronary artery disease.

In all, 5% of patients hospitalized for cardiac cause died in hospital, compared with 2% of patients hospitalized for other reasons (P = .044).

However, in logistic regression analyses adjusting for age, sex, and race, this difference was no longer significant.

Similarly, an unadjusted analysis showed that patients with cardiac disease were twice as likely to be discharged to a nursing facility (8% vs 4%, respectively), but this difference too disappeared in adjusted analyses.

The risk for in-hospital mortality appeared to be highest among those patients with a primary diagnosis of heart failure, who had an 11% rate of in-hospital death, compared with 2% among patients with CF hospitalized for other causes.

The total number of deaths was too small, however, to allow for regression analysis, Bhat said.

Nonetheless, taken together, the data indicate a trend toward increased mortality from cardiovascular causes among older patients with CF, as well as the need for further research into the cardiovascular health of these patients, Bhat concluded.
 

Better Nutrition, Higher Risk

In an interview, Yuqing A. Gao, MD, from the Santa Monica Pulmonary Sleep Clinic in California, who was not involved in the study, commented that with the advent of elexacaftor/tezacaftor/ivacaftor modulator therapy, patients with CF tend to have increases in body mass index and improved nutritional intake and absorption, which in turn could increase hyperlipidemia and other factors that might in turn contribute to increased CVD risk.

“It’s really an interesting area of research, and there’s hope that this will bring more focus on how to better screen [for CVD risk] because that’s something that’s very much not known at this time,” she said.

Gao was co-moderator for the session where Bhat presented the data. Bhat did not report a study funding source. Bhat and Gao reported no relevant financial relationships.

A version of this article appeared on Medscape.com.

BOSTON — The sooner that patients with acute pulmonary embolism (PE) get treated with mechanical thrombectomy, the greater the likelihood that they will have favorable short- and long-term outcomes, regardless of their degree of initial risk, a study of registry data showed.

Among nearly 800 patients with acute PE whose data are recorded in the FlowTriever All-Comer Registry for Patient Safety and Hemodynamics (FLASH), a prospective multicenter registry of individuals treated with mechanical thrombectomy using the FlowTriever system (Inari Medical), shorter time from admission to mechanical thrombectomy was associated with significantly greater reductions in intraprocedural mean and systolic pulmonary artery pressures (PAP), greater reductions in the right ventricular/left ventricular (RV/LV) ratio, and longer 6-minute walk times at 6 months, reported Krunal H. Patel, MD, a pulmonary and critical care fellow at the Lewis Katz School of Medicine at Temple University Hospital in Philadelphia.

“Mechanical thrombectomy in the FLASH registry showed a mortality benefit. I think as time progresses and mechanical thrombectomy becomes more popular, we’re just going to need to figure out what is the ideal time for intervention,” he said during an oral abstract session at the American College of Chest Physicians (CHEST) 2024 Annual Meeting.

“There’s mortality benefit in any case whether the patient is high-risk or intermediate-high. This is a thought-provoking retrospective analysis that says that early intervention is probably better than doing it late, but regardless, the FLASH registry trial showed that early thrombectomy or thrombectomy in general shows positive mortality benefit,” Patel said in an interview.

He likened the challenge for pulmonary and critical care specialists to that of interventional cardiologists, who have determined that the ideal window for starting percutaneous coronary interventions is within 90 minutes of the patient’s arrival at the facility.

“I think we have to get our ‘door-to-balloon’ time for PE care,” he said.
 

Study Details

Patel and colleague Parth M. Rali, MD, FCCP, associate professor of thoracic medicine at Temple, conducted a retrospective review of data on 787 US patients in the FLASH registry for whom time to mechanical thrombectomy data were available. They stratified the patients into short and long time to mechanical thrombectomy groups, with “short” defined as ≤ 12 hours of presentation and “long” as > 12 hours.

They found that the median time to thrombectomy was 19.68 hours. In all, 242 patients (31%) were treated within the short window, and the remaining 545 patients (69%) were treated after at least 12 hours had passed.

Comparing clinical characteristics between the groups, the investigators noted that significantly more patients in the short time group vs long time group were categorized as high-risk (11.2% vs 6.2%; P = .0026). This difference is likely due to the need for greater urgency among high-risk patients, Patel said.

