A common refrain in psychiatry is that the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision, (DSM-5-TR), published in 2022, is the best we can do.

Since the DSM-III was released in 1980, the American Psychiatric Association, which publishes the manual, has espoused the position that we should list symptoms, in a manner that is reminiscent of a checklist. For example, having a depressed mood on most days for a 2-week period, or a loss of interest in pleasurable things, as well as 4 additional symptoms – among them changes in appetite, changes in sleep, changes in psychomotor activity, fatigue, worthlessness, poor concentration, or thoughts of death – can lead to a diagnosis of a major depressive episode as part of a major depressive disorder.

Criticisms of this approach can be apparent. Patients subjected to such checklists, including being repeatedly asked to complete the Patient Health Questionnaire 9 (PHQ-9), which closely follows those criteria, can feel lost and even alienated by their providers. After all, one can ask all those questions and make a diagnosis of depression without even knowing about the patient’s stressors, their history, or their social context.

The DSM permits the diagnosis of psychiatric disorders without an understanding of the narrative of the patient. In its defense, the DSM is not a textbook of psychiatry, it is a guide on how to diagnose individuals. The DSM does not demand that psychiatrists only ask about the symptoms on the checklists; it is the providers who can choose to dismiss asking about the important facets of one’s life.

Yet every time we attend a lecture that starts by enumerating the DSM symptoms of the disorder being discussed, we are left with the dissatisfying impression that a specialist of this disorder should have a more nuanced and interesting description of their disorder of study. This feeling of discontent is compounded when we see a movie that encompasses so much of what is missing in today’s psychiatric parlance, and even more so if that movie is ostensibly made for children. Movies, by design, are particularly adept at encapsulating the narrative of someone’s life in a way that psychiatry can learn from.

Other than the embarrassment of not knowing a patient outside the checklist, the importance of narrative cannot be understated. Dr. Erik Erikson rightfully suggested that the point of life is “the acceptance of one’s one and only life cycle”¹ or rather to know it was okay to have been oneself without additions or substitutions. Therefore, one must know what it has meant to be themselves to reconcile this question and achieve Ego Integrity rather than disgust and despair. Narrative is the way in which we understand who we are and what it has meant to be ourselves. An understanding of our personal narrative presents a unique opportunity in expressing what is missing in the DSM. Below, we provide two of our favorite examples in Disney films, among many.
 

‘Ratatouille’ (2007)

One of the missing features of the DSM is its inability to explain to patients the intrapsychic processes that guide us. One of these processes is how our values can lead us to a deep sense of guilt, shame, and the resulting feelings of alienation. It is extremely common for patients to enter our clinical practice feeling shackled by beliefs that they should accomplish more and be more than they are.

The animated film “Ratatouille” does an excellent job at addressing this feeling. The film follows Remy, the protagonist rat, and his adventures as he explores his passion for cooking. Remy teams up with the inept but good-natured human Alfredo Linguini and guides him through cooking while hiding under his chef’s hat. The primary antagonist, Anton Ego, is a particularly harsh food critic. His presence and appearance are somber. He exudes disdain. His trim physique and scarf suggest a man that will break and react to anything, and his skull-shaped typewriter in his coffin-shaped office informs the viewer that he is out to kill with his cruel words. Anton Ego serves as our projected super-ego. He is not an external judge but the judgment deep inside ourselves, goading us to be better with such severity that we are ultimately left feeling condemned.

Remy is the younger of two siblings. He is less physically adept but more intellectual than his older brother, who does not understand why Remy isn’t content eating scraps from the garbage like the rest of their rat clan. Remy is the creative part within us that wants to challenge the status quo and try something new. Remy also represents our shame and guilt for leaving our home. On one hand, we want to dare greatly, in this case at being an extraordinary chef, but on the other we are shy and cook in secret, hiding within the hat of another person. Remy struggles with the deep feeling that we do not deserve our success, that our family will leave us for being who we are, and that we are better off isolating and segregating from our challenges.

The movie concludes that through talent and hard work, our critics will accept us. Furthermore, once accepted for what we do, we can be further accepted for who we are. The movie ends with Remy cooking the eponymous dish ratatouille. He prepares it so remarkably well, the dish transports Anton Ego back to a sublime experience of eating ratatouille as a child, a touching moment which not only underscores food’s evocative link to memory but gives a glimpse at Anton Ego’s own narrative.

Ego is first won over by the dish, and only afterward learns of Remy’s true identity. Remy’s talent is undeniable though, and even the stuffy Ego must accept the film’s theme that “Anyone can cook,” even a rat – the rat that we all sometimes feel we are deep inside, rotten to the core but trying so hard to be accepted by others, and ultimately by ourselves. In the end, we overcome the disgust inherent in the imagery of a rat in a kitchen and instead embrace our hero’s achievement of ego integrity as he combines his identities as a member of a clan of rats, and one of Paris’s finest chefs.

While modern psychiatry can favor looking at people through the lens of biology rather than narrative, “Ratatouille” can serve as a reminder of the powerful unconscious forces that guide our lives. “Ratatouille” is not a successful movie only because of the compelling narrative, but also because the narrative matches the important psychic paradigms that psychiatry once embraced.
 

‘Inside Out’ (2015)

Another missing feature of the DSM is its inability to explain how symptoms feel and manifest psychologically. One such feeling is that of control – whether one is in control of one’s life, feelings, and action or rather a victim of external forces. It is extremely common for patients to enter our clinical practice feeling traumatized by the life they’ve lived and powerless to produce any change. Part of our role is to guide them through this journey from the object of their lives to the subject of their lives.

In the animated feature “Inside Out,” Riley, a preteen girl, goes through the tribulation of growing up and learning about herself. This seemingly happy child, content playing hockey with her best friend, Meg, on the picturesque frozen lakes of Minnesota, reaches her inevitable conflict. Her parents uproot her life, moving the family to San Francisco. By doing so, they disconnect her from her school, her friends, and her hobbies. While all this is happening, we spend time inside Riley’s psyche with the personified characters of Riley’s emotions as they affect her decisions and daily actions amidst the backdrop of her core memories and islands of personality.

During the move, her parents seemingly change and ultimately destroy every facet of Riley’s sense of self, which is animated as the collapse of her personality islands. Her best friend engages Riley in a video call just to inform her that she has a new friend who plays hockey equally well. Her parents do not hear Riley’s concerns and are portrayed as distracted by their adult problems. Riley feels ridiculed in her new school and unable to share her feelings with her parents, who ask her to still be their “happy girl” and indirectly ask her to fake pleasure to alleviate their own anxiety.

The climax of the movie is when Riley decides to run away from San Francisco and her parents, to return to her perceived true home, Minnesota. The climax is resolved when Riley realizes that her parents’ love, representing the connection we have to others, transcends her need for control. To some degree, we are all powerless in the face of the tremendous forces of life and share the difficult task of accepting the cards we were dealt, thus making the story of Riley so compelling.

Additionally, the climax is further resolved by another argument that psychiatry (and the DSM) should consider embracing. Emotions are not all symptoms and living without negative emotion is not the goal of life. Riley grows from preteen to teenager, and from object to subject of her life, by realizing that her symptoms/feelings are not just nuisances to avoid and hide, but the key to meaning. Our anger drives us to try hard. Our fear protects us from harm. Our sadness attracts the warmth and care of others. Our disgust protects us physically from noxious material (symbolized as a dreaded broccoli floret for preteen Riley) and socially by encouraging us to share societal norms. Similarly, patients and people in general would benefit by being taught that, while symptoms may permit the better assessment of psychiatric conditions using the DSM, life is much more than that.

It is unfair to blame the DSM for things it was not designed to do. The DSM doesn’t advertise itself as a guidebook of all behaviors, at all times. However, for a variety of reasons, it has become the main way psychiatry describes people. While we commend the APA for its effort and do not know that we could make it any better, we are frequently happily reminded that in about 90 minutes, filmmakers are able to display an empathic understanding of personal narratives that biologic psychiatry can miss.

Dr. Pulido is a psychiatry resident at the University of California, San Diego. She is interested in women’s mental health, medical education, and outpatient psychiatry. Dr. Badre is a clinical and forensic psychiatrist in San Diego. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Badre can be reached at his website, BadreMD.com. He has no conflicts of interest.

References

1. Erikson, EH. Childhood and society (New York: WW Norton, 1950).

A common refrain in psychiatry is that the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision, (DSM-5-TR), published in 2022, is the best we can do.

Since the DSM-III was released in 1980, the American Psychiatric Association, which publishes the manual, has espoused the position that we should list symptoms, in a manner that is reminiscent of a checklist. For example, having a depressed mood on most days for a 2-week period, or a loss of interest in pleasurable things, as well as 4 additional symptoms – among them changes in appetite, changes in sleep, changes in psychomotor activity, fatigue, worthlessness, poor concentration, or thoughts of death – can lead to a diagnosis of a major depressive episode as part of a major depressive disorder.

Criticisms of this approach can be apparent. Patients subjected to such checklists, including being repeatedly asked to complete the Patient Health Questionnaire 9 (PHQ-9), which closely follows those criteria, can feel lost and even alienated by their providers. After all, one can ask all those questions and make a diagnosis of depression without even knowing about the patient’s stressors, their history, or their social context.

The DSM permits the diagnosis of psychiatric disorders without an understanding of the narrative of the patient. In its defense, the DSM is not a textbook of psychiatry, it is a guide on how to diagnose individuals. The DSM does not demand that psychiatrists only ask about the symptoms on the checklists; it is the providers who can choose to dismiss asking about the important facets of one’s life.

Yet every time we attend a lecture that starts by enumerating the DSM symptoms of the disorder being discussed, we are left with the dissatisfying impression that a specialist of this disorder should have a more nuanced and interesting description of their disorder of study. This feeling of discontent is compounded when we see a movie that encompasses so much of what is missing in today’s psychiatric parlance, and even more so if that movie is ostensibly made for children. Movies, by design, are particularly adept at encapsulating the narrative of someone’s life in a way that psychiatry can learn from.

Other than the embarrassment of not knowing a patient outside the checklist, the importance of narrative cannot be understated. Dr. Erik Erikson rightfully suggested that the point of life is “the acceptance of one’s one and only life cycle”¹ or rather to know it was okay to have been oneself without additions or substitutions. Therefore, one must know what it has meant to be themselves to reconcile this question and achieve Ego Integrity rather than disgust and despair. Narrative is the way in which we understand who we are and what it has meant to be ourselves. An understanding of our personal narrative presents a unique opportunity in expressing what is missing in the DSM. Below, we provide two of our favorite examples in Disney films, among many.
 

‘Ratatouille’ (2007)

One of the missing features of the DSM is its inability to explain to patients the intrapsychic processes that guide us. One of these processes is how our values can lead us to a deep sense of guilt, shame, and the resulting feelings of alienation. It is extremely common for patients to enter our clinical practice feeling shackled by beliefs that they should accomplish more and be more than they are.

The animated film “Ratatouille” does an excellent job at addressing this feeling. The film follows Remy, the protagonist rat, and his adventures as he explores his passion for cooking. Remy teams up with the inept but good-natured human Alfredo Linguini and guides him through cooking while hiding under his chef’s hat. The primary antagonist, Anton Ego, is a particularly harsh food critic. His presence and appearance are somber. He exudes disdain. His trim physique and scarf suggest a man that will break and react to anything, and his skull-shaped typewriter in his coffin-shaped office informs the viewer that he is out to kill with his cruel words. Anton Ego serves as our projected super-ego. He is not an external judge but the judgment deep inside ourselves, goading us to be better with such severity that we are ultimately left feeling condemned.

Remy is the younger of two siblings. He is less physically adept but more intellectual than his older brother, who does not understand why Remy isn’t content eating scraps from the garbage like the rest of their rat clan. Remy is the creative part within us that wants to challenge the status quo and try something new. Remy also represents our shame and guilt for leaving our home. On one hand, we want to dare greatly, in this case at being an extraordinary chef, but on the other we are shy and cook in secret, hiding within the hat of another person. Remy struggles with the deep feeling that we do not deserve our success, that our family will leave us for being who we are, and that we are better off isolating and segregating from our challenges.

The movie concludes that through talent and hard work, our critics will accept us. Furthermore, once accepted for what we do, we can be further accepted for who we are. The movie ends with Remy cooking the eponymous dish ratatouille. He prepares it so remarkably well, the dish transports Anton Ego back to a sublime experience of eating ratatouille as a child, a touching moment which not only underscores food’s evocative link to memory but gives a glimpse at Anton Ego’s own narrative.

Ego is first won over by the dish, and only afterward learns of Remy’s true identity. Remy’s talent is undeniable though, and even the stuffy Ego must accept the film’s theme that “Anyone can cook,” even a rat – the rat that we all sometimes feel we are deep inside, rotten to the core but trying so hard to be accepted by others, and ultimately by ourselves. In the end, we overcome the disgust inherent in the imagery of a rat in a kitchen and instead embrace our hero’s achievement of ego integrity as he combines his identities as a member of a clan of rats, and one of Paris’s finest chefs.

While modern psychiatry can favor looking at people through the lens of biology rather than narrative, “Ratatouille” can serve as a reminder of the powerful unconscious forces that guide our lives. “Ratatouille” is not a successful movie only because of the compelling narrative, but also because the narrative matches the important psychic paradigms that psychiatry once embraced.
 

‘Inside Out’ (2015)

Another missing feature of the DSM is its inability to explain how symptoms feel and manifest psychologically. One such feeling is that of control – whether one is in control of one’s life, feelings, and action or rather a victim of external forces. It is extremely common for patients to enter our clinical practice feeling traumatized by the life they’ve lived and powerless to produce any change. Part of our role is to guide them through this journey from the object of their lives to the subject of their lives.

In the animated feature “Inside Out,” Riley, a preteen girl, goes through the tribulation of growing up and learning about herself. This seemingly happy child, content playing hockey with her best friend, Meg, on the picturesque frozen lakes of Minnesota, reaches her inevitable conflict. Her parents uproot her life, moving the family to San Francisco. By doing so, they disconnect her from her school, her friends, and her hobbies. While all this is happening, we spend time inside Riley’s psyche with the personified characters of Riley’s emotions as they affect her decisions and daily actions amidst the backdrop of her core memories and islands of personality.

During the move, her parents seemingly change and ultimately destroy every facet of Riley’s sense of self, which is animated as the collapse of her personality islands. Her best friend engages Riley in a video call just to inform her that she has a new friend who plays hockey equally well. Her parents do not hear Riley’s concerns and are portrayed as distracted by their adult problems. Riley feels ridiculed in her new school and unable to share her feelings with her parents, who ask her to still be their “happy girl” and indirectly ask her to fake pleasure to alleviate their own anxiety.

The climax of the movie is when Riley decides to run away from San Francisco and her parents, to return to her perceived true home, Minnesota. The climax is resolved when Riley realizes that her parents’ love, representing the connection we have to others, transcends her need for control. To some degree, we are all powerless in the face of the tremendous forces of life and share the difficult task of accepting the cards we were dealt, thus making the story of Riley so compelling.

