Pulmonology

Approximately 20% of adults screened for early lung cancer met criteria undiagnosed chronic obstructive pulmonary disease (COPD), based on new data from approximately 300 individuals presented at the American Thoracic Society (ATS) 2026 International Conference.

“Patients undergoing lung cancer screening with low-dose CT scans represent a high-risk population for smoking-related lung disease, including COPD,” said lead author Stephen Dachert, MD, assistant professor of clinical thoracic medicine at the Lewis Katz School of Medicine at Temple University, Philadelphia.

“While lung cancer screening programs are well established, COPD remains frequently underrecognized despite many patients having respiratory symptoms, airflow obstruction, and structural lung abnormalities detectable during screening,” Dachert told Medscape Medical News. Currently, the US Preventive Services Task Force does not recommend routine COPD screening, he noted.

To evaluate how often COPD was being missed and whether patients were receiving appropriate therapy, a particular concern in underserved populations, Dachert and colleagues reviewed data from electronic medical record, and pre-bronchodilator spirometry data were collected for 305 adults enrolled in the Temple Healthy Chest Initiative. Symptom burden was assessed using questionnaires about prior inhaler use and the COPD Airway Assessment Test (CAAT). The median age of the participants was 63 years; 182 were women, and 187 were active smokers. Most of the participants (228) self-identified as Black/African American, 42 as non-Caucasian Hispanic, and 31 as White/Caucasian.

About half of the participants (52%) had no previous COPD diagnosis. Of these, 49 (31.2%) had evidence of airflow obstruction, and almost all (97%) had symptoms defined as CAAT scores of > 1 for mucus, cough, or breathlessness.

Overall, “Twenty-one percent met criteria for undiagnosed COPD based on airflow obstruction and positive CAAT symptoms, and many had moderate disease severity by GOLD COPD classification,” Dachert said.

The high prevalence of previously undiagnosed COPD, despite a substantial symptom burden, was a striking finding, Dachert told Medscape Medical News. “We were also struck by the degree of undertreatment, with more than 60% of these patients not receiving any inhaler therapy,” he added. Among the 48 undiagnosed COPD patients in the total cohort, approximately 10% had received short-acting beta 2-agonist-only therapy.

“While prior studies have suggested underdiagnosis in lung cancer screening populations, the magnitude seen in this predominantly minority cohort reinforces how common missed opportunities for diagnosis remain in clinical practice,” Dachert said.

The findings were limited by the use of data from a single region and may not be generalized to other areas. However, the results suggest that lung cancer screening (LCS) programs are an opportunity to identify and treat chronic smoking-related lung disease, Dachert said. “Incorporating spirometry, symptom assessment, and review of respiratory therapies into LCS programs may help identify patients with clinically significant but previously unrecognized COPD, and earlier diagnosis could allow for smoking cessation reinforcement, initiation of evidence-based inhaler therapy, symptom improvement, and potentially reduction in exacerbations and health care utilization,” he said.

“Future studies should evaluate whether systematic COPD screening embedded within lung cancer screening programs improves clinical outcomes such as quality of life, exacerbations, hospitalizations, and healthcare utilization,” Dachert said. Additional work is needed to determine the best combination of screening tools to efficiently identify high-risk patients, which may include spirometry, quantitative CT imaging, symptom questionnaires, and biomarkers, he noted. “Longitudinal studies may help clarify whether earlier identification during lung cancer screening changes disease trajectory over time,” Dachert added.

Value Added for Underserved Populations

The new study’s results suggest that incorporating routine symptom assessment and spirometry into LCS pathways may improve earlier diagnosis and optimization of COPD management, said Jesse R. Sherratt, DO, a pulmonologist and critical care specialist at the University of Texas Health Science Center at San Antonio.

“Individuals undergoing lung cancer screening are at particularly high risk for smoking-related lung disease, yet COPD frequently remains unrecognized and untreated in this population,” said Sherratt, who was not involved in the study. The current study highlights the potential value, particularly among underserved populations, of incorporating spirometry and symptom assessment into LCS programs for earlier identification of patients with clinically significant COPD, he said.

The high rates of undiagnosed COPD and undertreatment were not unexpected, given the substantial smoking exposure and high-risk characteristics of patients undergoing LCS, said Sherratt. “However, the degree of symptom burden and the disproportionate impact on minority populations were especially notable and emphasize ongoing disparities in respiratory healthcare access and diagnosis,” he said.

“Additional studies are needed to determine whether integrating spirometry and structured COPD screening into lung cancer screening programs improves long-term clinical outcomes, healthcare utilization, and quality of life,” Sherratt noted. Further research also should evaluate strategies to reduce disparities in COPD diagnosis and treatment among minority populations, he said.

The study was supported by grants from AstraZeneca and the Temple Lung Center. AstraZeneca collaborators participated in the study as coauthors. Sherratt had no financial conflicts to disclose.

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

Approximately 20% of adults screened for early lung cancer met criteria undiagnosed chronic obstructive pulmonary disease (COPD), based on new data from approximately 300 individuals presented at the American Thoracic Society (ATS) 2026 International Conference.

“Patients undergoing lung cancer screening with low-dose CT scans represent a high-risk population for smoking-related lung disease, including COPD,” said lead author Stephen Dachert, MD, assistant professor of clinical thoracic medicine at the Lewis Katz School of Medicine at Temple University, Philadelphia.

“While lung cancer screening programs are well established, COPD remains frequently underrecognized despite many patients having respiratory symptoms, airflow obstruction, and structural lung abnormalities detectable during screening,” Dachert told Medscape Medical News. Currently, the US Preventive Services Task Force does not recommend routine COPD screening, he noted.

To evaluate how often COPD was being missed and whether patients were receiving appropriate therapy, a particular concern in underserved populations, Dachert and colleagues reviewed data from electronic medical record, and pre-bronchodilator spirometry data were collected for 305 adults enrolled in the Temple Healthy Chest Initiative. Symptom burden was assessed using questionnaires about prior inhaler use and the COPD Airway Assessment Test (CAAT). The median age of the participants was 63 years; 182 were women, and 187 were active smokers. Most of the participants (228) self-identified as Black/African American, 42 as non-Caucasian Hispanic, and 31 as White/Caucasian.

About half of the participants (52%) had no previous COPD diagnosis. Of these, 49 (31.2%) had evidence of airflow obstruction, and almost all (97%) had symptoms defined as CAAT scores of > 1 for mucus, cough, or breathlessness.

Overall, “Twenty-one percent met criteria for undiagnosed COPD based on airflow obstruction and positive CAAT symptoms, and many had moderate disease severity by GOLD COPD classification,” Dachert said.

The high prevalence of previously undiagnosed COPD, despite a substantial symptom burden, was a striking finding, Dachert told Medscape Medical News. “We were also struck by the degree of undertreatment, with more than 60% of these patients not receiving any inhaler therapy,” he added. Among the 48 undiagnosed COPD patients in the total cohort, approximately 10% had received short-acting beta 2-agonist-only therapy.

“While prior studies have suggested underdiagnosis in lung cancer screening populations, the magnitude seen in this predominantly minority cohort reinforces how common missed opportunities for diagnosis remain in clinical practice,” Dachert said.

The findings were limited by the use of data from a single region and may not be generalized to other areas. However, the results suggest that lung cancer screening (LCS) programs are an opportunity to identify and treat chronic smoking-related lung disease, Dachert said. “Incorporating spirometry, symptom assessment, and review of respiratory therapies into LCS programs may help identify patients with clinically significant but previously unrecognized COPD, and earlier diagnosis could allow for smoking cessation reinforcement, initiation of evidence-based inhaler therapy, symptom improvement, and potentially reduction in exacerbations and health care utilization,” he said.

“Future studies should evaluate whether systematic COPD screening embedded within lung cancer screening programs improves clinical outcomes such as quality of life, exacerbations, hospitalizations, and healthcare utilization,” Dachert said. Additional work is needed to determine the best combination of screening tools to efficiently identify high-risk patients, which may include spirometry, quantitative CT imaging, symptom questionnaires, and biomarkers, he noted. “Longitudinal studies may help clarify whether earlier identification during lung cancer screening changes disease trajectory over time,” Dachert added.

Value Added for Underserved Populations

The new study’s results suggest that incorporating routine symptom assessment and spirometry into LCS pathways may improve earlier diagnosis and optimization of COPD management, said Jesse R. Sherratt, DO, a pulmonologist and critical care specialist at the University of Texas Health Science Center at San Antonio.

“Individuals undergoing lung cancer screening are at particularly high risk for smoking-related lung disease, yet COPD frequently remains unrecognized and untreated in this population,” said Sherratt, who was not involved in the study. The current study highlights the potential value, particularly among underserved populations, of incorporating spirometry and symptom assessment into LCS programs for earlier identification of patients with clinically significant COPD, he said.

The high rates of undiagnosed COPD and undertreatment were not unexpected, given the substantial smoking exposure and high-risk characteristics of patients undergoing LCS, said Sherratt. “However, the degree of symptom burden and the disproportionate impact on minority populations were especially notable and emphasize ongoing disparities in respiratory healthcare access and diagnosis,” he said.

“Additional studies are needed to determine whether integrating spirometry and structured COPD screening into lung cancer screening programs improves long-term clinical outcomes, healthcare utilization, and quality of life,” Sherratt noted. Further research also should evaluate strategies to reduce disparities in COPD diagnosis and treatment among minority populations, he said.

The study was supported by grants from AstraZeneca and the Temple Lung Center. AstraZeneca collaborators participated in the study as coauthors. Sherratt had no financial conflicts to disclose.

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

Approximately 20% of adults screened for early lung cancer met criteria undiagnosed chronic obstructive pulmonary disease (COPD), based on new data from approximately 300 individuals presented at the American Thoracic Society (ATS) 2026 International Conference.

“Patients undergoing lung cancer screening with low-dose CT scans represent a high-risk population for smoking-related lung disease, including COPD,” said lead author Stephen Dachert, MD, assistant professor of clinical thoracic medicine at the Lewis Katz School of Medicine at Temple University, Philadelphia.

“While lung cancer screening programs are well established, COPD remains frequently underrecognized despite many patients having respiratory symptoms, airflow obstruction, and structural lung abnormalities detectable during screening,” Dachert told Medscape Medical News. Currently, the US Preventive Services Task Force does not recommend routine COPD screening, he noted.

To evaluate how often COPD was being missed and whether patients were receiving appropriate therapy, a particular concern in underserved populations, Dachert and colleagues reviewed data from electronic medical record, and pre-bronchodilator spirometry data were collected for 305 adults enrolled in the Temple Healthy Chest Initiative. Symptom burden was assessed using questionnaires about prior inhaler use and the COPD Airway Assessment Test (CAAT). The median age of the participants was 63 years; 182 were women, and 187 were active smokers. Most of the participants (228) self-identified as Black/African American, 42 as non-Caucasian Hispanic, and 31 as White/Caucasian.

About half of the participants (52%) had no previous COPD diagnosis. Of these, 49 (31.2%) had evidence of airflow obstruction, and almost all (97%) had symptoms defined as CAAT scores of > 1 for mucus, cough, or breathlessness.

Overall, “Twenty-one percent met criteria for undiagnosed COPD based on airflow obstruction and positive CAAT symptoms, and many had moderate disease severity by GOLD COPD classification,” Dachert said.

The high prevalence of previously undiagnosed COPD, despite a substantial symptom burden, was a striking finding, Dachert told Medscape Medical News. “We were also struck by the degree of undertreatment, with more than 60% of these patients not receiving any inhaler therapy,” he added. Among the 48 undiagnosed COPD patients in the total cohort, approximately 10% had received short-acting beta 2-agonist-only therapy.

“While prior studies have suggested underdiagnosis in lung cancer screening populations, the magnitude seen in this predominantly minority cohort reinforces how common missed opportunities for diagnosis remain in clinical practice,” Dachert said.

The findings were limited by the use of data from a single region and may not be generalized to other areas. However, the results suggest that lung cancer screening (LCS) programs are an opportunity to identify and treat chronic smoking-related lung disease, Dachert said. “Incorporating spirometry, symptom assessment, and review of respiratory therapies into LCS programs may help identify patients with clinically significant but previously unrecognized COPD, and earlier diagnosis could allow for smoking cessation reinforcement, initiation of evidence-based inhaler therapy, symptom improvement, and potentially reduction in exacerbations and health care utilization,” he said.

“Future studies should evaluate whether systematic COPD screening embedded within lung cancer screening programs improves clinical outcomes such as quality of life, exacerbations, hospitalizations, and healthcare utilization,” Dachert said. Additional work is needed to determine the best combination of screening tools to efficiently identify high-risk patients, which may include spirometry, quantitative CT imaging, symptom questionnaires, and biomarkers, he noted. “Longitudinal studies may help clarify whether earlier identification during lung cancer screening changes disease trajectory over time,” Dachert added.

Value Added for Underserved Populations

The new study’s results suggest that incorporating routine symptom assessment and spirometry into LCS pathways may improve earlier diagnosis and optimization of COPD management, said Jesse R. Sherratt, DO, a pulmonologist and critical care specialist at the University of Texas Health Science Center at San Antonio.

“Individuals undergoing lung cancer screening are at particularly high risk for smoking-related lung disease, yet COPD frequently remains unrecognized and untreated in this population,” said Sherratt, who was not involved in the study. The current study highlights the potential value, particularly among underserved populations, of incorporating spirometry and symptom assessment into LCS programs for earlier identification of patients with clinically significant COPD, he said.

The high rates of undiagnosed COPD and undertreatment were not unexpected, given the substantial smoking exposure and high-risk characteristics of patients undergoing LCS, said Sherratt. “However, the degree of symptom burden and the disproportionate impact on minority populations were especially notable and emphasize ongoing disparities in respiratory healthcare access and diagnosis,” he said.

“Additional studies are needed to determine whether integrating spirometry and structured COPD screening into lung cancer screening programs improves long-term clinical outcomes, healthcare utilization, and quality of life,” Sherratt noted. Further research also should evaluate strategies to reduce disparities in COPD diagnosis and treatment among minority populations, he said.

The study was supported by grants from AstraZeneca and the Temple Lung Center. AstraZeneca collaborators participated in the study as coauthors. Sherratt had no financial conflicts to disclose.

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

Treatment with ralinepag, an investigational prostacyclin receptor agonist, reduced the risk for clinical disease worsening by 55% compared to placebo in patients with pulmonary arterial hypertension (PAH), based on new data from the ADVANCE Outcomes study presented at the American Thoracic Society (ATS) 2026 International Conference.

Ralinepag works by restoring prostacyclin signaling and activating prostacyclin receptors to affect pathways that play a role in the progression of PAH. The drug was originally formulated as an immediate-release capsule but modified to the extended-release tablet used in the current study as a way to optimize once daily dosing.

“The prostacyclin pathway is foundational in the management of PAH, and advancing prostacyclin science has benefited patients over the years,” said lead author Vallerie V. McLaughlin, MD, professor of cardiovascular medicine and director of the Pulmonary Hypertension Program at the University of Michigan, Ann Arbor, Michigan, who presented the findings at the meeting. Although other oral prostacyclin pathway agents available, ralinepag has the advantages of high potency and longer half-life that could be effective and well-tolerated in a more patient-friendly once daily formulation, McLaughlin said.

The international study population included 687 adults with PAH from 30 countries across five continents. Participants were randomized to ralinepag or placebo in addition to their standard PAH background therapies. Ralinepag was orally dosed once daily and titrated for tolerability and response. The mean age of the participants was 52 years, 80% were White, and the median time since PAH diagnosis was 2.3 years. A majority of 62% had idiopathic or heritable PAH, 28.2% had PAH as a result of connective tissue disease, 4.1% had a congenital heart defect, 3.1% had drug- or toxin-induced PAH, and 2.6% had PAH as a result of HIV infection. More than two thirds were considered low risk (characterized as Functional Class II).

The primary endpoint was the time to first indication of clinical worsening, which was defined as death, hospital admission for worsening PAH, initiation of a parenteral or inhaled prostacyclin pathway agent for worsening PAH, or unsatisfactory long-term clinical response.

Overall, patients treated with ralinepag were significantly less likely to experience a clinical worsening event than placebo patients (hazard ratio [HR], 0.45; 95% CI, 0.33-0.62; P < .0001), and 47% more likely to achieve the secondary endpoint of clinical improvement (P = .015).

Patients treated with ralinepag also showed significant improvements over placebo patients in the secondary endpoints of pro-B-type natriuretic peptide levels (24.3% reduction from baseline to week 28 over placebo; P = .0013), and in the 6-minute walk test (a placebo-corrected difference of 20.4 m from baseline to week 28; P = .0033).

Although more than 90% of participants treated with ralinepag reported an adverse event related to the drug, approximately 5% experienced drug-related serious adverse events, and the overall safety profile reflected previous ralinepag studies, with a positive risk-benefit ratio, the investigators noted.

