Hormone replacement therapy and development of new asthma. By Dr. E. Hansen et al.



Sex and gender omic biomarkers in men and women with COPD: Considerations for precision medicine. By Dr. D. Demeo.



Pulmonary function and radiological features in survivors of critical covid-19: A 3-month prospective cohort. By Dr. F. Barbe et al.



Characteristics and prevalence of domestic and occupational inhalational exposures across interstitial lung diseases. By Dr. C. Lee et al.



Identification and remediation of environmental exposures in patients with interstitial lung disease: Evidence review and practical considerations. By Dr. M. Salisbury et al.



How we do it: Creating an organizational culture for the chest physician. By Dr. J. Stoller et al..



Proposed quality metrics for lung cancer screening programs: A national lung cancer roundtable project. By Dr. P. Mazzone et al.

Hormone replacement therapy and development of new asthma. By Dr. E. Hansen et al.



Sex and gender omic biomarkers in men and women with COPD: Considerations for precision medicine. By Dr. D. Demeo.



Pulmonary function and radiological features in survivors of critical covid-19: A 3-month prospective cohort. By Dr. F. Barbe et al.



Characteristics and prevalence of domestic and occupational inhalational exposures across interstitial lung diseases. By Dr. C. Lee et al.



Identification and remediation of environmental exposures in patients with interstitial lung disease: Evidence review and practical considerations. By Dr. M. Salisbury et al.



How we do it: Creating an organizational culture for the chest physician. By Dr. J. Stoller et al..



Proposed quality metrics for lung cancer screening programs: A national lung cancer roundtable project. By Dr. P. Mazzone et al.

Hormone replacement therapy and development of new asthma. By Dr. E. Hansen et al.



Sex and gender omic biomarkers in men and women with COPD: Considerations for precision medicine. By Dr. D. Demeo.



Pulmonary function and radiological features in survivors of critical covid-19: A 3-month prospective cohort. By Dr. F. Barbe et al.



Characteristics and prevalence of domestic and occupational inhalational exposures across interstitial lung diseases. By Dr. C. Lee et al.



Identification and remediation of environmental exposures in patients with interstitial lung disease: Evidence review and practical considerations. By Dr. M. Salisbury et al.



How we do it: Creating an organizational culture for the chest physician. By Dr. J. Stoller et al..



Proposed quality metrics for lung cancer screening programs: A national lung cancer roundtable project. By Dr. P. Mazzone et al.

The NetWorks Challenge 2021 is kicking off in July with a 25k to celebrate the Foundation’s 25th anniversary. This year, we’re asking each NetWork to participate in a physical challenge, virtually. Make your way to 25k by walking, running, biking – or any activity that suits you.

Through the challenge, you can engage in friendly competition while supporting the goals of the Foundation. This year, money raised will directly help us in addressing health disparities through our microgrants program and will support travel grants for doctors-in-training looking to attend CHEST 2021.

With your help, by participating in the NetWorks Challenge, we can fund grants that aim to lend a hand to those who need it the most. Expanding research capabilities, improving patient care, and giving access to medical equipment are just a few ways microgrants from the CHEST Foundation have been used in the past.

Salim Surani, MD, MSc, FCCP, is a long-time supporter of the NetWorks Challenge and the Foundation’s grants program. “Whatever the Foundation pays in terms of grants and awards not only impacts the recipient but also the community as a whole ... For me, it was a no-brainer to get involved in an organization that actually raises funding to support community, education, and research,” Dr. Surani said.

With your support, during the NetWorks Challenge, we can provide grants to more clinicians looking to make a difference in chest medicine.

Encourage your NetWork members to join you this summer in the race to 25k.

“When you work within the NetWorks and join together, and work along with the CHEST Foundation, the impact is much more powerful. I always believed that it is a privilege for us that we have the outlet at the CHEST Foundation to provide grants,” Dr. Surani said.

To learn more about this initiative and this year’s NetWorks Challenge, visit the CHEST Foundation’s website at https://foundation.chestnet.org/.

The NetWorks Challenge 2021 is kicking off in July with a 25k to celebrate the Foundation’s 25th anniversary. This year, we’re asking each NetWork to participate in a physical challenge, virtually. Make your way to 25k by walking, running, biking – or any activity that suits you.

Through the challenge, you can engage in friendly competition while supporting the goals of the Foundation. This year, money raised will directly help us in addressing health disparities through our microgrants program and will support travel grants for doctors-in-training looking to attend CHEST 2021.

With your help, by participating in the NetWorks Challenge, we can fund grants that aim to lend a hand to those who need it the most. Expanding research capabilities, improving patient care, and giving access to medical equipment are just a few ways microgrants from the CHEST Foundation have been used in the past.

Salim Surani, MD, MSc, FCCP, is a long-time supporter of the NetWorks Challenge and the Foundation’s grants program. “Whatever the Foundation pays in terms of grants and awards not only impacts the recipient but also the community as a whole ... For me, it was a no-brainer to get involved in an organization that actually raises funding to support community, education, and research,” Dr. Surani said.

With your support, during the NetWorks Challenge, we can provide grants to more clinicians looking to make a difference in chest medicine.

Encourage your NetWork members to join you this summer in the race to 25k.

“When you work within the NetWorks and join together, and work along with the CHEST Foundation, the impact is much more powerful. I always believed that it is a privilege for us that we have the outlet at the CHEST Foundation to provide grants,” Dr. Surani said.

To learn more about this initiative and this year’s NetWorks Challenge, visit the CHEST Foundation’s website at https://foundation.chestnet.org/.

The NetWorks Challenge 2021 is kicking off in July with a 25k to celebrate the Foundation’s 25th anniversary. This year, we’re asking each NetWork to participate in a physical challenge, virtually. Make your way to 25k by walking, running, biking – or any activity that suits you.

Through the challenge, you can engage in friendly competition while supporting the goals of the Foundation. This year, money raised will directly help us in addressing health disparities through our microgrants program and will support travel grants for doctors-in-training looking to attend CHEST 2021.

With your help, by participating in the NetWorks Challenge, we can fund grants that aim to lend a hand to those who need it the most. Expanding research capabilities, improving patient care, and giving access to medical equipment are just a few ways microgrants from the CHEST Foundation have been used in the past.

Salim Surani, MD, MSc, FCCP, is a long-time supporter of the NetWorks Challenge and the Foundation’s grants program. “Whatever the Foundation pays in terms of grants and awards not only impacts the recipient but also the community as a whole ... For me, it was a no-brainer to get involved in an organization that actually raises funding to support community, education, and research,” Dr. Surani said.

With your support, during the NetWorks Challenge, we can provide grants to more clinicians looking to make a difference in chest medicine.

Encourage your NetWork members to join you this summer in the race to 25k.

“When you work within the NetWorks and join together, and work along with the CHEST Foundation, the impact is much more powerful. I always believed that it is a privilege for us that we have the outlet at the CHEST Foundation to provide grants,” Dr. Surani said.

To learn more about this initiative and this year’s NetWorks Challenge, visit the CHEST Foundation’s website at https://foundation.chestnet.org/.

This year’s CHEST Annual Meeting will push the envelope of fun through various educational games and experiences for those attending on-site and online.

CHEST is supercharging the escape room experience with the expansion of two unique on-site escape scenarios to solve, First Contact and Shuttle Crash. In escape rooms, small teams work against the clock to solve a medical puzzle and unlock the final challenges. Those attending online can take a break and join the excitement with First Contact, a mission to Jupiter led by our space lieutenant, William Kelly, MD, FCCP, and faculty and staff game fleet. To build off the futuristic hands-on experiences, CHEST will be debuting intubation procedural simulations using state-of-the-art virtual reality technology.

If you prefer to join the fun using your mobile device, CHEST is releasing daily task-based missions that you can track and complete using your phone. These missions will include a variety of social activities designed around the conference halls, hotels, clinic, and your own home that are sure to get you moving and working as a team.

During the 4 days of the annual meeting, CHEST will also host an exclusive event called “Play With the Pros.” You can test your knowledge and play alongside annual meeting cochairs, Chris Carroll, MD, FCCP, and David Zielinski, MD, FCCP, for the chance to win a grand prize. As an added bonus, CHEST is offering daily prize drawings for players and social media recognition to those who top the leaderboards in the CHEST Player Hub. The Player Hub hosts more than 10 bite-sized mobile games and is available on demand with your CHEST ID.

Additionally, live game breaks hosted by our faculty between education sessions will give you the chance to unwind and play in real time with your peers and colleagues. On-site, CHEST invites you to shoot hoops, drive remote-controlled cars, and shuffle across the gameboard floors. From your couch or desk, you can tune in to test your knowledge in our livestreamed trivia or sign up for the chance to receive a trivia question phone call from our faculty, which is tied to a grand prize.

The opportunities to play and learn during CHEST Games are endless at CHEST 2021!

This year’s CHEST Annual Meeting will push the envelope of fun through various educational games and experiences for those attending on-site and online.

CHEST is supercharging the escape room experience with the expansion of two unique on-site escape scenarios to solve, First Contact and Shuttle Crash. In escape rooms, small teams work against the clock to solve a medical puzzle and unlock the final challenges. Those attending online can take a break and join the excitement with First Contact, a mission to Jupiter led by our space lieutenant, William Kelly, MD, FCCP, and faculty and staff game fleet. To build off the futuristic hands-on experiences, CHEST will be debuting intubation procedural simulations using state-of-the-art virtual reality technology.

If you prefer to join the fun using your mobile device, CHEST is releasing daily task-based missions that you can track and complete using your phone. These missions will include a variety of social activities designed around the conference halls, hotels, clinic, and your own home that are sure to get you moving and working as a team.

During the 4 days of the annual meeting, CHEST will also host an exclusive event called “Play With the Pros.” You can test your knowledge and play alongside annual meeting cochairs, Chris Carroll, MD, FCCP, and David Zielinski, MD, FCCP, for the chance to win a grand prize. As an added bonus, CHEST is offering daily prize drawings for players and social media recognition to those who top the leaderboards in the CHEST Player Hub. The Player Hub hosts more than 10 bite-sized mobile games and is available on demand with your CHEST ID.

Additionally, live game breaks hosted by our faculty between education sessions will give you the chance to unwind and play in real time with your peers and colleagues. On-site, CHEST invites you to shoot hoops, drive remote-controlled cars, and shuffle across the gameboard floors. From your couch or desk, you can tune in to test your knowledge in our livestreamed trivia or sign up for the chance to receive a trivia question phone call from our faculty, which is tied to a grand prize.

The opportunities to play and learn during CHEST Games are endless at CHEST 2021!

This year’s CHEST Annual Meeting will push the envelope of fun through various educational games and experiences for those attending on-site and online.

CHEST is supercharging the escape room experience with the expansion of two unique on-site escape scenarios to solve, First Contact and Shuttle Crash. In escape rooms, small teams work against the clock to solve a medical puzzle and unlock the final challenges. Those attending online can take a break and join the excitement with First Contact, a mission to Jupiter led by our space lieutenant, William Kelly, MD, FCCP, and faculty and staff game fleet. To build off the futuristic hands-on experiences, CHEST will be debuting intubation procedural simulations using state-of-the-art virtual reality technology.