Additionally, the climax is further resolved by another argument that psychiatry (and the DSM) should consider embracing. Emotions are not all symptoms and living without negative emotion is not the goal of life. Riley grows from preteen to teenager, and from object to subject of her life, by realizing that her symptoms/feelings are not just nuisances to avoid and hide, but the key to meaning. Our anger drives us to try hard. Our fear protects us from harm. Our sadness attracts the warmth and care of others. Our disgust protects us physically from noxious material (symbolized as a dreaded broccoli floret for preteen Riley) and socially by encouraging us to share societal norms. Similarly, patients and people in general would benefit by being taught that, while symptoms may permit the better assessment of psychiatric conditions using the DSM, life is much more than that.

It is unfair to blame the DSM for things it was not designed to do. The DSM doesn’t advertise itself as a guidebook of all behaviors, at all times. However, for a variety of reasons, it has become the main way psychiatry describes people. While we commend the APA for its effort and do not know that we could make it any better, we are frequently happily reminded that in about 90 minutes, filmmakers are able to display an empathic understanding of personal narratives that biologic psychiatry can miss.

Dr. Pulido is a psychiatry resident at the University of California, San Diego. She is interested in women’s mental health, medical education, and outpatient psychiatry. Dr. Badre is a clinical and forensic psychiatrist in San Diego. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Badre can be reached at his website, BadreMD.com. He has no conflicts of interest.

References

1. Erikson, EH. Childhood and society (New York: WW Norton, 1950).

A common refrain in psychiatry is that the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision, (DSM-5-TR), published in 2022, is the best we can do.

Since the DSM-III was released in 1980, the American Psychiatric Association, which publishes the manual, has espoused the position that we should list symptoms, in a manner that is reminiscent of a checklist. For example, having a depressed mood on most days for a 2-week period, or a loss of interest in pleasurable things, as well as 4 additional symptoms – among them changes in appetite, changes in sleep, changes in psychomotor activity, fatigue, worthlessness, poor concentration, or thoughts of death – can lead to a diagnosis of a major depressive episode as part of a major depressive disorder.

Criticisms of this approach can be apparent. Patients subjected to such checklists, including being repeatedly asked to complete the Patient Health Questionnaire 9 (PHQ-9), which closely follows those criteria, can feel lost and even alienated by their providers. After all, one can ask all those questions and make a diagnosis of depression without even knowing about the patient’s stressors, their history, or their social context.

The DSM permits the diagnosis of psychiatric disorders without an understanding of the narrative of the patient. In its defense, the DSM is not a textbook of psychiatry, it is a guide on how to diagnose individuals. The DSM does not demand that psychiatrists only ask about the symptoms on the checklists; it is the providers who can choose to dismiss asking about the important facets of one’s life.

Yet every time we attend a lecture that starts by enumerating the DSM symptoms of the disorder being discussed, we are left with the dissatisfying impression that a specialist of this disorder should have a more nuanced and interesting description of their disorder of study. This feeling of discontent is compounded when we see a movie that encompasses so much of what is missing in today’s psychiatric parlance, and even more so if that movie is ostensibly made for children. Movies, by design, are particularly adept at encapsulating the narrative of someone’s life in a way that psychiatry can learn from.

Other than the embarrassment of not knowing a patient outside the checklist, the importance of narrative cannot be understated. Dr. Erik Erikson rightfully suggested that the point of life is “the acceptance of one’s one and only life cycle”¹ or rather to know it was okay to have been oneself without additions or substitutions. Therefore, one must know what it has meant to be themselves to reconcile this question and achieve Ego Integrity rather than disgust and despair. Narrative is the way in which we understand who we are and what it has meant to be ourselves. An understanding of our personal narrative presents a unique opportunity in expressing what is missing in the DSM. Below, we provide two of our favorite examples in Disney films, among many.
 

‘Ratatouille’ (2007)

One of the missing features of the DSM is its inability to explain to patients the intrapsychic processes that guide us. One of these processes is how our values can lead us to a deep sense of guilt, shame, and the resulting feelings of alienation. It is extremely common for patients to enter our clinical practice feeling shackled by beliefs that they should accomplish more and be more than they are.

The animated film “Ratatouille” does an excellent job at addressing this feeling. The film follows Remy, the protagonist rat, and his adventures as he explores his passion for cooking. Remy teams up with the inept but good-natured human Alfredo Linguini and guides him through cooking while hiding under his chef’s hat. The primary antagonist, Anton Ego, is a particularly harsh food critic. His presence and appearance are somber. He exudes disdain. His trim physique and scarf suggest a man that will break and react to anything, and his skull-shaped typewriter in his coffin-shaped office informs the viewer that he is out to kill with his cruel words. Anton Ego serves as our projected super-ego. He is not an external judge but the judgment deep inside ourselves, goading us to be better with such severity that we are ultimately left feeling condemned.

Remy is the younger of two siblings. He is less physically adept but more intellectual than his older brother, who does not understand why Remy isn’t content eating scraps from the garbage like the rest of their rat clan. Remy is the creative part within us that wants to challenge the status quo and try something new. Remy also represents our shame and guilt for leaving our home. On one hand, we want to dare greatly, in this case at being an extraordinary chef, but on the other we are shy and cook in secret, hiding within the hat of another person. Remy struggles with the deep feeling that we do not deserve our success, that our family will leave us for being who we are, and that we are better off isolating and segregating from our challenges.

The movie concludes that through talent and hard work, our critics will accept us. Furthermore, once accepted for what we do, we can be further accepted for who we are. The movie ends with Remy cooking the eponymous dish ratatouille. He prepares it so remarkably well, the dish transports Anton Ego back to a sublime experience of eating ratatouille as a child, a touching moment which not only underscores food’s evocative link to memory but gives a glimpse at Anton Ego’s own narrative.

Ego is first won over by the dish, and only afterward learns of Remy’s true identity. Remy’s talent is undeniable though, and even the stuffy Ego must accept the film’s theme that “Anyone can cook,” even a rat – the rat that we all sometimes feel we are deep inside, rotten to the core but trying so hard to be accepted by others, and ultimately by ourselves. In the end, we overcome the disgust inherent in the imagery of a rat in a kitchen and instead embrace our hero’s achievement of ego integrity as he combines his identities as a member of a clan of rats, and one of Paris’s finest chefs.

While modern psychiatry can favor looking at people through the lens of biology rather than narrative, “Ratatouille” can serve as a reminder of the powerful unconscious forces that guide our lives. “Ratatouille” is not a successful movie only because of the compelling narrative, but also because the narrative matches the important psychic paradigms that psychiatry once embraced.
 

‘Inside Out’ (2015)

Another missing feature of the DSM is its inability to explain how symptoms feel and manifest psychologically. One such feeling is that of control – whether one is in control of one’s life, feelings, and action or rather a victim of external forces. It is extremely common for patients to enter our clinical practice feeling traumatized by the life they’ve lived and powerless to produce any change. Part of our role is to guide them through this journey from the object of their lives to the subject of their lives.

In the animated feature “Inside Out,” Riley, a preteen girl, goes through the tribulation of growing up and learning about herself. This seemingly happy child, content playing hockey with her best friend, Meg, on the picturesque frozen lakes of Minnesota, reaches her inevitable conflict. Her parents uproot her life, moving the family to San Francisco. By doing so, they disconnect her from her school, her friends, and her hobbies. While all this is happening, we spend time inside Riley’s psyche with the personified characters of Riley’s emotions as they affect her decisions and daily actions amidst the backdrop of her core memories and islands of personality.

During the move, her parents seemingly change and ultimately destroy every facet of Riley’s sense of self, which is animated as the collapse of her personality islands. Her best friend engages Riley in a video call just to inform her that she has a new friend who plays hockey equally well. Her parents do not hear Riley’s concerns and are portrayed as distracted by their adult problems. Riley feels ridiculed in her new school and unable to share her feelings with her parents, who ask her to still be their “happy girl” and indirectly ask her to fake pleasure to alleviate their own anxiety.

The climax of the movie is when Riley decides to run away from San Francisco and her parents, to return to her perceived true home, Minnesota. The climax is resolved when Riley realizes that her parents’ love, representing the connection we have to others, transcends her need for control. To some degree, we are all powerless in the face of the tremendous forces of life and share the difficult task of accepting the cards we were dealt, thus making the story of Riley so compelling.

Additionally, the climax is further resolved by another argument that psychiatry (and the DSM) should consider embracing. Emotions are not all symptoms and living without negative emotion is not the goal of life. Riley grows from preteen to teenager, and from object to subject of her life, by realizing that her symptoms/feelings are not just nuisances to avoid and hide, but the key to meaning. Our anger drives us to try hard. Our fear protects us from harm. Our sadness attracts the warmth and care of others. Our disgust protects us physically from noxious material (symbolized as a dreaded broccoli floret for preteen Riley) and socially by encouraging us to share societal norms. Similarly, patients and people in general would benefit by being taught that, while symptoms may permit the better assessment of psychiatric conditions using the DSM, life is much more than that.

It is unfair to blame the DSM for things it was not designed to do. The DSM doesn’t advertise itself as a guidebook of all behaviors, at all times. However, for a variety of reasons, it has become the main way psychiatry describes people. While we commend the APA for its effort and do not know that we could make it any better, we are frequently happily reminded that in about 90 minutes, filmmakers are able to display an empathic understanding of personal narratives that biologic psychiatry can miss.

Dr. Pulido is a psychiatry resident at the University of California, San Diego. She is interested in women’s mental health, medical education, and outpatient psychiatry. Dr. Badre is a clinical and forensic psychiatrist in San Diego. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Badre can be reached at his website, BadreMD.com. He has no conflicts of interest.

References

1. Erikson, EH. Childhood and society (New York: WW Norton, 1950).

For people with inflammatory bowel disease (IBD) taking immunosuppressive medication, a third dose of a COVID-19 mRNA vaccine significantly increases neutralizing antibodies against the original SARS-CoV-2 strain, but the picture is more complicated for protection against the Omicron variant, according to a research letter published in Gastroenterology.

Though IBD patients do mount a response against Omicron, the response is substantially lower for those taking tofacitinib or infliximab, particularly infliximab monotherapy.

“As further mutations in the viral genome accumulate over time, with the attendant risk of immune evasion, it remains important to continue to reappraise vaccination strategy, including the implementation of personalized approaches for some patients, such as those treated with anti-TNF drugs and JAK inhibitors,” wrote Zhigang Liu, PhD, a research associate in the department of metabolism, digestion, and reproduction at Imperial College London, and his colleagues. “Preferential use of bivalent vaccines may be especially valuable in IBD patients taking anti-TNF agents or JAK inhibitors,” they wrote. Their study did not assess neutralizing antibodies resulting from use of the bivalent vaccine, however.

The researchers tracked 268 participants, including 49 healthy participants serving as controls, from May 2021 through March 2022. The other participants had IBD and included 51 patients taking thiopurines, 36 patients taking infliximab, 39 taking both infliximab and thiopurines, 39 taking ustekinumab, 38 taking vedolizumab, and 16 taking tofacitinib. The IBD patients were all enrolled in the SARS-CoV-2 Vaccination Immunogenicity in Immunosuppressed Inflammatory Bowel Disease Patients (VIP) cohort.

None of the participants had evidence of a SARS-CoV-2 infection at baseline. All had received two doses of an mRNA COVID-19 vaccine (all received Pfizer, except two controls who received Moderna) or two doses of the AstraZeneca vaccine as their primary vaccination. All received an mRNA vaccine for their third dose. Among the IBD patients, 137 received the AstraZeneca in their primary two-dose series, and 82 received Pfizer.

First the researchers assessed the participants’ humoral response to the vaccine against the original SARS-CoV-2 strain and against the Omicron BA.1 variant. Neutralizing antibody titers rose significantly against both strains after the third vaccine dose for all participants.

“However, 50% neutralization titer (NT50) values were significantly lower against Omicron than against the ancestral strain in all study groups, irrespective of the immunosuppressive treatment regimen,” the authors reported. NT50 values are a measure that reflect a vaccine-induced humoral immunity against SARS-CoV-2 after vaccination.

Compared to the healthy controls, individuals receiving infliximab, tofacitinib, or infliximab/thiopurine combination therapy showed significantly lower responses after the second and third vaccine doses. Thirteen patients did not generate NT50 against Omicron after the second vaccine dose, and 7 of them were on infliximab monotherapy. They represented nearly 20% of all infliximab monotherapy participants.

Next the researchers assessed the risk of a breakthrough infection according to neutralizing titer thresholds. Individuals with an NT50 less than 500 had 1.6 times greater odds of a breakthrough infection than those with an NT50 above 500, they noted. After two vaccine doses, 46% of participants with IBD had an NT50 above 500 for the ancestral strain, which rose to 85% of those with IBD after a third dose.

In the healthy control group, 35% had an NT50 under 500 after two doses, and 14% of them had a breakthrough infection, all of which were mild and none of which required hospitalization. The NT50 in healthy controls, however, was not significantly associated with risk of breakthrough infection.

“In this study, neutralizing titers elicited against the omicron variant were generally poor for all individuals and were substantially lower in recipients of infliximab, infliximab/thiopurine combination, or tofacitinib therapy,” the authors concluded. “This raises concerns about whether currently available vaccines will be sufficient to protect against continually evolving SARS-CoV-2 variants, especially in patients established on certain immunosuppressive drugs.”

The small population sizes for each subgroup based on medication was one of the study’s limitations. Another was the fact that it was underpowered to conclusively determine whether an increased risk of breakthrough infection exists in IBD patients who have lower titers of neutralizing antibodies. A limitation for generalization to U.S. patients is that just 64% of the IBD patients received the AstraZeneca vaccine, which is not offered in the United States, for their first two doses before receiving the third mRNA (Pfizer) dose.

The study was funded by Pfizer in an independent research grant and by the NIHR Biomedical Research Centres in Imperial College London and Imperial College Healthcare NHS Trust and Cambridge, and the NIHR Clinical Research Facility Cambridge.

Dr. Liu and one other author had no disclosures. The other 18 authors have a range of disclosures related to various pharmaceutical companies, including Pfizer.

For people with inflammatory bowel disease (IBD) taking immunosuppressive medication, a third dose of a COVID-19 mRNA vaccine significantly increases neutralizing antibodies against the original SARS-CoV-2 strain, but the picture is more complicated for protection against the Omicron variant, according to a research letter published in Gastroenterology.

Though IBD patients do mount a response against Omicron, the response is substantially lower for those taking tofacitinib or infliximab, particularly infliximab monotherapy.