Support for Early Introduction

The researchers expected the efficacy associated with prostacyclin therapy, said McLaughlin. “We were very pleased to see such a strong treatment effect in a relatively low-risk population, primarily Functional Class II with a mean 6-minute walk of nearly 440 meters, with the majority of patients on dual oral therapy,” she said.

If approved, ralinepag could help optimized risk status in PAH, said McLaughlin. “Many patients do not get to low risk with first-line therapy, and oral and inhaled prostacyclin pathway agents are often used in addition to dual therapy with phosphodiesterase type-5 inhibitors and endothelin receptor antagonists,” she said. “The impressive treatment effect of ralinepag in patients primarily treated with dual oral therapy reflects this real-world scenario,” she added. The significant event reduction makes a case for earlier introduction of ralinepag in relatively low-risk patients; a highly effective therapy that targets the prostacyclin pathway may reduce the need for more cumbersome and invasive prostacyclin therapies, McLaughlin added.

Ralinepag remains an investigational drug, but the company plans to seek a New Drug Application from the FDA for the treatment of PAH by the second half of 2026, according to a press release.

The research team would like to continue evaluating the ADVANCE Outcomes database to learn more about dose response, tolerability, and subgroup response, said McLaughlin. At that point, real-world data would be useful, and additional research areas in that setting would include combination therapy with other agents such as sotatercept, as well as the use of ralinepag to transition patients on more complicated and invasive therapy, she said.

Attention to Adverse Effects

Prostacyclin therapies are often offered in oral, inhaled, and the most invasive intravenous/subcutaneous routes, but a gap remains between the strong efficacy seen with parenteral therapy and what many patients are willing or able to use in real-world practice, said Parth M. Rali, MD, director of the Temple University Health System Pulmonary Embolism Response Team Program, Section Temple Lung Pulmonary Vascular Disease Program, Philadelphia, who was not involved in the study.

“Ralinepag provides sustained activation of IP receptors and has very long effective half-life, giving drug exposure comparable to parenteral therapy, and offers the first daily treatment option, which is important for the patients with PAH who are often on multiple drugs therapies,” Rali said.

Given the encouraging phase 2 findings demonstrating meaningful reductions in pulmonary vascular resistance and signals toward clinical benefit, we would like to see a favorable outcome in the phase 3 program. Primary outcome studied was time to clinical worsening in the large, randomized trial that involved global populations from the US, Europe, Latin-America, and Asia Pacific Region. Ralinepag arm had 55% reduction in risk for clinical worsening (HR, ~ 0.45) compared to placebo arm. “The positive results of the trial were primarily driven by disease progression, initiation of prostacyclin therapy, and unsatisfactory long-term clinical response at 28 weeks in ralinepag group compared to placebo group,” Rali said.

Although ralinepag offers a good option for once-a-day oral prostacyclin options for the patients, the significant number of patients in the new study who discontinued because of adverse effects is notable, said Rali. “Treating clinicians will have to watch very closely, as the real-world patient population seems to be more complex than clinical trial populations,” he said. “At the same time, clinicians will have an option to weigh against growing list of inhaled prostacyclin pathway therapies that may not have systemic side effects of the oral agents,” he added.

“Given the strong scientific data in the ADVANCE trials, ralinepag may become drug of choice for oral prostacyclin pathway agents,” Rali added. However, its place in the treatment sequence, whether it is best used early in the disease course, as an add-on for patients already receiving dual oral therapy, or potentially part of upfront combination strategies, will call for some clinician judgement, Rali said. “Patient education and gradual dose titration will likely play a major role in improving adherence and limiting prostacyclin-related adverse effects,” he added.

Questions for future research include what percentage of the patients were able to tolerate the maximum dose of the drug, and whether any changes in primary or secondary outcomes occurred depending on the dose, said Rali. Other areas of interest include whether certain patient populations derive greater benefit than others, including connective tissue disease-associated PAH, idiopathic PAH, and higher-risk patient populations. “Comparative effectiveness data against currently available oral prostacyclin pathway agents and studies evaluating transition strategies from parenteral or inhaled therapies would help clinicians better understand where ralinepag ultimately fits in the PAH treatment algorithm,” Rali said. “I also would be curious to see what the authors thought of the failure to achieve the primary endpoint in cohorts of patients from Latin America and Asia Pacific regions,” he added.

The study was funded by United Therapeutics, and McLaughlin disclosed serving as a consultant for the company. Rali had no financial conflicts to disclose.

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

Treatment with ralinepag, an investigational prostacyclin receptor agonist, reduced the risk for clinical disease worsening by 55% compared to placebo in patients with pulmonary arterial hypertension (PAH), based on new data from the ADVANCE Outcomes study presented at the American Thoracic Society (ATS) 2026 International Conference.

Ralinepag works by restoring prostacyclin signaling and activating prostacyclin receptors to affect pathways that play a role in the progression of PAH. The drug was originally formulated as an immediate-release capsule but modified to the extended-release tablet used in the current study as a way to optimize once daily dosing.

“The prostacyclin pathway is foundational in the management of PAH, and advancing prostacyclin science has benefited patients over the years,” said lead author Vallerie V. McLaughlin, MD, professor of cardiovascular medicine and director of the Pulmonary Hypertension Program at the University of Michigan, Ann Arbor, Michigan, who presented the findings at the meeting. Although other oral prostacyclin pathway agents available, ralinepag has the advantages of high potency and longer half-life that could be effective and well-tolerated in a more patient-friendly once daily formulation, McLaughlin said.

The international study population included 687 adults with PAH from 30 countries across five continents. Participants were randomized to ralinepag or placebo in addition to their standard PAH background therapies. Ralinepag was orally dosed once daily and titrated for tolerability and response. The mean age of the participants was 52 years, 80% were White, and the median time since PAH diagnosis was 2.3 years. A majority of 62% had idiopathic or heritable PAH, 28.2% had PAH as a result of connective tissue disease, 4.1% had a congenital heart defect, 3.1% had drug- or toxin-induced PAH, and 2.6% had PAH as a result of HIV infection. More than two thirds were considered low risk (characterized as Functional Class II).

The primary endpoint was the time to first indication of clinical worsening, which was defined as death, hospital admission for worsening PAH, initiation of a parenteral or inhaled prostacyclin pathway agent for worsening PAH, or unsatisfactory long-term clinical response.

Overall, patients treated with ralinepag were significantly less likely to experience a clinical worsening event than placebo patients (hazard ratio [HR], 0.45; 95% CI, 0.33-0.62; P < .0001), and 47% more likely to achieve the secondary endpoint of clinical improvement (P = .015).

Patients treated with ralinepag also showed significant improvements over placebo patients in the secondary endpoints of pro-B-type natriuretic peptide levels (24.3% reduction from baseline to week 28 over placebo; P = .0013), and in the 6-minute walk test (a placebo-corrected difference of 20.4 m from baseline to week 28; P = .0033).

Although more than 90% of participants treated with ralinepag reported an adverse event related to the drug, approximately 5% experienced drug-related serious adverse events, and the overall safety profile reflected previous ralinepag studies, with a positive risk-benefit ratio, the investigators noted.

Support for Early Introduction

The researchers expected the efficacy associated with prostacyclin therapy, said McLaughlin. “We were very pleased to see such a strong treatment effect in a relatively low-risk population, primarily Functional Class II with a mean 6-minute walk of nearly 440 meters, with the majority of patients on dual oral therapy,” she said.

If approved, ralinepag could help optimized risk status in PAH, said McLaughlin. “Many patients do not get to low risk with first-line therapy, and oral and inhaled prostacyclin pathway agents are often used in addition to dual therapy with phosphodiesterase type-5 inhibitors and endothelin receptor antagonists,” she said. “The impressive treatment effect of ralinepag in patients primarily treated with dual oral therapy reflects this real-world scenario,” she added. The significant event reduction makes a case for earlier introduction of ralinepag in relatively low-risk patients; a highly effective therapy that targets the prostacyclin pathway may reduce the need for more cumbersome and invasive prostacyclin therapies, McLaughlin added.

Ralinepag remains an investigational drug, but the company plans to seek a New Drug Application from the FDA for the treatment of PAH by the second half of 2026, according to a press release.

The research team would like to continue evaluating the ADVANCE Outcomes database to learn more about dose response, tolerability, and subgroup response, said McLaughlin. At that point, real-world data would be useful, and additional research areas in that setting would include combination therapy with other agents such as sotatercept, as well as the use of ralinepag to transition patients on more complicated and invasive therapy, she said.

Attention to Adverse Effects

Prostacyclin therapies are often offered in oral, inhaled, and the most invasive intravenous/subcutaneous routes, but a gap remains between the strong efficacy seen with parenteral therapy and what many patients are willing or able to use in real-world practice, said Parth M. Rali, MD, director of the Temple University Health System Pulmonary Embolism Response Team Program, Section Temple Lung Pulmonary Vascular Disease Program, Philadelphia, who was not involved in the study.

“Ralinepag provides sustained activation of IP receptors and has very long effective half-life, giving drug exposure comparable to parenteral therapy, and offers the first daily treatment option, which is important for the patients with PAH who are often on multiple drugs therapies,” Rali said.

Given the encouraging phase 2 findings demonstrating meaningful reductions in pulmonary vascular resistance and signals toward clinical benefit, we would like to see a favorable outcome in the phase 3 program. Primary outcome studied was time to clinical worsening in the large, randomized trial that involved global populations from the US, Europe, Latin-America, and Asia Pacific Region. Ralinepag arm had 55% reduction in risk for clinical worsening (HR, ~ 0.45) compared to placebo arm. “The positive results of the trial were primarily driven by disease progression, initiation of prostacyclin therapy, and unsatisfactory long-term clinical response at 28 weeks in ralinepag group compared to placebo group,” Rali said.

Although ralinepag offers a good option for once-a-day oral prostacyclin options for the patients, the significant number of patients in the new study who discontinued because of adverse effects is notable, said Rali. “Treating clinicians will have to watch very closely, as the real-world patient population seems to be more complex than clinical trial populations,” he said. “At the same time, clinicians will have an option to weigh against growing list of inhaled prostacyclin pathway therapies that may not have systemic side effects of the oral agents,” he added.

“Given the strong scientific data in the ADVANCE trials, ralinepag may become drug of choice for oral prostacyclin pathway agents,” Rali added. However, its place in the treatment sequence, whether it is best used early in the disease course, as an add-on for patients already receiving dual oral therapy, or potentially part of upfront combination strategies, will call for some clinician judgement, Rali said. “Patient education and gradual dose titration will likely play a major role in improving adherence and limiting prostacyclin-related adverse effects,” he added.

Questions for future research include what percentage of the patients were able to tolerate the maximum dose of the drug, and whether any changes in primary or secondary outcomes occurred depending on the dose, said Rali. Other areas of interest include whether certain patient populations derive greater benefit than others, including connective tissue disease-associated PAH, idiopathic PAH, and higher-risk patient populations. “Comparative effectiveness data against currently available oral prostacyclin pathway agents and studies evaluating transition strategies from parenteral or inhaled therapies would help clinicians better understand where ralinepag ultimately fits in the PAH treatment algorithm,” Rali said. “I also would be curious to see what the authors thought of the failure to achieve the primary endpoint in cohorts of patients from Latin America and Asia Pacific regions,” he added.

The study was funded by United Therapeutics, and McLaughlin disclosed serving as a consultant for the company. Rali had no financial conflicts to disclose.

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

Treatment with ralinepag, an investigational prostacyclin receptor agonist, reduced the risk for clinical disease worsening by 55% compared to placebo in patients with pulmonary arterial hypertension (PAH), based on new data from the ADVANCE Outcomes study presented at the American Thoracic Society (ATS) 2026 International Conference.

Ralinepag works by restoring prostacyclin signaling and activating prostacyclin receptors to affect pathways that play a role in the progression of PAH. The drug was originally formulated as an immediate-release capsule but modified to the extended-release tablet used in the current study as a way to optimize once daily dosing.

“The prostacyclin pathway is foundational in the management of PAH, and advancing prostacyclin science has benefited patients over the years,” said lead author Vallerie V. McLaughlin, MD, professor of cardiovascular medicine and director of the Pulmonary Hypertension Program at the University of Michigan, Ann Arbor, Michigan, who presented the findings at the meeting. Although other oral prostacyclin pathway agents available, ralinepag has the advantages of high potency and longer half-life that could be effective and well-tolerated in a more patient-friendly once daily formulation, McLaughlin said.

The international study population included 687 adults with PAH from 30 countries across five continents. Participants were randomized to ralinepag or placebo in addition to their standard PAH background therapies. Ralinepag was orally dosed once daily and titrated for tolerability and response. The mean age of the participants was 52 years, 80% were White, and the median time since PAH diagnosis was 2.3 years. A majority of 62% had idiopathic or heritable PAH, 28.2% had PAH as a result of connective tissue disease, 4.1% had a congenital heart defect, 3.1% had drug- or toxin-induced PAH, and 2.6% had PAH as a result of HIV infection. More than two thirds were considered low risk (characterized as Functional Class II).

The primary endpoint was the time to first indication of clinical worsening, which was defined as death, hospital admission for worsening PAH, initiation of a parenteral or inhaled prostacyclin pathway agent for worsening PAH, or unsatisfactory long-term clinical response.

Overall, patients treated with ralinepag were significantly less likely to experience a clinical worsening event than placebo patients (hazard ratio [HR], 0.45; 95% CI, 0.33-0.62; P < .0001), and 47% more likely to achieve the secondary endpoint of clinical improvement (P = .015).

Patients treated with ralinepag also showed significant improvements over placebo patients in the secondary endpoints of pro-B-type natriuretic peptide levels (24.3% reduction from baseline to week 28 over placebo; P = .0013), and in the 6-minute walk test (a placebo-corrected difference of 20.4 m from baseline to week 28; P = .0033).

Although more than 90% of participants treated with ralinepag reported an adverse event related to the drug, approximately 5% experienced drug-related serious adverse events, and the overall safety profile reflected previous ralinepag studies, with a positive risk-benefit ratio, the investigators noted.

Support for Early Introduction

The researchers expected the efficacy associated with prostacyclin therapy, said McLaughlin. “We were very pleased to see such a strong treatment effect in a relatively low-risk population, primarily Functional Class II with a mean 6-minute walk of nearly 440 meters, with the majority of patients on dual oral therapy,” she said.

If approved, ralinepag could help optimized risk status in PAH, said McLaughlin. “Many patients do not get to low risk with first-line therapy, and oral and inhaled prostacyclin pathway agents are often used in addition to dual therapy with phosphodiesterase type-5 inhibitors and endothelin receptor antagonists,” she said. “The impressive treatment effect of ralinepag in patients primarily treated with dual oral therapy reflects this real-world scenario,” she added. The significant event reduction makes a case for earlier introduction of ralinepag in relatively low-risk patients; a highly effective therapy that targets the prostacyclin pathway may reduce the need for more cumbersome and invasive prostacyclin therapies, McLaughlin added.

Ralinepag remains an investigational drug, but the company plans to seek a New Drug Application from the FDA for the treatment of PAH by the second half of 2026, according to a press release.

The research team would like to continue evaluating the ADVANCE Outcomes database to learn more about dose response, tolerability, and subgroup response, said McLaughlin. At that point, real-world data would be useful, and additional research areas in that setting would include combination therapy with other agents such as sotatercept, as well as the use of ralinepag to transition patients on more complicated and invasive therapy, she said.

Attention to Adverse Effects

Prostacyclin therapies are often offered in oral, inhaled, and the most invasive intravenous/subcutaneous routes, but a gap remains between the strong efficacy seen with parenteral therapy and what many patients are willing or able to use in real-world practice, said Parth M. Rali, MD, director of the Temple University Health System Pulmonary Embolism Response Team Program, Section Temple Lung Pulmonary Vascular Disease Program, Philadelphia, who was not involved in the study.

“Ralinepag provides sustained activation of IP receptors and has very long effective half-life, giving drug exposure comparable to parenteral therapy, and offers the first daily treatment option, which is important for the patients with PAH who are often on multiple drugs therapies,” Rali said.

Given the encouraging phase 2 findings demonstrating meaningful reductions in pulmonary vascular resistance and signals toward clinical benefit, we would like to see a favorable outcome in the phase 3 program. Primary outcome studied was time to clinical worsening in the large, randomized trial that involved global populations from the US, Europe, Latin-America, and Asia Pacific Region. Ralinepag arm had 55% reduction in risk for clinical worsening (HR, ~ 0.45) compared to placebo arm. “The positive results of the trial were primarily driven by disease progression, initiation of prostacyclin therapy, and unsatisfactory long-term clinical response at 28 weeks in ralinepag group compared to placebo group,” Rali said.