If you prefer to join the fun using your mobile device, CHEST is releasing daily task-based missions that you can track and complete using your phone. These missions will include a variety of social activities designed around the conference halls, hotels, clinic, and your own home that are sure to get you moving and working as a team.

During the 4 days of the annual meeting, CHEST will also host an exclusive event called “Play With the Pros.” You can test your knowledge and play alongside annual meeting cochairs, Chris Carroll, MD, FCCP, and David Zielinski, MD, FCCP, for the chance to win a grand prize. As an added bonus, CHEST is offering daily prize drawings for players and social media recognition to those who top the leaderboards in the CHEST Player Hub. The Player Hub hosts more than 10 bite-sized mobile games and is available on demand with your CHEST ID.

Additionally, live game breaks hosted by our faculty between education sessions will give you the chance to unwind and play in real time with your peers and colleagues. On-site, CHEST invites you to shoot hoops, drive remote-controlled cars, and shuffle across the gameboard floors. From your couch or desk, you can tune in to test your knowledge in our livestreamed trivia or sign up for the chance to receive a trivia question phone call from our faculty, which is tied to a grand prize.

The opportunities to play and learn during CHEST Games are endless at CHEST 2021!

The CHEST Board of Regents met in mid-June for its first in-person meeting in more than a year. It served as a lovely reminder that not only are in-person meetings a more effective way to conduct the business of the College, but that the members of the board have really missed seeing each other without an intervening screen and webcam.

First on the agenda was a recap by the CHEST presidents of their recent strategic retreat. Most relevant to the organization was a recommendation that we revise the manner by which the CHEST strategic plan is set. If the last year has taught us anything, it is that planning for the future is essential, but we must also allow for flexibility when external forces change what the future holds. Accordingly, we will be replacing the former 5-year planning cycle with a more nimble annual review. From a member’s standpoint, this means that you will see more frequent revisions of those plans (Strategic Plan, American College of Chest Physicians).

Over the last year, the CHEST Foundation has sponsored a series of “listening tours,” which has allowed our members and leaders to hear from many of our patients who feel disenfranchised from the medical system because of struggles with communication, finances, and access, among other issues. The willingness of our patients to share their struggles with us has inspired the Foundation to try to make inroads into these, better navigating these barriers. In direct response to what we’ve heard, the team is designing programs to help our caregivers focus on the psychological, social, environmental, and personal factors that impact our patients’ ability to obtain the critical health care that all need and deserve.

Our ability to execute and deliver such programs is contingent on successful fundraising efforts. Ian Nathanson, president of the CHEST Foundation, reviewed fundraising progress with the board. Over these long months, donors, participants, and friends of the Foundation have participated in virtual events designed to foster engagement and comradery through this difficult time. This June, we held a virtual and in-person Belmont Stakes event that has shown that we can adapt to challenging times and that our membership is still incredibly supportive of the Foundation’s mission. Thank you to all of you who participated in or donated to the CHEST Foundation over the last year!

The last 18 months have had a marked impact on our ability to provide the live, interactive learning experiences for which CHEST is known, but efforts in the remote learning space have yielded impressive increases in both the number of remote learning opportunities and the breadth of our members who are using them. As one example, the number of CHEST podcast views quadrupled last year compared with 2019. Although CHEST reopened its headquarters for live learning opportunities this summer, and we are looking to move significantly back toward “business as usual” with CHEST 2021 in Orlando this October, we will also be carefully considering how best to incorporate the lessons learned in the remote offering space as the world reopens in the coming year.

Neil Freedman, chair of CHEST’s Health Advocacy and Policy Committee (HPAC), presented a review of the committee’s work since its inception just over 1 year ago. In addition to putting together a multi-society Technical Expert Panel on the use and coverage of noninvasive ventilation, HPAC worked with 18 other societies in drafting a response to the Agency for Healthcare Research and Quality’s draft on coverage for CPAP therapy for obstructive sleep apnea. For members interested in getting more involved in CHEST’s advocacy efforts, we are seeking self-nominations for members of several working groups (nominations to open soon); in addition, there will be sessions during CHEST 2021 focused on our advocacy efforts and how you can participate, as well as best practices in the advocacy space.

Several months ago, the Exeter Group was asked by the board to analyze how CHEST can expand our organizational efforts in diversity, equity, and inclusion (DEI). Representatives from the Exeter Group joined the meeting to provide board members with preliminary data. Limited interviews with both members and staff have begun to provide a picture of where CHEST has already made some progress in this space, and where our ongoing challenges and opportunities for improvement still exist; it is clear that there is a wide range of opinions on these complicated issues. As our consultants are only 1 month into this 6-month phase of the project, we expect a great deal more information to come, with a plan for ongoing surveys of and focus groups for our members; when you receive one of these requests, please make every effort to complete it as candidly as possible, regardless of your viewpoint. The consulting work will culminate with a final presentation to the board just before the annual meeting in the fall, with specific recommendations on organizational actions that will be used to implement a multiyear DEI plan.

The Governance Committee, represented by Stephanie Levine, made several recommendations to revision of the CHEST Foundations bylaws. Specifically, the new bylaws permit Trustees of the Foundation to be re-elected to positions on the board beyond the current 6-year maximum term after several years away from the position. The position of President-Designate of the Foundation will also be eliminated, allowing for a 2-year term for the President-Elect of the Foundation and a 2-year term for the President of the Foundation.

One of the main challenges for an organization of 19,000 people is to ensure that we can engage as many of our members as possible. The NetWorks structure has historically been the primary mechanism for members to pursue initial leadership opportunities within the College. CHEST Past-President Stephanie Levine previously established a working group to revisit NetWork structure in an effort to ensure ample opportunities for engagement within CHEST. The final agenda item at this board meeting was a discussion about restructuring the CHEST NetWorks to create mechanisms that will help us balance the needs of the College with the energy of the volunteers to maximize productivity and engagement of all parties. The plan would increase the number of leadership positions available within the NetWork structure. While the final nomenclature and distribution of NetWorks amongst the pillars has yet to be finalized, the board was supportive of this modification and expects implementation in the next 12 months, with details to be provided to the membership as they are fleshed out.

After a full day’s agenda, CHEST President Steve Simpson adjourned the board meeting. The Board of Regents will meet remotely in August (the summer call has always been a remote meeting) and again in Orlando in October.

The CHEST Board of Regents met in mid-June for its first in-person meeting in more than a year. It served as a lovely reminder that not only are in-person meetings a more effective way to conduct the business of the College, but that the members of the board have really missed seeing each other without an intervening screen and webcam.

First on the agenda was a recap by the CHEST presidents of their recent strategic retreat. Most relevant to the organization was a recommendation that we revise the manner by which the CHEST strategic plan is set. If the last year has taught us anything, it is that planning for the future is essential, but we must also allow for flexibility when external forces change what the future holds. Accordingly, we will be replacing the former 5-year planning cycle with a more nimble annual review. From a member’s standpoint, this means that you will see more frequent revisions of those plans (Strategic Plan, American College of Chest Physicians).

Over the last year, the CHEST Foundation has sponsored a series of “listening tours,” which has allowed our members and leaders to hear from many of our patients who feel disenfranchised from the medical system because of struggles with communication, finances, and access, among other issues. The willingness of our patients to share their struggles with us has inspired the Foundation to try to make inroads into these, better navigating these barriers. In direct response to what we’ve heard, the team is designing programs to help our caregivers focus on the psychological, social, environmental, and personal factors that impact our patients’ ability to obtain the critical health care that all need and deserve.

Our ability to execute and deliver such programs is contingent on successful fundraising efforts. Ian Nathanson, president of the CHEST Foundation, reviewed fundraising progress with the board. Over these long months, donors, participants, and friends of the Foundation have participated in virtual events designed to foster engagement and comradery through this difficult time. This June, we held a virtual and in-person Belmont Stakes event that has shown that we can adapt to challenging times and that our membership is still incredibly supportive of the Foundation’s mission. Thank you to all of you who participated in or donated to the CHEST Foundation over the last year!

The last 18 months have had a marked impact on our ability to provide the live, interactive learning experiences for which CHEST is known, but efforts in the remote learning space have yielded impressive increases in both the number of remote learning opportunities and the breadth of our members who are using them. As one example, the number of CHEST podcast views quadrupled last year compared with 2019. Although CHEST reopened its headquarters for live learning opportunities this summer, and we are looking to move significantly back toward “business as usual” with CHEST 2021 in Orlando this October, we will also be carefully considering how best to incorporate the lessons learned in the remote offering space as the world reopens in the coming year.

Neil Freedman, chair of CHEST’s Health Advocacy and Policy Committee (HPAC), presented a review of the committee’s work since its inception just over 1 year ago. In addition to putting together a multi-society Technical Expert Panel on the use and coverage of noninvasive ventilation, HPAC worked with 18 other societies in drafting a response to the Agency for Healthcare Research and Quality’s draft on coverage for CPAP therapy for obstructive sleep apnea. For members interested in getting more involved in CHEST’s advocacy efforts, we are seeking self-nominations for members of several working groups (nominations to open soon); in addition, there will be sessions during CHEST 2021 focused on our advocacy efforts and how you can participate, as well as best practices in the advocacy space.

Several months ago, the Exeter Group was asked by the board to analyze how CHEST can expand our organizational efforts in diversity, equity, and inclusion (DEI). Representatives from the Exeter Group joined the meeting to provide board members with preliminary data. Limited interviews with both members and staff have begun to provide a picture of where CHEST has already made some progress in this space, and where our ongoing challenges and opportunities for improvement still exist; it is clear that there is a wide range of opinions on these complicated issues. As our consultants are only 1 month into this 6-month phase of the project, we expect a great deal more information to come, with a plan for ongoing surveys of and focus groups for our members; when you receive one of these requests, please make every effort to complete it as candidly as possible, regardless of your viewpoint. The consulting work will culminate with a final presentation to the board just before the annual meeting in the fall, with specific recommendations on organizational actions that will be used to implement a multiyear DEI plan.

The Governance Committee, represented by Stephanie Levine, made several recommendations to revision of the CHEST Foundations bylaws. Specifically, the new bylaws permit Trustees of the Foundation to be re-elected to positions on the board beyond the current 6-year maximum term after several years away from the position. The position of President-Designate of the Foundation will also be eliminated, allowing for a 2-year term for the President-Elect of the Foundation and a 2-year term for the President of the Foundation.

One of the main challenges for an organization of 19,000 people is to ensure that we can engage as many of our members as possible. The NetWorks structure has historically been the primary mechanism for members to pursue initial leadership opportunities within the College. CHEST Past-President Stephanie Levine previously established a working group to revisit NetWork structure in an effort to ensure ample opportunities for engagement within CHEST. The final agenda item at this board meeting was a discussion about restructuring the CHEST NetWorks to create mechanisms that will help us balance the needs of the College with the energy of the volunteers to maximize productivity and engagement of all parties. The plan would increase the number of leadership positions available within the NetWork structure. While the final nomenclature and distribution of NetWorks amongst the pillars has yet to be finalized, the board was supportive of this modification and expects implementation in the next 12 months, with details to be provided to the membership as they are fleshed out.