“As further mutations in the viral genome accumulate over time, with the attendant risk of immune evasion, it remains important to continue to reappraise vaccination strategy, including the implementation of personalized approaches for some patients, such as those treated with anti-TNF drugs and JAK inhibitors,” wrote Zhigang Liu, PhD, a research associate in the department of metabolism, digestion, and reproduction at Imperial College London, and his colleagues. “Preferential use of bivalent vaccines may be especially valuable in IBD patients taking anti-TNF agents or JAK inhibitors,” they wrote. Their study did not assess neutralizing antibodies resulting from use of the bivalent vaccine, however.

The researchers tracked 268 participants, including 49 healthy participants serving as controls, from May 2021 through March 2022. The other participants had IBD and included 51 patients taking thiopurines, 36 patients taking infliximab, 39 taking both infliximab and thiopurines, 39 taking ustekinumab, 38 taking vedolizumab, and 16 taking tofacitinib. The IBD patients were all enrolled in the SARS-CoV-2 Vaccination Immunogenicity in Immunosuppressed Inflammatory Bowel Disease Patients (VIP) cohort.

None of the participants had evidence of a SARS-CoV-2 infection at baseline. All had received two doses of an mRNA COVID-19 vaccine (all received Pfizer, except two controls who received Moderna) or two doses of the AstraZeneca vaccine as their primary vaccination. All received an mRNA vaccine for their third dose. Among the IBD patients, 137 received the AstraZeneca in their primary two-dose series, and 82 received Pfizer.

First the researchers assessed the participants’ humoral response to the vaccine against the original SARS-CoV-2 strain and against the Omicron BA.1 variant. Neutralizing antibody titers rose significantly against both strains after the third vaccine dose for all participants.

“However, 50% neutralization titer (NT50) values were significantly lower against Omicron than against the ancestral strain in all study groups, irrespective of the immunosuppressive treatment regimen,” the authors reported. NT50 values are a measure that reflect a vaccine-induced humoral immunity against SARS-CoV-2 after vaccination.

Compared to the healthy controls, individuals receiving infliximab, tofacitinib, or infliximab/thiopurine combination therapy showed significantly lower responses after the second and third vaccine doses. Thirteen patients did not generate NT50 against Omicron after the second vaccine dose, and 7 of them were on infliximab monotherapy. They represented nearly 20% of all infliximab monotherapy participants.

Next the researchers assessed the risk of a breakthrough infection according to neutralizing titer thresholds. Individuals with an NT50 less than 500 had 1.6 times greater odds of a breakthrough infection than those with an NT50 above 500, they noted. After two vaccine doses, 46% of participants with IBD had an NT50 above 500 for the ancestral strain, which rose to 85% of those with IBD after a third dose.

In the healthy control group, 35% had an NT50 under 500 after two doses, and 14% of them had a breakthrough infection, all of which were mild and none of which required hospitalization. The NT50 in healthy controls, however, was not significantly associated with risk of breakthrough infection.

“In this study, neutralizing titers elicited against the omicron variant were generally poor for all individuals and were substantially lower in recipients of infliximab, infliximab/thiopurine combination, or tofacitinib therapy,” the authors concluded. “This raises concerns about whether currently available vaccines will be sufficient to protect against continually evolving SARS-CoV-2 variants, especially in patients established on certain immunosuppressive drugs.”

The small population sizes for each subgroup based on medication was one of the study’s limitations. Another was the fact that it was underpowered to conclusively determine whether an increased risk of breakthrough infection exists in IBD patients who have lower titers of neutralizing antibodies. A limitation for generalization to U.S. patients is that just 64% of the IBD patients received the AstraZeneca vaccine, which is not offered in the United States, for their first two doses before receiving the third mRNA (Pfizer) dose.

The study was funded by Pfizer in an independent research grant and by the NIHR Biomedical Research Centres in Imperial College London and Imperial College Healthcare NHS Trust and Cambridge, and the NIHR Clinical Research Facility Cambridge.

Dr. Liu and one other author had no disclosures. The other 18 authors have a range of disclosures related to various pharmaceutical companies, including Pfizer.

For people with inflammatory bowel disease (IBD) taking immunosuppressive medication, a third dose of a COVID-19 mRNA vaccine significantly increases neutralizing antibodies against the original SARS-CoV-2 strain, but the picture is more complicated for protection against the Omicron variant, according to a research letter published in Gastroenterology.

Though IBD patients do mount a response against Omicron, the response is substantially lower for those taking tofacitinib or infliximab, particularly infliximab monotherapy.

“As further mutations in the viral genome accumulate over time, with the attendant risk of immune evasion, it remains important to continue to reappraise vaccination strategy, including the implementation of personalized approaches for some patients, such as those treated with anti-TNF drugs and JAK inhibitors,” wrote Zhigang Liu, PhD, a research associate in the department of metabolism, digestion, and reproduction at Imperial College London, and his colleagues. “Preferential use of bivalent vaccines may be especially valuable in IBD patients taking anti-TNF agents or JAK inhibitors,” they wrote. Their study did not assess neutralizing antibodies resulting from use of the bivalent vaccine, however.

The researchers tracked 268 participants, including 49 healthy participants serving as controls, from May 2021 through March 2022. The other participants had IBD and included 51 patients taking thiopurines, 36 patients taking infliximab, 39 taking both infliximab and thiopurines, 39 taking ustekinumab, 38 taking vedolizumab, and 16 taking tofacitinib. The IBD patients were all enrolled in the SARS-CoV-2 Vaccination Immunogenicity in Immunosuppressed Inflammatory Bowel Disease Patients (VIP) cohort.

None of the participants had evidence of a SARS-CoV-2 infection at baseline. All had received two doses of an mRNA COVID-19 vaccine (all received Pfizer, except two controls who received Moderna) or two doses of the AstraZeneca vaccine as their primary vaccination. All received an mRNA vaccine for their third dose. Among the IBD patients, 137 received the AstraZeneca in their primary two-dose series, and 82 received Pfizer.

First the researchers assessed the participants’ humoral response to the vaccine against the original SARS-CoV-2 strain and against the Omicron BA.1 variant. Neutralizing antibody titers rose significantly against both strains after the third vaccine dose for all participants.

“However, 50% neutralization titer (NT50) values were significantly lower against Omicron than against the ancestral strain in all study groups, irrespective of the immunosuppressive treatment regimen,” the authors reported. NT50 values are a measure that reflect a vaccine-induced humoral immunity against SARS-CoV-2 after vaccination.

Compared to the healthy controls, individuals receiving infliximab, tofacitinib, or infliximab/thiopurine combination therapy showed significantly lower responses after the second and third vaccine doses. Thirteen patients did not generate NT50 against Omicron after the second vaccine dose, and 7 of them were on infliximab monotherapy. They represented nearly 20% of all infliximab monotherapy participants.

Next the researchers assessed the risk of a breakthrough infection according to neutralizing titer thresholds. Individuals with an NT50 less than 500 had 1.6 times greater odds of a breakthrough infection than those with an NT50 above 500, they noted. After two vaccine doses, 46% of participants with IBD had an NT50 above 500 for the ancestral strain, which rose to 85% of those with IBD after a third dose.

In the healthy control group, 35% had an NT50 under 500 after two doses, and 14% of them had a breakthrough infection, all of which were mild and none of which required hospitalization. The NT50 in healthy controls, however, was not significantly associated with risk of breakthrough infection.

“In this study, neutralizing titers elicited against the omicron variant were generally poor for all individuals and were substantially lower in recipients of infliximab, infliximab/thiopurine combination, or tofacitinib therapy,” the authors concluded. “This raises concerns about whether currently available vaccines will be sufficient to protect against continually evolving SARS-CoV-2 variants, especially in patients established on certain immunosuppressive drugs.”

The small population sizes for each subgroup based on medication was one of the study’s limitations. Another was the fact that it was underpowered to conclusively determine whether an increased risk of breakthrough infection exists in IBD patients who have lower titers of neutralizing antibodies. A limitation for generalization to U.S. patients is that just 64% of the IBD patients received the AstraZeneca vaccine, which is not offered in the United States, for their first two doses before receiving the third mRNA (Pfizer) dose.

The study was funded by Pfizer in an independent research grant and by the NIHR Biomedical Research Centres in Imperial College London and Imperial College Healthcare NHS Trust and Cambridge, and the NIHR Clinical Research Facility Cambridge.

Dr. Liu and one other author had no disclosures. The other 18 authors have a range of disclosures related to various pharmaceutical companies, including Pfizer.

One mark of an excellent clinician is their commitment to lifelong learning, and CHEST’s hands-on simulation courses offer the chance for practitioners of all experience levels to enhance their knowledge.

A variety of interactive courses are offered at CHEST’s state-of-the-art Innovation, Simulation, and Training Center in Glenview, Illinois, covering topics like ultrasonography, bronchoscopy, and mechanical ventilation. And this year, our simulation schedule will offer several new sessions on advances in invasive and noninvasive ventilation, critical care transesophageal echocardiography, master-level EBUS practice, and mechanical circulatory support.

Each course is led by expert instructors and includes attendees from a full range of career stages, from trainees and mid-career clinicians to long-time CHEST faculty members.

At a fall 2022 session of the Ultrasonography: Essentials in Critical Care course, Adil Ahmed, MD, an intern at the University of Texas Health Science Center at San Antonio, shared his perspective attending as a resident.

“CHEST has lots of specialized resources and renowned faculty members, and they’re doing an exceptional job,” he said. “A lot of the things I’ve learned in the first workshop alone are completely brand new to me. I think more programs should start sending residents to these courses.”

Trainees don’t just attend simulation courses – they teach them, too. Carmen Mei, MD, a pulmonary and critical care fellow at Rutgers University, was a faculty member at the recent ultrasound course. She taught attendees representing a wide array of ages.

“It’s a learning environment. Everybody’s very engaged, no matter where they are in their career,” she said.

As a mid-career clinician, Yonatan Y. Greenstein, MD, FCCP – who serves as a co-chair of the ultrasonography course – appreciates the diversity of experiences among attendees.

“Over the years, we’ve found that the wide breadth enhances the course because learners appreciate the questions that are brought up from different angles,” he said.

For experienced clinicians like CHEST Immediate Past President David Schulman, MD, MPH, FCCP, the interactive courses provide an opportunity to continue expanding his expertise. At the ultrasound course, Dr. Schulman said he enjoyed the chance to extend and refine his skillset alongside clinicians with a broad range of experience levels.

“Ultrasound is one of those skills that many clinicians, even in their forties and older, have never trained in. It’s great to see how the more junior learners approach this with a very excited mindset, and they’re learning right beside mid-career faculty who didn’t have the exposure to ultrasound when they were young,” he said.

To find the simulation course that’s the best fit for your practice, visit chestnet.org/simulation.

One mark of an excellent clinician is their commitment to lifelong learning, and CHEST’s hands-on simulation courses offer the chance for practitioners of all experience levels to enhance their knowledge.

A variety of interactive courses are offered at CHEST’s state-of-the-art Innovation, Simulation, and Training Center in Glenview, Illinois, covering topics like ultrasonography, bronchoscopy, and mechanical ventilation. And this year, our simulation schedule will offer several new sessions on advances in invasive and noninvasive ventilation, critical care transesophageal echocardiography, master-level EBUS practice, and mechanical circulatory support.

Each course is led by expert instructors and includes attendees from a full range of career stages, from trainees and mid-career clinicians to long-time CHEST faculty members.

At a fall 2022 session of the Ultrasonography: Essentials in Critical Care course, Adil Ahmed, MD, an intern at the University of Texas Health Science Center at San Antonio, shared his perspective attending as a resident.

“CHEST has lots of specialized resources and renowned faculty members, and they’re doing an exceptional job,” he said. “A lot of the things I’ve learned in the first workshop alone are completely brand new to me. I think more programs should start sending residents to these courses.”

Trainees don’t just attend simulation courses – they teach them, too. Carmen Mei, MD, a pulmonary and critical care fellow at Rutgers University, was a faculty member at the recent ultrasound course. She taught attendees representing a wide array of ages.

“It’s a learning environment. Everybody’s very engaged, no matter where they are in their career,” she said.

As a mid-career clinician, Yonatan Y. Greenstein, MD, FCCP – who serves as a co-chair of the ultrasonography course – appreciates the diversity of experiences among attendees.

“Over the years, we’ve found that the wide breadth enhances the course because learners appreciate the questions that are brought up from different angles,” he said.

For experienced clinicians like CHEST Immediate Past President David Schulman, MD, MPH, FCCP, the interactive courses provide an opportunity to continue expanding his expertise. At the ultrasound course, Dr. Schulman said he enjoyed the chance to extend and refine his skillset alongside clinicians with a broad range of experience levels.

“Ultrasound is one of those skills that many clinicians, even in their forties and older, have never trained in. It’s great to see how the more junior learners approach this with a very excited mindset, and they’re learning right beside mid-career faculty who didn’t have the exposure to ultrasound when they were young,” he said.

To find the simulation course that’s the best fit for your practice, visit chestnet.org/simulation.

One mark of an excellent clinician is their commitment to lifelong learning, and CHEST’s hands-on simulation courses offer the chance for practitioners of all experience levels to enhance their knowledge.

A variety of interactive courses are offered at CHEST’s state-of-the-art Innovation, Simulation, and Training Center in Glenview, Illinois, covering topics like ultrasonography, bronchoscopy, and mechanical ventilation. And this year, our simulation schedule will offer several new sessions on advances in invasive and noninvasive ventilation, critical care transesophageal echocardiography, master-level EBUS practice, and mechanical circulatory support.

Each course is led by expert instructors and includes attendees from a full range of career stages, from trainees and mid-career clinicians to long-time CHEST faculty members.

At a fall 2022 session of the Ultrasonography: Essentials in Critical Care course, Adil Ahmed, MD, an intern at the University of Texas Health Science Center at San Antonio, shared his perspective attending as a resident.

“CHEST has lots of specialized resources and renowned faculty members, and they’re doing an exceptional job,” he said. “A lot of the things I’ve learned in the first workshop alone are completely brand new to me. I think more programs should start sending residents to these courses.”

Trainees don’t just attend simulation courses – they teach them, too. Carmen Mei, MD, a pulmonary and critical care fellow at Rutgers University, was a faculty member at the recent ultrasound course. She taught attendees representing a wide array of ages.

“It’s a learning environment. Everybody’s very engaged, no matter where they are in their career,” she said.

As a mid-career clinician, Yonatan Y. Greenstein, MD, FCCP – who serves as a co-chair of the ultrasonography course – appreciates the diversity of experiences among attendees.

“Over the years, we’ve found that the wide breadth enhances the course because learners appreciate the questions that are brought up from different angles,” he said.

For experienced clinicians like CHEST Immediate Past President David Schulman, MD, MPH, FCCP, the interactive courses provide an opportunity to continue expanding his expertise. At the ultrasound course, Dr. Schulman said he enjoyed the chance to extend and refine his skillset alongside clinicians with a broad range of experience levels.

“Ultrasound is one of those skills that many clinicians, even in their forties and older, have never trained in. It’s great to see how the more junior learners approach this with a very excited mindset, and they’re learning right beside mid-career faculty who didn’t have the exposure to ultrasound when they were young,” he said.