Although ralinepag offers a good option for once-a-day oral prostacyclin options for the patients, the significant number of patients in the new study who discontinued because of adverse effects is notable, said Rali. “Treating clinicians will have to watch very closely, as the real-world patient population seems to be more complex than clinical trial populations,” he said. “At the same time, clinicians will have an option to weigh against growing list of inhaled prostacyclin pathway therapies that may not have systemic side effects of the oral agents,” he added.

“Given the strong scientific data in the ADVANCE trials, ralinepag may become drug of choice for oral prostacyclin pathway agents,” Rali added. However, its place in the treatment sequence, whether it is best used early in the disease course, as an add-on for patients already receiving dual oral therapy, or potentially part of upfront combination strategies, will call for some clinician judgement, Rali said. “Patient education and gradual dose titration will likely play a major role in improving adherence and limiting prostacyclin-related adverse effects,” he added.

Questions for future research include what percentage of the patients were able to tolerate the maximum dose of the drug, and whether any changes in primary or secondary outcomes occurred depending on the dose, said Rali. Other areas of interest include whether certain patient populations derive greater benefit than others, including connective tissue disease-associated PAH, idiopathic PAH, and higher-risk patient populations. “Comparative effectiveness data against currently available oral prostacyclin pathway agents and studies evaluating transition strategies from parenteral or inhaled therapies would help clinicians better understand where ralinepag ultimately fits in the PAH treatment algorithm,” Rali said. “I also would be curious to see what the authors thought of the failure to achieve the primary endpoint in cohorts of patients from Latin America and Asia Pacific regions,” he added.

The study was funded by United Therapeutics, and McLaughlin disclosed serving as a consultant for the company. Rali had no financial conflicts to disclose.

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

TOPLINE:

Higher baseline counts of blood eosinophils (EOS) were associated with an increased risk for exacerbations in patients with asthma over 1 year, and higher baseline levels of fractional exhaled nitric oxide (FeNO) were linked to increased odds of exacerbations treated with only oral corticosteroids (OCS) in asthma and asthma plus chronic obstructive pulmonary disease (COPD) but linked to a decreased risk for all exacerbations in COPD.

METHODOLOGY:

• Researchers analyzed data from the multinational NOVELTY study to assess whether blood EOS counts and FeNO levels, alone and together, predict the risk for future exacerbations in patients with asthma, COPD, or both.
• Overall, 4319 patients were included in the EOS analysis (2138 with asthma, 1541 with COPD, and 640 with asthma plus COPD), and 7770 patients were included in the FeNO analysis (4166 with asthma, 2588 with COPD, and 1016 with asthma plus COPD).
• Baseline data included demographics, treatments, exacerbations, and lung function (spirometry and FeNO levels).
• Outcomes were assessed over the first year of follow‑up, and patients received usual care from their treating physicians.
• Exacerbation subtypes were categorized as all exacerbations, exacerbations treated with only antibiotics, and exacerbations treated with only OCS.

TAKEAWAY:

• Higher EOS counts at baseline were associated with an increased risk for all exacerbations in asthma (incidence rate ratio [IRR], 1.09; P = .033), meaning each doubling of the count corresponded to a 9% higher exacerbation rate; a similar trend of higher risk was seen in COPD that did not reach statistical significance.
• Higher FeNO levels at baseline were associated with a lower risk for all exacerbations in COPD (IRR, 0.91; P = .025). In asthma, FeNO levels showed no association with an overall risk for exacerbations; in asthma plus COPD, neither biomarker predicted the overall risk.
• In asthma, higher FeNO levels at baseline were linked to increased odds of exacerbations treated with only OCS (odds ratio [OR], 1.16) but decreased odds of exacerbations treated with only antibiotics (OR, 0.75); in asthma plus COPD, higher FeNO levels were also linked to increased odds of exacerbations treated with only OCS (OR, 1.55; P < .05 for all).
• In an analysis including both biomarkers, higher EOS counts at baseline independently predicted all exacerbations in asthma; however, both higher EOS counts and lower FeNO levels were independently associated with a higher risk for all exacerbations in COPD (P < .05 for all).

IN PRACTICE:

“[The study] finding is of importance for future studies and daily clinical practice as it indicates that assessment of exacerbation subtype might improve personalized treatment management,” the authors wrote.

SOURCE:

This study was led by Susan Muiser, University Medical Centre Groningen, Groningen, Netherlands. It was published online on April 21, 2026, in Thorax.

LIMITATIONS:

Diagnoses were assigned by treating physicians without standardized diagnostic criteria. Physicians had access to type 2 inflammation biomarker results, which may have influenced treatment decisions. Exacerbation subtypes were categorized using medical records and patient-reported information, introducing a potential recall bias.

DISCLOSURES:

The NOVELTY study was funded by AstraZeneca. Four authors reported being employees of AstraZeneca, with 2 of them also being shareholders. Several authors disclosed receiving travel grants, research grants, consulting fees, honoraria, and support to attend meetings; serving on advisory boards; and holding stock or stock options with multiple pharmaceutical companies and organizations, including AstraZeneca and WebMD Global.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

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

TOPLINE:

Higher baseline counts of blood eosinophils (EOS) were associated with an increased risk for exacerbations in patients with asthma over 1 year, and higher baseline levels of fractional exhaled nitric oxide (FeNO) were linked to increased odds of exacerbations treated with only oral corticosteroids (OCS) in asthma and asthma plus chronic obstructive pulmonary disease (COPD) but linked to a decreased risk for all exacerbations in COPD.

METHODOLOGY:

• Researchers analyzed data from the multinational NOVELTY study to assess whether blood EOS counts and FeNO levels, alone and together, predict the risk for future exacerbations in patients with asthma, COPD, or both.
• Overall, 4319 patients were included in the EOS analysis (2138 with asthma, 1541 with COPD, and 640 with asthma plus COPD), and 7770 patients were included in the FeNO analysis (4166 with asthma, 2588 with COPD, and 1016 with asthma plus COPD).
• Baseline data included demographics, treatments, exacerbations, and lung function (spirometry and FeNO levels).
• Outcomes were assessed over the first year of follow‑up, and patients received usual care from their treating physicians.
• Exacerbation subtypes were categorized as all exacerbations, exacerbations treated with only antibiotics, and exacerbations treated with only OCS.

TAKEAWAY:

• Higher EOS counts at baseline were associated with an increased risk for all exacerbations in asthma (incidence rate ratio [IRR], 1.09; P = .033), meaning each doubling of the count corresponded to a 9% higher exacerbation rate; a similar trend of higher risk was seen in COPD that did not reach statistical significance.
• Higher FeNO levels at baseline were associated with a lower risk for all exacerbations in COPD (IRR, 0.91; P = .025). In asthma, FeNO levels showed no association with an overall risk for exacerbations; in asthma plus COPD, neither biomarker predicted the overall risk.
• In asthma, higher FeNO levels at baseline were linked to increased odds of exacerbations treated with only OCS (odds ratio [OR], 1.16) but decreased odds of exacerbations treated with only antibiotics (OR, 0.75); in asthma plus COPD, higher FeNO levels were also linked to increased odds of exacerbations treated with only OCS (OR, 1.55; P < .05 for all).
• In an analysis including both biomarkers, higher EOS counts at baseline independently predicted all exacerbations in asthma; however, both higher EOS counts and lower FeNO levels were independently associated with a higher risk for all exacerbations in COPD (P < .05 for all).

IN PRACTICE:

“[The study] finding is of importance for future studies and daily clinical practice as it indicates that assessment of exacerbation subtype might improve personalized treatment management,” the authors wrote.

SOURCE:

This study was led by Susan Muiser, University Medical Centre Groningen, Groningen, Netherlands. It was published online on April 21, 2026, in Thorax.

LIMITATIONS:

Diagnoses were assigned by treating physicians without standardized diagnostic criteria. Physicians had access to type 2 inflammation biomarker results, which may have influenced treatment decisions. Exacerbation subtypes were categorized using medical records and patient-reported information, introducing a potential recall bias.

DISCLOSURES:

The NOVELTY study was funded by AstraZeneca. Four authors reported being employees of AstraZeneca, with 2 of them also being shareholders. Several authors disclosed receiving travel grants, research grants, consulting fees, honoraria, and support to attend meetings; serving on advisory boards; and holding stock or stock options with multiple pharmaceutical companies and organizations, including AstraZeneca and WebMD Global.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

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

TOPLINE:

Higher baseline counts of blood eosinophils (EOS) were associated with an increased risk for exacerbations in patients with asthma over 1 year, and higher baseline levels of fractional exhaled nitric oxide (FeNO) were linked to increased odds of exacerbations treated with only oral corticosteroids (OCS) in asthma and asthma plus chronic obstructive pulmonary disease (COPD) but linked to a decreased risk for all exacerbations in COPD.

METHODOLOGY:

• Researchers analyzed data from the multinational NOVELTY study to assess whether blood EOS counts and FeNO levels, alone and together, predict the risk for future exacerbations in patients with asthma, COPD, or both.
• Overall, 4319 patients were included in the EOS analysis (2138 with asthma, 1541 with COPD, and 640 with asthma plus COPD), and 7770 patients were included in the FeNO analysis (4166 with asthma, 2588 with COPD, and 1016 with asthma plus COPD).
• Baseline data included demographics, treatments, exacerbations, and lung function (spirometry and FeNO levels).
• Outcomes were assessed over the first year of follow‑up, and patients received usual care from their treating physicians.
• Exacerbation subtypes were categorized as all exacerbations, exacerbations treated with only antibiotics, and exacerbations treated with only OCS.

TAKEAWAY:

• Higher EOS counts at baseline were associated with an increased risk for all exacerbations in asthma (incidence rate ratio [IRR], 1.09; P = .033), meaning each doubling of the count corresponded to a 9% higher exacerbation rate; a similar trend of higher risk was seen in COPD that did not reach statistical significance.
• Higher FeNO levels at baseline were associated with a lower risk for all exacerbations in COPD (IRR, 0.91; P = .025). In asthma, FeNO levels showed no association with an overall risk for exacerbations; in asthma plus COPD, neither biomarker predicted the overall risk.
• In asthma, higher FeNO levels at baseline were linked to increased odds of exacerbations treated with only OCS (odds ratio [OR], 1.16) but decreased odds of exacerbations treated with only antibiotics (OR, 0.75); in asthma plus COPD, higher FeNO levels were also linked to increased odds of exacerbations treated with only OCS (OR, 1.55; P < .05 for all).
• In an analysis including both biomarkers, higher EOS counts at baseline independently predicted all exacerbations in asthma; however, both higher EOS counts and lower FeNO levels were independently associated with a higher risk for all exacerbations in COPD (P < .05 for all).

IN PRACTICE:

“[The study] finding is of importance for future studies and daily clinical practice as it indicates that assessment of exacerbation subtype might improve personalized treatment management,” the authors wrote.

SOURCE:

This study was led by Susan Muiser, University Medical Centre Groningen, Groningen, Netherlands. It was published online on April 21, 2026, in Thorax.

LIMITATIONS:

Diagnoses were assigned by treating physicians without standardized diagnostic criteria. Physicians had access to type 2 inflammation biomarker results, which may have influenced treatment decisions. Exacerbation subtypes were categorized using medical records and patient-reported information, introducing a potential recall bias.

DISCLOSURES:

The NOVELTY study was funded by AstraZeneca. Four authors reported being employees of AstraZeneca, with 2 of them also being shareholders. Several authors disclosed receiving travel grants, research grants, consulting fees, honoraria, and support to attend meetings; serving on advisory boards; and holding stock or stock options with multiple pharmaceutical companies and organizations, including AstraZeneca and WebMD Global.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

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

Mild asthma is not benign. Underdiagnosis in children exposes them to preventable morbidity — including impaired lung growth that can lead to fixed airway obstruction and a higher lifetime risk for chronic obstructive pulmonary disease (COPD), as well as severe exacerbations and increased need for systemic corticosteroids. Experts at the 21st Francophone Allergy Congress 2026 said preserving respiratory function depends on early diagnosis and disease control.

Mild asthma is retrospectively defined as the level of treatment required to achieve and maintain disease control. It corresponds to asthma controlled with a low dose of inhaled corticosteroids or with a combination of inhaled corticosteroids and formoterol as needed (Global Initiative for Asthma(GINA)/French Society of Pediatric Pulmonology and Allergology, steps 1-2).

Mélisande Bourgoin-Heck, MD, PhD, Department of Pediatric Allergology, Armand Trousseau University Hospital, Sorbonne University, AP-HP, Paris, France, emphasized a fundamental distinction: “While control is based on symptoms, exacerbations, activity limitations, and quality of life, severity corresponds to the level of treatment required to achieve this control. The term mild therefore depends on the treatment required and not solely on the frequency or intensity of symptoms.”

How to Identify It?

Clinically, asthma most often presents with wheezing, cough, shortness of breath, and chest tightness, with symptoms that fluctuate in frequency and severity. Nighttime symptoms are common. Symptoms often start or worsen with viral infections, physical exertion (including after exercise), laughter, or exposure to allergens or cold air. “Symptoms are often dismissed as minor and intermittent,” the pediatrician said, “which leads to delayed diagnosis.”

That’s why recognizing risk factors is important because they help guide diagnosis: male sex, a first-degree family history of asthma, exposure to secondhand smoke, prematurity, maternal obesity, living in group settings or having school-aged siblings which raise the risk for early infections, a history of severe bronchiolitis, and an atopic tendency, demonstrated by atopic dermatitis, allergic rhinitis, or sensitization to food and respiratory allergens.

How Much Should We Trust Predictive Scores?

Several clinical scores for predicting asthma exist, notably the Asthma Predictive Index, the modified Asthma Predictive Index, and the Pediatric Asthma Risk Score; the latter demonstrates better overall discrimination, making it useful for children at low-to-moderate risk.

“These scores place significant emphasis on the atopic predisposition,” noted Bourgoin-Heck, “including allergic sensitivities, allergic rhinitis, and atopic dermatitis. Their performance varies by age and clinical phenotype. They are highly specific for the diagnosis of allergic asthma, with a positive score associated with a high risk of asthma. However, their sensitivity is not up to par: A negative score does not rule out the diagnosis, leading to a risk of overlooking nonallergic forms.”

A chest x-ray is used to rule out differential diagnoses. It may be normal or reveal chest distension or bronchial signs. During follow-up, it is only recommended in cases of fever or severe illness to look for complications such as bronchopulmonary superinfection, pneumothorax, pneumomediastinum, subcutaneous emphysema and ventilation disorders/atelectasis.

Normal Spirometry: Could Asthma Really be Ruled Out?

Pulmonary function tests (PFTs) may be normal and do not rule out asthma. Spirometry can be performed around age 6 years and is often normal. “The reversibility test is a diagnostic indicator but may be negative in cases of normal forced expiratory volume in 1 second (FEV₁),” warned the specialist.

Provocation tests are useful in cases of doubt.

In children unable to perform a forced exhalation, spirometry is impossible or unreliable, which justifies the use of respiratory resistance measurements (starting at age 3). Several methods are then used: flow-interruption resistance (FIR) identifies bronchial obstruction with an expiratory FIR > 2 Z scores (how many SDs a result is from the predicted value for a child’s age/height/sex). Oscillometry, suitable for young children, is considered pathologic for values exceeding 150% of the predicted value. Plethysmography indicates obstruction with a Raw value > 150% of the predicted value or an sRaw value > 180%.

Interpretation is based on standards adapted to the technique and the study population, with thresholds varying by method (threshold values for PFTs, page e4).

When in Doubt, How Useful Are Biomarkers?

As a biomarker of atopy, a blood eosinophil count of at least 150/mm³ is associated with asthma symptoms and exacerbations. Specific Immunoglobulin E (IgE) indicates allergic sensitization associated with asthma. Finally, elevated fractional concentration of exhaled nitric oxide (> 20-25 parts per billion depending on age) is associated with wheezing, corticosteroid use, and persistent asthma. The combination of atopy markers — including maternal allergy, eczema, wheezing, positive specific IgE levels, and eosinophilia — significantly increases the likelihood of asthma.

“However, when diagnostic uncertainty persists in a child younger than 5 years (absence of atopy; normal PFTs — which is common), a trial of treatment based on initial symptoms may be recommended according to GINA 2025 (Box 10-2),” explained Bourgoin-Heck.

In the presence of mild and intermittent symptoms, a short-acting bronchodilator challenge test on demand is indicated for a maximum duration of 2-3 months. This strategy applies to infrequent wheezing episodes, without the need for emergency care and therefore without any severe exacerbations, with symptoms occurring twice or less per week. Treatment consists of administering two puffs when symptoms occur (to be repeated as needed), with an assessment of improvement within 20-60 minutes. In cases of a history of a severe wheezing episode within the past year (systemic corticosteroids, emergency department visit, and hospitalization) or symptoms more than twice a week, the therapeutic trial involves long-term inhaled corticosteroids (eg, fluticasone 100 µg/d to 250 µg/d) combined with a short-acting bronchodilator as needed for 2-3 months. If the response is favorable, treatment is adjusted to the minimum effective dose.