After a full day’s agenda, CHEST President Steve Simpson adjourned the board meeting. The Board of Regents will meet remotely in August (the summer call has always been a remote meeting) and again in Orlando in October.

The CHEST Board of Regents met in mid-June for its first in-person meeting in more than a year. It served as a lovely reminder that not only are in-person meetings a more effective way to conduct the business of the College, but that the members of the board have really missed seeing each other without an intervening screen and webcam.

First on the agenda was a recap by the CHEST presidents of their recent strategic retreat. Most relevant to the organization was a recommendation that we revise the manner by which the CHEST strategic plan is set. If the last year has taught us anything, it is that planning for the future is essential, but we must also allow for flexibility when external forces change what the future holds. Accordingly, we will be replacing the former 5-year planning cycle with a more nimble annual review. From a member’s standpoint, this means that you will see more frequent revisions of those plans (Strategic Plan, American College of Chest Physicians).

Over the last year, the CHEST Foundation has sponsored a series of “listening tours,” which has allowed our members and leaders to hear from many of our patients who feel disenfranchised from the medical system because of struggles with communication, finances, and access, among other issues. The willingness of our patients to share their struggles with us has inspired the Foundation to try to make inroads into these, better navigating these barriers. In direct response to what we’ve heard, the team is designing programs to help our caregivers focus on the psychological, social, environmental, and personal factors that impact our patients’ ability to obtain the critical health care that all need and deserve.

Our ability to execute and deliver such programs is contingent on successful fundraising efforts. Ian Nathanson, president of the CHEST Foundation, reviewed fundraising progress with the board. Over these long months, donors, participants, and friends of the Foundation have participated in virtual events designed to foster engagement and comradery through this difficult time. This June, we held a virtual and in-person Belmont Stakes event that has shown that we can adapt to challenging times and that our membership is still incredibly supportive of the Foundation’s mission. Thank you to all of you who participated in or donated to the CHEST Foundation over the last year!

The last 18 months have had a marked impact on our ability to provide the live, interactive learning experiences for which CHEST is known, but efforts in the remote learning space have yielded impressive increases in both the number of remote learning opportunities and the breadth of our members who are using them. As one example, the number of CHEST podcast views quadrupled last year compared with 2019. Although CHEST reopened its headquarters for live learning opportunities this summer, and we are looking to move significantly back toward “business as usual” with CHEST 2021 in Orlando this October, we will also be carefully considering how best to incorporate the lessons learned in the remote offering space as the world reopens in the coming year.

Neil Freedman, chair of CHEST’s Health Advocacy and Policy Committee (HPAC), presented a review of the committee’s work since its inception just over 1 year ago. In addition to putting together a multi-society Technical Expert Panel on the use and coverage of noninvasive ventilation, HPAC worked with 18 other societies in drafting a response to the Agency for Healthcare Research and Quality’s draft on coverage for CPAP therapy for obstructive sleep apnea. For members interested in getting more involved in CHEST’s advocacy efforts, we are seeking self-nominations for members of several working groups (nominations to open soon); in addition, there will be sessions during CHEST 2021 focused on our advocacy efforts and how you can participate, as well as best practices in the advocacy space.

Several months ago, the Exeter Group was asked by the board to analyze how CHEST can expand our organizational efforts in diversity, equity, and inclusion (DEI). Representatives from the Exeter Group joined the meeting to provide board members with preliminary data. Limited interviews with both members and staff have begun to provide a picture of where CHEST has already made some progress in this space, and where our ongoing challenges and opportunities for improvement still exist; it is clear that there is a wide range of opinions on these complicated issues. As our consultants are only 1 month into this 6-month phase of the project, we expect a great deal more information to come, with a plan for ongoing surveys of and focus groups for our members; when you receive one of these requests, please make every effort to complete it as candidly as possible, regardless of your viewpoint. The consulting work will culminate with a final presentation to the board just before the annual meeting in the fall, with specific recommendations on organizational actions that will be used to implement a multiyear DEI plan.

The Governance Committee, represented by Stephanie Levine, made several recommendations to revision of the CHEST Foundations bylaws. Specifically, the new bylaws permit Trustees of the Foundation to be re-elected to positions on the board beyond the current 6-year maximum term after several years away from the position. The position of President-Designate of the Foundation will also be eliminated, allowing for a 2-year term for the President-Elect of the Foundation and a 2-year term for the President of the Foundation.

One of the main challenges for an organization of 19,000 people is to ensure that we can engage as many of our members as possible. The NetWorks structure has historically been the primary mechanism for members to pursue initial leadership opportunities within the College. CHEST Past-President Stephanie Levine previously established a working group to revisit NetWork structure in an effort to ensure ample opportunities for engagement within CHEST. The final agenda item at this board meeting was a discussion about restructuring the CHEST NetWorks to create mechanisms that will help us balance the needs of the College with the energy of the volunteers to maximize productivity and engagement of all parties. The plan would increase the number of leadership positions available within the NetWork structure. While the final nomenclature and distribution of NetWorks amongst the pillars has yet to be finalized, the board was supportive of this modification and expects implementation in the next 12 months, with details to be provided to the membership as they are fleshed out.

After a full day’s agenda, CHEST President Steve Simpson adjourned the board meeting. The Board of Regents will meet remotely in August (the summer call has always been a remote meeting) and again in Orlando in October.

Airways disorders

Eosinophils in COPD

Using peripheral blood eosinophilia (PBE) as a treatable biomarker of airway inflammation in patients with COPD has become an area of controversy in pulmonary medicine.

The proponents find a role for PBE testing in initiation and withdrawal of inhaled corticosteroids (ICS) and as a target for monoclonal antibodies in future studies.¹ Post hoc analyses showed that variable doses of ICS/LABA combination compared with LABA alone in COPD patients were associated with much higher exacerbation reduction in patients with eosinophils counts of ≥2% and magnitude of effect proportionally increased from 29% to 42% with increasing eosinophil count from ≥2% to ≥6% suggesting a dose-response relationship.² A post hoc analysis of the WISDOM trial showed increased risk of exacerbation after ICS discontinuation in COPD patients with high eosinophils (≥300 cells/mcL or ≥4%) while exacerbation risk was not increased in patients with low eosinophils (<150 cells/mcL or <2%).³

The opponents of eosinophil-guided therapy object that the level of evidence is weak as this is based on the post hoc analyses of randomized control trials on patients with increased exacerbation risk at baseline, which in itself is an independent predictor of future exacerbations.⁴ Some observational studies failed to find increased risk of exacerbation with higher eosinophil count while others found that higher eosinophil count was associated with increased survival and better quality of life.^5,6 Anti-eosinophilic biologics have failed to show consistent benefit in exacerbation reduction in COPD patients so far, despite showing a reduction in the PBE.^7-9

The GOLD COPD Guidelines support the use of ICS in patients with eosinophils >300 cells/mcL especially with a history of exacerbation and recommend against ICS in patients with eosinophils <100 cells/mcL.¹⁰

Farrukh Abbas, MD
Steering Committee Fellow-in-Training
Allen J. Blaivas, MD, FCCP
NetWork Chair
 

References

1. Wade RC and Wells JM. Chest. 2020;157(5):1073-5.

2. Pascoe S et al. The Lancet Respir Med. 2015;3(6):435-42.

3. Watz H et al. The Lancet Respir Med. 2016;4(5):390-8.

4. Criner GJ. Chest. 2020;157(5):1075-8.

5. Shin SH et al. Respir Res. 2018;19(1):134.

6. Casanova C et al. Eur Respir J. 2017;50(5):1701162.

7. Pavord ID et al. N Engl J Med. 2017;377(17):1613-29.

8. Criner GJ et al. N Engl J Med. 2019;381(11):1023-34.

9. Mycroft K et al. J Allergy Clin Immunol Pract. 2020 Sep;8(8):2565-74.

10. Global Initiative for Chronic Obstructive Lung Disease 2021 Report.
 

Clinical research

Long-COVID: COVID-19 disease beyond the pandemic

There are increasing reports of persistent multiorgan symptoms following COVID-19 infection.

In December 2020, the National Institute for Health and Care Excellence (NICE) developed guidelines, based primarily on expert opinion, to define and manage ongoing symptomatic COVID-19 (symptoms for 4-12 weeks after infection) and post-COVID syndrome (symptoms present for > 12 weeks without alternative explanation). Subsequently, the National Institutes of Health (NIH), released in February 2021 an initiative to study Post-Acute Sequelae of SARS-CoV2 infection (PASC). Symptoms can include, respiratory (cough, shortness of breath), cardiac (palpitations, chest pain), fatigue and physical limitations, and neurologic (depression, insomnia, cognitive impairment) (Lancet 2020 Dec 12;396[10266]:1861). The majority of patients with post-COVID syndrome have microbiological recovery (PCR negative), and often have radiological recovery. Risk factors include older age, female sex, and comorbidities (Raveendran AV. Diabetes Metab Syndr. 2021 May-June;15[3]:869-75).

Diagnosis and access to care pose significant challenges for post-COVID syndrome, and it is difficult to estimate exactly how many are affected – one report from Italy found that up to 87% of discharged hospitalized patients had persistent symptom(s) at 60 days (Carfi A. JAMA 2020 Aug;324[6]:603-5). Thus far, management recommendations include a multidisciplinary approach to evaluation, symptomatic treatment, organ specific treatment (for example, consideration of corticosteroids for persistent inflammatory interstitial lung disease) (Myall KJ. Ann Am Thorac Soc. 2021 May;8[5]:799-806), physical/occupational therapy, and psychological support. Many institutions have established, or are working to establish post-COVID clinics (Aging Clin Exp Res. 2020 Aug;32[8]:1613-20). Currently, the NIH is offering funding opportunities and there are many clinical trials across the world actively recruiting patients.

Ankita Agarwal, MD
Steering Committee Fellow-in-Training
Bharat Bajantri, MD
Steering Committee Member
Aravind Menon, MD
Steering Committee Fellow-in-Training
 

Critical care

Sedation practices in the ICU: Moving past the COVID-19 pandemic

The COVID-19 pandemic brought unprecedented change to critical care practice patterns, and sedation practices in the intensive care unit are no exception. In a large cohort analysis of over 2,000 adults with COVID-19 (Pun BT, et al. Lancet Respir Med. 2021;9[3]:239-50), 64% of patients received benzodiazepines (median of 7 days), and patients were deeply sedated. More than half of the patients were delirious, with benzodiazepine use associated with increased incidence of delirium. These observations represent a significant departure from well-established pre-COVID best-practices in sedation: light targets, daily sedation interruption, and avoiding continuous benzodiazepine infusions whenever possible (Girard TD, et al. Lancet; 2008;371[9607]:126-34; Fraser GL, et al. Crit Care Med;2013 Sep;41[9 Suppl 1]:S30-8; Riker RR, et al. JAMA;2009;301[5]:489-99).