To find the simulation course that’s the best fit for your practice, visit chestnet.org/simulation.

Six subtypes of asthma that may facilitate personalized treatment were identified and confirmed in a large database review of approximately 50,000 patients, according to a recent study.

Previous studies of asthma subtypes have involved age of disease onset, the presence of allergies, and level of eosinophilic inflammation, and have been limited by factors including small sample size and lack of formal validation, Elsie M.F. Horne, MD, of the Asthma UK Centre for Applied Research, Edinburgh, and colleagues wrote.

In a study published in the International Journal of Medical Informatics, the researchers used data from two databases in the United Kingdom: the Optimum Patient Care Research Database (OPCRD) and the Secure Anonymised Information Linkage Database (SAIL). Each dataset included 50,000 randomly selected nonoverlapping adult asthma patients.

The researchers identified 45 categorical features from primary care electronic health records. The features included those directly linked to asthma, such as medications; and features indirectly linked to asthma, such as comorbidities.

The subtypes were defined by the clinically applicable features of level of inhaled corticosteroid use, level of health care use, and the presence of comorbidities, using multiple correspondence analysis and k-means cluster analysis.

The six asthma subtypes were identified in the OPCRD study population as follows: low inhaled corticosteroid use and low health care utilization (30%); low to medium ICS use (36%); low to medium ICS use and comorbidities (12%); varied ICS use and comorbid chronic obstructive pulmonary disease (4%); high ICS use (10%); and very high ICS use (7%).

The researchers replicated the subtypes with 91%-92% accuracy in an internal dataset and 84%-86% accuracy in an external dataset. “These subtypes generalized well at two future time points, and in an additional EHR database from a different U.K. nation (the SAIL Databank),” they wrote in their discussion.

The findings were limited by several factors including the retrospective design, the possible inclusion of people without asthma because of the cohort selection criteria, and the possible biases associated with the use of EHRs; however, the results were strengthened by the large dataset and the additional validations, the researchers noted.

“Using these subtypes to summarize asthma populations could help with management and resource planning at the practice level, and could be useful for understanding regional differences in the asthma population,” they noted. For example, key clinical implications for individuals in a low health care utilization subtype could include being flagged for barriers to care and misdiagnoses, while those in a high health care utilization subtype could be considered for reassessment of medication and other options.

The study received no outside funding. Lead author Dr. Horne had no financial conflicts to disclose.

Six subtypes of asthma that may facilitate personalized treatment were identified and confirmed in a large database review of approximately 50,000 patients, according to a recent study.

Previous studies of asthma subtypes have involved age of disease onset, the presence of allergies, and level of eosinophilic inflammation, and have been limited by factors including small sample size and lack of formal validation, Elsie M.F. Horne, MD, of the Asthma UK Centre for Applied Research, Edinburgh, and colleagues wrote.

In a study published in the International Journal of Medical Informatics, the researchers used data from two databases in the United Kingdom: the Optimum Patient Care Research Database (OPCRD) and the Secure Anonymised Information Linkage Database (SAIL). Each dataset included 50,000 randomly selected nonoverlapping adult asthma patients.

The researchers identified 45 categorical features from primary care electronic health records. The features included those directly linked to asthma, such as medications; and features indirectly linked to asthma, such as comorbidities.

The subtypes were defined by the clinically applicable features of level of inhaled corticosteroid use, level of health care use, and the presence of comorbidities, using multiple correspondence analysis and k-means cluster analysis.

The six asthma subtypes were identified in the OPCRD study population as follows: low inhaled corticosteroid use and low health care utilization (30%); low to medium ICS use (36%); low to medium ICS use and comorbidities (12%); varied ICS use and comorbid chronic obstructive pulmonary disease (4%); high ICS use (10%); and very high ICS use (7%).

The researchers replicated the subtypes with 91%-92% accuracy in an internal dataset and 84%-86% accuracy in an external dataset. “These subtypes generalized well at two future time points, and in an additional EHR database from a different U.K. nation (the SAIL Databank),” they wrote in their discussion.

The findings were limited by several factors including the retrospective design, the possible inclusion of people without asthma because of the cohort selection criteria, and the possible biases associated with the use of EHRs; however, the results were strengthened by the large dataset and the additional validations, the researchers noted.

“Using these subtypes to summarize asthma populations could help with management and resource planning at the practice level, and could be useful for understanding regional differences in the asthma population,” they noted. For example, key clinical implications for individuals in a low health care utilization subtype could include being flagged for barriers to care and misdiagnoses, while those in a high health care utilization subtype could be considered for reassessment of medication and other options.

The study received no outside funding. Lead author Dr. Horne had no financial conflicts to disclose.

Six subtypes of asthma that may facilitate personalized treatment were identified and confirmed in a large database review of approximately 50,000 patients, according to a recent study.

Previous studies of asthma subtypes have involved age of disease onset, the presence of allergies, and level of eosinophilic inflammation, and have been limited by factors including small sample size and lack of formal validation, Elsie M.F. Horne, MD, of the Asthma UK Centre for Applied Research, Edinburgh, and colleagues wrote.

In a study published in the International Journal of Medical Informatics, the researchers used data from two databases in the United Kingdom: the Optimum Patient Care Research Database (OPCRD) and the Secure Anonymised Information Linkage Database (SAIL). Each dataset included 50,000 randomly selected nonoverlapping adult asthma patients.

The researchers identified 45 categorical features from primary care electronic health records. The features included those directly linked to asthma, such as medications; and features indirectly linked to asthma, such as comorbidities.

The subtypes were defined by the clinically applicable features of level of inhaled corticosteroid use, level of health care use, and the presence of comorbidities, using multiple correspondence analysis and k-means cluster analysis.

The six asthma subtypes were identified in the OPCRD study population as follows: low inhaled corticosteroid use and low health care utilization (30%); low to medium ICS use (36%); low to medium ICS use and comorbidities (12%); varied ICS use and comorbid chronic obstructive pulmonary disease (4%); high ICS use (10%); and very high ICS use (7%).

The researchers replicated the subtypes with 91%-92% accuracy in an internal dataset and 84%-86% accuracy in an external dataset. “These subtypes generalized well at two future time points, and in an additional EHR database from a different U.K. nation (the SAIL Databank),” they wrote in their discussion.

The findings were limited by several factors including the retrospective design, the possible inclusion of people without asthma because of the cohort selection criteria, and the possible biases associated with the use of EHRs; however, the results were strengthened by the large dataset and the additional validations, the researchers noted.

“Using these subtypes to summarize asthma populations could help with management and resource planning at the practice level, and could be useful for understanding regional differences in the asthma population,” they noted. For example, key clinical implications for individuals in a low health care utilization subtype could include being flagged for barriers to care and misdiagnoses, while those in a high health care utilization subtype could be considered for reassessment of medication and other options.

The study received no outside funding. Lead author Dr. Horne had no financial conflicts to disclose.

Attendees at the CHEST 2022 Opening Session on October 16 got a sneak peek into plans and priorities for CHEST President Doreen J. Addrizzo-Harris, MD, FCCP, in 2023 – and some insights into her own path to the role.

A longtime leader at CHEST, she shared how members’ pandemic response reminded her of the great impact the organization can have. In March 2020, Dr. Addrizzo-Harris was overseeing ICU staffing at NYU Langone Health’s Bellevue Hospital Center and organizing dozens of volunteer physicians to help meet the pandemic care burden.

“I knew all too quickly that we wouldn’t have enough intensivists,” said Dr. Addrizzo-Harris. “It was a quick call very late one night, probably around 1 am, that I made to CHEST CEO, Bob Musacchio, that helped materialize a monumental effort ... many of these physicians were CHEST members themselves. They were fearless and unselfish, and they came to help us in our time of need.”

She saw this same spirit of dedication and drive in CHEST’s leadership and staff, she said – one she will continue and expand upon during her presidency.

“I’ve watched our last three presidents lead by great example ... with innovation and nimbleness, in a time when we were so isolated from each other and so tired from the long hours that we worked each day,” she said. “They, along with the Board of Regents, the CEO, and our phenomenal staff, were able to keep CHEST amazingly alive and vibrant and more connected than ever. They are truly inspiring. For 2023, I hope to take this incredible energy to the next level.”

As CHEST president, Dr. Addrizzo-Harris plans to expand and strengthen the CHEST community by supporting greater cooperation and collaboration with sister societies in the United States and advancing international outreach initiatives launched by CHEST Past President David Schulman, MD, MPH, FCCP. This also includes supporting and building upon CHEST’s ongoing commitment to diversity, equity, and inclusion initiatives to encourage greater representation in the field and improve patient care.

“Whether it’s through supporting our clinical research grants, expanding patient education and advocacy, or programs like the First 5 Minutes™ and the Harold Amos scholarship program, we want to train our leaders for the future,” she said.

Revisit the September issue of CHEST Physician, and watch future issues to learn more about Dr. Addrizzo-Harris and her plans for the presidency.

Attendees at the CHEST 2022 Opening Session on October 16 got a sneak peek into plans and priorities for CHEST President Doreen J. Addrizzo-Harris, MD, FCCP, in 2023 – and some insights into her own path to the role.

A longtime leader at CHEST, she shared how members’ pandemic response reminded her of the great impact the organization can have. In March 2020, Dr. Addrizzo-Harris was overseeing ICU staffing at NYU Langone Health’s Bellevue Hospital Center and organizing dozens of volunteer physicians to help meet the pandemic care burden.

“I knew all too quickly that we wouldn’t have enough intensivists,” said Dr. Addrizzo-Harris. “It was a quick call very late one night, probably around 1 am, that I made to CHEST CEO, Bob Musacchio, that helped materialize a monumental effort ... many of these physicians were CHEST members themselves. They were fearless and unselfish, and they came to help us in our time of need.”

She saw this same spirit of dedication and drive in CHEST’s leadership and staff, she said – one she will continue and expand upon during her presidency.

“I’ve watched our last three presidents lead by great example ... with innovation and nimbleness, in a time when we were so isolated from each other and so tired from the long hours that we worked each day,” she said. “They, along with the Board of Regents, the CEO, and our phenomenal staff, were able to keep CHEST amazingly alive and vibrant and more connected than ever. They are truly inspiring. For 2023, I hope to take this incredible energy to the next level.”

As CHEST president, Dr. Addrizzo-Harris plans to expand and strengthen the CHEST community by supporting greater cooperation and collaboration with sister societies in the United States and advancing international outreach initiatives launched by CHEST Past President David Schulman, MD, MPH, FCCP. This also includes supporting and building upon CHEST’s ongoing commitment to diversity, equity, and inclusion initiatives to encourage greater representation in the field and improve patient care.

“Whether it’s through supporting our clinical research grants, expanding patient education and advocacy, or programs like the First 5 Minutes™ and the Harold Amos scholarship program, we want to train our leaders for the future,” she said.

Revisit the September issue of CHEST Physician, and watch future issues to learn more about Dr. Addrizzo-Harris and her plans for the presidency.

Attendees at the CHEST 2022 Opening Session on October 16 got a sneak peek into plans and priorities for CHEST President Doreen J. Addrizzo-Harris, MD, FCCP, in 2023 – and some insights into her own path to the role.

A longtime leader at CHEST, she shared how members’ pandemic response reminded her of the great impact the organization can have. In March 2020, Dr. Addrizzo-Harris was overseeing ICU staffing at NYU Langone Health’s Bellevue Hospital Center and organizing dozens of volunteer physicians to help meet the pandemic care burden.

“I knew all too quickly that we wouldn’t have enough intensivists,” said Dr. Addrizzo-Harris. “It was a quick call very late one night, probably around 1 am, that I made to CHEST CEO, Bob Musacchio, that helped materialize a monumental effort ... many of these physicians were CHEST members themselves. They were fearless and unselfish, and they came to help us in our time of need.”

She saw this same spirit of dedication and drive in CHEST’s leadership and staff, she said – one she will continue and expand upon during her presidency.

“I’ve watched our last three presidents lead by great example ... with innovation and nimbleness, in a time when we were so isolated from each other and so tired from the long hours that we worked each day,” she said. “They, along with the Board of Regents, the CEO, and our phenomenal staff, were able to keep CHEST amazingly alive and vibrant and more connected than ever. They are truly inspiring. For 2023, I hope to take this incredible energy to the next level.”

As CHEST president, Dr. Addrizzo-Harris plans to expand and strengthen the CHEST community by supporting greater cooperation and collaboration with sister societies in the United States and advancing international outreach initiatives launched by CHEST Past President David Schulman, MD, MPH, FCCP. This also includes supporting and building upon CHEST’s ongoing commitment to diversity, equity, and inclusion initiatives to encourage greater representation in the field and improve patient care.

“Whether it’s through supporting our clinical research grants, expanding patient education and advocacy, or programs like the First 5 Minutes™ and the Harold Amos scholarship program, we want to train our leaders for the future,” she said.

Revisit the September issue of CHEST Physician, and watch future issues to learn more about Dr. Addrizzo-Harris and her plans for the presidency.

An investigation of genomics data related to primary sclerosing cholangitis (PSC) in published medical literature revealed several genes likely involved in the pathogenesis of this autoimmune diseases, according to a study published in Gastro Hep Advances.

PSC is very rare, with an incidence of 0-1.3 cases per 100,000 people per year. Because up to 80% of patients with PSC also have inflammatory bowel disease (IBD), a link along the gut-liver axis is suspected. So far, scientists have not understood the causes of PSC, the main complications of which include biliary cirrhosis, bacterial cholangitis, and cholangiocarcinoma.

No treatment is currently available for PSC, but the findings of this genomics study suggest several targets that may be worth pursuing, particularly the gene NR0B2.

“The therapeutic targeting of NR0B2 may potentiate that of FXR [farnesoid X receptor] and enable action on early events of the disease and prevent its progression,” wrote Christophe Desterke, PhD, of the Paul-Brousse Hospital, the French National Institute of Health and Medical Research, and the University of Paris-Saclay in Villejuif, France, and his associates.

The researchers used an algorithmic tool to mine the MEDLINE/PubMed/NCBI database using the three key symptoms of PSC – biliary fibrosis, biliary inflammation, and biliary stasis – as their keywords. This approach allowed them to discover the genes and potential pathways related to PSC in published research text or in clinical, animal, and cellular models.

The researchers initially found 525 genes linked to PSC and then compared them to RNA data from liver biopsies taken from patients with liver disease from various causes. This process led to a ranking of the 10 best markers of PSC, based on the data-mining method and the genes’ association with one or more of the three PSC symptoms.

At the top of the list is NR1H4, also called FXR, which ranks most highly with biliary fibrosis and biliary stasis. NR1H4 is already a clear target for cholestatic and fatty liver diseases, the authors noted. The other genes, in descending order of relevance, are: ABCB4, ABCB11, TGFB1, IFNL3, PNPLA3, IL6, TLR4, GPBAR1, and IL17A. In addition, complications of PSC were significantly associated with upregulation of TNFRS12A, SOX9, ANXA2, MMP7, and LCN2.