Monitoring of clinical progress relies on asthma control scores such as the Asthma Control Test, considering both parental perception and the child’s self-assessment. Because the goal in mild asthma is indeed to achieve complete control.

Mild Asthma: Behind the Triviality, Real Risks

Mild childhood asthma is the most common form of asthma. It is by no means benign and carries a risk for exacerbations requiring systemic corticosteroids and potential long-term consequences.

Asthma is often missed — an estimated 20% of children age ≥ 6 years to 70% by age 1 year are not identified — and therefore go untreated, leading to a lower quality of life from attacks and persistent symptoms between episodes that could limit activity and disrupt sleep.

Even seemingly mild asthma is associated with a risk for severe exacerbation, including in patients with infrequent and mild symptoms.

There is also impaired lung growth, with a decrease in peak lung function and the potential for progression to fixed bronchial obstruction, which can lead to COPD. However, it has been shown that early treatment reduces chronic inflammation, limits bronchial remodeling, and prevents the decline in lung function.

In a Danish neonatal cohort 9125 infants, were followed at 1, 3, and 6 years of age and analyzed at 50 years of age via the Danish COPD patient registry, early asthma symptoms were associated with a decrease in FEV1 (-3.36%) and the FEV1/ Forced Vital Capacity ratio (-1.28), as well as an increased risk for a COPD diagnosis in adulthood (odds ratio [OR], 1.96).

Epidemiologic data confirm this: A history of asthma increases the risk of developing COPD by 10-30 times, and a reduced peak FEV1 in early adulthood is associated with an increased risk for early‑onset COPD and greater severity.

“Asthma is associated with a decline in lung function that can begin as early as infancy,” noted the pediatrician, “or even during the prenatal period, persists throughout childhood, continues into adulthood, and predisposes individuals to established bronchial obstruction.”

Early Inhaled Corticosteroids Reduced Exacerbations

In the inhaled steroid treatment as regular therapy in early asthma trial, which enrolled about 7000 adults and children and included a subgroup of 1900 children aged < 11 years with recent-onset mild asthma, inhaled budesonide was compared with placebo. Over 3 years of follow-up, the placebo group showed poorer lung function, whereas those treated with budesonide had improved FEV1 and about a 40% reduction in severe exacerbations. A partial functional “catch-up” was observed when treatment was initiated in the third year.

However, the study does not allow for conclusions regarding the very long-term prevention of functional decline, due to the lack of sufficient follow-up time.

Delayed Treatment Increases Risks

Furthermore, delayed treatment is associated with an increased use of short-acting bronchodilators and systemic corticosteroids, carrying a risk for complications. The specialist warned: “Adverse effects appear after just a few courses of oral corticosteroids, notably an increased risk of fractures (odds ratio, 2.15 for low doses of prednisolone < 70 mg; OR, 3.09 for higher doses > 70 mg). These risks are real and emerge quickly.”

Another study confirms the adverse effects of oral corticosteroid therapy: A cumulative dose of 500 mg to 1000 mg (approximately four to five courses of systemic corticosteroids over a lifetime) already increases the risk. Complications include osteoporosis, diabetes, cataracts, heart failure, and pneumonia. “Cumulative exposure, even intermittent, is associated with increased morbidity, which can be prevented through appropriate management of mild asthma,” she added. “Yet it has been clearly demonstrated that inhaled therapy reduces the need for oral corticosteroids.”

This story was translated from Medscape’s French edition.

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

Mild asthma is not benign. Underdiagnosis in children exposes them to preventable morbidity — including impaired lung growth that can lead to fixed airway obstruction and a higher lifetime risk for chronic obstructive pulmonary disease (COPD), as well as severe exacerbations and increased need for systemic corticosteroids. Experts at the 21st Francophone Allergy Congress 2026 said preserving respiratory function depends on early diagnosis and disease control.

Mild asthma is retrospectively defined as the level of treatment required to achieve and maintain disease control. It corresponds to asthma controlled with a low dose of inhaled corticosteroids or with a combination of inhaled corticosteroids and formoterol as needed (Global Initiative for Asthma(GINA)/French Society of Pediatric Pulmonology and Allergology, steps 1-2).

Mélisande Bourgoin-Heck, MD, PhD, Department of Pediatric Allergology, Armand Trousseau University Hospital, Sorbonne University, AP-HP, Paris, France, emphasized a fundamental distinction: “While control is based on symptoms, exacerbations, activity limitations, and quality of life, severity corresponds to the level of treatment required to achieve this control. The term mild therefore depends on the treatment required and not solely on the frequency or intensity of symptoms.”

How to Identify It?

Clinically, asthma most often presents with wheezing, cough, shortness of breath, and chest tightness, with symptoms that fluctuate in frequency and severity. Nighttime symptoms are common. Symptoms often start or worsen with viral infections, physical exertion (including after exercise), laughter, or exposure to allergens or cold air. “Symptoms are often dismissed as minor and intermittent,” the pediatrician said, “which leads to delayed diagnosis.”

That’s why recognizing risk factors is important because they help guide diagnosis: male sex, a first-degree family history of asthma, exposure to secondhand smoke, prematurity, maternal obesity, living in group settings or having school-aged siblings which raise the risk for early infections, a history of severe bronchiolitis, and an atopic tendency, demonstrated by atopic dermatitis, allergic rhinitis, or sensitization to food and respiratory allergens.

How Much Should We Trust Predictive Scores?

Several clinical scores for predicting asthma exist, notably the Asthma Predictive Index, the modified Asthma Predictive Index, and the Pediatric Asthma Risk Score; the latter demonstrates better overall discrimination, making it useful for children at low-to-moderate risk.

“These scores place significant emphasis on the atopic predisposition,” noted Bourgoin-Heck, “including allergic sensitivities, allergic rhinitis, and atopic dermatitis. Their performance varies by age and clinical phenotype. They are highly specific for the diagnosis of allergic asthma, with a positive score associated with a high risk of asthma. However, their sensitivity is not up to par: A negative score does not rule out the diagnosis, leading to a risk of overlooking nonallergic forms.”

A chest x-ray is used to rule out differential diagnoses. It may be normal or reveal chest distension or bronchial signs. During follow-up, it is only recommended in cases of fever or severe illness to look for complications such as bronchopulmonary superinfection, pneumothorax, pneumomediastinum, subcutaneous emphysema and ventilation disorders/atelectasis.

Normal Spirometry: Could Asthma Really be Ruled Out?

Pulmonary function tests (PFTs) may be normal and do not rule out asthma. Spirometry can be performed around age 6 years and is often normal. “The reversibility test is a diagnostic indicator but may be negative in cases of normal forced expiratory volume in 1 second (FEV₁),” warned the specialist.

Provocation tests are useful in cases of doubt.

In children unable to perform a forced exhalation, spirometry is impossible or unreliable, which justifies the use of respiratory resistance measurements (starting at age 3). Several methods are then used: flow-interruption resistance (FIR) identifies bronchial obstruction with an expiratory FIR > 2 Z scores (how many SDs a result is from the predicted value for a child’s age/height/sex). Oscillometry, suitable for young children, is considered pathologic for values exceeding 150% of the predicted value. Plethysmography indicates obstruction with a Raw value > 150% of the predicted value or an sRaw value > 180%.

Interpretation is based on standards adapted to the technique and the study population, with thresholds varying by method (threshold values for PFTs, page e4).

When in Doubt, How Useful Are Biomarkers?

As a biomarker of atopy, a blood eosinophil count of at least 150/mm³ is associated with asthma symptoms and exacerbations. Specific Immunoglobulin E (IgE) indicates allergic sensitization associated with asthma. Finally, elevated fractional concentration of exhaled nitric oxide (> 20-25 parts per billion depending on age) is associated with wheezing, corticosteroid use, and persistent asthma. The combination of atopy markers — including maternal allergy, eczema, wheezing, positive specific IgE levels, and eosinophilia — significantly increases the likelihood of asthma.

“However, when diagnostic uncertainty persists in a child younger than 5 years (absence of atopy; normal PFTs — which is common), a trial of treatment based on initial symptoms may be recommended according to GINA 2025 (Box 10-2),” explained Bourgoin-Heck.

In the presence of mild and intermittent symptoms, a short-acting bronchodilator challenge test on demand is indicated for a maximum duration of 2-3 months. This strategy applies to infrequent wheezing episodes, without the need for emergency care and therefore without any severe exacerbations, with symptoms occurring twice or less per week. Treatment consists of administering two puffs when symptoms occur (to be repeated as needed), with an assessment of improvement within 20-60 minutes. In cases of a history of a severe wheezing episode within the past year (systemic corticosteroids, emergency department visit, and hospitalization) or symptoms more than twice a week, the therapeutic trial involves long-term inhaled corticosteroids (eg, fluticasone 100 µg/d to 250 µg/d) combined with a short-acting bronchodilator as needed for 2-3 months. If the response is favorable, treatment is adjusted to the minimum effective dose.

Monitoring of clinical progress relies on asthma control scores such as the Asthma Control Test, considering both parental perception and the child’s self-assessment. Because the goal in mild asthma is indeed to achieve complete control.

Mild Asthma: Behind the Triviality, Real Risks

Mild childhood asthma is the most common form of asthma. It is by no means benign and carries a risk for exacerbations requiring systemic corticosteroids and potential long-term consequences.

Asthma is often missed — an estimated 20% of children age ≥ 6 years to 70% by age 1 year are not identified — and therefore go untreated, leading to a lower quality of life from attacks and persistent symptoms between episodes that could limit activity and disrupt sleep.

Even seemingly mild asthma is associated with a risk for severe exacerbation, including in patients with infrequent and mild symptoms.

There is also impaired lung growth, with a decrease in peak lung function and the potential for progression to fixed bronchial obstruction, which can lead to COPD. However, it has been shown that early treatment reduces chronic inflammation, limits bronchial remodeling, and prevents the decline in lung function.

In a Danish neonatal cohort 9125 infants, were followed at 1, 3, and 6 years of age and analyzed at 50 years of age via the Danish COPD patient registry, early asthma symptoms were associated with a decrease in FEV1 (-3.36%) and the FEV1/ Forced Vital Capacity ratio (-1.28), as well as an increased risk for a COPD diagnosis in adulthood (odds ratio [OR], 1.96).

Epidemiologic data confirm this: A history of asthma increases the risk of developing COPD by 10-30 times, and a reduced peak FEV1 in early adulthood is associated with an increased risk for early‑onset COPD and greater severity.

“Asthma is associated with a decline in lung function that can begin as early as infancy,” noted the pediatrician, “or even during the prenatal period, persists throughout childhood, continues into adulthood, and predisposes individuals to established bronchial obstruction.”

Early Inhaled Corticosteroids Reduced Exacerbations

In the inhaled steroid treatment as regular therapy in early asthma trial, which enrolled about 7000 adults and children and included a subgroup of 1900 children aged < 11 years with recent-onset mild asthma, inhaled budesonide was compared with placebo. Over 3 years of follow-up, the placebo group showed poorer lung function, whereas those treated with budesonide had improved FEV1 and about a 40% reduction in severe exacerbations. A partial functional “catch-up” was observed when treatment was initiated in the third year.

However, the study does not allow for conclusions regarding the very long-term prevention of functional decline, due to the lack of sufficient follow-up time.

Delayed Treatment Increases Risks

Furthermore, delayed treatment is associated with an increased use of short-acting bronchodilators and systemic corticosteroids, carrying a risk for complications. The specialist warned: “Adverse effects appear after just a few courses of oral corticosteroids, notably an increased risk of fractures (odds ratio, 2.15 for low doses of prednisolone < 70 mg; OR, 3.09 for higher doses > 70 mg). These risks are real and emerge quickly.”

Another study confirms the adverse effects of oral corticosteroid therapy: A cumulative dose of 500 mg to 1000 mg (approximately four to five courses of systemic corticosteroids over a lifetime) already increases the risk. Complications include osteoporosis, diabetes, cataracts, heart failure, and pneumonia. “Cumulative exposure, even intermittent, is associated with increased morbidity, which can be prevented through appropriate management of mild asthma,” she added. “Yet it has been clearly demonstrated that inhaled therapy reduces the need for oral corticosteroids.”

This story was translated from Medscape’s French edition.

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

Mild asthma is not benign. Underdiagnosis in children exposes them to preventable morbidity — including impaired lung growth that can lead to fixed airway obstruction and a higher lifetime risk for chronic obstructive pulmonary disease (COPD), as well as severe exacerbations and increased need for systemic corticosteroids. Experts at the 21st Francophone Allergy Congress 2026 said preserving respiratory function depends on early diagnosis and disease control.

Mild asthma is retrospectively defined as the level of treatment required to achieve and maintain disease control. It corresponds to asthma controlled with a low dose of inhaled corticosteroids or with a combination of inhaled corticosteroids and formoterol as needed (Global Initiative for Asthma(GINA)/French Society of Pediatric Pulmonology and Allergology, steps 1-2).

Mélisande Bourgoin-Heck, MD, PhD, Department of Pediatric Allergology, Armand Trousseau University Hospital, Sorbonne University, AP-HP, Paris, France, emphasized a fundamental distinction: “While control is based on symptoms, exacerbations, activity limitations, and quality of life, severity corresponds to the level of treatment required to achieve this control. The term mild therefore depends on the treatment required and not solely on the frequency or intensity of symptoms.”

How to Identify It?

Clinically, asthma most often presents with wheezing, cough, shortness of breath, and chest tightness, with symptoms that fluctuate in frequency and severity. Nighttime symptoms are common. Symptoms often start or worsen with viral infections, physical exertion (including after exercise), laughter, or exposure to allergens or cold air. “Symptoms are often dismissed as minor and intermittent,” the pediatrician said, “which leads to delayed diagnosis.”

That’s why recognizing risk factors is important because they help guide diagnosis: male sex, a first-degree family history of asthma, exposure to secondhand smoke, prematurity, maternal obesity, living in group settings or having school-aged siblings which raise the risk for early infections, a history of severe bronchiolitis, and an atopic tendency, demonstrated by atopic dermatitis, allergic rhinitis, or sensitization to food and respiratory allergens.

How Much Should We Trust Predictive Scores?

Several clinical scores for predicting asthma exist, notably the Asthma Predictive Index, the modified Asthma Predictive Index, and the Pediatric Asthma Risk Score; the latter demonstrates better overall discrimination, making it useful for children at low-to-moderate risk.

“These scores place significant emphasis on the atopic predisposition,” noted Bourgoin-Heck, “including allergic sensitivities, allergic rhinitis, and atopic dermatitis. Their performance varies by age and clinical phenotype. They are highly specific for the diagnosis of allergic asthma, with a positive score associated with a high risk of asthma. However, their sensitivity is not up to par: A negative score does not rule out the diagnosis, leading to a risk of overlooking nonallergic forms.”

A chest x-ray is used to rule out differential diagnoses. It may be normal or reveal chest distension or bronchial signs. During follow-up, it is only recommended in cases of fever or severe illness to look for complications such as bronchopulmonary superinfection, pneumothorax, pneumomediastinum, subcutaneous emphysema and ventilation disorders/atelectasis.

Normal Spirometry: Could Asthma Really be Ruled Out?

Pulmonary function tests (PFTs) may be normal and do not rule out asthma. Spirometry can be performed around age 6 years and is often normal. “The reversibility test is a diagnostic indicator but may be negative in cases of normal forced expiratory volume in 1 second (FEV₁),” warned the specialist.

Provocation tests are useful in cases of doubt.

In children unable to perform a forced exhalation, spirometry is impossible or unreliable, which justifies the use of respiratory resistance measurements (starting at age 3). Several methods are then used: flow-interruption resistance (FIR) identifies bronchial obstruction with an expiratory FIR > 2 Z scores (how many SDs a result is from the predicted value for a child’s age/height/sex). Oscillometry, suitable for young children, is considered pathologic for values exceeding 150% of the predicted value. Plethysmography indicates obstruction with a Raw value > 150% of the predicted value or an sRaw value > 180%.

Interpretation is based on standards adapted to the technique and the study population, with thresholds varying by method (threshold values for PFTs, page e4).

When in Doubt, How Useful Are Biomarkers?

As a biomarker of atopy, a blood eosinophil count of at least 150/mm³ is associated with asthma symptoms and exacerbations. Specific Immunoglobulin E (IgE) indicates allergic sensitization associated with asthma. Finally, elevated fractional concentration of exhaled nitric oxide (> 20-25 parts per billion depending on age) is associated with wheezing, corticosteroid use, and persistent asthma. The combination of atopy markers — including maternal allergy, eczema, wheezing, positive specific IgE levels, and eosinophilia — significantly increases the likelihood of asthma.