As COVID-19 case counts begin to improve in many of our communities, we have the opportunity to refocus on best sedation practices and build on a growing body of recent evidence. The MENDS2 trial, completed pre-COVID-19, assigned mechanically ventilated patients with sepsis to either propofol or dexmedetomidine and showed no difference in delirium or coma in this cohort of lightly sedated patients (Hughes CG, et al. N Engl J Med. 2021;384[15]:1424-36). Furthering this point, Olsen et al. found no difference in outcomes when mechanically ventilated patients were randomized to no sedation vs light sedation (Olsen HT, et al. N Engl J Med; 2020;382[12]:1103-11).

While the evidence surrounding sedation strategies in the critically ill continues to grow, one thing is certain: promoting lighter sedation targets and reengaging in sedation-related best practices following the COVID-19 pandemic will continue to play a vital role in improving both short and long-term outcomes for our critically ill patients.

Casey Cable, MD, MSc
Steering Committee Member

Kyle Stinehart, MD
Steering Committee Member
 

Home mechanical ventilation

How to initiate a chronic respiratory failure clinic

Noninvasive ventilation (NIV) is an established treatment for chronic hypercapnic respiratory failure from neuromuscular disorders, COPD, obesity hypoventilation syndrome (OHS), and restrictive thoracic disorders. Previously, hospital admission was considered essential for setup of chronic NIV but with advances in the modes of ventilation and remote monitoring, hospital admission has become less justifiable, especially in countries with centralized medical systems and presence of centers of excellence for home ventilation (Van Den Biggelaar RJM, et al. Chest. 2020;158[6]:2493-2501); Duiverman ML, et al. Thorax. 2020;75:244-52). In the United States, where centralized health care is atypical, management of NIV has been disparate with no clear consensus on practice patterns. Thus, we hope to provide some guidance toward the establishment of such clinics in the U.S.
 

Prior to developing an NIV clinic, establishing a referral source from neuromuscular, rehabilitation/spinal cord injury, bariatric surgery, and COPD programs is important. After this, collaboration with a respiratory therapist through durable medical equipment is essential to building a robust care team. These companies are also important for assisting in remote monitoring, providing overnight pulse oximetry/CO₂ monitoring, mask fitting, and airway clearance. Clinicians are encouraged to develop protocols for initiation and titration of NIV and mouthpiece ventilation. Clinics should provide spirometry, maximal inspiratory pressure, transcutaneous CO₂, and/or blood gas testing. Additionally, in this patient population, wheelchair scales are necessary. Clinical workflow should include a review of NIV downloads, identify asynchronies and troubleshoot it in timely and reliable manner (Blouet S, et al. Int J Chron Obstruct Pulmon Dis. 2018;13:2577-86). Lastly, effort should be made for an adequate assessment of the home situation including layout of home along with family support utilizing social worker and palliative care team. Due to patient mobility, we encourage continued availability of telehealth for these patients.

In summary, strong clinical infrastructure, a robust care team, and an efficient, secure, reliable telemonitoring system are key to provide better care to this vulnerable patient population.

Ashima S. Sahni, MD, MBBS, FCCP
NetWork Member

Amen Sergew, MD
Steering Committee Member

Interstitial and diffuse lung disease

Treatment for pulmonary hypertension secondary to interstitial lung disease

The development of pulmonary hypertension (PH) in patients with interstitial lung disease (ILD) (PH-ILD) is associated with increased supplemental oxygen requirements, reduced functional status, and decreased survival (King CS, et al. Chest. 2020;158[4]:1651).

An inhaled formulation of treprostinil (Tyvaso) is the first treatment option approved by the FDA for patients with PH-ILD, including those with idiopathic pulmonary fibrosis, connective tissue disease-associated ILD, and combined pulmonary fibrosis and emphysema. Approval was based on results from the INCREASE trial (Waxman A, et al. N Engl J Med. 2021;384[4]:325), a phase III multicenter, randomized, double-blinded study comparing the inhaled formulation to placebo in 326 patients over a 16-week period. Participants in the treatment arm were given up to 12 breaths of the formulation per session, four times per day. Subjects treated with this inhaled formulation met the primary study endpoint, an increase in 6-minute walk distance (6MWD) from baseline to week 16, walking 21 m farther than placebo-treated control subjects. Furthermore, patients receiving the new formulation had a decrease in NT-proBNP levels (compared with increases in the placebo arm) and a reduction in clinical worsening (23% of inhalation formulation-treated vs. 33% of placebo-treated subjects). This formulation of treprostinil was well-tolerated with a safety profile consistent with common prostacyclin-related adverse events, including cough, headache, dyspnea, dizziness, nausea, fatigue, and diarrhea. Its approval will dramatically alter the ILD treatment landscape. It now necessitates the use of PH screening in this patient population. However, care will need to be exercised in appropriate patient selection for treatment, using the study inclusion and exclusion criteria as a starting point. Appropriate use of this formulation will hopefully help mitigate the negative outcomes impacting patients with PH-ILD.

Rebecca Anna Gersten, MD
Adrian Shifren, MD
Steering Committee Members

Airways disorders

Eosinophils in COPD

Using peripheral blood eosinophilia (PBE) as a treatable biomarker of airway inflammation in patients with COPD has become an area of controversy in pulmonary medicine.

The proponents find a role for PBE testing in initiation and withdrawal of inhaled corticosteroids (ICS) and as a target for monoclonal antibodies in future studies.¹ Post hoc analyses showed that variable doses of ICS/LABA combination compared with LABA alone in COPD patients were associated with much higher exacerbation reduction in patients with eosinophils counts of ≥2% and magnitude of effect proportionally increased from 29% to 42% with increasing eosinophil count from ≥2% to ≥6% suggesting a dose-response relationship.² A post hoc analysis of the WISDOM trial showed increased risk of exacerbation after ICS discontinuation in COPD patients with high eosinophils (≥300 cells/mcL or ≥4%) while exacerbation risk was not increased in patients with low eosinophils (<150 cells/mcL or <2%).³

The opponents of eosinophil-guided therapy object that the level of evidence is weak as this is based on the post hoc analyses of randomized control trials on patients with increased exacerbation risk at baseline, which in itself is an independent predictor of future exacerbations.⁴ Some observational studies failed to find increased risk of exacerbation with higher eosinophil count while others found that higher eosinophil count was associated with increased survival and better quality of life.^5,6 Anti-eosinophilic biologics have failed to show consistent benefit in exacerbation reduction in COPD patients so far, despite showing a reduction in the PBE.^7-9

The GOLD COPD Guidelines support the use of ICS in patients with eosinophils >300 cells/mcL especially with a history of exacerbation and recommend against ICS in patients with eosinophils <100 cells/mcL.¹⁰

Farrukh Abbas, MD
Steering Committee Fellow-in-Training
Allen J. Blaivas, MD, FCCP
NetWork Chair
 

References

1. Wade RC and Wells JM. Chest. 2020;157(5):1073-5.

2. Pascoe S et al. The Lancet Respir Med. 2015;3(6):435-42.

3. Watz H et al. The Lancet Respir Med. 2016;4(5):390-8.

4. Criner GJ. Chest. 2020;157(5):1075-8.

5. Shin SH et al. Respir Res. 2018;19(1):134.

6. Casanova C et al. Eur Respir J. 2017;50(5):1701162.

7. Pavord ID et al. N Engl J Med. 2017;377(17):1613-29.

8. Criner GJ et al. N Engl J Med. 2019;381(11):1023-34.

9. Mycroft K et al. J Allergy Clin Immunol Pract. 2020 Sep;8(8):2565-74.

10. Global Initiative for Chronic Obstructive Lung Disease 2021 Report.
 

Clinical research

Long-COVID: COVID-19 disease beyond the pandemic

There are increasing reports of persistent multiorgan symptoms following COVID-19 infection.

In December 2020, the National Institute for Health and Care Excellence (NICE) developed guidelines, based primarily on expert opinion, to define and manage ongoing symptomatic COVID-19 (symptoms for 4-12 weeks after infection) and post-COVID syndrome (symptoms present for > 12 weeks without alternative explanation). Subsequently, the National Institutes of Health (NIH), released in February 2021 an initiative to study Post-Acute Sequelae of SARS-CoV2 infection (PASC). Symptoms can include, respiratory (cough, shortness of breath), cardiac (palpitations, chest pain), fatigue and physical limitations, and neurologic (depression, insomnia, cognitive impairment) (Lancet 2020 Dec 12;396[10266]:1861). The majority of patients with post-COVID syndrome have microbiological recovery (PCR negative), and often have radiological recovery. Risk factors include older age, female sex, and comorbidities (Raveendran AV. Diabetes Metab Syndr. 2021 May-June;15[3]:869-75).

Diagnosis and access to care pose significant challenges for post-COVID syndrome, and it is difficult to estimate exactly how many are affected – one report from Italy found that up to 87% of discharged hospitalized patients had persistent symptom(s) at 60 days (Carfi A. JAMA 2020 Aug;324[6]:603-5). Thus far, management recommendations include a multidisciplinary approach to evaluation, symptomatic treatment, organ specific treatment (for example, consideration of corticosteroids for persistent inflammatory interstitial lung disease) (Myall KJ. Ann Am Thorac Soc. 2021 May;8[5]:799-806), physical/occupational therapy, and psychological support. Many institutions have established, or are working to establish post-COVID clinics (Aging Clin Exp Res. 2020 Aug;32[8]:1613-20). Currently, the NIH is offering funding opportunities and there are many clinical trials across the world actively recruiting patients.

Ankita Agarwal, MD
Steering Committee Fellow-in-Training
Bharat Bajantri, MD
Steering Committee Member
Aravind Menon, MD
Steering Committee Fellow-in-Training
 

Critical care

Sedation practices in the ICU: Moving past the COVID-19 pandemic

The COVID-19 pandemic brought unprecedented change to critical care practice patterns, and sedation practices in the intensive care unit are no exception. In a large cohort analysis of over 2,000 adults with COVID-19 (Pun BT, et al. Lancet Respir Med. 2021;9[3]:239-50), 64% of patients received benzodiazepines (median of 7 days), and patients were deeply sedated. More than half of the patients were delirious, with benzodiazepine use associated with increased incidence of delirium. These observations represent a significant departure from well-established pre-COVID best-practices in sedation: light targets, daily sedation interruption, and avoiding continuous benzodiazepine infusions whenever possible (Girard TD, et al. Lancet; 2008;371[9607]:126-34; Fraser GL, et al. Crit Care Med;2013 Sep;41[9 Suppl 1]:S30-8; Riker RR, et al. JAMA;2009;301[5]:489-99).

As COVID-19 case counts begin to improve in many of our communities, we have the opportunity to refocus on best sedation practices and build on a growing body of recent evidence. The MENDS2 trial, completed pre-COVID-19, assigned mechanically ventilated patients with sepsis to either propofol or dexmedetomidine and showed no difference in delirium or coma in this cohort of lightly sedated patients (Hughes CG, et al. N Engl J Med. 2021;384[15]:1424-36). Furthering this point, Olsen et al. found no difference in outcomes when mechanically ventilated patients were randomized to no sedation vs light sedation (Olsen HT, et al. N Engl J Med; 2020;382[12]:1103-11).