Separately, investigation of the 525 initially identified genes in mouse models of PSC revealed that NR0B2 is also a key player in the pathogenesis of PSC.

"NR0B2 was upregulated in PSC livers independent of gender, age, and body mass index,” the authors reported. “Importantly, it was not dependent on the severity of PSC in the prognostic cohort, suggesting that this may be an early event during the disease.”

The researchers also found a possible pathway explaining the autoimmunity of PSC – the involvement of CD274, also known as the PDL1 immune checkpoint. The authors noted that the PDL1 inhibitor pembrolizumab has previously been reported as a cause of sclerosing cholangitis.

Further, the researchers discovered overexpression of FOXP3 in the livers of patients with PSC. Because FOXP3 determines what T-cell subtypes look like, the finding suggests that an “imbalance between Foxp3þ regulatory T cells and Th17 cells may be involved in IBD and PSC,” they wrote.

Also of note was the overexpression of SOX9 in the livers of patients with PSC whose profiles suggested the worst clinical prognoses.

Finally, the researchers identified three genes as potentially involved in development of cholangiocarcinoma: GSTA3, ID2 (which is overexpressed in biliary tract cancer), and especially TMEM45A, a protein in cells’ Golgi apparatus that is already known to be involved in the development of several other cancers.

The research was funded by the French National Institute of Health and Medical Research. The authors reported no conflicts of interest.

An investigation of genomics data related to primary sclerosing cholangitis (PSC) in published medical literature revealed several genes likely involved in the pathogenesis of this autoimmune diseases, according to a study published in Gastro Hep Advances.

PSC is very rare, with an incidence of 0-1.3 cases per 100,000 people per year. Because up to 80% of patients with PSC also have inflammatory bowel disease (IBD), a link along the gut-liver axis is suspected. So far, scientists have not understood the causes of PSC, the main complications of which include biliary cirrhosis, bacterial cholangitis, and cholangiocarcinoma.

No treatment is currently available for PSC, but the findings of this genomics study suggest several targets that may be worth pursuing, particularly the gene NR0B2.

“The therapeutic targeting of NR0B2 may potentiate that of FXR [farnesoid X receptor] and enable action on early events of the disease and prevent its progression,” wrote Christophe Desterke, PhD, of the Paul-Brousse Hospital, the French National Institute of Health and Medical Research, and the University of Paris-Saclay in Villejuif, France, and his associates.

The researchers used an algorithmic tool to mine the MEDLINE/PubMed/NCBI database using the three key symptoms of PSC – biliary fibrosis, biliary inflammation, and biliary stasis – as their keywords. This approach allowed them to discover the genes and potential pathways related to PSC in published research text or in clinical, animal, and cellular models.

The researchers initially found 525 genes linked to PSC and then compared them to RNA data from liver biopsies taken from patients with liver disease from various causes. This process led to a ranking of the 10 best markers of PSC, based on the data-mining method and the genes’ association with one or more of the three PSC symptoms.

At the top of the list is NR1H4, also called FXR, which ranks most highly with biliary fibrosis and biliary stasis. NR1H4 is already a clear target for cholestatic and fatty liver diseases, the authors noted. The other genes, in descending order of relevance, are: ABCB4, ABCB11, TGFB1, IFNL3, PNPLA3, IL6, TLR4, GPBAR1, and IL17A. In addition, complications of PSC were significantly associated with upregulation of TNFRS12A, SOX9, ANXA2, MMP7, and LCN2.

Separately, investigation of the 525 initially identified genes in mouse models of PSC revealed that NR0B2 is also a key player in the pathogenesis of PSC.

"NR0B2 was upregulated in PSC livers independent of gender, age, and body mass index,” the authors reported. “Importantly, it was not dependent on the severity of PSC in the prognostic cohort, suggesting that this may be an early event during the disease.”

The researchers also found a possible pathway explaining the autoimmunity of PSC – the involvement of CD274, also known as the PDL1 immune checkpoint. The authors noted that the PDL1 inhibitor pembrolizumab has previously been reported as a cause of sclerosing cholangitis.

Further, the researchers discovered overexpression of FOXP3 in the livers of patients with PSC. Because FOXP3 determines what T-cell subtypes look like, the finding suggests that an “imbalance between Foxp3þ regulatory T cells and Th17 cells may be involved in IBD and PSC,” they wrote.

Also of note was the overexpression of SOX9 in the livers of patients with PSC whose profiles suggested the worst clinical prognoses.

Finally, the researchers identified three genes as potentially involved in development of cholangiocarcinoma: GSTA3, ID2 (which is overexpressed in biliary tract cancer), and especially TMEM45A, a protein in cells’ Golgi apparatus that is already known to be involved in the development of several other cancers.

The research was funded by the French National Institute of Health and Medical Research. The authors reported no conflicts of interest.

An investigation of genomics data related to primary sclerosing cholangitis (PSC) in published medical literature revealed several genes likely involved in the pathogenesis of this autoimmune diseases, according to a study published in Gastro Hep Advances.

PSC is very rare, with an incidence of 0-1.3 cases per 100,000 people per year. Because up to 80% of patients with PSC also have inflammatory bowel disease (IBD), a link along the gut-liver axis is suspected. So far, scientists have not understood the causes of PSC, the main complications of which include biliary cirrhosis, bacterial cholangitis, and cholangiocarcinoma.

No treatment is currently available for PSC, but the findings of this genomics study suggest several targets that may be worth pursuing, particularly the gene NR0B2.

“The therapeutic targeting of NR0B2 may potentiate that of FXR [farnesoid X receptor] and enable action on early events of the disease and prevent its progression,” wrote Christophe Desterke, PhD, of the Paul-Brousse Hospital, the French National Institute of Health and Medical Research, and the University of Paris-Saclay in Villejuif, France, and his associates.

The researchers used an algorithmic tool to mine the MEDLINE/PubMed/NCBI database using the three key symptoms of PSC – biliary fibrosis, biliary inflammation, and biliary stasis – as their keywords. This approach allowed them to discover the genes and potential pathways related to PSC in published research text or in clinical, animal, and cellular models.

The researchers initially found 525 genes linked to PSC and then compared them to RNA data from liver biopsies taken from patients with liver disease from various causes. This process led to a ranking of the 10 best markers of PSC, based on the data-mining method and the genes’ association with one or more of the three PSC symptoms.

At the top of the list is NR1H4, also called FXR, which ranks most highly with biliary fibrosis and biliary stasis. NR1H4 is already a clear target for cholestatic and fatty liver diseases, the authors noted. The other genes, in descending order of relevance, are: ABCB4, ABCB11, TGFB1, IFNL3, PNPLA3, IL6, TLR4, GPBAR1, and IL17A. In addition, complications of PSC were significantly associated with upregulation of TNFRS12A, SOX9, ANXA2, MMP7, and LCN2.

Separately, investigation of the 525 initially identified genes in mouse models of PSC revealed that NR0B2 is also a key player in the pathogenesis of PSC.

"NR0B2 was upregulated in PSC livers independent of gender, age, and body mass index,” the authors reported. “Importantly, it was not dependent on the severity of PSC in the prognostic cohort, suggesting that this may be an early event during the disease.”

The researchers also found a possible pathway explaining the autoimmunity of PSC – the involvement of CD274, also known as the PDL1 immune checkpoint. The authors noted that the PDL1 inhibitor pembrolizumab has previously been reported as a cause of sclerosing cholangitis.

Further, the researchers discovered overexpression of FOXP3 in the livers of patients with PSC. Because FOXP3 determines what T-cell subtypes look like, the finding suggests that an “imbalance between Foxp3þ regulatory T cells and Th17 cells may be involved in IBD and PSC,” they wrote.

Also of note was the overexpression of SOX9 in the livers of patients with PSC whose profiles suggested the worst clinical prognoses.

Finally, the researchers identified three genes as potentially involved in development of cholangiocarcinoma: GSTA3, ID2 (which is overexpressed in biliary tract cancer), and especially TMEM45A, a protein in cells’ Golgi apparatus that is already known to be involved in the development of several other cancers.

The research was funded by the French National Institute of Health and Medical Research. The authors reported no conflicts of interest.

Dermatopathology was consistent with a diagnosis of cutaneous myxoma (CM). There are very few dermoscopic descriptions of CM in the literature, so diagnostic features are not established. However, the absence of more diagnostic features of basal cell carcinoma or squamous cell carcinoma (SCC) increases the likelihood of a rare diagnosis, such as CM.

CMs are rare benign neoplasms that manifest most commonly in young adults as small (< 1 cm) flesh-colored to blue papules on the head, neck, and trunk. The size of this particular CM was an outlier. CMs may be associated with Carney Complex (CNC), a rare inherited syndrome that has been linked to multiple endocrine neoplasias—namely, pituitary adenomas, testicular Sertoli cell tumors, thyroid tumors, and cardiac atrial myxomas.¹ Additionally, in CNC, lentigines and multiple blue nevi develop on the skin and mucosal surfaces.

The differential diagnosis for a large, pink to flesh-colored nodule of this size includes benign histiocytoma, SCC, CM, and dermatofibrosarcoma protuberans. Benign histiocytomas and SCCs are much more common than CM. Clinical features only hint at the correct diagnosis, which must be made histologically.

Patients with CMs benefit from ongoing dermatology surveillance to monitor for the development of atypical nevi or new CMs. In this case, a wide excision with generous margins was planned with plastic surgery. (CMs have been reported to recur after surgery, which is why wide margins are essential.)

Additionally, 2 factors prompted an echocardiogram: the association between CMs and possible cardiac tumors and the patient’s need to undergo future orthopedic surgery under general anesthesia. No cardiac tumors were visible on echocardiogram. Thyroid imaging and genetic evaluation were planned but not completed.

‌

Photos and text for Photo Rounds Friday courtesy of Jonathan Karnes, MD (copyright retained). Dr. Karnes is the medical director of MDFMR Dermatology Services, Augusta, ME.

Dermatopathology was consistent with a diagnosis of cutaneous myxoma (CM). There are very few dermoscopic descriptions of CM in the literature, so diagnostic features are not established. However, the absence of more diagnostic features of basal cell carcinoma or squamous cell carcinoma (SCC) increases the likelihood of a rare diagnosis, such as CM.

CMs are rare benign neoplasms that manifest most commonly in young adults as small (< 1 cm) flesh-colored to blue papules on the head, neck, and trunk. The size of this particular CM was an outlier. CMs may be associated with Carney Complex (CNC), a rare inherited syndrome that has been linked to multiple endocrine neoplasias—namely, pituitary adenomas, testicular Sertoli cell tumors, thyroid tumors, and cardiac atrial myxomas.¹ Additionally, in CNC, lentigines and multiple blue nevi develop on the skin and mucosal surfaces.

The differential diagnosis for a large, pink to flesh-colored nodule of this size includes benign histiocytoma, SCC, CM, and dermatofibrosarcoma protuberans. Benign histiocytomas and SCCs are much more common than CM. Clinical features only hint at the correct diagnosis, which must be made histologically.

Patients with CMs benefit from ongoing dermatology surveillance to monitor for the development of atypical nevi or new CMs. In this case, a wide excision with generous margins was planned with plastic surgery. (CMs have been reported to recur after surgery, which is why wide margins are essential.)

Additionally, 2 factors prompted an echocardiogram: the association between CMs and possible cardiac tumors and the patient’s need to undergo future orthopedic surgery under general anesthesia. No cardiac tumors were visible on echocardiogram. Thyroid imaging and genetic evaluation were planned but not completed.

‌

Photos and text for Photo Rounds Friday courtesy of Jonathan Karnes, MD (copyright retained). Dr. Karnes is the medical director of MDFMR Dermatology Services, Augusta, ME.

Dermatopathology was consistent with a diagnosis of cutaneous myxoma (CM). There are very few dermoscopic descriptions of CM in the literature, so diagnostic features are not established. However, the absence of more diagnostic features of basal cell carcinoma or squamous cell carcinoma (SCC) increases the likelihood of a rare diagnosis, such as CM.

CMs are rare benign neoplasms that manifest most commonly in young adults as small (< 1 cm) flesh-colored to blue papules on the head, neck, and trunk. The size of this particular CM was an outlier. CMs may be associated with Carney Complex (CNC), a rare inherited syndrome that has been linked to multiple endocrine neoplasias—namely, pituitary adenomas, testicular Sertoli cell tumors, thyroid tumors, and cardiac atrial myxomas.¹ Additionally, in CNC, lentigines and multiple blue nevi develop on the skin and mucosal surfaces.

The differential diagnosis for a large, pink to flesh-colored nodule of this size includes benign histiocytoma, SCC, CM, and dermatofibrosarcoma protuberans. Benign histiocytomas and SCCs are much more common than CM. Clinical features only hint at the correct diagnosis, which must be made histologically.

Patients with CMs benefit from ongoing dermatology surveillance to monitor for the development of atypical nevi or new CMs. In this case, a wide excision with generous margins was planned with plastic surgery. (CMs have been reported to recur after surgery, which is why wide margins are essential.)

Additionally, 2 factors prompted an echocardiogram: the association between CMs and possible cardiac tumors and the patient’s need to undergo future orthopedic surgery under general anesthesia. No cardiac tumors were visible on echocardiogram. Thyroid imaging and genetic evaluation were planned but not completed.

‌

Photos and text for Photo Rounds Friday courtesy of Jonathan Karnes, MD (copyright retained). Dr. Karnes is the medical director of MDFMR Dermatology Services, Augusta, ME.

Each year, CHEST recognizes members who make an impact – through dedication to the organization, by contributions to research and practice, through their commitment to educating the next generation, and so much more.