“However, when diagnostic uncertainty persists in a child younger than 5 years (absence of atopy; normal PFTs — which is common), a trial of treatment based on initial symptoms may be recommended according to GINA 2025 (Box 10-2),” explained Bourgoin-Heck.

In the presence of mild and intermittent symptoms, a short-acting bronchodilator challenge test on demand is indicated for a maximum duration of 2-3 months. This strategy applies to infrequent wheezing episodes, without the need for emergency care and therefore without any severe exacerbations, with symptoms occurring twice or less per week. Treatment consists of administering two puffs when symptoms occur (to be repeated as needed), with an assessment of improvement within 20-60 minutes. In cases of a history of a severe wheezing episode within the past year (systemic corticosteroids, emergency department visit, and hospitalization) or symptoms more than twice a week, the therapeutic trial involves long-term inhaled corticosteroids (eg, fluticasone 100 µg/d to 250 µg/d) combined with a short-acting bronchodilator as needed for 2-3 months. If the response is favorable, treatment is adjusted to the minimum effective dose.

Monitoring of clinical progress relies on asthma control scores such as the Asthma Control Test, considering both parental perception and the child’s self-assessment. Because the goal in mild asthma is indeed to achieve complete control.

Mild Asthma: Behind the Triviality, Real Risks

Mild childhood asthma is the most common form of asthma. It is by no means benign and carries a risk for exacerbations requiring systemic corticosteroids and potential long-term consequences.

Asthma is often missed — an estimated 20% of children age ≥ 6 years to 70% by age 1 year are not identified — and therefore go untreated, leading to a lower quality of life from attacks and persistent symptoms between episodes that could limit activity and disrupt sleep.

Even seemingly mild asthma is associated with a risk for severe exacerbation, including in patients with infrequent and mild symptoms.

There is also impaired lung growth, with a decrease in peak lung function and the potential for progression to fixed bronchial obstruction, which can lead to COPD. However, it has been shown that early treatment reduces chronic inflammation, limits bronchial remodeling, and prevents the decline in lung function.

In a Danish neonatal cohort 9125 infants, were followed at 1, 3, and 6 years of age and analyzed at 50 years of age via the Danish COPD patient registry, early asthma symptoms were associated with a decrease in FEV1 (-3.36%) and the FEV1/ Forced Vital Capacity ratio (-1.28), as well as an increased risk for a COPD diagnosis in adulthood (odds ratio [OR], 1.96).

Epidemiologic data confirm this: A history of asthma increases the risk of developing COPD by 10-30 times, and a reduced peak FEV1 in early adulthood is associated with an increased risk for early‑onset COPD and greater severity.

“Asthma is associated with a decline in lung function that can begin as early as infancy,” noted the pediatrician, “or even during the prenatal period, persists throughout childhood, continues into adulthood, and predisposes individuals to established bronchial obstruction.”

Early Inhaled Corticosteroids Reduced Exacerbations

In the inhaled steroid treatment as regular therapy in early asthma trial, which enrolled about 7000 adults and children and included a subgroup of 1900 children aged < 11 years with recent-onset mild asthma, inhaled budesonide was compared with placebo. Over 3 years of follow-up, the placebo group showed poorer lung function, whereas those treated with budesonide had improved FEV1 and about a 40% reduction in severe exacerbations. A partial functional “catch-up” was observed when treatment was initiated in the third year.

However, the study does not allow for conclusions regarding the very long-term prevention of functional decline, due to the lack of sufficient follow-up time.

Delayed Treatment Increases Risks

Furthermore, delayed treatment is associated with an increased use of short-acting bronchodilators and systemic corticosteroids, carrying a risk for complications. The specialist warned: “Adverse effects appear after just a few courses of oral corticosteroids, notably an increased risk of fractures (odds ratio, 2.15 for low doses of prednisolone < 70 mg; OR, 3.09 for higher doses > 70 mg). These risks are real and emerge quickly.”

Another study confirms the adverse effects of oral corticosteroid therapy: A cumulative dose of 500 mg to 1000 mg (approximately four to five courses of systemic corticosteroids over a lifetime) already increases the risk. Complications include osteoporosis, diabetes, cataracts, heart failure, and pneumonia. “Cumulative exposure, even intermittent, is associated with increased morbidity, which can be prevented through appropriate management of mild asthma,” she added. “Yet it has been clearly demonstrated that inhaled therapy reduces the need for oral corticosteroids.”

This story was translated from Medscape’s French edition.

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

TOPLINE:

Military veterans exposed to burn pits during deployment are > 4 times higher risk for persistent cough and 3 times higher risk for dyspnea and wheezing compared with unexposed veterans. Following clinical evaluation, nearly half of veterans received diagnoses of respiratory diseases, including asthma (about 30%), chronic obstructive pulmonary disease (about 13%), and bronchitis (about 12%). Diagnostic uncertainty remains common, with nearly one-third of symptomatic veterans still lacking a specific diagnosis after extensive noninvasive testing.

METHODOLOGY:

• Focused review that proposed an assessment and monitoring strategy for deployed US military veterans with unexplained dyspnea that incorporates multidisciplinary review and patient discussion.
• Analysis included data from the Study of Active Duty Military for Pulmonary Disease Related to Environmental Deployment Exposures (STAMPEDE), which evaluated respiratory symptoms in military personnel within 6 months of returning from Southwest Asia.
• Registry and survey input included Airborne Hazards and Open Burn Pit Registry clinical evaluations in 24,578 veterans in addition to a survey of 479 veterans.
• Biopsy guidance emphasized case-by-case decisions after review; supporting examples include 49 symptomatic veterans undergoing high-resolution computed tomography in STAMPEDE and 38 veterans with biopsy-proven constrictive bronchiolitis, many with normal or near normal pulmonary function tests (PFTs).

TAKEAWAY: 

• Veterans with persistent unexplained cough, dyspnea, or chest tightness for > 3 months, reduced exercise tolerance, or abnormal PFTs should be referred to a pulmonary specialist for diagnostic evaluation.
• Among 380 military personnel with chronic respiratory symptoms in STAMPEDE III, 22.9% had diagnoses of asthma, 15.0% had airway hyperreactivity, 10.8% had upper and large airways disorders, and 32.0% did not meet criteria for a specific diagnosis after extensive noninvasive testing.
• Standard testing can miss disease: among 38 veterans with biopsy-proven constrictive bronchiolitis, 19 had normal or near normal PFTs compared with the general population, despite reductions vs a historical asymptomatic military cohort.
• Long-term management centers on follow-up, with proposed PFT monitoring every 6 to 12 months in symptomatic patients even when initial findings are normal.

IN PRACTICE:

“Significant gaps remain in the provision of health care and benefits,” the authors wrote. “The assessment of veterans with suspected lung disease should be comprehensive, involving a thorough medical and exposure history, as well as PFTs and imaging.

SOURCE:

The study was led by Robert M. Tighe, MD, Duke University Medical Center in Durham, North Carolina; Le Roy Torres, Burn Pits 360 in Robstown, Texas; and Robert Miller, Vanderbilt University Medical Center in Nashville, Tennessee. It was published online in Annals of the American Thoracic Society.

LIMITATIONS:

This article synthesizes existing literature and expert recommendations without presenting new primary data or statistical analyses. The review acknowledges that diagnosing deployment-related respiratory disorders can be challenging as symptoms are often nonspecific and may present months or years after deployment with variable latency. The current Post-Deployment Cardiopulmonary Evaluation Network structure does not have the capacity to evaluate the large number of veterans with respiratory disorders and is limited to those who have registered symptoms through the Airborne Hazards and Open Burn Pit Registry.

DISCLOSURES:

Writing support was provided by Julie Fleming and Wendy Morris of Fleishman-Hillard, which was contracted and funded by Boehringer Ingelheim Pharmaceuticals. Boehringer Ingelheim was given the opportunity to review the article for medical and scientific accuracy as well as intellectual property considerations. No disclosures or conflict of interest statements for the individual authors are provided in the study.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

TOPLINE:

Military veterans exposed to burn pits during deployment are > 4 times higher risk for persistent cough and 3 times higher risk for dyspnea and wheezing compared with unexposed veterans. Following clinical evaluation, nearly half of veterans received diagnoses of respiratory diseases, including asthma (about 30%), chronic obstructive pulmonary disease (about 13%), and bronchitis (about 12%). Diagnostic uncertainty remains common, with nearly one-third of symptomatic veterans still lacking a specific diagnosis after extensive noninvasive testing.

METHODOLOGY:

• Focused review that proposed an assessment and monitoring strategy for deployed US military veterans with unexplained dyspnea that incorporates multidisciplinary review and patient discussion.
• Analysis included data from the Study of Active Duty Military for Pulmonary Disease Related to Environmental Deployment Exposures (STAMPEDE), which evaluated respiratory symptoms in military personnel within 6 months of returning from Southwest Asia.
• Registry and survey input included Airborne Hazards and Open Burn Pit Registry clinical evaluations in 24,578 veterans in addition to a survey of 479 veterans.
• Biopsy guidance emphasized case-by-case decisions after review; supporting examples include 49 symptomatic veterans undergoing high-resolution computed tomography in STAMPEDE and 38 veterans with biopsy-proven constrictive bronchiolitis, many with normal or near normal pulmonary function tests (PFTs).

TAKEAWAY: 

• Veterans with persistent unexplained cough, dyspnea, or chest tightness for > 3 months, reduced exercise tolerance, or abnormal PFTs should be referred to a pulmonary specialist for diagnostic evaluation.
• Among 380 military personnel with chronic respiratory symptoms in STAMPEDE III, 22.9% had diagnoses of asthma, 15.0% had airway hyperreactivity, 10.8% had upper and large airways disorders, and 32.0% did not meet criteria for a specific diagnosis after extensive noninvasive testing.
• Standard testing can miss disease: among 38 veterans with biopsy-proven constrictive bronchiolitis, 19 had normal or near normal PFTs compared with the general population, despite reductions vs a historical asymptomatic military cohort.
• Long-term management centers on follow-up, with proposed PFT monitoring every 6 to 12 months in symptomatic patients even when initial findings are normal.

IN PRACTICE:

“Significant gaps remain in the provision of health care and benefits,” the authors wrote. “The assessment of veterans with suspected lung disease should be comprehensive, involving a thorough medical and exposure history, as well as PFTs and imaging.

SOURCE:

The study was led by Robert M. Tighe, MD, Duke University Medical Center in Durham, North Carolina; Le Roy Torres, Burn Pits 360 in Robstown, Texas; and Robert Miller, Vanderbilt University Medical Center in Nashville, Tennessee. It was published online in Annals of the American Thoracic Society.

LIMITATIONS:

This article synthesizes existing literature and expert recommendations without presenting new primary data or statistical analyses. The review acknowledges that diagnosing deployment-related respiratory disorders can be challenging as symptoms are often nonspecific and may present months or years after deployment with variable latency. The current Post-Deployment Cardiopulmonary Evaluation Network structure does not have the capacity to evaluate the large number of veterans with respiratory disorders and is limited to those who have registered symptoms through the Airborne Hazards and Open Burn Pit Registry.

DISCLOSURES:

Writing support was provided by Julie Fleming and Wendy Morris of Fleishman-Hillard, which was contracted and funded by Boehringer Ingelheim Pharmaceuticals. Boehringer Ingelheim was given the opportunity to review the article for medical and scientific accuracy as well as intellectual property considerations. No disclosures or conflict of interest statements for the individual authors are provided in the study.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

TOPLINE:

Military veterans exposed to burn pits during deployment are > 4 times higher risk for persistent cough and 3 times higher risk for dyspnea and wheezing compared with unexposed veterans. Following clinical evaluation, nearly half of veterans received diagnoses of respiratory diseases, including asthma (about 30%), chronic obstructive pulmonary disease (about 13%), and bronchitis (about 12%). Diagnostic uncertainty remains common, with nearly one-third of symptomatic veterans still lacking a specific diagnosis after extensive noninvasive testing.

METHODOLOGY:

• Focused review that proposed an assessment and monitoring strategy for deployed US military veterans with unexplained dyspnea that incorporates multidisciplinary review and patient discussion.
• Analysis included data from the Study of Active Duty Military for Pulmonary Disease Related to Environmental Deployment Exposures (STAMPEDE), which evaluated respiratory symptoms in military personnel within 6 months of returning from Southwest Asia.
• Registry and survey input included Airborne Hazards and Open Burn Pit Registry clinical evaluations in 24,578 veterans in addition to a survey of 479 veterans.
• Biopsy guidance emphasized case-by-case decisions after review; supporting examples include 49 symptomatic veterans undergoing high-resolution computed tomography in STAMPEDE and 38 veterans with biopsy-proven constrictive bronchiolitis, many with normal or near normal pulmonary function tests (PFTs).

TAKEAWAY: 

• Veterans with persistent unexplained cough, dyspnea, or chest tightness for > 3 months, reduced exercise tolerance, or abnormal PFTs should be referred to a pulmonary specialist for diagnostic evaluation.
• Among 380 military personnel with chronic respiratory symptoms in STAMPEDE III, 22.9% had diagnoses of asthma, 15.0% had airway hyperreactivity, 10.8% had upper and large airways disorders, and 32.0% did not meet criteria for a specific diagnosis after extensive noninvasive testing.
• Standard testing can miss disease: among 38 veterans with biopsy-proven constrictive bronchiolitis, 19 had normal or near normal PFTs compared with the general population, despite reductions vs a historical asymptomatic military cohort.
• Long-term management centers on follow-up, with proposed PFT monitoring every 6 to 12 months in symptomatic patients even when initial findings are normal.

IN PRACTICE:

“Significant gaps remain in the provision of health care and benefits,” the authors wrote. “The assessment of veterans with suspected lung disease should be comprehensive, involving a thorough medical and exposure history, as well as PFTs and imaging.

SOURCE:

The study was led by Robert M. Tighe, MD, Duke University Medical Center in Durham, North Carolina; Le Roy Torres, Burn Pits 360 in Robstown, Texas; and Robert Miller, Vanderbilt University Medical Center in Nashville, Tennessee. It was published online in Annals of the American Thoracic Society.

LIMITATIONS:

This article synthesizes existing literature and expert recommendations without presenting new primary data or statistical analyses. The review acknowledges that diagnosing deployment-related respiratory disorders can be challenging as symptoms are often nonspecific and may present months or years after deployment with variable latency. The current Post-Deployment Cardiopulmonary Evaluation Network structure does not have the capacity to evaluate the large number of veterans with respiratory disorders and is limited to those who have registered symptoms through the Airborne Hazards and Open Burn Pit Registry.

DISCLOSURES:

Writing support was provided by Julie Fleming and Wendy Morris of Fleishman-Hillard, which was contracted and funded by Boehringer Ingelheim Pharmaceuticals. Boehringer Ingelheim was given the opportunity to review the article for medical and scientific accuracy as well as intellectual property considerations. No disclosures or conflict of interest statements for the individual authors are provided in the study.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

TOPLINE: Veterans with chronic obstructive pulmonary disease (COPD) who had follow-up outcome data after completing a 12-week telehealth pulmonary rehabilitation program had improved functional capacity, with 6-minute walk distance increasing by 41.3 m (15.7%) and quality-of-life scores improving by 27.9% to 42.7%. The virtual program had an 86% completion rate, suggesting telehealth rehabilitation may be a feasible alternative to traditional in-person programs.

METHODOLOGY:

• A 12-week single-arm cohort intervention evaluated effectiveness, acceptability, and feasibility of in-home, supervised telehealth pulmonary rehabilitation delivered via US Department of Veterans Affairs (VA) Video Connect in Houston, Texas. 

• Participants included 51 veterans with COPD aged ≥ 18 years and referred to the program; exclusions included mobility-limiting surgery, neurologic disease impairing walking, likely nonadherence, or unwillingness to consent. 

• Intervention consisted of 1 session weekly for about 120 minutes led by a licensed physical therapist and respiratory therapist, with home monitoring of blood pressure, heart rate, SpO₂, respiratory rate, and exertion. 

• In-person outcome assessments occurred at baseline and 12 weeks; the primary outcome was the 6-minute walk test, and secondary outcomes included Timed Up & Go test, Five Times Sit-to-Stand test, and quality of life via the St. George’s Respiratory Questionnaire and COPD Assessment Test.

TAKEAWAY:

• Functional capacity improved significantly with a mean increase of 41.3 m in 6-minute walk distance, a 15.7% improvement (P < .001; d = 0.76), surpassing the minimal clinically important difference of 25 m for patients with COPD. 

• COPD-affected quality of life improved, with St. George’s Respiratory Questionnaire scores decreasing by 18.2 points, a 27.9% improvement (P < .001), and COPD Assessment Test scores decreasing by 12.1 points, a 42.7% improvement (P < .001). 