While the evidence surrounding sedation strategies in the critically ill continues to grow, one thing is certain: promoting lighter sedation targets and reengaging in sedation-related best practices following the COVID-19 pandemic will continue to play a vital role in improving both short and long-term outcomes for our critically ill patients.

Casey Cable, MD, MSc
Steering Committee Member

Kyle Stinehart, MD
Steering Committee Member
 

Home mechanical ventilation

How to initiate a chronic respiratory failure clinic

Noninvasive ventilation (NIV) is an established treatment for chronic hypercapnic respiratory failure from neuromuscular disorders, COPD, obesity hypoventilation syndrome (OHS), and restrictive thoracic disorders. Previously, hospital admission was considered essential for setup of chronic NIV but with advances in the modes of ventilation and remote monitoring, hospital admission has become less justifiable, especially in countries with centralized medical systems and presence of centers of excellence for home ventilation (Van Den Biggelaar RJM, et al. Chest. 2020;158[6]:2493-2501); Duiverman ML, et al. Thorax. 2020;75:244-52). In the United States, where centralized health care is atypical, management of NIV has been disparate with no clear consensus on practice patterns. Thus, we hope to provide some guidance toward the establishment of such clinics in the U.S.
 

Prior to developing an NIV clinic, establishing a referral source from neuromuscular, rehabilitation/spinal cord injury, bariatric surgery, and COPD programs is important. After this, collaboration with a respiratory therapist through durable medical equipment is essential to building a robust care team. These companies are also important for assisting in remote monitoring, providing overnight pulse oximetry/CO₂ monitoring, mask fitting, and airway clearance. Clinicians are encouraged to develop protocols for initiation and titration of NIV and mouthpiece ventilation. Clinics should provide spirometry, maximal inspiratory pressure, transcutaneous CO₂, and/or blood gas testing. Additionally, in this patient population, wheelchair scales are necessary. Clinical workflow should include a review of NIV downloads, identify asynchronies and troubleshoot it in timely and reliable manner (Blouet S, et al. Int J Chron Obstruct Pulmon Dis. 2018;13:2577-86). Lastly, effort should be made for an adequate assessment of the home situation including layout of home along with family support utilizing social worker and palliative care team. Due to patient mobility, we encourage continued availability of telehealth for these patients.

In summary, strong clinical infrastructure, a robust care team, and an efficient, secure, reliable telemonitoring system are key to provide better care to this vulnerable patient population.

Ashima S. Sahni, MD, MBBS, FCCP
NetWork Member

Amen Sergew, MD
Steering Committee Member

Interstitial and diffuse lung disease

Treatment for pulmonary hypertension secondary to interstitial lung disease

The development of pulmonary hypertension (PH) in patients with interstitial lung disease (ILD) (PH-ILD) is associated with increased supplemental oxygen requirements, reduced functional status, and decreased survival (King CS, et al. Chest. 2020;158[4]:1651).

An inhaled formulation of treprostinil (Tyvaso) is the first treatment option approved by the FDA for patients with PH-ILD, including those with idiopathic pulmonary fibrosis, connective tissue disease-associated ILD, and combined pulmonary fibrosis and emphysema. Approval was based on results from the INCREASE trial (Waxman A, et al. N Engl J Med. 2021;384[4]:325), a phase III multicenter, randomized, double-blinded study comparing the inhaled formulation to placebo in 326 patients over a 16-week period. Participants in the treatment arm were given up to 12 breaths of the formulation per session, four times per day. Subjects treated with this inhaled formulation met the primary study endpoint, an increase in 6-minute walk distance (6MWD) from baseline to week 16, walking 21 m farther than placebo-treated control subjects. Furthermore, patients receiving the new formulation had a decrease in NT-proBNP levels (compared with increases in the placebo arm) and a reduction in clinical worsening (23% of inhalation formulation-treated vs. 33% of placebo-treated subjects). This formulation of treprostinil was well-tolerated with a safety profile consistent with common prostacyclin-related adverse events, including cough, headache, dyspnea, dizziness, nausea, fatigue, and diarrhea. Its approval will dramatically alter the ILD treatment landscape. It now necessitates the use of PH screening in this patient population. However, care will need to be exercised in appropriate patient selection for treatment, using the study inclusion and exclusion criteria as a starting point. Appropriate use of this formulation will hopefully help mitigate the negative outcomes impacting patients with PH-ILD.

Rebecca Anna Gersten, MD
Adrian Shifren, MD
Steering Committee Members

Airways disorders

Eosinophils in COPD

Using peripheral blood eosinophilia (PBE) as a treatable biomarker of airway inflammation in patients with COPD has become an area of controversy in pulmonary medicine.

The proponents find a role for PBE testing in initiation and withdrawal of inhaled corticosteroids (ICS) and as a target for monoclonal antibodies in future studies.¹ Post hoc analyses showed that variable doses of ICS/LABA combination compared with LABA alone in COPD patients were associated with much higher exacerbation reduction in patients with eosinophils counts of ≥2% and magnitude of effect proportionally increased from 29% to 42% with increasing eosinophil count from ≥2% to ≥6% suggesting a dose-response relationship.² A post hoc analysis of the WISDOM trial showed increased risk of exacerbation after ICS discontinuation in COPD patients with high eosinophils (≥300 cells/mcL or ≥4%) while exacerbation risk was not increased in patients with low eosinophils (<150 cells/mcL or <2%).³

The opponents of eosinophil-guided therapy object that the level of evidence is weak as this is based on the post hoc analyses of randomized control trials on patients with increased exacerbation risk at baseline, which in itself is an independent predictor of future exacerbations.⁴ Some observational studies failed to find increased risk of exacerbation with higher eosinophil count while others found that higher eosinophil count was associated with increased survival and better quality of life.^5,6 Anti-eosinophilic biologics have failed to show consistent benefit in exacerbation reduction in COPD patients so far, despite showing a reduction in the PBE.^7-9

The GOLD COPD Guidelines support the use of ICS in patients with eosinophils >300 cells/mcL especially with a history of exacerbation and recommend against ICS in patients with eosinophils <100 cells/mcL.¹⁰

Farrukh Abbas, MD
Steering Committee Fellow-in-Training
Allen J. Blaivas, MD, FCCP
NetWork Chair
 

References

1. Wade RC and Wells JM. Chest. 2020;157(5):1073-5.

2. Pascoe S et al. The Lancet Respir Med. 2015;3(6):435-42.

3. Watz H et al. The Lancet Respir Med. 2016;4(5):390-8.

4. Criner GJ. Chest. 2020;157(5):1075-8.

5. Shin SH et al. Respir Res. 2018;19(1):134.

6. Casanova C et al. Eur Respir J. 2017;50(5):1701162.

7. Pavord ID et al. N Engl J Med. 2017;377(17):1613-29.

8. Criner GJ et al. N Engl J Med. 2019;381(11):1023-34.

9. Mycroft K et al. J Allergy Clin Immunol Pract. 2020 Sep;8(8):2565-74.

10. Global Initiative for Chronic Obstructive Lung Disease 2021 Report.
 

Clinical research

Long-COVID: COVID-19 disease beyond the pandemic

There are increasing reports of persistent multiorgan symptoms following COVID-19 infection.

In December 2020, the National Institute for Health and Care Excellence (NICE) developed guidelines, based primarily on expert opinion, to define and manage ongoing symptomatic COVID-19 (symptoms for 4-12 weeks after infection) and post-COVID syndrome (symptoms present for > 12 weeks without alternative explanation). Subsequently, the National Institutes of Health (NIH), released in February 2021 an initiative to study Post-Acute Sequelae of SARS-CoV2 infection (PASC). Symptoms can include, respiratory (cough, shortness of breath), cardiac (palpitations, chest pain), fatigue and physical limitations, and neurologic (depression, insomnia, cognitive impairment) (Lancet 2020 Dec 12;396[10266]:1861). The majority of patients with post-COVID syndrome have microbiological recovery (PCR negative), and often have radiological recovery. Risk factors include older age, female sex, and comorbidities (Raveendran AV. Diabetes Metab Syndr. 2021 May-June;15[3]:869-75).

Diagnosis and access to care pose significant challenges for post-COVID syndrome, and it is difficult to estimate exactly how many are affected – one report from Italy found that up to 87% of discharged hospitalized patients had persistent symptom(s) at 60 days (Carfi A. JAMA 2020 Aug;324[6]:603-5). Thus far, management recommendations include a multidisciplinary approach to evaluation, symptomatic treatment, organ specific treatment (for example, consideration of corticosteroids for persistent inflammatory interstitial lung disease) (Myall KJ. Ann Am Thorac Soc. 2021 May;8[5]:799-806), physical/occupational therapy, and psychological support. Many institutions have established, or are working to establish post-COVID clinics (Aging Clin Exp Res. 2020 Aug;32[8]:1613-20). Currently, the NIH is offering funding opportunities and there are many clinical trials across the world actively recruiting patients.

Ankita Agarwal, MD
Steering Committee Fellow-in-Training
Bharat Bajantri, MD
Steering Committee Member
Aravind Menon, MD
Steering Committee Fellow-in-Training
 

Critical care

Sedation practices in the ICU: Moving past the COVID-19 pandemic

The COVID-19 pandemic brought unprecedented change to critical care practice patterns, and sedation practices in the intensive care unit are no exception. In a large cohort analysis of over 2,000 adults with COVID-19 (Pun BT, et al. Lancet Respir Med. 2021;9[3]:239-50), 64% of patients received benzodiazepines (median of 7 days), and patients were deeply sedated. More than half of the patients were delirious, with benzodiazepine use associated with increased incidence of delirium. These observations represent a significant departure from well-established pre-COVID best-practices in sedation: light targets, daily sedation interruption, and avoiding continuous benzodiazepine infusions whenever possible (Girard TD, et al. Lancet; 2008;371[9607]:126-34; Fraser GL, et al. Crit Care Med;2013 Sep;41[9 Suppl 1]:S30-8; Riker RR, et al. JAMA;2009;301[5]:489-99).

As COVID-19 case counts begin to improve in many of our communities, we have the opportunity to refocus on best sedation practices and build on a growing body of recent evidence. The MENDS2 trial, completed pre-COVID-19, assigned mechanically ventilated patients with sepsis to either propofol or dexmedetomidine and showed no difference in delirium or coma in this cohort of lightly sedated patients (Hughes CG, et al. N Engl J Med. 2021;384[15]:1424-36). Furthering this point, Olsen et al. found no difference in outcomes when mechanically ventilated patients were randomized to no sedation vs light sedation (Olsen HT, et al. N Engl J Med; 2020;382[12]:1103-11).

While the evidence surrounding sedation strategies in the critically ill continues to grow, one thing is certain: promoting lighter sedation targets and reengaging in sedation-related best practices following the COVID-19 pandemic will continue to play a vital role in improving both short and long-term outcomes for our critically ill patients.