Patients in the short time group also had significantly higher baseline RV/LV ratios and lactate levels, but baseline dyspnea scores and pre-procedure median and systolic PAP were similar between the groups.

The mean time to thrombectomy was 6.08 hours in the short time group vs 34.04 hours in the long time group. Their respective median times were 6.01 and 24.73 hours.

The procedural time was similar between the groups, at 45 and 42 minutes, respectively.

The location of the treated thrombus was central only in 35.1% and 26.5% patients in the short and long time groups, respectively. Lobar-only thrombi were treated in 7.9% and 14.3%, respectively, and both central and lobar thrombi were treated in 57.0% and 59.2%, respectively.

Both 48-hour and 30-day all-cause mortality rates were similar between the groups (0.4%/0.2% and 0.5%/1.0%).

Patients in the short time group had slightly but significantly longer post-procedure hospital and intensive care unit stays, but 30-day readmission rates — whether for PE- or non-PE–related causes — were similar.

Where the differences between the groups really showed, however, were PAP reductions over baseline, with decline in median pressures of −8.7 mm Hg in the short group vs −7.2 mm Hg in the long group (P = .0008), and drops in systolic PAP of −14.4 vs −12.1 mm Hg, respectively (P = .0011).

In addition, reductions in RV/LV ratios from baseline were also significantly greater among patients whose thrombectomies had been expedited at the 48-hour, 30-day, and 6-month follow-up periods.

At 6 months, patients who had received mechanical thrombectomy within 12 hours also had significantly longer 6-minute walk distances (442.2 vs 390.5 m; P = .0032).
 

Low Thrombolysis Rate

Following his presentation, session co-moderator Galina Glazman-Kuczaj, MD, from the Division of Pulmonary and Critical Care Medicine at Albany Med Health System, Albany, New York, asked Patel what percentage of patients, if any, had received thrombolytic therapy before the thrombectomy procedure.

He noted that only 1% or 2% patients in the FLASH registry received thrombolysis.

In an interview, Glazman-Kuczaj said that “it was reassuring for [Patel] to report that it was only a small population of patients who got thrombolysis beforehand in either group because you would expect that maybe people in the group that took longer to have a thrombectomy got some thrombolysis beforehand and that perhaps they were more stable, but it seems like thrombectomy was the first-line treatment in both groups.”

The FLASH Registry is funded by Inari Medical. Patel and Glazman-Kuczaj reported no relevant financial relationships.
 

A version of this article appeared on Medscape.com.

BOSTON — The sooner that patients with acute pulmonary embolism (PE) get treated with mechanical thrombectomy, the greater the likelihood that they will have favorable short- and long-term outcomes, regardless of their degree of initial risk, a study of registry data showed.

Among nearly 800 patients with acute PE whose data are recorded in the FlowTriever All-Comer Registry for Patient Safety and Hemodynamics (FLASH), a prospective multicenter registry of individuals treated with mechanical thrombectomy using the FlowTriever system (Inari Medical), shorter time from admission to mechanical thrombectomy was associated with significantly greater reductions in intraprocedural mean and systolic pulmonary artery pressures (PAP), greater reductions in the right ventricular/left ventricular (RV/LV) ratio, and longer 6-minute walk times at 6 months, reported Krunal H. Patel, MD, a pulmonary and critical care fellow at the Lewis Katz School of Medicine at Temple University Hospital in Philadelphia.

“Mechanical thrombectomy in the FLASH registry showed a mortality benefit. I think as time progresses and mechanical thrombectomy becomes more popular, we’re just going to need to figure out what is the ideal time for intervention,” he said during an oral abstract session at the American College of Chest Physicians (CHEST) 2024 Annual Meeting.

“There’s mortality benefit in any case whether the patient is high-risk or intermediate-high. This is a thought-provoking retrospective analysis that says that early intervention is probably better than doing it late, but regardless, the FLASH registry trial showed that early thrombectomy or thrombectomy in general shows positive mortality benefit,” Patel said in an interview.

He likened the challenge for pulmonary and critical care specialists to that of interventional cardiologists, who have determined that the ideal window for starting percutaneous coronary interventions is within 90 minutes of the patient’s arrival at the facility.