• Functional mobility and lower-body strength also improved, with Timed Up and Go test completion time decreasing by 1.2 seconds (9.9% faster; P = .02) and Five Times Sit-to-Stand test time improving by 1.2 seconds (9.0% faster; P = .02). 

• Program retention was high, with 44 of 51 participants (86.3%) completing the full intervention. When excluding COVID-19 pandemic–related dropouts, the retention rate increased to 90.2%

IN PRACTICE: “Our study not only highlights the effectiveness of pulmonary rehabilitation in improving the functional performance of COPD patients but also emphasizes the potential use of telehealth-rehabilitation as a viable alternative to traditional in-clinic programs,” the authors wrote.

SOURCE:The study’s first author was Abderrahman Ouattas, Interdisciplinary Consortium on Advanced Motion Performance, Michael E. DeBakey VA Medical Center, Baylor College of Medicine in Houston. It was published online in Scientific Reports.

LIMITATIONS: According to the authors, the study lacked a control group and included predominantly male participants, which may limit generalizability. The modest sample size and insufficient exploration of potential confounding factors further constrain the generalizability of findings. Additionally, the study was limited to veterans living within 80 miles of Houston, creating an unusual proximity requirement for telehealth programs that could introduce selection bias. The researchers noted that actively recruiting during the COVID-19 pandemic presented unforeseen challenges, and the absence of remote biomechanical data collection may have limited the ability to monitor rehabilitation progress and make necessary adjustments.

DISCLOSURES: The authors report no commercial or financial relationships that could be construed as potential conflicts of interest. No specific funding sources or financial disclosures were mentioned.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

TOPLINE: Veterans with chronic obstructive pulmonary disease (COPD) who had follow-up outcome data after completing a 12-week telehealth pulmonary rehabilitation program had improved functional capacity, with 6-minute walk distance increasing by 41.3 m (15.7%) and quality-of-life scores improving by 27.9% to 42.7%. The virtual program had an 86% completion rate, suggesting telehealth rehabilitation may be a feasible alternative to traditional in-person programs.

METHODOLOGY:

• A 12-week single-arm cohort intervention evaluated effectiveness, acceptability, and feasibility of in-home, supervised telehealth pulmonary rehabilitation delivered via US Department of Veterans Affairs (VA) Video Connect in Houston, Texas. 

• Participants included 51 veterans with COPD aged ≥ 18 years and referred to the program; exclusions included mobility-limiting surgery, neurologic disease impairing walking, likely nonadherence, or unwillingness to consent. 

• Intervention consisted of 1 session weekly for about 120 minutes led by a licensed physical therapist and respiratory therapist, with home monitoring of blood pressure, heart rate, SpO₂, respiratory rate, and exertion. 

• In-person outcome assessments occurred at baseline and 12 weeks; the primary outcome was the 6-minute walk test, and secondary outcomes included Timed Up & Go test, Five Times Sit-to-Stand test, and quality of life via the St. George’s Respiratory Questionnaire and COPD Assessment Test.

TAKEAWAY:

• Functional capacity improved significantly with a mean increase of 41.3 m in 6-minute walk distance, a 15.7% improvement (P < .001; d = 0.76), surpassing the minimal clinically important difference of 25 m for patients with COPD. 

• COPD-affected quality of life improved, with St. George’s Respiratory Questionnaire scores decreasing by 18.2 points, a 27.9% improvement (P < .001), and COPD Assessment Test scores decreasing by 12.1 points, a 42.7% improvement (P < .001). 

• Functional mobility and lower-body strength also improved, with Timed Up and Go test completion time decreasing by 1.2 seconds (9.9% faster; P = .02) and Five Times Sit-to-Stand test time improving by 1.2 seconds (9.0% faster; P = .02). 

• Program retention was high, with 44 of 51 participants (86.3%) completing the full intervention. When excluding COVID-19 pandemic–related dropouts, the retention rate increased to 90.2%

IN PRACTICE: “Our study not only highlights the effectiveness of pulmonary rehabilitation in improving the functional performance of COPD patients but also emphasizes the potential use of telehealth-rehabilitation as a viable alternative to traditional in-clinic programs,” the authors wrote.

SOURCE:The study’s first author was Abderrahman Ouattas, Interdisciplinary Consortium on Advanced Motion Performance, Michael E. DeBakey VA Medical Center, Baylor College of Medicine in Houston. It was published online in Scientific Reports.

LIMITATIONS: According to the authors, the study lacked a control group and included predominantly male participants, which may limit generalizability. The modest sample size and insufficient exploration of potential confounding factors further constrain the generalizability of findings. Additionally, the study was limited to veterans living within 80 miles of Houston, creating an unusual proximity requirement for telehealth programs that could introduce selection bias. The researchers noted that actively recruiting during the COVID-19 pandemic presented unforeseen challenges, and the absence of remote biomechanical data collection may have limited the ability to monitor rehabilitation progress and make necessary adjustments.

DISCLOSURES: The authors report no commercial or financial relationships that could be construed as potential conflicts of interest. No specific funding sources or financial disclosures were mentioned.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

TOPLINE: Veterans with chronic obstructive pulmonary disease (COPD) who had follow-up outcome data after completing a 12-week telehealth pulmonary rehabilitation program had improved functional capacity, with 6-minute walk distance increasing by 41.3 m (15.7%) and quality-of-life scores improving by 27.9% to 42.7%. The virtual program had an 86% completion rate, suggesting telehealth rehabilitation may be a feasible alternative to traditional in-person programs.

METHODOLOGY:

• A 12-week single-arm cohort intervention evaluated effectiveness, acceptability, and feasibility of in-home, supervised telehealth pulmonary rehabilitation delivered via US Department of Veterans Affairs (VA) Video Connect in Houston, Texas. 

• Participants included 51 veterans with COPD aged ≥ 18 years and referred to the program; exclusions included mobility-limiting surgery, neurologic disease impairing walking, likely nonadherence, or unwillingness to consent. 

• Intervention consisted of 1 session weekly for about 120 minutes led by a licensed physical therapist and respiratory therapist, with home monitoring of blood pressure, heart rate, SpO₂, respiratory rate, and exertion. 

• In-person outcome assessments occurred at baseline and 12 weeks; the primary outcome was the 6-minute walk test, and secondary outcomes included Timed Up & Go test, Five Times Sit-to-Stand test, and quality of life via the St. George’s Respiratory Questionnaire and COPD Assessment Test.

TAKEAWAY:

• Functional capacity improved significantly with a mean increase of 41.3 m in 6-minute walk distance, a 15.7% improvement (P < .001; d = 0.76), surpassing the minimal clinically important difference of 25 m for patients with COPD. 

• COPD-affected quality of life improved, with St. George’s Respiratory Questionnaire scores decreasing by 18.2 points, a 27.9% improvement (P < .001), and COPD Assessment Test scores decreasing by 12.1 points, a 42.7% improvement (P < .001). 

• Functional mobility and lower-body strength also improved, with Timed Up and Go test completion time decreasing by 1.2 seconds (9.9% faster; P = .02) and Five Times Sit-to-Stand test time improving by 1.2 seconds (9.0% faster; P = .02). 

• Program retention was high, with 44 of 51 participants (86.3%) completing the full intervention. When excluding COVID-19 pandemic–related dropouts, the retention rate increased to 90.2%

IN PRACTICE: “Our study not only highlights the effectiveness of pulmonary rehabilitation in improving the functional performance of COPD patients but also emphasizes the potential use of telehealth-rehabilitation as a viable alternative to traditional in-clinic programs,” the authors wrote.

SOURCE:The study’s first author was Abderrahman Ouattas, Interdisciplinary Consortium on Advanced Motion Performance, Michael E. DeBakey VA Medical Center, Baylor College of Medicine in Houston. It was published online in Scientific Reports.

LIMITATIONS: According to the authors, the study lacked a control group and included predominantly male participants, which may limit generalizability. The modest sample size and insufficient exploration of potential confounding factors further constrain the generalizability of findings. Additionally, the study was limited to veterans living within 80 miles of Houston, creating an unusual proximity requirement for telehealth programs that could introduce selection bias. The researchers noted that actively recruiting during the COVID-19 pandemic presented unforeseen challenges, and the absence of remote biomechanical data collection may have limited the ability to monitor rehabilitation progress and make necessary adjustments.

DISCLOSURES: The authors report no commercial or financial relationships that could be construed as potential conflicts of interest. No specific funding sources or financial disclosures were mentioned.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

Patients treated for chronic obstructive pulmonary disease (COPD) or pneumonia experienced worse outcomes when treated at hospitals acquired by private equity firms, based on data from a new study presented at the American Thoracic Society (ATS) 2026 International Conference.

“Previous studies have linked private equity acquisition of hospitals to worse patient experiences and higher rates of hospital-acquired adverse events, such as falls, although findings for specific medical conditions have been more variable,” according to lead author Stephen Mein, MD, a pulmonologist at Beth Israel Deaconess Medical Center in Boston.

“We wanted to understand whether private equity acquisitions impacted outcomes for patients hospitalized with COPD and pneumonia because these conditions are among the most common reasons for hospitalization and they are widely included in measures of hospital care quality,” he said.

Mein and colleagues reviewed data from Medicare fee-for-service claims data from 41 private equity hospitals and 192 matched control hospitals between 2010 and 2019, including 146,904 COPD visits and 194,993 pneumonia visits.

The study population was Medicare beneficiaries aged 65 years or older who had at least one hospital encounter (defined as observation stay or inpatient admission) for asthma, COPD, or pneumonia. The clinical outcomes were in-hospital mortality, 30-day mortality, and 30-day hospital revisit rates. The researchers compared changes in outcomes across 3 years before and after acquisition in a linear regression analysis. Models adjusted for patient age, sex, race and ethnicity, clinical risk score, and dual eligibility status.

Overall, no changes in patient age, sex, clinical risk scores or dual-eligibility status across all conditions at private equity hospitals were noted compared with control hospitals. However, 30-day hospital revisits among patients with asthma increased significantly at private equity hospitals compared to control hospitals (difference-in-differences, + 8.3 percentage points; 95% CI, 4.0-12.7). No significant changes were noted for in-hospital mortality or 30-day mortality.

Similarly, 30-day hospital revisits were significantly higher for patients with COPD at private equity hospitals than at control hospitals (+ 0.9 percentage points; 95% CI, 0.1-1.6). Patients with pneumonia had an increased in-hospital mortality at private equity hospitals compared with control hospitals (+ 0.7 percentage points; 95% CI, 0.2-1.2), with no differences in 30-day mortality or revisits.

The findings that patients treated for COPD at private equity-acquired hospitals more often returned to the hospital within 30 days after hospital discharge and that patients with pneumonia were more likely to die during their hospital stay were surprising, Mein noted. “The 1-percentage-point increase in deaths among patients with pneumonia is especially concerning as the baseline in-hospital mortality rate for this condition was only 3%-4%,” he said.

“Our findings add to growing concerns around the potential negative effects of private equity ownership in healthcare and highlight the need for stronger oversight of these acquisitions to help protect our patients, and the results have implications for many patients as private equity acquisitions of US hospitals are becoming more common,” Mein said.

The findings were limited by the focus on older adults with Medicare insurance, and may not be generalizable to other patient populations, said Mein. “In addition, we were unable to account for differences in private equity firm practices or identify potential heterogeneity in outcomes across hospitals acquired by different private equity firms,” he said. More research is needed to understand the factors contributing to worse outcomes at private equity-acquired hospitals in the current study and other published work, Mein added.

Vigilance is Needed to Optimize Outcomes

“Given the rapid increase in acquisitions of US hospitals by private equity firms, it is important to evaluate how these acquisitions affect patient health outcomes,” said Arianne K. Baldomero, MD, MS, a pulmonologist, critical care physician, and assistant professor of medicine at the University of Minnesota, Minneapolis.

“The worse outcomes observed among patients hospitalized in privately acquired hospitals were not entirely unexpected,” said Baldomero, who was not involved in the study. “Although not explicitly stated in the abstract, these acquisitions may involve cost-containment strategies, such as potential reductions in staffing. particularly nursing and support staff, changes in supply chain management, or the scaling back of less profitable services, which likely contribute to worse patient outcomes,” she said.

More research is needed to identify the potential etiologies driving these differences in outcomes, which would help inform strategies for improvement, said Baldomero. However, the results of the new study suggest that clinicians managing patients discharged from acquired hospitals should be vigilant about discharge planning, transitions, and follow-up to mitigate poor health outcomes, she said.

The study received no outside funding. The researchers and Baldomero had no financial conflicts to disclose.

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

Patients treated for chronic obstructive pulmonary disease (COPD) or pneumonia experienced worse outcomes when treated at hospitals acquired by private equity firms, based on data from a new study presented at the American Thoracic Society (ATS) 2026 International Conference.

“Previous studies have linked private equity acquisition of hospitals to worse patient experiences and higher rates of hospital-acquired adverse events, such as falls, although findings for specific medical conditions have been more variable,” according to lead author Stephen Mein, MD, a pulmonologist at Beth Israel Deaconess Medical Center in Boston.

“We wanted to understand whether private equity acquisitions impacted outcomes for patients hospitalized with COPD and pneumonia because these conditions are among the most common reasons for hospitalization and they are widely included in measures of hospital care quality,” he said.

Mein and colleagues reviewed data from Medicare fee-for-service claims data from 41 private equity hospitals and 192 matched control hospitals between 2010 and 2019, including 146,904 COPD visits and 194,993 pneumonia visits.

The study population was Medicare beneficiaries aged 65 years or older who had at least one hospital encounter (defined as observation stay or inpatient admission) for asthma, COPD, or pneumonia. The clinical outcomes were in-hospital mortality, 30-day mortality, and 30-day hospital revisit rates. The researchers compared changes in outcomes across 3 years before and after acquisition in a linear regression analysis. Models adjusted for patient age, sex, race and ethnicity, clinical risk score, and dual eligibility status.

Overall, no changes in patient age, sex, clinical risk scores or dual-eligibility status across all conditions at private equity hospitals were noted compared with control hospitals. However, 30-day hospital revisits among patients with asthma increased significantly at private equity hospitals compared to control hospitals (difference-in-differences, + 8.3 percentage points; 95% CI, 4.0-12.7). No significant changes were noted for in-hospital mortality or 30-day mortality.

Similarly, 30-day hospital revisits were significantly higher for patients with COPD at private equity hospitals than at control hospitals (+ 0.9 percentage points; 95% CI, 0.1-1.6). Patients with pneumonia had an increased in-hospital mortality at private equity hospitals compared with control hospitals (+ 0.7 percentage points; 95% CI, 0.2-1.2), with no differences in 30-day mortality or revisits.

The findings that patients treated for COPD at private equity-acquired hospitals more often returned to the hospital within 30 days after hospital discharge and that patients with pneumonia were more likely to die during their hospital stay were surprising, Mein noted. “The 1-percentage-point increase in deaths among patients with pneumonia is especially concerning as the baseline in-hospital mortality rate for this condition was only 3%-4%,” he said.

“Our findings add to growing concerns around the potential negative effects of private equity ownership in healthcare and highlight the need for stronger oversight of these acquisitions to help protect our patients, and the results have implications for many patients as private equity acquisitions of US hospitals are becoming more common,” Mein said.

The findings were limited by the focus on older adults with Medicare insurance, and may not be generalizable to other patient populations, said Mein. “In addition, we were unable to account for differences in private equity firm practices or identify potential heterogeneity in outcomes across hospitals acquired by different private equity firms,” he said. More research is needed to understand the factors contributing to worse outcomes at private equity-acquired hospitals in the current study and other published work, Mein added.

Vigilance is Needed to Optimize Outcomes

“Given the rapid increase in acquisitions of US hospitals by private equity firms, it is important to evaluate how these acquisitions affect patient health outcomes,” said Arianne K. Baldomero, MD, MS, a pulmonologist, critical care physician, and assistant professor of medicine at the University of Minnesota, Minneapolis.

“The worse outcomes observed among patients hospitalized in privately acquired hospitals were not entirely unexpected,” said Baldomero, who was not involved in the study. “Although not explicitly stated in the abstract, these acquisitions may involve cost-containment strategies, such as potential reductions in staffing. particularly nursing and support staff, changes in supply chain management, or the scaling back of less profitable services, which likely contribute to worse patient outcomes,” she said.

More research is needed to identify the potential etiologies driving these differences in outcomes, which would help inform strategies for improvement, said Baldomero. However, the results of the new study suggest that clinicians managing patients discharged from acquired hospitals should be vigilant about discharge planning, transitions, and follow-up to mitigate poor health outcomes, she said.

The study received no outside funding. The researchers and Baldomero had no financial conflicts to disclose.

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

Patients treated for chronic obstructive pulmonary disease (COPD) or pneumonia experienced worse outcomes when treated at hospitals acquired by private equity firms, based on data from a new study presented at the American Thoracic Society (ATS) 2026 International Conference.