Casey Cable, MD, MSc
Steering Committee Member

Kyle Stinehart, MD
Steering Committee Member
 

Home mechanical ventilation

How to initiate a chronic respiratory failure clinic

Noninvasive ventilation (NIV) is an established treatment for chronic hypercapnic respiratory failure from neuromuscular disorders, COPD, obesity hypoventilation syndrome (OHS), and restrictive thoracic disorders. Previously, hospital admission was considered essential for setup of chronic NIV but with advances in the modes of ventilation and remote monitoring, hospital admission has become less justifiable, especially in countries with centralized medical systems and presence of centers of excellence for home ventilation (Van Den Biggelaar RJM, et al. Chest. 2020;158[6]:2493-2501); Duiverman ML, et al. Thorax. 2020;75:244-52). In the United States, where centralized health care is atypical, management of NIV has been disparate with no clear consensus on practice patterns. Thus, we hope to provide some guidance toward the establishment of such clinics in the U.S.
 

Prior to developing an NIV clinic, establishing a referral source from neuromuscular, rehabilitation/spinal cord injury, bariatric surgery, and COPD programs is important. After this, collaboration with a respiratory therapist through durable medical equipment is essential to building a robust care team. These companies are also important for assisting in remote monitoring, providing overnight pulse oximetry/CO₂ monitoring, mask fitting, and airway clearance. Clinicians are encouraged to develop protocols for initiation and titration of NIV and mouthpiece ventilation. Clinics should provide spirometry, maximal inspiratory pressure, transcutaneous CO₂, and/or blood gas testing. Additionally, in this patient population, wheelchair scales are necessary. Clinical workflow should include a review of NIV downloads, identify asynchronies and troubleshoot it in timely and reliable manner (Blouet S, et al. Int J Chron Obstruct Pulmon Dis. 2018;13:2577-86). Lastly, effort should be made for an adequate assessment of the home situation including layout of home along with family support utilizing social worker and palliative care team. Due to patient mobility, we encourage continued availability of telehealth for these patients.

In summary, strong clinical infrastructure, a robust care team, and an efficient, secure, reliable telemonitoring system are key to provide better care to this vulnerable patient population.

Ashima S. Sahni, MD, MBBS, FCCP
NetWork Member

Amen Sergew, MD
Steering Committee Member

Interstitial and diffuse lung disease

Treatment for pulmonary hypertension secondary to interstitial lung disease

The development of pulmonary hypertension (PH) in patients with interstitial lung disease (ILD) (PH-ILD) is associated with increased supplemental oxygen requirements, reduced functional status, and decreased survival (King CS, et al. Chest. 2020;158[4]:1651).

An inhaled formulation of treprostinil (Tyvaso) is the first treatment option approved by the FDA for patients with PH-ILD, including those with idiopathic pulmonary fibrosis, connective tissue disease-associated ILD, and combined pulmonary fibrosis and emphysema. Approval was based on results from the INCREASE trial (Waxman A, et al. N Engl J Med. 2021;384[4]:325), a phase III multicenter, randomized, double-blinded study comparing the inhaled formulation to placebo in 326 patients over a 16-week period. Participants in the treatment arm were given up to 12 breaths of the formulation per session, four times per day. Subjects treated with this inhaled formulation met the primary study endpoint, an increase in 6-minute walk distance (6MWD) from baseline to week 16, walking 21 m farther than placebo-treated control subjects. Furthermore, patients receiving the new formulation had a decrease in NT-proBNP levels (compared with increases in the placebo arm) and a reduction in clinical worsening (23% of inhalation formulation-treated vs. 33% of placebo-treated subjects). This formulation of treprostinil was well-tolerated with a safety profile consistent with common prostacyclin-related adverse events, including cough, headache, dyspnea, dizziness, nausea, fatigue, and diarrhea. Its approval will dramatically alter the ILD treatment landscape. It now necessitates the use of PH screening in this patient population. However, care will need to be exercised in appropriate patient selection for treatment, using the study inclusion and exclusion criteria as a starting point. Appropriate use of this formulation will hopefully help mitigate the negative outcomes impacting patients with PH-ILD.

Rebecca Anna Gersten, MD
Adrian Shifren, MD
Steering Committee Members

Telemedicine has been proposed as a solution for an array of health care access problems over decades of gradual growth. The vast ramping up of telemedicine during the COVID-19 pandemic greatly expanded the evidence of its feasibility and what appears to be its inevitable incorporation into models of care, according to an update at the Health Policy and Advocacy Conference (HPAC) sponsored by the American College of Chest Physicians.

“The cat is out of the bag,” said Jaspal Singh, MD, FCCP, professor of medicine, Atrium Health, Charlotte, N.C. Due to changes in access and reimbursement to telemedicine driven by the pandemic, he said, “we now have permission to explore new models of care.”

Prior to February 2020, telemedicine was crawling forward at a leisurely pace, according to Dr. Singh. After March 2020, it broke into a run due to enormous demand and met by a rapid response from the U.S. Congress. The first of four legislative bills that directly or indirectly supported telemedicine was passed on March 6.

The Centers for Medicare and Medicaid Services (CMS) responded in kind, making modifications in a number of rules that removed obstacles to telehealth. One modification on April 6, for example, removed the requirement for a preexisting relationship between the clinician and patient, Dr. Singh said. The CMS also subsequently modified reimbursement policies in order to make telemedicine more tenable for physicians.

Given the risk of contagion from face-to-face encounters, telemedicine in the early days of the pandemic was not just attractive but the only practical and safe approach to medical care in many circumstances. Physicians and patients were anxious for health care that did not require in-office visits even though many critical issues for telemedicine, including its relative effectiveness, had not yet been fully evaluated.

Much has been learned regarding the feasibility and acceptability of telemedicine during the pandemic, but Dr. Singh noted that quality of care relative to in-person visits remains weakly supported for most indications. Indeed, he outlined a sizable list of incompletely resolved issues, including optimal payment models, management of privacy concerns, and how to balance advantages to disadvantages.

For patients and physicians, the strengths of telemedicine include greater convenience made possible by the elimination of travel and waiting rooms. For the health care system, it can include less infrastructure and overhead. For many physicians, telemedicine might be perceived as more efficient.

On the other hand, some patients might feel that a clinical encounter is incomplete without a physical examination even when the physician does not feel the physical examination is needed, according to Dr. Singh. He cited a survey suggesting nearly half of patients expressed concern about a lack of connection to health care providers following a virtual visit.

In the same 2020 National Poll on Healthy Aging 2020 survey conducted by the University of Michigan, 67% of respondents reported that the quality of care was not as good as that provided by in-patient visits, and 24% expressed concern about privacy. However, at the time the poll was taken in May 2020, experience with telemedicine among many of the respondents may have been limited. As telemedicine is integrated into routine care, perceptions might change as experience increases.

A distinction between telemedicine in routine care and telemedicine as a strategy to respond to a pandemic is important, Dr. Singh indicated. Dr. Singh was the lead author for a position paper on telemedicine for the diagnosis and treatment of sleep disorders from the American Academy of Sleep Medicine 5 years ago (J Clin Sleep Med. 2015;11:1187-98), but he acknowledged that models of care might differ when responding to abnormal surges in health care demand.

The surge in demand for COVID-19–related care engendered numerous innovative solutions. As examples, Dr. Singh recounted how a virtual hospital was created at his own institution. In a published study, 1,477 patients diagnosed with COVID19 over a 6-week period remained at home and received care in a virtual observation unit (VCU) or a virtual acute care unit (VACU) (Ann Intern Med. 2020;174:192-9). Only a small percentage required eventual hospital admission. In the VACU, patients were able to receive advanced care, including IV fluids and some form of respiratory support .

It is unclear how the COVID-19 pandemic will change telemedicine. Now, with declining cases of the infection, telemedicine is back to a walk after the sprint required during the height of the pandemic, according to Dr. Singh. However, Dr. Singh thinks many physicians and patients will have a different perception of telemedicine after the widespread exposure to this type of care.

In terms of the relative role of in-patient and virtual visits across indications, “we do not know how this will play out, but we will probably end up toggling between the two,” Dr. Singh said.

This is an area that is being followed closely by the CHEST Health Policy and Advocacy Committee, according to Kathleen Sarmiento, MD, FCCP, director, VISN 21 Sleep Clinical Resource Hub for the San Francisco VA Health Care System. A member of that Committee and moderator of the session in which Dr. Singh spoke, Dr. Sarmiento called the effort to bring permanent coverage of telehealth services “the shared responsibility of every medical society engaged in advocacy.”

However, she cautioned that there might be intended and unintended consequences from telehealth that require analysis to develop policies that are in the best interests of effective care. She said, the “ACCP [CHEST], along with its sister societies, does have a role in supporting the evaluation of the impact of these changes on both patients and providers in the fields of pulmonary medicine, critical care, and sleep medicine.”

Dr. Singh reports a financial relationship with AstraZeneca. Dr. Sarmiento reports no relevant financial relationships.

Telemedicine has been proposed as a solution for an array of health care access problems over decades of gradual growth. The vast ramping up of telemedicine during the COVID-19 pandemic greatly expanded the evidence of its feasibility and what appears to be its inevitable incorporation into models of care, according to an update at the Health Policy and Advocacy Conference (HPAC) sponsored by the American College of Chest Physicians.

“The cat is out of the bag,” said Jaspal Singh, MD, FCCP, professor of medicine, Atrium Health, Charlotte, N.C. Due to changes in access and reimbursement to telemedicine driven by the pandemic, he said, “we now have permission to explore new models of care.”

Prior to February 2020, telemedicine was crawling forward at a leisurely pace, according to Dr. Singh. After March 2020, it broke into a run due to enormous demand and met by a rapid response from the U.S. Congress. The first of four legislative bills that directly or indirectly supported telemedicine was passed on March 6.

The Centers for Medicare and Medicaid Services (CMS) responded in kind, making modifications in a number of rules that removed obstacles to telehealth. One modification on April 6, for example, removed the requirement for a preexisting relationship between the clinician and patient, Dr. Singh said. The CMS also subsequently modified reimbursement policies in order to make telemedicine more tenable for physicians.

Given the risk of contagion from face-to-face encounters, telemedicine in the early days of the pandemic was not just attractive but the only practical and safe approach to medical care in many circumstances. Physicians and patients were anxious for health care that did not require in-office visits even though many critical issues for telemedicine, including its relative effectiveness, had not yet been fully evaluated.

Much has been learned regarding the feasibility and acceptability of telemedicine during the pandemic, but Dr. Singh noted that quality of care relative to in-person visits remains weakly supported for most indications. Indeed, he outlined a sizable list of incompletely resolved issues, including optimal payment models, management of privacy concerns, and how to balance advantages to disadvantages.

For patients and physicians, the strengths of telemedicine include greater convenience made possible by the elimination of travel and waiting rooms. For the health care system, it can include less infrastructure and overhead. For many physicians, telemedicine might be perceived as more efficient.

On the other hand, some patients might feel that a clinical encounter is incomplete without a physical examination even when the physician does not feel the physical examination is needed, according to Dr. Singh. He cited a survey suggesting nearly half of patients expressed concern about a lack of connection to health care providers following a virtual visit.

In the same 2020 National Poll on Healthy Aging 2020 survey conducted by the University of Michigan, 67% of respondents reported that the quality of care was not as good as that provided by in-patient visits, and 24% expressed concern about privacy. However, at the time the poll was taken in May 2020, experience with telemedicine among many of the respondents may have been limited. As telemedicine is integrated into routine care, perceptions might change as experience increases.