“I think we have to get our ‘door-to-balloon’ time for PE care,” he said.
 

Study Details

Patel and colleague Parth M. Rali, MD, FCCP, associate professor of thoracic medicine at Temple, conducted a retrospective review of data on 787 US patients in the FLASH registry for whom time to mechanical thrombectomy data were available. They stratified the patients into short and long time to mechanical thrombectomy groups, with “short” defined as ≤ 12 hours of presentation and “long” as > 12 hours.

They found that the median time to thrombectomy was 19.68 hours. In all, 242 patients (31%) were treated within the short window, and the remaining 545 patients (69%) were treated after at least 12 hours had passed.

Comparing clinical characteristics between the groups, the investigators noted that significantly more patients in the short time group vs long time group were categorized as high-risk (11.2% vs 6.2%; P = .0026). This difference is likely due to the need for greater urgency among high-risk patients, Patel said.

Patients in the short time group also had significantly higher baseline RV/LV ratios and lactate levels, but baseline dyspnea scores and pre-procedure median and systolic PAP were similar between the groups.

The mean time to thrombectomy was 6.08 hours in the short time group vs 34.04 hours in the long time group. Their respective median times were 6.01 and 24.73 hours.

The procedural time was similar between the groups, at 45 and 42 minutes, respectively.

The location of the treated thrombus was central only in 35.1% and 26.5% patients in the short and long time groups, respectively. Lobar-only thrombi were treated in 7.9% and 14.3%, respectively, and both central and lobar thrombi were treated in 57.0% and 59.2%, respectively.

Both 48-hour and 30-day all-cause mortality rates were similar between the groups (0.4%/0.2% and 0.5%/1.0%).

Patients in the short time group had slightly but significantly longer post-procedure hospital and intensive care unit stays, but 30-day readmission rates — whether for PE- or non-PE–related causes — were similar.

Where the differences between the groups really showed, however, were PAP reductions over baseline, with decline in median pressures of −8.7 mm Hg in the short group vs −7.2 mm Hg in the long group (P = .0008), and drops in systolic PAP of −14.4 vs −12.1 mm Hg, respectively (P = .0011).

In addition, reductions in RV/LV ratios from baseline were also significantly greater among patients whose thrombectomies had been expedited at the 48-hour, 30-day, and 6-month follow-up periods.

At 6 months, patients who had received mechanical thrombectomy within 12 hours also had significantly longer 6-minute walk distances (442.2 vs 390.5 m; P = .0032).
 

Low Thrombolysis Rate

Following his presentation, session co-moderator Galina Glazman-Kuczaj, MD, from the Division of Pulmonary and Critical Care Medicine at Albany Med Health System, Albany, New York, asked Patel what percentage of patients, if any, had received thrombolytic therapy before the thrombectomy procedure.

He noted that only 1% or 2% patients in the FLASH registry received thrombolysis.

In an interview, Glazman-Kuczaj said that “it was reassuring for [Patel] to report that it was only a small population of patients who got thrombolysis beforehand in either group because you would expect that maybe people in the group that took longer to have a thrombectomy got some thrombolysis beforehand and that perhaps they were more stable, but it seems like thrombectomy was the first-line treatment in both groups.”

The FLASH Registry is funded by Inari Medical. Patel and Glazman-Kuczaj reported no relevant financial relationships.
 

A version of this article appeared on Medscape.com.

BOSTON — The sooner that patients with acute pulmonary embolism (PE) get treated with mechanical thrombectomy, the greater the likelihood that they will have favorable short- and long-term outcomes, regardless of their degree of initial risk, a study of registry data showed.

Among nearly 800 patients with acute PE whose data are recorded in the FlowTriever All-Comer Registry for Patient Safety and Hemodynamics (FLASH), a prospective multicenter registry of individuals treated with mechanical thrombectomy using the FlowTriever system (Inari Medical), shorter time from admission to mechanical thrombectomy was associated with significantly greater reductions in intraprocedural mean and systolic pulmonary artery pressures (PAP), greater reductions in the right ventricular/left ventricular (RV/LV) ratio, and longer 6-minute walk times at 6 months, reported Krunal H. Patel, MD, a pulmonary and critical care fellow at the Lewis Katz School of Medicine at Temple University Hospital in Philadelphia.