“Previous studies have linked private equity acquisition of hospitals to worse patient experiences and higher rates of hospital-acquired adverse events, such as falls, although findings for specific medical conditions have been more variable,” according to lead author Stephen Mein, MD, a pulmonologist at Beth Israel Deaconess Medical Center in Boston.

“We wanted to understand whether private equity acquisitions impacted outcomes for patients hospitalized with COPD and pneumonia because these conditions are among the most common reasons for hospitalization and they are widely included in measures of hospital care quality,” he said.

Mein and colleagues reviewed data from Medicare fee-for-service claims data from 41 private equity hospitals and 192 matched control hospitals between 2010 and 2019, including 146,904 COPD visits and 194,993 pneumonia visits.

The study population was Medicare beneficiaries aged 65 years or older who had at least one hospital encounter (defined as observation stay or inpatient admission) for asthma, COPD, or pneumonia. The clinical outcomes were in-hospital mortality, 30-day mortality, and 30-day hospital revisit rates. The researchers compared changes in outcomes across 3 years before and after acquisition in a linear regression analysis. Models adjusted for patient age, sex, race and ethnicity, clinical risk score, and dual eligibility status.

Overall, no changes in patient age, sex, clinical risk scores or dual-eligibility status across all conditions at private equity hospitals were noted compared with control hospitals. However, 30-day hospital revisits among patients with asthma increased significantly at private equity hospitals compared to control hospitals (difference-in-differences, + 8.3 percentage points; 95% CI, 4.0-12.7). No significant changes were noted for in-hospital mortality or 30-day mortality.

Similarly, 30-day hospital revisits were significantly higher for patients with COPD at private equity hospitals than at control hospitals (+ 0.9 percentage points; 95% CI, 0.1-1.6). Patients with pneumonia had an increased in-hospital mortality at private equity hospitals compared with control hospitals (+ 0.7 percentage points; 95% CI, 0.2-1.2), with no differences in 30-day mortality or revisits.

The findings that patients treated for COPD at private equity-acquired hospitals more often returned to the hospital within 30 days after hospital discharge and that patients with pneumonia were more likely to die during their hospital stay were surprising, Mein noted. “The 1-percentage-point increase in deaths among patients with pneumonia is especially concerning as the baseline in-hospital mortality rate for this condition was only 3%-4%,” he said.

“Our findings add to growing concerns around the potential negative effects of private equity ownership in healthcare and highlight the need for stronger oversight of these acquisitions to help protect our patients, and the results have implications for many patients as private equity acquisitions of US hospitals are becoming more common,” Mein said.

The findings were limited by the focus on older adults with Medicare insurance, and may not be generalizable to other patient populations, said Mein. “In addition, we were unable to account for differences in private equity firm practices or identify potential heterogeneity in outcomes across hospitals acquired by different private equity firms,” he said. More research is needed to understand the factors contributing to worse outcomes at private equity-acquired hospitals in the current study and other published work, Mein added.

Vigilance is Needed to Optimize Outcomes

“Given the rapid increase in acquisitions of US hospitals by private equity firms, it is important to evaluate how these acquisitions affect patient health outcomes,” said Arianne K. Baldomero, MD, MS, a pulmonologist, critical care physician, and assistant professor of medicine at the University of Minnesota, Minneapolis.

“The worse outcomes observed among patients hospitalized in privately acquired hospitals were not entirely unexpected,” said Baldomero, who was not involved in the study. “Although not explicitly stated in the abstract, these acquisitions may involve cost-containment strategies, such as potential reductions in staffing. particularly nursing and support staff, changes in supply chain management, or the scaling back of less profitable services, which likely contribute to worse patient outcomes,” she said.

More research is needed to identify the potential etiologies driving these differences in outcomes, which would help inform strategies for improvement, said Baldomero. However, the results of the new study suggest that clinicians managing patients discharged from acquired hospitals should be vigilant about discharge planning, transitions, and follow-up to mitigate poor health outcomes, she said.

The study received no outside funding. The researchers and Baldomero had no financial conflicts to disclose.

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

Approximately about 1 in 4 eligible Americans are up to date on their lung cancer screening, according to a recent study in JAMA Internal Medicine, prompting a need for clinicians to simplify referrals and scheduling of annual appointments.

Despite a 32% increase in lung cancer screening between 2022 and 2024, rates overall remain low at nearly 25%, and especially among patients between ages 50 and 54 years (11.32%; P < .05).

Determining eligibility entails calculating the total years a patient smoked cigarettes, whereas other screenings are based solely on age, such as breast cancer and colon cancer.

Some clinicians “will get into trying to do an actual pack year calculation, or where they smoked half a pack for this many years, and then they quit for this many years, and then, you know, they’re trying to do this massive calculation. And the reality is, we’re just trying to get a patient who’s at high risk for lung cancer” in for screening, said Timothy Mullett, MD, a thoracic surgeon and medical director of the Markey Cancer Center Network Development, University of Kentucky in Lexington, Kentucky, who helped the study authors.

As the second most common form of the disease, lung cancer is the leading cause of such mortality in the US. But low rates of screening mean opportunities for early detection are missed.

In an analysis of national survey data including 26,104 patients (45.6% women and 54.4% men) eligible for lung cancer screening between ages 50 and 79 years, rates increased from 18.49% to 24.49% (P < .05) over a 2-year period starting in 2022. 

Approximately one quarter of men and women were up to date on their screening (P < .05). Nearly one third of patients aged 65 years or older were up to date, whereas those between ages 50 and 54 years (11.32%), 55 and 59 years (19.45%), and 60 and 64 years (23.99%) showed lower rates.

Patients were most likely to be up to date on their screenings in the Northeast region of the country, with Massachusetts showing the highest prevalence rate (38.36%). The rate was lowest in South Dakota (13.43%).

No significant changes in rates were observed for Asian, Black, or Hispanic adults. Adults who were American Indian or Alaska native showed the largest improvement, from 18.74% in 2022 to 30.8% in 2024 (P < .05).

The US Preventive Services Task Force recommends annual screening starting at age 50 for individuals who are current smokers or previous smokers who have a history of consuming at least a pack a day for two decades. Previous smokers must have quit within the previous 15 years to qualify.

Making these calculations can be tricky, Mullett said. Patients’ tobacco use can change over time and a screening tool may not account for those changes. He encourages clinicians to take time to ask patients for more detail about their history. For instance, someone who smokes a half a pack a day now may not immediately qualify for screening, but deeper probing might reveal that they previously smoked two packs a day.

Tamatha Hughes, RN, a nurse navigator for the Missouri Baptist Lung Cancer Screening Program, Missouri Baptist Medical Center in St. Louis, said she often calms fears and corrects misinformation when scheduling patients for their first screening. Some patients think the screening involves an MRI or that radiation from the CT scan is dangerous.

“We go through explaining it as simple as possible,” she said.

If she has a referral for a patient who does not move forward with scheduling, she said she will try them again a few weeks later. Annual screenings are scheduled at a patient’s first appointment, and she said her clinic has an 80% rate for returning patients.

Getting the first scan is the biggest hurdle. Many patients feel stigma or associate lung cancer with a hopeless diagnosis, which can reduce rates, Mullet said.

“There’s a sense of fatalism, because all they’ve ever experienced with lung cancer has been someone who’s died from lung cancer, their grandmother, their grandfather, died of lung cancer. And historically, lung cancer has been found in late stages over 80% of the time,” he said. But screening has drastically improved rates of survival.

“We keep trying to tell patients that this is not your grandfather’s lung cancer,” Mullett said. “This is not what you saw in your family growing up, and we can find it early and we can treat it, and we even if we find it late, we have better treatments now.”

The study was funded by grants from the National Cancer Institute, the William Stamps Farish Endowed Chair in Cancer Research, and the CDC. Mullett and Hughes reported having no relevant financial disclosures.

Kelsey Mesmer, PhD, is a freelance journalist and journalism professor at Saint Louis University in St. Louis.

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

Approximately about 1 in 4 eligible Americans are up to date on their lung cancer screening, according to a recent study in JAMA Internal Medicine, prompting a need for clinicians to simplify referrals and scheduling of annual appointments.

Despite a 32% increase in lung cancer screening between 2022 and 2024, rates overall remain low at nearly 25%, and especially among patients between ages 50 and 54 years (11.32%; P < .05).

Determining eligibility entails calculating the total years a patient smoked cigarettes, whereas other screenings are based solely on age, such as breast cancer and colon cancer.

Some clinicians “will get into trying to do an actual pack year calculation, or where they smoked half a pack for this many years, and then they quit for this many years, and then, you know, they’re trying to do this massive calculation. And the reality is, we’re just trying to get a patient who’s at high risk for lung cancer” in for screening, said Timothy Mullett, MD, a thoracic surgeon and medical director of the Markey Cancer Center Network Development, University of Kentucky in Lexington, Kentucky, who helped the study authors.

As the second most common form of the disease, lung cancer is the leading cause of such mortality in the US. But low rates of screening mean opportunities for early detection are missed.

In an analysis of national survey data including 26,104 patients (45.6% women and 54.4% men) eligible for lung cancer screening between ages 50 and 79 years, rates increased from 18.49% to 24.49% (P < .05) over a 2-year period starting in 2022. 

Approximately one quarter of men and women were up to date on their screening (P < .05). Nearly one third of patients aged 65 years or older were up to date, whereas those between ages 50 and 54 years (11.32%), 55 and 59 years (19.45%), and 60 and 64 years (23.99%) showed lower rates.

Patients were most likely to be up to date on their screenings in the Northeast region of the country, with Massachusetts showing the highest prevalence rate (38.36%). The rate was lowest in South Dakota (13.43%).

No significant changes in rates were observed for Asian, Black, or Hispanic adults. Adults who were American Indian or Alaska native showed the largest improvement, from 18.74% in 2022 to 30.8% in 2024 (P < .05).

The US Preventive Services Task Force recommends annual screening starting at age 50 for individuals who are current smokers or previous smokers who have a history of consuming at least a pack a day for two decades. Previous smokers must have quit within the previous 15 years to qualify.

Making these calculations can be tricky, Mullett said. Patients’ tobacco use can change over time and a screening tool may not account for those changes. He encourages clinicians to take time to ask patients for more detail about their history. For instance, someone who smokes a half a pack a day now may not immediately qualify for screening, but deeper probing might reveal that they previously smoked two packs a day.

Tamatha Hughes, RN, a nurse navigator for the Missouri Baptist Lung Cancer Screening Program, Missouri Baptist Medical Center in St. Louis, said she often calms fears and corrects misinformation when scheduling patients for their first screening. Some patients think the screening involves an MRI or that radiation from the CT scan is dangerous.

“We go through explaining it as simple as possible,” she said.

If she has a referral for a patient who does not move forward with scheduling, she said she will try them again a few weeks later. Annual screenings are scheduled at a patient’s first appointment, and she said her clinic has an 80% rate for returning patients.

Getting the first scan is the biggest hurdle. Many patients feel stigma or associate lung cancer with a hopeless diagnosis, which can reduce rates, Mullet said.

“There’s a sense of fatalism, because all they’ve ever experienced with lung cancer has been someone who’s died from lung cancer, their grandmother, their grandfather, died of lung cancer. And historically, lung cancer has been found in late stages over 80% of the time,” he said. But screening has drastically improved rates of survival.

“We keep trying to tell patients that this is not your grandfather’s lung cancer,” Mullett said. “This is not what you saw in your family growing up, and we can find it early and we can treat it, and we even if we find it late, we have better treatments now.”

The study was funded by grants from the National Cancer Institute, the William Stamps Farish Endowed Chair in Cancer Research, and the CDC. Mullett and Hughes reported having no relevant financial disclosures.

Kelsey Mesmer, PhD, is a freelance journalist and journalism professor at Saint Louis University in St. Louis.

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

Approximately about 1 in 4 eligible Americans are up to date on their lung cancer screening, according to a recent study in JAMA Internal Medicine, prompting a need for clinicians to simplify referrals and scheduling of annual appointments.

Despite a 32% increase in lung cancer screening between 2022 and 2024, rates overall remain low at nearly 25%, and especially among patients between ages 50 and 54 years (11.32%; P < .05).

Determining eligibility entails calculating the total years a patient smoked cigarettes, whereas other screenings are based solely on age, such as breast cancer and colon cancer.

Some clinicians “will get into trying to do an actual pack year calculation, or where they smoked half a pack for this many years, and then they quit for this many years, and then, you know, they’re trying to do this massive calculation. And the reality is, we’re just trying to get a patient who’s at high risk for lung cancer” in for screening, said Timothy Mullett, MD, a thoracic surgeon and medical director of the Markey Cancer Center Network Development, University of Kentucky in Lexington, Kentucky, who helped the study authors.

As the second most common form of the disease, lung cancer is the leading cause of such mortality in the US. But low rates of screening mean opportunities for early detection are missed.

In an analysis of national survey data including 26,104 patients (45.6% women and 54.4% men) eligible for lung cancer screening between ages 50 and 79 years, rates increased from 18.49% to 24.49% (P < .05) over a 2-year period starting in 2022. 

Approximately one quarter of men and women were up to date on their screening (P < .05). Nearly one third of patients aged 65 years or older were up to date, whereas those between ages 50 and 54 years (11.32%), 55 and 59 years (19.45%), and 60 and 64 years (23.99%) showed lower rates.

Patients were most likely to be up to date on their screenings in the Northeast region of the country, with Massachusetts showing the highest prevalence rate (38.36%). The rate was lowest in South Dakota (13.43%).

No significant changes in rates were observed for Asian, Black, or Hispanic adults. Adults who were American Indian or Alaska native showed the largest improvement, from 18.74% in 2022 to 30.8% in 2024 (P < .05).

The US Preventive Services Task Force recommends annual screening starting at age 50 for individuals who are current smokers or previous smokers who have a history of consuming at least a pack a day for two decades. Previous smokers must have quit within the previous 15 years to qualify.

Making these calculations can be tricky, Mullett said. Patients’ tobacco use can change over time and a screening tool may not account for those changes. He encourages clinicians to take time to ask patients for more detail about their history. For instance, someone who smokes a half a pack a day now may not immediately qualify for screening, but deeper probing might reveal that they previously smoked two packs a day.

Tamatha Hughes, RN, a nurse navigator for the Missouri Baptist Lung Cancer Screening Program, Missouri Baptist Medical Center in St. Louis, said she often calms fears and corrects misinformation when scheduling patients for their first screening. Some patients think the screening involves an MRI or that radiation from the CT scan is dangerous.

“We go through explaining it as simple as possible,” she said.

If she has a referral for a patient who does not move forward with scheduling, she said she will try them again a few weeks later. Annual screenings are scheduled at a patient’s first appointment, and she said her clinic has an 80% rate for returning patients.

Getting the first scan is the biggest hurdle. Many patients feel stigma or associate lung cancer with a hopeless diagnosis, which can reduce rates, Mullet said.

“There’s a sense of fatalism, because all they’ve ever experienced with lung cancer has been someone who’s died from lung cancer, their grandmother, their grandfather, died of lung cancer. And historically, lung cancer has been found in late stages over 80% of the time,” he said. But screening has drastically improved rates of survival.

“We keep trying to tell patients that this is not your grandfather’s lung cancer,” Mullett said. “This is not what you saw in your family growing up, and we can find it early and we can treat it, and we even if we find it late, we have better treatments now.”

The study was funded by grants from the National Cancer Institute, the William Stamps Farish Endowed Chair in Cancer Research, and the CDC. Mullett and Hughes reported having no relevant financial disclosures.

Kelsey Mesmer, PhD, is a freelance journalist and journalism professor at Saint Louis University in St. Louis.

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

Chest CT is being ordered too often for incidental pulmonary nodules found on neck imaging, according to a study at one US health system.

It’s not uncommon for neck CT or MRI to show nodules in the lung apices, but there’s been no data on how often those incidental findings turn out to be lung cancer.

For the new study, researchers analyzed data of 22,173 patients who underwent neck, brachial plexus, or parathyroid imaging at the Massachusetts General Brigham in Boston.

Of those patients, 273 (1.2%) had requests for supplemental chest CTs due to incidental lung findings. Ultimately, only one new lung cancer was detected — an indolent adenocarcinoma — yielding a 2-year incidence rate of 0.40%.

The results suggest that recommendations for chest CT “should likely be substantially decreased,” the researchers conclude in the Journal of the American College of Radiology — though they also acknowledge a need for studies of larger datasets.

As for what drives such CT requests, study co-author Mark Hammer, MD, a thoracic radiologist at Brigham and Women’s Hospital, Harvard Medical School in Boston, offered one possibility: Neuroradiologists, who typically interpret neck imaging, might be less familiar with lung nodule follow-up guidelines.