A distinction between telemedicine in routine care and telemedicine as a strategy to respond to a pandemic is important, Dr. Singh indicated. Dr. Singh was the lead author for a position paper on telemedicine for the diagnosis and treatment of sleep disorders from the American Academy of Sleep Medicine 5 years ago (J Clin Sleep Med. 2015;11:1187-98), but he acknowledged that models of care might differ when responding to abnormal surges in health care demand.

The surge in demand for COVID-19–related care engendered numerous innovative solutions. As examples, Dr. Singh recounted how a virtual hospital was created at his own institution. In a published study, 1,477 patients diagnosed with COVID19 over a 6-week period remained at home and received care in a virtual observation unit (VCU) or a virtual acute care unit (VACU) (Ann Intern Med. 2020;174:192-9). Only a small percentage required eventual hospital admission. In the VACU, patients were able to receive advanced care, including IV fluids and some form of respiratory support .

It is unclear how the COVID-19 pandemic will change telemedicine. Now, with declining cases of the infection, telemedicine is back to a walk after the sprint required during the height of the pandemic, according to Dr. Singh. However, Dr. Singh thinks many physicians and patients will have a different perception of telemedicine after the widespread exposure to this type of care.

In terms of the relative role of in-patient and virtual visits across indications, “we do not know how this will play out, but we will probably end up toggling between the two,” Dr. Singh said.

This is an area that is being followed closely by the CHEST Health Policy and Advocacy Committee, according to Kathleen Sarmiento, MD, FCCP, director, VISN 21 Sleep Clinical Resource Hub for the San Francisco VA Health Care System. A member of that Committee and moderator of the session in which Dr. Singh spoke, Dr. Sarmiento called the effort to bring permanent coverage of telehealth services “the shared responsibility of every medical society engaged in advocacy.”

However, she cautioned that there might be intended and unintended consequences from telehealth that require analysis to develop policies that are in the best interests of effective care. She said, the “ACCP [CHEST], along with its sister societies, does have a role in supporting the evaluation of the impact of these changes on both patients and providers in the fields of pulmonary medicine, critical care, and sleep medicine.”

Dr. Singh reports a financial relationship with AstraZeneca. Dr. Sarmiento reports no relevant financial relationships.

Telemedicine has been proposed as a solution for an array of health care access problems over decades of gradual growth. The vast ramping up of telemedicine during the COVID-19 pandemic greatly expanded the evidence of its feasibility and what appears to be its inevitable incorporation into models of care, according to an update at the Health Policy and Advocacy Conference (HPAC) sponsored by the American College of Chest Physicians.

“The cat is out of the bag,” said Jaspal Singh, MD, FCCP, professor of medicine, Atrium Health, Charlotte, N.C. Due to changes in access and reimbursement to telemedicine driven by the pandemic, he said, “we now have permission to explore new models of care.”

Prior to February 2020, telemedicine was crawling forward at a leisurely pace, according to Dr. Singh. After March 2020, it broke into a run due to enormous demand and met by a rapid response from the U.S. Congress. The first of four legislative bills that directly or indirectly supported telemedicine was passed on March 6.

The Centers for Medicare and Medicaid Services (CMS) responded in kind, making modifications in a number of rules that removed obstacles to telehealth. One modification on April 6, for example, removed the requirement for a preexisting relationship between the clinician and patient, Dr. Singh said. The CMS also subsequently modified reimbursement policies in order to make telemedicine more tenable for physicians.

Given the risk of contagion from face-to-face encounters, telemedicine in the early days of the pandemic was not just attractive but the only practical and safe approach to medical care in many circumstances. Physicians and patients were anxious for health care that did not require in-office visits even though many critical issues for telemedicine, including its relative effectiveness, had not yet been fully evaluated.

Much has been learned regarding the feasibility and acceptability of telemedicine during the pandemic, but Dr. Singh noted that quality of care relative to in-person visits remains weakly supported for most indications. Indeed, he outlined a sizable list of incompletely resolved issues, including optimal payment models, management of privacy concerns, and how to balance advantages to disadvantages.

For patients and physicians, the strengths of telemedicine include greater convenience made possible by the elimination of travel and waiting rooms. For the health care system, it can include less infrastructure and overhead. For many physicians, telemedicine might be perceived as more efficient.

On the other hand, some patients might feel that a clinical encounter is incomplete without a physical examination even when the physician does not feel the physical examination is needed, according to Dr. Singh. He cited a survey suggesting nearly half of patients expressed concern about a lack of connection to health care providers following a virtual visit.

In the same 2020 National Poll on Healthy Aging 2020 survey conducted by the University of Michigan, 67% of respondents reported that the quality of care was not as good as that provided by in-patient visits, and 24% expressed concern about privacy. However, at the time the poll was taken in May 2020, experience with telemedicine among many of the respondents may have been limited. As telemedicine is integrated into routine care, perceptions might change as experience increases.

A distinction between telemedicine in routine care and telemedicine as a strategy to respond to a pandemic is important, Dr. Singh indicated. Dr. Singh was the lead author for a position paper on telemedicine for the diagnosis and treatment of sleep disorders from the American Academy of Sleep Medicine 5 years ago (J Clin Sleep Med. 2015;11:1187-98), but he acknowledged that models of care might differ when responding to abnormal surges in health care demand.

The surge in demand for COVID-19–related care engendered numerous innovative solutions. As examples, Dr. Singh recounted how a virtual hospital was created at his own institution. In a published study, 1,477 patients diagnosed with COVID19 over a 6-week period remained at home and received care in a virtual observation unit (VCU) or a virtual acute care unit (VACU) (Ann Intern Med. 2020;174:192-9). Only a small percentage required eventual hospital admission. In the VACU, patients were able to receive advanced care, including IV fluids and some form of respiratory support .

It is unclear how the COVID-19 pandemic will change telemedicine. Now, with declining cases of the infection, telemedicine is back to a walk after the sprint required during the height of the pandemic, according to Dr. Singh. However, Dr. Singh thinks many physicians and patients will have a different perception of telemedicine after the widespread exposure to this type of care.

In terms of the relative role of in-patient and virtual visits across indications, “we do not know how this will play out, but we will probably end up toggling between the two,” Dr. Singh said.

This is an area that is being followed closely by the CHEST Health Policy and Advocacy Committee, according to Kathleen Sarmiento, MD, FCCP, director, VISN 21 Sleep Clinical Resource Hub for the San Francisco VA Health Care System. A member of that Committee and moderator of the session in which Dr. Singh spoke, Dr. Sarmiento called the effort to bring permanent coverage of telehealth services “the shared responsibility of every medical society engaged in advocacy.”

However, she cautioned that there might be intended and unintended consequences from telehealth that require analysis to develop policies that are in the best interests of effective care. She said, the “ACCP [CHEST], along with its sister societies, does have a role in supporting the evaluation of the impact of these changes on both patients and providers in the fields of pulmonary medicine, critical care, and sleep medicine.”

Dr. Singh reports a financial relationship with AstraZeneca. Dr. Sarmiento reports no relevant financial relationships.

Simultaneous pancreas-kidney transplants are increasingly performed in the United States in people with type 2 diabetes who also have chronic kidney disease, with outcomes similar to those of people with type 1 diabetes.

Traditionally, recipients of pancreas transplants have been people with type 1 diabetes who also have either chronic kidney disease (CKD) or hypoglycemic unawareness. The former group could receive either a simultaneous pancreas-kidney or a pancreas after kidney transplant, while the latter – if they have normal kidney function – would be eligible for a pancreas transplant alone.

But increasingly in recent years, patients with type 2 diabetes and CKD have been receiving simultaneous pancreas-kidney transplants, with similar success rates to those of people with type 1 diabetes.

Such candidates are typically sufficiently fit, not morbidly obese, and taking insulin regardless of their C-peptide status, said Jon S. Odorico, MD, professor of surgery and director of pancreas and islet transplantation at the University of Wisconsin–Madison Transplant Program.

“One might ask: Is it a crazy idea to do a pancreas transplant for patients with type 2 diabetes? Based on the known mechanisms of hyperglycemia in these patients, it might seem so,” he said, noting that while individuals with type 2 diabetes usually have insulin resistance, many also have relative or absolute deficiency of insulin production.

“So by replacing beta-cell mass, pancreas transplantation addresses this beta-cell defect mechanism,” he explained when discussing the topic during a symposium held June 26 at the virtual American Diabetes Association (ADA) 81st Scientific Sessions.

Arguments in favor of simultaneous pancreas-kidney transplant in people with type 2 diabetes and CKD include the fact that type 2 diabetes is the leading cause of kidney disease in the United States – roughly 50-60% of candidates on the kidney transplant waiting list also have type 2 diabetes – and that kidney transplant alone tends to worsen diabetes control due to the required immunosuppression.

Moreover, due to a 2014 allocation policy change that separates simultaneous pancreas-kidney from kidney transplant–alone donor organs, waiting times are shorter for the former, and kidney quality is generally better than for kidney transplant alone, unless a living kidney donor is available.

And, Dr. Odorico added, “adding a pancreas to a kidney transplant does not appear to jeopardize patient survival or kidney graft survival in appropriately selected patients with diabetes.” However, he also noted that because type 2 diabetes is so heterogeneous, ideal candidates for simultaneous pancreas-kidney transplant are not yet clear.

Currently, people with type 2 diabetes account for about 20% of those receiving simultaneous pancreas-kidney transplants and about 50% of pancreas after kidney transplants. Few pancreas transplants alone are performed in type 2 diabetes because those individuals rarely experience severe life-threatening hypoglycemia, Dr. Odorico explained.
 

Criteria have shifted over time, C-peptide removed in 2019

In an interview, symposium moderator Peter G. Stock, MD, PhD, surgical director of the Kidney and Pancreas Transplant Program at the University of California, San Francisco, said he agreed that “it’s a surprising trend. It doesn’t make intuitive sense. In type 1 diabetes, it makes sense to replace the beta cells. But type 2 is due to a whole cluster of etiologies ... The view in the public domain is that it’s not due to the lack of insulin but problems with insulin resistance and obesity. So it doesn’t make a whole lot of sense to give you more insulin if it’s a receptor problem.”

But Dr. Stock noted that because in the past diabetes type wasn’t always rigorously assessed using C-peptide and antibody testing, which most centers measure today, “a number of transplants were done in people who turned out to have type 2. Our perception is that everybody who has type 2 is obese, but that’s not true anymore.”

Once it became apparent that some patients with type 2 diabetes who received pancreas transplants seemed to be doing well, the pancreas transplantation committee of the United Network for Organ Sharing (UNOS) established general criteria for the procedure in people with diabetes. They had to be taking insulin and have a C-peptide value of 2 ng/mL or below or taking insulin with a C-peptide greater than 2 ng/mL and a body mass index less than or equal to the maximum allowable BMI (28 kg/m² at the time).

Dr. Stock, who chaired that committee from 2005 to 2007, said: “We thought it was risky to offer a scarce pool of donor pancreases to people with type 2 when we had people with type 1 who we know will benefit from it. So initially, the committee decided to limit pancreas transplantation to those with type 2 who have fairly low insulin requirements and BMIs that are more in the range of people with type 1. And lo and behold the results were comparable.”