MASTER FELLOW AWARD
Gerard A. Silvestri, MD, MS, Master FCCP

DISTINGUISHED SERVICE AWARD
Aneesa M. Das, MD, FCCP

COLLEGE MEDALIST AWARD
William R. Auger, MD, FCCP

ALFRED SOFFER AWARD FOR EDITORIAL EXCELLENCE
Todd W. Rice, MD, FCCP

EARLY CAREER CLINICIAN EDUCATOR AWARD
Mauricio Danckers, MD, FCCP

MASTER CLINICIAN EDUCATOR AWARD
Neil R. MacIntyre, MD, FCCP

PRESIDENTIAL CITATION
CHEST Staff

EDWARD C. ROSENOW III, MD, MASTER FCCP/MASTER TEACHER ENDOWED HONOR LECTURE
Alexander S. Niven, MD, FCCP

THOMAS L. PETTY, MD, MASTER FCCP MEMORIAL LECTURE
Sandra G. Adams, MD, FCCP

2021 DISTINGUISHED SCIENTIST HONOR LECTURE IN CARDIOPULMONARY PHYSIOLOGY
Kenneth I. Berger, MD, FCCP

PRESIDENTIAL HONOR LECTURE
Jack D. Buckley, MD, MPH, FCCP

PASQUALE CIAGLIA MEMORIAL LECTURE IN INTERVENTIONAL MEDICINE
Nicholas J. Pastis, MD, FCCP

ROGER C. BONE MEMORIAL LECTURE IN CRITICAL CARE
E. Wesley Ely, MD, MPH, FCCP

MURRAY KORNFELD MEMORIAL FOUNDERS AWARD
Marin H. Kollef, MD, FCCP

OM P. SHARMA, MD, MASTER FCCP MEMORIAL LECTURE
Daniel A. Culver, DO, FCCP

RICHARD S. IRWIN, MD, MASTER FCCP HONOR LECTURE
Nneka O. Sederstrom, PhD, MS, MA, FCCP

2022 DISTINGUISHED SCIENTIST HONOR LECTURE IN CARDIOPULMONARY PHYSIOLOGY
Martin J. Tobin, MBBCh, FCCP

MARK J. ROSEN, MD, MASTER FCCP ENDOWED MEMORIAL LECTURE
Stephanie M. Levine, MD, FCCP

MARGARET PFROMMER ENDOWED MEMORIAL LECTURE IN HOME-BASED MECHANICAL VENTILATION
Lisa Wolfe, MD, FCCP

CHEST CHALLENGE FINALISTS
1st Place – Mayo Clinic
Amjad Kanj, MD
Paige Marty, MD
Zhenmei Zhang, MD
Program Director: Darlene Nelson, MD, FCCP

2nd Place – Brooke Army Medical Center
Joshua Boster, MD
Tyler Campbell, DO
Daniel Foster, MD
Program Director: Robert Walter, MD, PhD

3rd Place – NewYork-Presbyterian Brooklyn Methodist
Albina Guri, DO
Jahrul Islam, MD
Sylvana Salama, MD
Program Director: Anthony Saleh, MD, FCCP
 

Please Note: Award winners from the following categories will be listed in the February issue of CHEST Physician.

CHEST Foundation Grant Awards

Scientific Abstract Awards

Alfred Soffer Research Award Winners

Young Investigator Award Winners

Abstract Rapid Fire Winners

Case Report Session Winners

Case Report Rapid Fire Winners

Each year, CHEST recognizes members who make an impact – through dedication to the organization, by contributions to research and practice, through their commitment to educating the next generation, and so much more.

MASTER FELLOW AWARD
Gerard A. Silvestri, MD, MS, Master FCCP

DISTINGUISHED SERVICE AWARD
Aneesa M. Das, MD, FCCP

COLLEGE MEDALIST AWARD
William R. Auger, MD, FCCP

ALFRED SOFFER AWARD FOR EDITORIAL EXCELLENCE
Todd W. Rice, MD, FCCP

EARLY CAREER CLINICIAN EDUCATOR AWARD
Mauricio Danckers, MD, FCCP

MASTER CLINICIAN EDUCATOR AWARD
Neil R. MacIntyre, MD, FCCP

PRESIDENTIAL CITATION
CHEST Staff

EDWARD C. ROSENOW III, MD, MASTER FCCP/MASTER TEACHER ENDOWED HONOR LECTURE
Alexander S. Niven, MD, FCCP

THOMAS L. PETTY, MD, MASTER FCCP MEMORIAL LECTURE
Sandra G. Adams, MD, FCCP

2021 DISTINGUISHED SCIENTIST HONOR LECTURE IN CARDIOPULMONARY PHYSIOLOGY
Kenneth I. Berger, MD, FCCP

PRESIDENTIAL HONOR LECTURE
Jack D. Buckley, MD, MPH, FCCP

PASQUALE CIAGLIA MEMORIAL LECTURE IN INTERVENTIONAL MEDICINE
Nicholas J. Pastis, MD, FCCP

ROGER C. BONE MEMORIAL LECTURE IN CRITICAL CARE
E. Wesley Ely, MD, MPH, FCCP

MURRAY KORNFELD MEMORIAL FOUNDERS AWARD
Marin H. Kollef, MD, FCCP

OM P. SHARMA, MD, MASTER FCCP MEMORIAL LECTURE
Daniel A. Culver, DO, FCCP

RICHARD S. IRWIN, MD, MASTER FCCP HONOR LECTURE
Nneka O. Sederstrom, PhD, MS, MA, FCCP

2022 DISTINGUISHED SCIENTIST HONOR LECTURE IN CARDIOPULMONARY PHYSIOLOGY
Martin J. Tobin, MBBCh, FCCP

MARK J. ROSEN, MD, MASTER FCCP ENDOWED MEMORIAL LECTURE
Stephanie M. Levine, MD, FCCP

MARGARET PFROMMER ENDOWED MEMORIAL LECTURE IN HOME-BASED MECHANICAL VENTILATION
Lisa Wolfe, MD, FCCP

CHEST CHALLENGE FINALISTS
1st Place – Mayo Clinic
Amjad Kanj, MD
Paige Marty, MD
Zhenmei Zhang, MD
Program Director: Darlene Nelson, MD, FCCP

2nd Place – Brooke Army Medical Center
Joshua Boster, MD
Tyler Campbell, DO
Daniel Foster, MD
Program Director: Robert Walter, MD, PhD

3rd Place – NewYork-Presbyterian Brooklyn Methodist
Albina Guri, DO
Jahrul Islam, MD
Sylvana Salama, MD
Program Director: Anthony Saleh, MD, FCCP
 

Please Note: Award winners from the following categories will be listed in the February issue of CHEST Physician.

CHEST Foundation Grant Awards

Scientific Abstract Awards

Alfred Soffer Research Award Winners

Young Investigator Award Winners

Abstract Rapid Fire Winners

Case Report Session Winners

Case Report Rapid Fire Winners

Each year, CHEST recognizes members who make an impact – through dedication to the organization, by contributions to research and practice, through their commitment to educating the next generation, and so much more.

MASTER FELLOW AWARD
Gerard A. Silvestri, MD, MS, Master FCCP

DISTINGUISHED SERVICE AWARD
Aneesa M. Das, MD, FCCP

COLLEGE MEDALIST AWARD
William R. Auger, MD, FCCP

ALFRED SOFFER AWARD FOR EDITORIAL EXCELLENCE
Todd W. Rice, MD, FCCP

EARLY CAREER CLINICIAN EDUCATOR AWARD
Mauricio Danckers, MD, FCCP

MASTER CLINICIAN EDUCATOR AWARD
Neil R. MacIntyre, MD, FCCP

PRESIDENTIAL CITATION
CHEST Staff

EDWARD C. ROSENOW III, MD, MASTER FCCP/MASTER TEACHER ENDOWED HONOR LECTURE
Alexander S. Niven, MD, FCCP

THOMAS L. PETTY, MD, MASTER FCCP MEMORIAL LECTURE
Sandra G. Adams, MD, FCCP

2021 DISTINGUISHED SCIENTIST HONOR LECTURE IN CARDIOPULMONARY PHYSIOLOGY
Kenneth I. Berger, MD, FCCP

PRESIDENTIAL HONOR LECTURE
Jack D. Buckley, MD, MPH, FCCP

PASQUALE CIAGLIA MEMORIAL LECTURE IN INTERVENTIONAL MEDICINE
Nicholas J. Pastis, MD, FCCP

ROGER C. BONE MEMORIAL LECTURE IN CRITICAL CARE
E. Wesley Ely, MD, MPH, FCCP

MURRAY KORNFELD MEMORIAL FOUNDERS AWARD
Marin H. Kollef, MD, FCCP

OM P. SHARMA, MD, MASTER FCCP MEMORIAL LECTURE
Daniel A. Culver, DO, FCCP

RICHARD S. IRWIN, MD, MASTER FCCP HONOR LECTURE
Nneka O. Sederstrom, PhD, MS, MA, FCCP

2022 DISTINGUISHED SCIENTIST HONOR LECTURE IN CARDIOPULMONARY PHYSIOLOGY
Martin J. Tobin, MBBCh, FCCP

MARK J. ROSEN, MD, MASTER FCCP ENDOWED MEMORIAL LECTURE
Stephanie M. Levine, MD, FCCP

MARGARET PFROMMER ENDOWED MEMORIAL LECTURE IN HOME-BASED MECHANICAL VENTILATION
Lisa Wolfe, MD, FCCP

CHEST CHALLENGE FINALISTS
1st Place – Mayo Clinic
Amjad Kanj, MD
Paige Marty, MD
Zhenmei Zhang, MD
Program Director: Darlene Nelson, MD, FCCP

2nd Place – Brooke Army Medical Center
Joshua Boster, MD
Tyler Campbell, DO
Daniel Foster, MD
Program Director: Robert Walter, MD, PhD

3rd Place – NewYork-Presbyterian Brooklyn Methodist
Albina Guri, DO
Jahrul Islam, MD
Sylvana Salama, MD
Program Director: Anthony Saleh, MD, FCCP
 

Please Note: Award winners from the following categories will be listed in the February issue of CHEST Physician.

CHEST Foundation Grant Awards

Scientific Abstract Awards

Alfred Soffer Research Award Winners

Young Investigator Award Winners

Abstract Rapid Fire Winners

Case Report Session Winners

Case Report Rapid Fire Winners

The American College of Physicians has updated their guideline for pharmacotherapy to reduce fracture risk in adults with primary osteoporosis or osteopenia (low bone mass) based on a systematic review of the evidence.

This is the first update for 5 years since the previous guidance was published in 2017.

It strongly recommends initial therapy with bisphosphonates for postmenopausal women with osteoporosis, as well as men with osteoporosis, among other recommendations.

However, the author of an accompanying editorial, Susan M. Ott, MD, says: “The decision to start a bisphosphonate is actually not that easy.”

She also queries some of the other recommendations in the guidance.

Her editorial, along with the guideline by Amir Qaseem, MD, PhD, MPH, and colleagues, and systematic review by Chelsea Ayers, MPH, and colleagues, were published in the Annals of Internal Medicine.

Ryan D. Mire, MD, MACP, president of the ACP, gave a brief overview of the new guidance in a video.
 

Systematic review

The ACP commissioned a review of the evidence because it says new data have emerged on the efficacy of newer medications for osteoporosis and low bone mass, as well as treatment comparisons, and treatment in men.

The review authors identified 34 randomized controlled trials (in 100 publications) and 36 observational studies, which evaluated the following pharmacologic interventions:

• Antiresorptive drugs: four bisphosphonates (alendronate, ibandronate, risedronate, zoledronate) and a RANK ligand inhibitor (denosumab).
• Anabolic drugs: an analog of human parathyroid hormone (PTH)–related protein (abaloparatide), recombinant human PTH (teriparatide), and a sclerostin inhibitor (romosozumab).
• Estrogen agonists: selective estrogen receptor modulators (bazedoxifene, raloxifene).

The authors focused on effectiveness and harms of active drugs compared with placebo or bisphosphonates.
 

Major changes from 2017 guidelines, some questions

“Though there are many nuanced changes in this [2023 guideline] version, perhaps the major change is the explicit hierarchy of pharmacologic recommendations: bisphosphonates first, then denosumab,” Thomas G. Cooney, MD, senior author of the clinical guideline, explained in an interview.

“Bisphosphonates had the most favorable balance among benefits, harms, patient values and preferences, and cost among the examined drugs in postmenopausal females with primary osteoporosis,” Dr. Cooney, professor of medicine, Oregon Health & Science University, Portland, noted, as is stated in the guideline.

“Denosumab also had a favorable long-term net benefit, but bisphosphonates are much cheaper than other pharmacologic treatments and available in generic formulations,” the document states.

The new guideline suggests use of denosumab as second-line pharmacotherapy in adults who have contraindications to or experience adverse effects with bisphosphonates.

The choice among bisphosphonates (alendronate, risedronate, zoledronic acid) would be based on a patient-centered discussion between physician and patient, addressing costs (often related to insurance), delivery-mode preferences (oral versus intravenous), and “values,” which includes the patient’s priorities, concerns, and expectations regarding their health care, Dr. Cooney explained.

Another update in the new guideline is, “We also clarify the specific, albeit more limited, role of sclerostin inhibitors and recombinant PTH ‘to reduce the risk of fractures only in females with primary osteoporosis with very high-risk of fracture’,” Dr. Cooney noted.

In addition, the guideline now states, “treatment to reduce the risk of fractures in males rather than limiting it to ‘vertebral fracture’ in men,” as in the 2017 guideline.

It also explicitly includes denosumab as second-line therapy for men, Dr. Cooney noted, but as in 2017, the strength of evidence in men remains low.

“Finally, we also clarified that in females over the age of 65 with low bone mass or osteopenia that an individualized approach be taken to treatment (similar to last guideline), but if treatment is initiated, that a bisphosphonate be used (new content),” he said.

The use of estrogen, treatment duration, drug discontinuation, and serial bone mineral density monitoring were not addressed in this guideline, but will likely be evaluated within 2 to 3 years.
 

‘Osteoporosis treatment: Not easy’ – editorial

In her editorial, Dr. Ott writes: “The data about bisphosphonates may seem overwhelmingly positive, leading to strong recommendations for their use to treat osteoporosis, but the decision to start a bisphosphonate is actually not that easy.”

“A strong recommendation should be given only when future studies are unlikely to change it,” continues Dr. Ott, professor of medicine, University of Washington, Seattle.

“Yet, data already suggest that, in patients with serious osteoporosis, treatment should start with anabolic medications because previous treatment with either bisphosphonates or denosumab will prevent the anabolic response of newer medications.”

“Starting with bisphosphonate will change the bone so it will not respond to the newer medicines, and then a patient will lose the chance for getting the best improvement,” Dr. Ott clarified in an email to this news organization.

But, in fact, the new guidance does suggest that, to reduce the risk of fractures in females with primary osteoporosis at very high risk of fracture, one should consider use of the sclerostin inhibitor romosozumab (moderate-certainty evidence) or recombinant human parathyroid hormone (teriparatide) (low-certainty evidence) followed by a bisphosphonate (conditional recommendation).

Dr. Ott said: “If the [fracture] risk is high, then we should start with an anabolic medication for 1-2 years. If the risk is medium, then use a bisphosphonate for up to 5 years, and then stop and monitor the patient for signs that the medicine is wearing off,” based on blood and urine tests.
 

‘We need medicines that will stop bone aging’

Osteopenia is defined by an arbitrary bone density measurement, Dr. Ott explained. “About half of women over 65 will have osteopenia, and by age 85 there are hardly any ‘normal’ women left.”

“We need medicines that will stop bone aging, which might sound impossible, but we should still try,” she continued.

“In the meantime, while waiting on new discoveries,” Dr. Ott said, “I would not use bisphosphonates in patients who did not already have a fracture or whose bone density T-score was better than –2.5 because, in the major study, alendronate did not prevent fractures in this group.”

Many people are worried about bisphosphonates because of problems with the jaw or femur. These are real, but they are very rare during the first 5 years of treatment, Dr. Ott noted. Then the risk starts to rise, up to more than 1 in 1,000 after 8 years. So people can get the benefits of these drugs with very low risk for 5 years.