“Mechanical thrombectomy in the FLASH registry showed a mortality benefit. I think as time progresses and mechanical thrombectomy becomes more popular, we’re just going to need to figure out what is the ideal time for intervention,” he said during an oral abstract session at the American College of Chest Physicians (CHEST) 2024 Annual Meeting.

“There’s mortality benefit in any case whether the patient is high-risk or intermediate-high. This is a thought-provoking retrospective analysis that says that early intervention is probably better than doing it late, but regardless, the FLASH registry trial showed that early thrombectomy or thrombectomy in general shows positive mortality benefit,” Patel said in an interview.

He likened the challenge for pulmonary and critical care specialists to that of interventional cardiologists, who have determined that the ideal window for starting percutaneous coronary interventions is within 90 minutes of the patient’s arrival at the facility.

“I think we have to get our ‘door-to-balloon’ time for PE care,” he said.
 

Study Details

Patel and colleague Parth M. Rali, MD, FCCP, associate professor of thoracic medicine at Temple, conducted a retrospective review of data on 787 US patients in the FLASH registry for whom time to mechanical thrombectomy data were available. They stratified the patients into short and long time to mechanical thrombectomy groups, with “short” defined as ≤ 12 hours of presentation and “long” as > 12 hours.

They found that the median time to thrombectomy was 19.68 hours. In all, 242 patients (31%) were treated within the short window, and the remaining 545 patients (69%) were treated after at least 12 hours had passed.

Comparing clinical characteristics between the groups, the investigators noted that significantly more patients in the short time group vs long time group were categorized as high-risk (11.2% vs 6.2%; P = .0026). This difference is likely due to the need for greater urgency among high-risk patients, Patel said.

Patients in the short time group also had significantly higher baseline RV/LV ratios and lactate levels, but baseline dyspnea scores and pre-procedure median and systolic PAP were similar between the groups.

The mean time to thrombectomy was 6.08 hours in the short time group vs 34.04 hours in the long time group. Their respective median times were 6.01 and 24.73 hours.

The procedural time was similar between the groups, at 45 and 42 minutes, respectively.

The location of the treated thrombus was central only in 35.1% and 26.5% patients in the short and long time groups, respectively. Lobar-only thrombi were treated in 7.9% and 14.3%, respectively, and both central and lobar thrombi were treated in 57.0% and 59.2%, respectively.

Both 48-hour and 30-day all-cause mortality rates were similar between the groups (0.4%/0.2% and 0.5%/1.0%).

Patients in the short time group had slightly but significantly longer post-procedure hospital and intensive care unit stays, but 30-day readmission rates — whether for PE- or non-PE–related causes — were similar.

Where the differences between the groups really showed, however, were PAP reductions over baseline, with decline in median pressures of −8.7 mm Hg in the short group vs −7.2 mm Hg in the long group (P = .0008), and drops in systolic PAP of −14.4 vs −12.1 mm Hg, respectively (P = .0011).

In addition, reductions in RV/LV ratios from baseline were also significantly greater among patients whose thrombectomies had been expedited at the 48-hour, 30-day, and 6-month follow-up periods.

At 6 months, patients who had received mechanical thrombectomy within 12 hours also had significantly longer 6-minute walk distances (442.2 vs 390.5 m; P = .0032).
 

Low Thrombolysis Rate

Following his presentation, session co-moderator Galina Glazman-Kuczaj, MD, from the Division of Pulmonary and Critical Care Medicine at Albany Med Health System, Albany, New York, asked Patel what percentage of patients, if any, had received thrombolytic therapy before the thrombectomy procedure.

He noted that only 1% or 2% patients in the FLASH registry received thrombolysis.

In an interview, Glazman-Kuczaj said that “it was reassuring for [Patel] to report that it was only a small population of patients who got thrombolysis beforehand in either group because you would expect that maybe people in the group that took longer to have a thrombectomy got some thrombolysis beforehand and that perhaps they were more stable, but it seems like thrombectomy was the first-line treatment in both groups.”

The FLASH Registry is funded by Inari Medical. Patel and Glazman-Kuczaj reported no relevant financial relationships.
 

A version of this article appeared on Medscape.com.