At his institution, Hammer told Medscape Medical News, thoracic radiologists generally follow the Fleischner Society guidelines on management of incidentally detected pulmonary nodules.

“The reality is that neuroradiologists are often unfamiliar with those guidelines and may recommend follow-up for nodules that do not require it,” he said.

The Fleischner guidelines don’t recommend imaging nodules smaller than 6 mm given the very low cancer risk. For nodules of 6-8 mm, they recommend follow-up chest CTs at 3-12 months to see if the nodule has grown or changed. For larger or otherwise suspicious lesions, they advise prompt evaluation.

But while guidelines exist, follow-up decisions after neck imaging are largely at the discretion of the provider, said Dave Yousem, MD, MBA, a neuroradiologist at Johns Hopkins University in Baltimore.

According to Yousem, some physicians might be comfortable with the possibility of missing a low-risk indolent cancer to spare many patients from unnecessary CTs. But there’s also concern that overlooking even one tumor could trigger litigation, he said.

Hammer’s team found that of all patients with chest CT recommendations, only 171 (62.6%) underwent scanning — a rate consistent with previous reports of incidentaloma follow-up.

Hammer said, thoracic radiologists might have been applying the Fleischner guidelines, but some patients might simply have been lost to follow-up, among other possibilities.

He and his colleagues said recommendations for additional imaging should be evidence-based and judicious to ensure “appropriate follow-up and early detection of lung cancer.”

Potential solutions, they added, include incidentaloma tracking systems, improved communication between providers, and AI-assisted image interpretation.

The study was funded by the Association of University Radiologists and the Agency for Healthcare Research and Quality. Hammer and Yousem had no relevant disclosures.

M. Alexander Otto is a physician assistant with a master’s degree in medical science and a journalism degree from Newhouse. He is an award-winning medical journalist who worked for several major news outlets before joining Medscape. He is also an MIT Knight Science Journalism fellow. Email: [email protected].

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

Chest CT is being ordered too often for incidental pulmonary nodules found on neck imaging, according to a study at one US health system.

It’s not uncommon for neck CT or MRI to show nodules in the lung apices, but there’s been no data on how often those incidental findings turn out to be lung cancer.

For the new study, researchers analyzed data of 22,173 patients who underwent neck, brachial plexus, or parathyroid imaging at the Massachusetts General Brigham in Boston.

Of those patients, 273 (1.2%) had requests for supplemental chest CTs due to incidental lung findings. Ultimately, only one new lung cancer was detected — an indolent adenocarcinoma — yielding a 2-year incidence rate of 0.40%.

The results suggest that recommendations for chest CT “should likely be substantially decreased,” the researchers conclude in the Journal of the American College of Radiology — though they also acknowledge a need for studies of larger datasets.

As for what drives such CT requests, study co-author Mark Hammer, MD, a thoracic radiologist at Brigham and Women’s Hospital, Harvard Medical School in Boston, offered one possibility: Neuroradiologists, who typically interpret neck imaging, might be less familiar with lung nodule follow-up guidelines.

At his institution, Hammer told Medscape Medical News, thoracic radiologists generally follow the Fleischner Society guidelines on management of incidentally detected pulmonary nodules.

“The reality is that neuroradiologists are often unfamiliar with those guidelines and may recommend follow-up for nodules that do not require it,” he said.

The Fleischner guidelines don’t recommend imaging nodules smaller than 6 mm given the very low cancer risk. For nodules of 6-8 mm, they recommend follow-up chest CTs at 3-12 months to see if the nodule has grown or changed. For larger or otherwise suspicious lesions, they advise prompt evaluation.

But while guidelines exist, follow-up decisions after neck imaging are largely at the discretion of the provider, said Dave Yousem, MD, MBA, a neuroradiologist at Johns Hopkins University in Baltimore.

According to Yousem, some physicians might be comfortable with the possibility of missing a low-risk indolent cancer to spare many patients from unnecessary CTs. But there’s also concern that overlooking even one tumor could trigger litigation, he said.

Hammer’s team found that of all patients with chest CT recommendations, only 171 (62.6%) underwent scanning — a rate consistent with previous reports of incidentaloma follow-up.

Hammer said, thoracic radiologists might have been applying the Fleischner guidelines, but some patients might simply have been lost to follow-up, among other possibilities.

He and his colleagues said recommendations for additional imaging should be evidence-based and judicious to ensure “appropriate follow-up and early detection of lung cancer.”

Potential solutions, they added, include incidentaloma tracking systems, improved communication between providers, and AI-assisted image interpretation.

The study was funded by the Association of University Radiologists and the Agency for Healthcare Research and Quality. Hammer and Yousem had no relevant disclosures.

M. Alexander Otto is a physician assistant with a master’s degree in medical science and a journalism degree from Newhouse. He is an award-winning medical journalist who worked for several major news outlets before joining Medscape. He is also an MIT Knight Science Journalism fellow. Email: [email protected].

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

Chest CT is being ordered too often for incidental pulmonary nodules found on neck imaging, according to a study at one US health system.

It’s not uncommon for neck CT or MRI to show nodules in the lung apices, but there’s been no data on how often those incidental findings turn out to be lung cancer.

For the new study, researchers analyzed data of 22,173 patients who underwent neck, brachial plexus, or parathyroid imaging at the Massachusetts General Brigham in Boston.

Of those patients, 273 (1.2%) had requests for supplemental chest CTs due to incidental lung findings. Ultimately, only one new lung cancer was detected — an indolent adenocarcinoma — yielding a 2-year incidence rate of 0.40%.

The results suggest that recommendations for chest CT “should likely be substantially decreased,” the researchers conclude in the Journal of the American College of Radiology — though they also acknowledge a need for studies of larger datasets.

As for what drives such CT requests, study co-author Mark Hammer, MD, a thoracic radiologist at Brigham and Women’s Hospital, Harvard Medical School in Boston, offered one possibility: Neuroradiologists, who typically interpret neck imaging, might be less familiar with lung nodule follow-up guidelines.

At his institution, Hammer told Medscape Medical News, thoracic radiologists generally follow the Fleischner Society guidelines on management of incidentally detected pulmonary nodules.

“The reality is that neuroradiologists are often unfamiliar with those guidelines and may recommend follow-up for nodules that do not require it,” he said.

The Fleischner guidelines don’t recommend imaging nodules smaller than 6 mm given the very low cancer risk. For nodules of 6-8 mm, they recommend follow-up chest CTs at 3-12 months to see if the nodule has grown or changed. For larger or otherwise suspicious lesions, they advise prompt evaluation.

But while guidelines exist, follow-up decisions after neck imaging are largely at the discretion of the provider, said Dave Yousem, MD, MBA, a neuroradiologist at Johns Hopkins University in Baltimore.

According to Yousem, some physicians might be comfortable with the possibility of missing a low-risk indolent cancer to spare many patients from unnecessary CTs. But there’s also concern that overlooking even one tumor could trigger litigation, he said.

Hammer’s team found that of all patients with chest CT recommendations, only 171 (62.6%) underwent scanning — a rate consistent with previous reports of incidentaloma follow-up.

Hammer said, thoracic radiologists might have been applying the Fleischner guidelines, but some patients might simply have been lost to follow-up, among other possibilities.

He and his colleagues said recommendations for additional imaging should be evidence-based and judicious to ensure “appropriate follow-up and early detection of lung cancer.”

Potential solutions, they added, include incidentaloma tracking systems, improved communication between providers, and AI-assisted image interpretation.

The study was funded by the Association of University Radiologists and the Agency for Healthcare Research and Quality. Hammer and Yousem had no relevant disclosures.

M. Alexander Otto is a physician assistant with a master’s degree in medical science and a journalism degree from Newhouse. He is an award-winning medical journalist who worked for several major news outlets before joining Medscape. He is also an MIT Knight Science Journalism fellow. Email: [email protected].

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

Several newly identified biomarkers can help distinguish invasive aspergillosis from aspergillus colonization in lung transplant recipients, according to data from a new study presented at the annual meeting of the International Society for Heart and Lung Transplantation.

Aspergillus, a common environmental mold, can cause potentially serious infection or asymptomatic colonization in patients who have significant lung disease or are immunosuppressed, said Aaron Mishkin, MD, associate professor of medicine at the Lewis Katz School of Medicine at Temple University, Philadelphia, who was not involved in the study.

“Determining if the aspergillus that is present is a colonizing organism vs disease is challenging clinically,” Mishkin said. Clinicians currently rely on criteria including a compatible patient, imaging findings, and a laboratory-based diagnostic such as tissue from a biopsy, cultures, polymerase chain reaction (PCR), or fungal antigen detection, said Mishkin. “Fungal antigen detection has variable specificity and sensitivity,” he noted. New biomarkers that look for an immune response could help differentiate between colonization and infection by assessing an immune-mediated inflammatory response, the hallmark of infection, he said.

To tease out potential biomarkers associated with invasive aspergillosis, Christine Ng, MS, a researcher at the University Health Network, Toronto, Ontario, Canada, and colleagues performed RNA sequencing on samples from 14 control lung transplant patients, 34 with aspergillus colonization, and seven with invasive aspergillosis. They identified potential candidate genes in 15 control samples, 17 aspergillus colonization samples, and 15 invasive aspergillosis samples.

Overall, signaling pathway analysis showed robust immune response, T-cell immunity, and leukocyte immunity in patients with invasive aspergillosis. By contrast, patients with aspergillus colonization showed enriched cellular responses (response to stimuli, epithelium development).

In a real-time quantitative PCR analysis, the researchers validated three biomarkers specific to invasive aspergillosis (IRF7, ZBP1, CYP27B1). Biomarkers AKR1C2, FGF10, and VGLL3 demonstrated specificity for aspergillus colonization. Additionally, biomarkers PTGER3, LPAR3, and COL14A1 were significant when aspergillus colonization was compared to controls but not in comparisons between invasive aspergillosis and aspergillus colonization. 

The study findings were limited by the small sample size, and larger studies are needed before they can be implemented in clinical practice, the researchers wrote. However, the results suggest that the new biomarkers reveal distinct host immune patterns and may improve differentiation of aspergillosis from colonization in lung transplant recipients, they concluded.

Clinical Implications and Next Steps

RNA testing can help differentiate colonization vs infection, Mishkin said. “Colonization is not typically treated, whereas infection would be treated with an anti-fungal and, in the case of a transplant recipient, a reduction in immunosuppression,” he said. “In lung transplantation, a delicate equilibrium must be maintained between achieving optimal immunosuppression and minimizing or treating infection. Any tools that can aid in this decision-making have the potential to enhance patient outcomes,” he added.

The current study was limited by the use of data only from a single center, and the broader applicability to additional populations, broader geographic areas, and a larger number of organisms remains unknown, Mishkin said. “This type of assay does have the possibility of applicability to a larger number of fungal and even bacterial species,” he noted.

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

Several newly identified biomarkers can help distinguish invasive aspergillosis from aspergillus colonization in lung transplant recipients, according to data from a new study presented at the annual meeting of the International Society for Heart and Lung Transplantation.

Aspergillus, a common environmental mold, can cause potentially serious infection or asymptomatic colonization in patients who have significant lung disease or are immunosuppressed, said Aaron Mishkin, MD, associate professor of medicine at the Lewis Katz School of Medicine at Temple University, Philadelphia, who was not involved in the study.

“Determining if the aspergillus that is present is a colonizing organism vs disease is challenging clinically,” Mishkin said. Clinicians currently rely on criteria including a compatible patient, imaging findings, and a laboratory-based diagnostic such as tissue from a biopsy, cultures, polymerase chain reaction (PCR), or fungal antigen detection, said Mishkin. “Fungal antigen detection has variable specificity and sensitivity,” he noted. New biomarkers that look for an immune response could help differentiate between colonization and infection by assessing an immune-mediated inflammatory response, the hallmark of infection, he said.

To tease out potential biomarkers associated with invasive aspergillosis, Christine Ng, MS, a researcher at the University Health Network, Toronto, Ontario, Canada, and colleagues performed RNA sequencing on samples from 14 control lung transplant patients, 34 with aspergillus colonization, and seven with invasive aspergillosis. They identified potential candidate genes in 15 control samples, 17 aspergillus colonization samples, and 15 invasive aspergillosis samples.

Overall, signaling pathway analysis showed robust immune response, T-cell immunity, and leukocyte immunity in patients with invasive aspergillosis. By contrast, patients with aspergillus colonization showed enriched cellular responses (response to stimuli, epithelium development).

In a real-time quantitative PCR analysis, the researchers validated three biomarkers specific to invasive aspergillosis (IRF7, ZBP1, CYP27B1). Biomarkers AKR1C2, FGF10, and VGLL3 demonstrated specificity for aspergillus colonization. Additionally, biomarkers PTGER3, LPAR3, and COL14A1 were significant when aspergillus colonization was compared to controls but not in comparisons between invasive aspergillosis and aspergillus colonization. 

The study findings were limited by the small sample size, and larger studies are needed before they can be implemented in clinical practice, the researchers wrote. However, the results suggest that the new biomarkers reveal distinct host immune patterns and may improve differentiation of aspergillosis from colonization in lung transplant recipients, they concluded.

Clinical Implications and Next Steps

RNA testing can help differentiate colonization vs infection, Mishkin said. “Colonization is not typically treated, whereas infection would be treated with an anti-fungal and, in the case of a transplant recipient, a reduction in immunosuppression,” he said. “In lung transplantation, a delicate equilibrium must be maintained between achieving optimal immunosuppression and minimizing or treating infection. Any tools that can aid in this decision-making have the potential to enhance patient outcomes,” he added.

The current study was limited by the use of data only from a single center, and the broader applicability to additional populations, broader geographic areas, and a larger number of organisms remains unknown, Mishkin said. “This type of assay does have the possibility of applicability to a larger number of fungal and even bacterial species,” he noted.

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

Several newly identified biomarkers can help distinguish invasive aspergillosis from aspergillus colonization in lung transplant recipients, according to data from a new study presented at the annual meeting of the International Society for Heart and Lung Transplantation.

Aspergillus, a common environmental mold, can cause potentially serious infection or asymptomatic colonization in patients who have significant lung disease or are immunosuppressed, said Aaron Mishkin, MD, associate professor of medicine at the Lewis Katz School of Medicine at Temple University, Philadelphia, who was not involved in the study.

“Determining if the aspergillus that is present is a colonizing organism vs disease is challenging clinically,” Mishkin said. Clinicians currently rely on criteria including a compatible patient, imaging findings, and a laboratory-based diagnostic such as tissue from a biopsy, cultures, polymerase chain reaction (PCR), or fungal antigen detection, said Mishkin. “Fungal antigen detection has variable specificity and sensitivity,” he noted. New biomarkers that look for an immune response could help differentiate between colonization and infection by assessing an immune-mediated inflammatory response, the hallmark of infection, he said.

To tease out potential biomarkers associated with invasive aspergillosis, Christine Ng, MS, a researcher at the University Health Network, Toronto, Ontario, Canada, and colleagues performed RNA sequencing on samples from 14 control lung transplant patients, 34 with aspergillus colonization, and seven with invasive aspergillosis. They identified potential candidate genes in 15 control samples, 17 aspergillus colonization samples, and 15 invasive aspergillosis samples.

Overall, signaling pathway analysis showed robust immune response, T-cell immunity, and leukocyte immunity in patients with invasive aspergillosis. By contrast, patients with aspergillus colonization showed enriched cellular responses (response to stimuli, epithelium development).

In a real-time quantitative PCR analysis, the researchers validated three biomarkers specific to invasive aspergillosis (IRF7, ZBP1, CYP27B1). Biomarkers AKR1C2, FGF10, and VGLL3 demonstrated specificity for aspergillus colonization. Additionally, biomarkers PTGER3, LPAR3, and COL14A1 were significant when aspergillus colonization was compared to controls but not in comparisons between invasive aspergillosis and aspergillus colonization. 

The study findings were limited by the small sample size, and larger studies are needed before they can be implemented in clinical practice, the researchers wrote. However, the results suggest that the new biomarkers reveal distinct host immune patterns and may improve differentiation of aspergillosis from colonization in lung transplant recipients, they concluded.

Clinical Implications and Next Steps

RNA testing can help differentiate colonization vs infection, Mishkin said. “Colonization is not typically treated, whereas infection would be treated with an anti-fungal and, in the case of a transplant recipient, a reduction in immunosuppression,” he said. “In lung transplantation, a delicate equilibrium must be maintained between achieving optimal immunosuppression and minimizing or treating infection. Any tools that can aid in this decision-making have the potential to enhance patient outcomes,” he added.

The current study was limited by the use of data only from a single center, and the broader applicability to additional populations, broader geographic areas, and a larger number of organisms remains unknown, Mishkin said. “This type of assay does have the possibility of applicability to a larger number of fungal and even bacterial species,” he noted.

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