“An immediate [guideline] update is necessary to address the severity of bone loss and the high risk for vertebral fractures after discontinuation of denosumab,” Dr. Ott urged.

“I don’t agree with using denosumab for osteoporosis as a second-line treatment,” she said. “I would use it only in patients who have cancer or unusually high bone resorption. You have to get a dose strictly every 6 months, and if you need to stop, it is recommended to treat with bisphosphonates. Denosumab is a poor choice for somebody who does not want to take a bisphosphonate. Many patients and even too many doctors do not realize how serious it can be to skip a dose.”

“I also think that men could be treated with anabolic medications,” Dr. Ott said. “Clinical trials show they respond the same as women. Many men have osteoporosis as a consequence of low testosterone, and then they can usually be treated with testosterone. Osteoporosis in men is a serious problem that is too often ignored – almost reverse discrimination.”

It is also unfortunate that the review and recommendations do not address estrogen, one of the most effective medications to prevent osteoporotic fractures, according to Dr. Ott.
 

Clinical considerations in addition to drug types

The new guideline also advises:

• Clinicians treating adults with osteoporosis should encourage adherence to recommended treatments and healthy lifestyle habits, including exercise, and counseling to evaluate and prevent falls.
• All adults with osteopenia or osteoporosis should have adequate calcium and vitamin D intake, as part of fracture prevention.
• Clinicians should assess baseline fracture risk based on bone density, fracture history, fracture risk factors, and response to prior osteoporosis treatments.
• Current evidence suggests that more than 3-5 years of bisphosphonate therapy reduces risk for new vertebral but not other fractures; however, it also increases risk for long-term harms. Therefore, clinicians should consider stopping bisphosphonate treatment after 5 years unless the patient has a strong indication for treatment continuation.
• The decision for a bisphosphonate holiday (temporary discontinuation) and its duration should be based on baseline fracture risk, medication half-life in bone, and benefits and harms.
• Women treated with an anabolic agent who discontinue it should be offered an antiresorptive agent to preserve gains and because of serious risk for rebound and multiple vertebral fractures.
• Adults older than 65 years with osteoporosis may be at increased risk for falls or other adverse events because of drug interactions.
• Transgender persons have variable risk for low bone mass.

The review and guideline were funded by the ACP. Dr. Ott has reported no relevant disclosures. Relevant financial disclosures for other authors are listed with the guideline and review.

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

The American College of Physicians has updated their guideline for pharmacotherapy to reduce fracture risk in adults with primary osteoporosis or osteopenia (low bone mass) based on a systematic review of the evidence.

This is the first update for 5 years since the previous guidance was published in 2017.

It strongly recommends initial therapy with bisphosphonates for postmenopausal women with osteoporosis, as well as men with osteoporosis, among other recommendations.

However, the author of an accompanying editorial, Susan M. Ott, MD, says: “The decision to start a bisphosphonate is actually not that easy.”

She also queries some of the other recommendations in the guidance.

Her editorial, along with the guideline by Amir Qaseem, MD, PhD, MPH, and colleagues, and systematic review by Chelsea Ayers, MPH, and colleagues, were published in the Annals of Internal Medicine.

Ryan D. Mire, MD, MACP, president of the ACP, gave a brief overview of the new guidance in a video.
 

Systematic review

The ACP commissioned a review of the evidence because it says new data have emerged on the efficacy of newer medications for osteoporosis and low bone mass, as well as treatment comparisons, and treatment in men.

The review authors identified 34 randomized controlled trials (in 100 publications) and 36 observational studies, which evaluated the following pharmacologic interventions:

• Antiresorptive drugs: four bisphosphonates (alendronate, ibandronate, risedronate, zoledronate) and a RANK ligand inhibitor (denosumab).
• Anabolic drugs: an analog of human parathyroid hormone (PTH)–related protein (abaloparatide), recombinant human PTH (teriparatide), and a sclerostin inhibitor (romosozumab).
• Estrogen agonists: selective estrogen receptor modulators (bazedoxifene, raloxifene).

The authors focused on effectiveness and harms of active drugs compared with placebo or bisphosphonates.
 

Major changes from 2017 guidelines, some questions

“Though there are many nuanced changes in this [2023 guideline] version, perhaps the major change is the explicit hierarchy of pharmacologic recommendations: bisphosphonates first, then denosumab,” Thomas G. Cooney, MD, senior author of the clinical guideline, explained in an interview.

“Bisphosphonates had the most favorable balance among benefits, harms, patient values and preferences, and cost among the examined drugs in postmenopausal females with primary osteoporosis,” Dr. Cooney, professor of medicine, Oregon Health & Science University, Portland, noted, as is stated in the guideline.

“Denosumab also had a favorable long-term net benefit, but bisphosphonates are much cheaper than other pharmacologic treatments and available in generic formulations,” the document states.

The new guideline suggests use of denosumab as second-line pharmacotherapy in adults who have contraindications to or experience adverse effects with bisphosphonates.

The choice among bisphosphonates (alendronate, risedronate, zoledronic acid) would be based on a patient-centered discussion between physician and patient, addressing costs (often related to insurance), delivery-mode preferences (oral versus intravenous), and “values,” which includes the patient’s priorities, concerns, and expectations regarding their health care, Dr. Cooney explained.

Another update in the new guideline is, “We also clarify the specific, albeit more limited, role of sclerostin inhibitors and recombinant PTH ‘to reduce the risk of fractures only in females with primary osteoporosis with very high-risk of fracture’,” Dr. Cooney noted.

In addition, the guideline now states, “treatment to reduce the risk of fractures in males rather than limiting it to ‘vertebral fracture’ in men,” as in the 2017 guideline.

It also explicitly includes denosumab as second-line therapy for men, Dr. Cooney noted, but as in 2017, the strength of evidence in men remains low.

“Finally, we also clarified that in females over the age of 65 with low bone mass or osteopenia that an individualized approach be taken to treatment (similar to last guideline), but if treatment is initiated, that a bisphosphonate be used (new content),” he said.

The use of estrogen, treatment duration, drug discontinuation, and serial bone mineral density monitoring were not addressed in this guideline, but will likely be evaluated within 2 to 3 years.
 

‘Osteoporosis treatment: Not easy’ – editorial

In her editorial, Dr. Ott writes: “The data about bisphosphonates may seem overwhelmingly positive, leading to strong recommendations for their use to treat osteoporosis, but the decision to start a bisphosphonate is actually not that easy.”

“A strong recommendation should be given only when future studies are unlikely to change it,” continues Dr. Ott, professor of medicine, University of Washington, Seattle.

“Yet, data already suggest that, in patients with serious osteoporosis, treatment should start with anabolic medications because previous treatment with either bisphosphonates or denosumab will prevent the anabolic response of newer medications.”

“Starting with bisphosphonate will change the bone so it will not respond to the newer medicines, and then a patient will lose the chance for getting the best improvement,” Dr. Ott clarified in an email to this news organization.

But, in fact, the new guidance does suggest that, to reduce the risk of fractures in females with primary osteoporosis at very high risk of fracture, one should consider use of the sclerostin inhibitor romosozumab (moderate-certainty evidence) or recombinant human parathyroid hormone (teriparatide) (low-certainty evidence) followed by a bisphosphonate (conditional recommendation).

Dr. Ott said: “If the [fracture] risk is high, then we should start with an anabolic medication for 1-2 years. If the risk is medium, then use a bisphosphonate for up to 5 years, and then stop and monitor the patient for signs that the medicine is wearing off,” based on blood and urine tests.
 

‘We need medicines that will stop bone aging’

Osteopenia is defined by an arbitrary bone density measurement, Dr. Ott explained. “About half of women over 65 will have osteopenia, and by age 85 there are hardly any ‘normal’ women left.”

“We need medicines that will stop bone aging, which might sound impossible, but we should still try,” she continued.

“In the meantime, while waiting on new discoveries,” Dr. Ott said, “I would not use bisphosphonates in patients who did not already have a fracture or whose bone density T-score was better than –2.5 because, in the major study, alendronate did not prevent fractures in this group.”

Many people are worried about bisphosphonates because of problems with the jaw or femur. These are real, but they are very rare during the first 5 years of treatment, Dr. Ott noted. Then the risk starts to rise, up to more than 1 in 1,000 after 8 years. So people can get the benefits of these drugs with very low risk for 5 years.

“An immediate [guideline] update is necessary to address the severity of bone loss and the high risk for vertebral fractures after discontinuation of denosumab,” Dr. Ott urged.

“I don’t agree with using denosumab for osteoporosis as a second-line treatment,” she said. “I would use it only in patients who have cancer or unusually high bone resorption. You have to get a dose strictly every 6 months, and if you need to stop, it is recommended to treat with bisphosphonates. Denosumab is a poor choice for somebody who does not want to take a bisphosphonate. Many patients and even too many doctors do not realize how serious it can be to skip a dose.”

“I also think that men could be treated with anabolic medications,” Dr. Ott said. “Clinical trials show they respond the same as women. Many men have osteoporosis as a consequence of low testosterone, and then they can usually be treated with testosterone. Osteoporosis in men is a serious problem that is too often ignored – almost reverse discrimination.”

It is also unfortunate that the review and recommendations do not address estrogen, one of the most effective medications to prevent osteoporotic fractures, according to Dr. Ott.
 

Clinical considerations in addition to drug types

The new guideline also advises:

• Clinicians treating adults with osteoporosis should encourage adherence to recommended treatments and healthy lifestyle habits, including exercise, and counseling to evaluate and prevent falls.
• All adults with osteopenia or osteoporosis should have adequate calcium and vitamin D intake, as part of fracture prevention.
• Clinicians should assess baseline fracture risk based on bone density, fracture history, fracture risk factors, and response to prior osteoporosis treatments.
• Current evidence suggests that more than 3-5 years of bisphosphonate therapy reduces risk for new vertebral but not other fractures; however, it also increases risk for long-term harms. Therefore, clinicians should consider stopping bisphosphonate treatment after 5 years unless the patient has a strong indication for treatment continuation.
• The decision for a bisphosphonate holiday (temporary discontinuation) and its duration should be based on baseline fracture risk, medication half-life in bone, and benefits and harms.
• Women treated with an anabolic agent who discontinue it should be offered an antiresorptive agent to preserve gains and because of serious risk for rebound and multiple vertebral fractures.
• Adults older than 65 years with osteoporosis may be at increased risk for falls or other adverse events because of drug interactions.
• Transgender persons have variable risk for low bone mass.

The review and guideline were funded by the ACP. Dr. Ott has reported no relevant disclosures. Relevant financial disclosures for other authors are listed with the guideline and review.

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

The American College of Physicians has updated their guideline for pharmacotherapy to reduce fracture risk in adults with primary osteoporosis or osteopenia (low bone mass) based on a systematic review of the evidence.

This is the first update for 5 years since the previous guidance was published in 2017.

It strongly recommends initial therapy with bisphosphonates for postmenopausal women with osteoporosis, as well as men with osteoporosis, among other recommendations.

However, the author of an accompanying editorial, Susan M. Ott, MD, says: “The decision to start a bisphosphonate is actually not that easy.”

She also queries some of the other recommendations in the guidance.

Her editorial, along with the guideline by Amir Qaseem, MD, PhD, MPH, and colleagues, and systematic review by Chelsea Ayers, MPH, and colleagues, were published in the Annals of Internal Medicine.

Ryan D. Mire, MD, MACP, president of the ACP, gave a brief overview of the new guidance in a video.
 

Systematic review

The ACP commissioned a review of the evidence because it says new data have emerged on the efficacy of newer medications for osteoporosis and low bone mass, as well as treatment comparisons, and treatment in men.

The review authors identified 34 randomized controlled trials (in 100 publications) and 36 observational studies, which evaluated the following pharmacologic interventions:

• Antiresorptive drugs: four bisphosphonates (alendronate, ibandronate, risedronate, zoledronate) and a RANK ligand inhibitor (denosumab).
• Anabolic drugs: an analog of human parathyroid hormone (PTH)–related protein (abaloparatide), recombinant human PTH (teriparatide), and a sclerostin inhibitor (romosozumab).
• Estrogen agonists: selective estrogen receptor modulators (bazedoxifene, raloxifene).

The authors focused on effectiveness and harms of active drugs compared with placebo or bisphosphonates.
 

Major changes from 2017 guidelines, some questions

“Though there are many nuanced changes in this [2023 guideline] version, perhaps the major change is the explicit hierarchy of pharmacologic recommendations: bisphosphonates first, then denosumab,” Thomas G. Cooney, MD, senior author of the clinical guideline, explained in an interview.

“Bisphosphonates had the most favorable balance among benefits, harms, patient values and preferences, and cost among the examined drugs in postmenopausal females with primary osteoporosis,” Dr. Cooney, professor of medicine, Oregon Health & Science University, Portland, noted, as is stated in the guideline.

“Denosumab also had a favorable long-term net benefit, but bisphosphonates are much cheaper than other pharmacologic treatments and available in generic formulations,” the document states.

The new guideline suggests use of denosumab as second-line pharmacotherapy in adults who have contraindications to or experience adverse effects with bisphosphonates.

The choice among bisphosphonates (alendronate, risedronate, zoledronic acid) would be based on a patient-centered discussion between physician and patient, addressing costs (often related to insurance), delivery-mode preferences (oral versus intravenous), and “values,” which includes the patient’s priorities, concerns, and expectations regarding their health care, Dr. Cooney explained.

Another update in the new guideline is, “We also clarify the specific, albeit more limited, role of sclerostin inhibitors and recombinant PTH ‘to reduce the risk of fractures only in females with primary osteoporosis with very high-risk of fracture’,” Dr. Cooney noted.

In addition, the guideline now states, “treatment to reduce the risk of fractures in males rather than limiting it to ‘vertebral fracture’ in men,” as in the 2017 guideline.

It also explicitly includes denosumab as second-line therapy for men, Dr. Cooney noted, but as in 2017, the strength of evidence in men remains low.

“Finally, we also clarified that in females over the age of 65 with low bone mass or osteopenia that an individualized approach be taken to treatment (similar to last guideline), but if treatment is initiated, that a bisphosphonate be used (new content),” he said.

The use of estrogen, treatment duration, drug discontinuation, and serial bone mineral density monitoring were not addressed in this guideline, but will likely be evaluated within 2 to 3 years.
 

‘Osteoporosis treatment: Not easy’ – editorial

In her editorial, Dr. Ott writes: “The data about bisphosphonates may seem overwhelmingly positive, leading to strong recommendations for their use to treat osteoporosis, but the decision to start a bisphosphonate is actually not that easy.”

“A strong recommendation should be given only when future studies are unlikely to change it,” continues Dr. Ott, professor of medicine, University of Washington, Seattle.

“Yet, data already suggest that, in patients with serious osteoporosis, treatment should start with anabolic medications because previous treatment with either bisphosphonates or denosumab will prevent the anabolic response of newer medications.”

“Starting with bisphosphonate will change the bone so it will not respond to the newer medicines, and then a patient will lose the chance for getting the best improvement,” Dr. Ott clarified in an email to this news organization.

But, in fact, the new guidance does suggest that, to reduce the risk of fractures in females with primary osteoporosis at very high risk of fracture, one should consider use of the sclerostin inhibitor romosozumab (moderate-certainty evidence) or recombinant human parathyroid hormone (teriparatide) (low-certainty evidence) followed by a bisphosphonate (conditional recommendation).

Dr. Ott said: “If the [fracture] risk is high, then we should start with an anabolic medication for 1-2 years. If the risk is medium, then use a bisphosphonate for up to 5 years, and then stop and monitor the patient for signs that the medicine is wearing off,” based on blood and urine tests.
 

‘We need medicines that will stop bone aging’

Osteopenia is defined by an arbitrary bone density measurement, Dr. Ott explained. “About half of women over 65 will have osteopenia, and by age 85 there are hardly any ‘normal’ women left.”

“We need medicines that will stop bone aging, which might sound impossible, but we should still try,” she continued.

“In the meantime, while waiting on new discoveries,” Dr. Ott said, “I would not use bisphosphonates in patients who did not already have a fracture or whose bone density T-score was better than –2.5 because, in the major study, alendronate did not prevent fractures in this group.”

Many people are worried about bisphosphonates because of problems with the jaw or femur. These are real, but they are very rare during the first 5 years of treatment, Dr. Ott noted. Then the risk starts to rise, up to more than 1 in 1,000 after 8 years. So people can get the benefits of these drugs with very low risk for 5 years.

“An immediate [guideline] update is necessary to address the severity of bone loss and the high risk for vertebral fractures after discontinuation of denosumab,” Dr. Ott urged.

“I don’t agree with using denosumab for osteoporosis as a second-line treatment,” she said. “I would use it only in patients who have cancer or unusually high bone resorption. You have to get a dose strictly every 6 months, and if you need to stop, it is recommended to treat with bisphosphonates. Denosumab is a poor choice for somebody who does not want to take a bisphosphonate. Many patients and even too many doctors do not realize how serious it can be to skip a dose.”

“I also think that men could be treated with anabolic medications,” Dr. Ott said. “Clinical trials show they respond the same as women. Many men have osteoporosis as a consequence of low testosterone, and then they can usually be treated with testosterone. Osteoporosis in men is a serious problem that is too often ignored – almost reverse discrimination.”

It is also unfortunate that the review and recommendations do not address estrogen, one of the most effective medications to prevent osteoporotic fractures, according to Dr. Ott.
 

Clinical considerations in addition to drug types

The new guideline also advises:

• Clinicians treating adults with osteoporosis should encourage adherence to recommended treatments and healthy lifestyle habits, including exercise, and counseling to evaluate and prevent falls.
• All adults with osteopenia or osteoporosis should have adequate calcium and vitamin D intake, as part of fracture prevention.
• Clinicians should assess baseline fracture risk based on bone density, fracture history, fracture risk factors, and response to prior osteoporosis treatments.
• Current evidence suggests that more than 3-5 years of bisphosphonate therapy reduces risk for new vertebral but not other fractures; however, it also increases risk for long-term harms. Therefore, clinicians should consider stopping bisphosphonate treatment after 5 years unless the patient has a strong indication for treatment continuation.
• The decision for a bisphosphonate holiday (temporary discontinuation) and its duration should be based on baseline fracture risk, medication half-life in bone, and benefits and harms.
• Women treated with an anabolic agent who discontinue it should be offered an antiresorptive agent to preserve gains and because of serious risk for rebound and multiple vertebral fractures.
• Adults older than 65 years with osteoporosis may be at increased risk for falls or other adverse events because of drug interactions.
• Transgender persons have variable risk for low bone mass.

The review and guideline were funded by the ACP. Dr. Ott has reported no relevant disclosures. Relevant financial disclosures for other authors are listed with the guideline and review.

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

The State Medical Board of Ohio has suspended the license of a plastic surgeon after she live-streamed surgical procedures on TikTok, potentially endangering patients. The surgeon has a large social media following.

In November, the State Medical Board of Ohio temporarily suspended the license of Katherine Roxanne Grawe, MD, who practices in the wealthy Columbus suburb of Powell.

Among other accusations of misconduct, the board stated that “during some videos/live-streams you engage in dialogue to respond to viewers’ online questions while the surgical procedure remains actively ongoing.”

One patient needed emergency treatment following liposuction and was diagnosed with a perforated bowel and serious bacterial infection.

“Despite liposuction being a blind surgery that requires awareness of the tip of the cannula to avoid injury, your attention to the camera meant at those moments you were not looking at the patient or palpating the location of the tip of the cannula,” the medical board said.

Neither Dr. Grawe nor her attorney responded to requests for comment.

Dr. Grawe, known as “Dr. Roxy,” has a popular TikTok account – now set to private – with 841,600 followers and 14.6 million likes. She has another 123,000 followers on her Instagram account, also now private.

The Columbus Dispatch reported that Dr. Grawe had previously been warned to protect patient privacy on social media. The board has yet to make a final decision regarding her license.

According to Columbus TV station WSYX, she said in a TikTok video, “We show our surgeries every single day on Snapchat. Patients get to decide if they want to be part of it. And if you do, you can watch your own surgery.”

The TV station quoted former patients who described surgical complications. One said: “I went to her because, I thought, from all of her social media that she uplifted women. That she helped women empower themselves. But she didn’t.”

Dallas plastic surgeon Rod J. Rohrich, MD, who has written about social-media best practices and has 430,000 followers on Instagram, said in an interview that many surgeons have been reprimanded by state medical boards for being distracted by social media during procedures.

“It is best not to do live-streaming unless it is an educational event to demonstrate techniques and technology with full informed consent of the patient. It should be a very well-rehearsed event for education,” he said.

Nurses also have been disciplined for inappropriate posts on social media. In December 2022, an Atlanta hospital announced that four nurses were no longer on the job after they appeared in a TikTok video in scrubs and revealed their “icks” regarding obstetric care.

“My ick is when you ask me how much the baby weighs,” one worker said in the video, “and it’s still ... in your hands.”

Plastic surgeon Christian J. Vercler, MD, of the University of Michigan, Ann Arbor, who’s studied social-media guidelines for surgeons, said in an interview that plastic surgery content on TikTok has “blown up” in recent years.

“Five years or so ago, it was Snapchat where I saw a lot of inappropriate things posted by surgeons,” Dr. Vercler said in an interview. “That may still be happening on Snapchat, but I actually don’t ever use that platform anymore, and neither do my trainees.”

Dr. Vercler cautioned colleagues to consider their motivations for live-streaming surgery and to think about whether they can fully focus on the patient.

“There are many potential distractions in the OR. We get pages, phone calls, nurses asking us questions, anesthesiologists trying to talk to us. Social media is just one more thing competing for the surgeon’s attention,” he said. “Every surgeon should strive to eliminate unnecessary or unavoidable distractions, so the question becomes, ‘who is best being served by me focusing my attention on recording this operation on someone’s phone so we can post it on social media? Is it the patient?’ ”

Dr. Vercler added, “There are many, many plastic surgeons using social media as the powerful platform that it is to build their brands, to connect with potential patients, and to educate the public about what they do. I believe that most are doing this in a way that is respectful to patients and doesn’t exploit patients for the surgeon’s benefit.

“Unfortunately,” he concluded, “there are some who do see patients as merely instruments by which they can achieve fame, notoriety, and wealth.”

Dr. Rohrich and Dr. Vercler disclosed no relevant financial relationships.

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

The State Medical Board of Ohio has suspended the license of a plastic surgeon after she live-streamed surgical procedures on TikTok, potentially endangering patients. The surgeon has a large social media following.

In November, the State Medical Board of Ohio temporarily suspended the license of Katherine Roxanne Grawe, MD, who practices in the wealthy Columbus suburb of Powell.

Among other accusations of misconduct, the board stated that “during some videos/live-streams you engage in dialogue to respond to viewers’ online questions while the surgical procedure remains actively ongoing.”

One patient needed emergency treatment following liposuction and was diagnosed with a perforated bowel and serious bacterial infection.

“Despite liposuction being a blind surgery that requires awareness of the tip of the cannula to avoid injury, your attention to the camera meant at those moments you were not looking at the patient or palpating the location of the tip of the cannula,” the medical board said.

Neither Dr. Grawe nor her attorney responded to requests for comment.

Dr. Grawe, known as “Dr. Roxy,” has a popular TikTok account – now set to private – with 841,600 followers and 14.6 million likes. She has another 123,000 followers on her Instagram account, also now private.

The Columbus Dispatch reported that Dr. Grawe had previously been warned to protect patient privacy on social media. The board has yet to make a final decision regarding her license.

According to Columbus TV station WSYX, she said in a TikTok video, “We show our surgeries every single day on Snapchat. Patients get to decide if they want to be part of it. And if you do, you can watch your own surgery.”

The TV station quoted former patients who described surgical complications. One said: “I went to her because, I thought, from all of her social media that she uplifted women. That she helped women empower themselves. But she didn’t.”

Dallas plastic surgeon Rod J. Rohrich, MD, who has written about social-media best practices and has 430,000 followers on Instagram, said in an interview that many surgeons have been reprimanded by state medical boards for being distracted by social media during procedures.

“It is best not to do live-streaming unless it is an educational event to demonstrate techniques and technology with full informed consent of the patient. It should be a very well-rehearsed event for education,” he said.

Nurses also have been disciplined for inappropriate posts on social media. In December 2022, an Atlanta hospital announced that four nurses were no longer on the job after they appeared in a TikTok video in scrubs and revealed their “icks” regarding obstetric care.

“My ick is when you ask me how much the baby weighs,” one worker said in the video, “and it’s still ... in your hands.”

Plastic surgeon Christian J. Vercler, MD, of the University of Michigan, Ann Arbor, who’s studied social-media guidelines for surgeons, said in an interview that plastic surgery content on TikTok has “blown up” in recent years.

“Five years or so ago, it was Snapchat where I saw a lot of inappropriate things posted by surgeons,” Dr. Vercler said in an interview. “That may still be happening on Snapchat, but I actually don’t ever use that platform anymore, and neither do my trainees.”

Dr. Vercler cautioned colleagues to consider their motivations for live-streaming surgery and to think about whether they can fully focus on the patient.

“There are many potential distractions in the OR. We get pages, phone calls, nurses asking us questions, anesthesiologists trying to talk to us. Social media is just one more thing competing for the surgeon’s attention,” he said. “Every surgeon should strive to eliminate unnecessary or unavoidable distractions, so the question becomes, ‘who is best being served by me focusing my attention on recording this operation on someone’s phone so we can post it on social media? Is it the patient?’ ”

Dr. Vercler added, “There are many, many plastic surgeons using social media as the powerful platform that it is to build their brands, to connect with potential patients, and to educate the public about what they do. I believe that most are doing this in a way that is respectful to patients and doesn’t exploit patients for the surgeon’s benefit.

“Unfortunately,” he concluded, “there are some who do see patients as merely instruments by which they can achieve fame, notoriety, and wealth.”

Dr. Rohrich and Dr. Vercler disclosed no relevant financial relationships.

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

The State Medical Board of Ohio has suspended the license of a plastic surgeon after she live-streamed surgical procedures on TikTok, potentially endangering patients. The surgeon has a large social media following.

In November, the State Medical Board of Ohio temporarily suspended the license of Katherine Roxanne Grawe, MD, who practices in the wealthy Columbus suburb of Powell.

Among other accusations of misconduct, the board stated that “during some videos/live-streams you engage in dialogue to respond to viewers’ online questions while the surgical procedure remains actively ongoing.”

One patient needed emergency treatment following liposuction and was diagnosed with a perforated bowel and serious bacterial infection.

“Despite liposuction being a blind surgery that requires awareness of the tip of the cannula to avoid injury, your attention to the camera meant at those moments you were not looking at the patient or palpating the location of the tip of the cannula,” the medical board said.

Neither Dr. Grawe nor her attorney responded to requests for comment.

Dr. Grawe, known as “Dr. Roxy,” has a popular TikTok account – now set to private – with 841,600 followers and 14.6 million likes. She has another 123,000 followers on her Instagram account, also now private.

The Columbus Dispatch reported that Dr. Grawe had previously been warned to protect patient privacy on social media. The board has yet to make a final decision regarding her license.

According to Columbus TV station WSYX, she said in a TikTok video, “We show our surgeries every single day on Snapchat. Patients get to decide if they want to be part of it. And if you do, you can watch your own surgery.”

The TV station quoted former patients who described surgical complications. One said: “I went to her because, I thought, from all of her social media that she uplifted women. That she helped women empower themselves. But she didn’t.”

Dallas plastic surgeon Rod J. Rohrich, MD, who has written about social-media best practices and has 430,000 followers on Instagram, said in an interview that many surgeons have been reprimanded by state medical boards for being distracted by social media during procedures.

“It is best not to do live-streaming unless it is an educational event to demonstrate techniques and technology with full informed consent of the patient. It should be a very well-rehearsed event for education,” he said.

Nurses also have been disciplined for inappropriate posts on social media. In December 2022, an Atlanta hospital announced that four nurses were no longer on the job after they appeared in a TikTok video in scrubs and revealed their “icks” regarding obstetric care.

“My ick is when you ask me how much the baby weighs,” one worker said in the video, “and it’s still ... in your hands.”

Plastic surgeon Christian J. Vercler, MD, of the University of Michigan, Ann Arbor, who’s studied social-media guidelines for surgeons, said in an interview that plastic surgery content on TikTok has “blown up” in recent years.

“Five years or so ago, it was Snapchat where I saw a lot of inappropriate things posted by surgeons,” Dr. Vercler said in an interview. “That may still be happening on Snapchat, but I actually don’t ever use that platform anymore, and neither do my trainees.”

Dr. Vercler cautioned colleagues to consider their motivations for live-streaming surgery and to think about whether they can fully focus on the patient.

“There are many potential distractions in the OR. We get pages, phone calls, nurses asking us questions, anesthesiologists trying to talk to us. Social media is just one more thing competing for the surgeon’s attention,” he said. “Every surgeon should strive to eliminate unnecessary or unavoidable distractions, so the question becomes, ‘who is best being served by me focusing my attention on recording this operation on someone’s phone so we can post it on social media? Is it the patient?’ ”

Dr. Vercler added, “There are many, many plastic surgeons using social media as the powerful platform that it is to build their brands, to connect with potential patients, and to educate the public about what they do. I believe that most are doing this in a way that is respectful to patients and doesn’t exploit patients for the surgeon’s benefit.

“Unfortunately,” he concluded, “there are some who do see patients as merely instruments by which they can achieve fame, notoriety, and wealth.”

Dr. Rohrich and Dr. Vercler disclosed no relevant financial relationships.

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