Subsequent to Dr. Stock’s tenure as chair, the UNOS committee decided that the BMI and C-peptide criteria for simultaneous pancreas-kidney were no longer scientifically justifiable and were potentially discriminatory both to minority populations with type 2 diabetes and people with type 1 diabetes who have a high BMI, so in 2019, they removed them.

Individual transplant centers must follow UNOS rules, but they can also add their own criteria. Some don’t perform simultaneous pancreas-kidney transplants in people with type 2 diabetes at all.

At Dr. Odorico’s center, which began doing so in 2012, patients with type 2 diabetes account for nearly 40% of all simultaneous pancreas-kidney transplants. Indications there include age 20-60 years, insulin dependent with requirements less than 1 unit/kg/day, CKD stage 3-5, predialysis or on dialysis, and BMI <33 kg/m².

“They are highly selected and a fairly fit group of patients,” Dr. Odorico noted.

Those who don’t meet all the requirements for simultaneous pancreas-kidney transplants may still be eligible for kidney transplant alone, from either a living or deceased donor, he said.

Dr. Stock’s criteria at UCSF are even more stringent for both BMI and insulin requirements.

SPK outcomes similar for type 1 and type 2 diabetes: Emerging data

Data to guide this area are accumulating slowly. Thus far, all studies have been retrospective and have used variable definitions for diabetes type and for graft failure. However, they’re fairly consistent in showing similar outcomes by diabetes type and little impact of C-peptide level on patient survival or survival of either kidney or pancreas graft, particularly after adjustment for confounding factors between the two types.

In a study from Dr. Odorico’s center of 284 type 1 and 39 type 2 diabetes patients undergoing simultaneous pancreas-kidney transplant between 2006 and 2017, pretransplant BMI and insulin requirements did not affect patient or graft survival in either type. There was a suggestion of greater risk for post-transplant diabetes with very high pretransplant insulin requirements (>75 units/day) but the numbers were too small to be definitive.  

“It’s clear we will be doing more pancreas transplants in the future in this group of patients, and it’s ripe for further investigation,” Dr. Odorico concluded.
 

Beta cells for all?

Dr. Stock added one more aspect. While of course whole-organ transplantation is limited by the shortage of human donors, stem cell–derived beta cells could potentially produce an unlimited supply. Both Dr. Stock and Dr. Odorico are working on different approaches to this.

“We’re really close,” he said, noting, “the data we get for people with type 2 diabetes undergoing solid organ pancreas transplant could also be applied to cellular therapy ... We need to get a better understanding of which patients will benefit. The data we have so far are very promising.”

Dr. Odorico is scientific founder, stock equity holder, scientific advisory board chair, and a prior grant support recipient from Regenerative Medical Solutions. He has reported receiving clinical trial support from Veloxis Pharmaceuticals, CareDx, Natera, and Vertex Pharmaceuticals. Dr. Stock has reported being on the scientific advisory board of Encellin and receives funding from the California Institute of Regenerative Medicine and National Institutes of Health.

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

Simultaneous pancreas-kidney transplants are increasingly performed in the United States in people with type 2 diabetes who also have chronic kidney disease, with outcomes similar to those of people with type 1 diabetes.

Traditionally, recipients of pancreas transplants have been people with type 1 diabetes who also have either chronic kidney disease (CKD) or hypoglycemic unawareness. The former group could receive either a simultaneous pancreas-kidney or a pancreas after kidney transplant, while the latter – if they have normal kidney function – would be eligible for a pancreas transplant alone.

But increasingly in recent years, patients with type 2 diabetes and CKD have been receiving simultaneous pancreas-kidney transplants, with similar success rates to those of people with type 1 diabetes.

Such candidates are typically sufficiently fit, not morbidly obese, and taking insulin regardless of their C-peptide status, said Jon S. Odorico, MD, professor of surgery and director of pancreas and islet transplantation at the University of Wisconsin–Madison Transplant Program.

“One might ask: Is it a crazy idea to do a pancreas transplant for patients with type 2 diabetes? Based on the known mechanisms of hyperglycemia in these patients, it might seem so,” he said, noting that while individuals with type 2 diabetes usually have insulin resistance, many also have relative or absolute deficiency of insulin production.

“So by replacing beta-cell mass, pancreas transplantation addresses this beta-cell defect mechanism,” he explained when discussing the topic during a symposium held June 26 at the virtual American Diabetes Association (ADA) 81st Scientific Sessions.

Arguments in favor of simultaneous pancreas-kidney transplant in people with type 2 diabetes and CKD include the fact that type 2 diabetes is the leading cause of kidney disease in the United States – roughly 50-60% of candidates on the kidney transplant waiting list also have type 2 diabetes – and that kidney transplant alone tends to worsen diabetes control due to the required immunosuppression.

Moreover, due to a 2014 allocation policy change that separates simultaneous pancreas-kidney from kidney transplant–alone donor organs, waiting times are shorter for the former, and kidney quality is generally better than for kidney transplant alone, unless a living kidney donor is available.

And, Dr. Odorico added, “adding a pancreas to a kidney transplant does not appear to jeopardize patient survival or kidney graft survival in appropriately selected patients with diabetes.” However, he also noted that because type 2 diabetes is so heterogeneous, ideal candidates for simultaneous pancreas-kidney transplant are not yet clear.

Currently, people with type 2 diabetes account for about 20% of those receiving simultaneous pancreas-kidney transplants and about 50% of pancreas after kidney transplants. Few pancreas transplants alone are performed in type 2 diabetes because those individuals rarely experience severe life-threatening hypoglycemia, Dr. Odorico explained.
 

Criteria have shifted over time, C-peptide removed in 2019

In an interview, symposium moderator Peter G. Stock, MD, PhD, surgical director of the Kidney and Pancreas Transplant Program at the University of California, San Francisco, said he agreed that “it’s a surprising trend. It doesn’t make intuitive sense. In type 1 diabetes, it makes sense to replace the beta cells. But type 2 is due to a whole cluster of etiologies ... The view in the public domain is that it’s not due to the lack of insulin but problems with insulin resistance and obesity. So it doesn’t make a whole lot of sense to give you more insulin if it’s a receptor problem.”

But Dr. Stock noted that because in the past diabetes type wasn’t always rigorously assessed using C-peptide and antibody testing, which most centers measure today, “a number of transplants were done in people who turned out to have type 2. Our perception is that everybody who has type 2 is obese, but that’s not true anymore.”

Once it became apparent that some patients with type 2 diabetes who received pancreas transplants seemed to be doing well, the pancreas transplantation committee of the United Network for Organ Sharing (UNOS) established general criteria for the procedure in people with diabetes. They had to be taking insulin and have a C-peptide value of 2 ng/mL or below or taking insulin with a C-peptide greater than 2 ng/mL and a body mass index less than or equal to the maximum allowable BMI (28 kg/m² at the time).

Dr. Stock, who chaired that committee from 2005 to 2007, said: “We thought it was risky to offer a scarce pool of donor pancreases to people with type 2 when we had people with type 1 who we know will benefit from it. So initially, the committee decided to limit pancreas transplantation to those with type 2 who have fairly low insulin requirements and BMIs that are more in the range of people with type 1. And lo and behold the results were comparable.”

Subsequent to Dr. Stock’s tenure as chair, the UNOS committee decided that the BMI and C-peptide criteria for simultaneous pancreas-kidney were no longer scientifically justifiable and were potentially discriminatory both to minority populations with type 2 diabetes and people with type 1 diabetes who have a high BMI, so in 2019, they removed them.

Individual transplant centers must follow UNOS rules, but they can also add their own criteria. Some don’t perform simultaneous pancreas-kidney transplants in people with type 2 diabetes at all.

At Dr. Odorico’s center, which began doing so in 2012, patients with type 2 diabetes account for nearly 40% of all simultaneous pancreas-kidney transplants. Indications there include age 20-60 years, insulin dependent with requirements less than 1 unit/kg/day, CKD stage 3-5, predialysis or on dialysis, and BMI <33 kg/m².

“They are highly selected and a fairly fit group of patients,” Dr. Odorico noted.

Those who don’t meet all the requirements for simultaneous pancreas-kidney transplants may still be eligible for kidney transplant alone, from either a living or deceased donor, he said.

Dr. Stock’s criteria at UCSF are even more stringent for both BMI and insulin requirements.

SPK outcomes similar for type 1 and type 2 diabetes: Emerging data

Data to guide this area are accumulating slowly. Thus far, all studies have been retrospective and have used variable definitions for diabetes type and for graft failure. However, they’re fairly consistent in showing similar outcomes by diabetes type and little impact of C-peptide level on patient survival or survival of either kidney or pancreas graft, particularly after adjustment for confounding factors between the two types.

In a study from Dr. Odorico’s center of 284 type 1 and 39 type 2 diabetes patients undergoing simultaneous pancreas-kidney transplant between 2006 and 2017, pretransplant BMI and insulin requirements did not affect patient or graft survival in either type. There was a suggestion of greater risk for post-transplant diabetes with very high pretransplant insulin requirements (>75 units/day) but the numbers were too small to be definitive.  

“It’s clear we will be doing more pancreas transplants in the future in this group of patients, and it’s ripe for further investigation,” Dr. Odorico concluded.
 

Beta cells for all?

Dr. Stock added one more aspect. While of course whole-organ transplantation is limited by the shortage of human donors, stem cell–derived beta cells could potentially produce an unlimited supply. Both Dr. Stock and Dr. Odorico are working on different approaches to this.

“We’re really close,” he said, noting, “the data we get for people with type 2 diabetes undergoing solid organ pancreas transplant could also be applied to cellular therapy ... We need to get a better understanding of which patients will benefit. The data we have so far are very promising.”

Dr. Odorico is scientific founder, stock equity holder, scientific advisory board chair, and a prior grant support recipient from Regenerative Medical Solutions. He has reported receiving clinical trial support from Veloxis Pharmaceuticals, CareDx, Natera, and Vertex Pharmaceuticals. Dr. Stock has reported being on the scientific advisory board of Encellin and receives funding from the California Institute of Regenerative Medicine and National Institutes of Health.

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

Simultaneous pancreas-kidney transplants are increasingly performed in the United States in people with type 2 diabetes who also have chronic kidney disease, with outcomes similar to those of people with type 1 diabetes.

Traditionally, recipients of pancreas transplants have been people with type 1 diabetes who also have either chronic kidney disease (CKD) or hypoglycemic unawareness. The former group could receive either a simultaneous pancreas-kidney or a pancreas after kidney transplant, while the latter – if they have normal kidney function – would be eligible for a pancreas transplant alone.

But increasingly in recent years, patients with type 2 diabetes and CKD have been receiving simultaneous pancreas-kidney transplants, with similar success rates to those of people with type 1 diabetes.

Such candidates are typically sufficiently fit, not morbidly obese, and taking insulin regardless of their C-peptide status, said Jon S. Odorico, MD, professor of surgery and director of pancreas and islet transplantation at the University of Wisconsin–Madison Transplant Program.

“One might ask: Is it a crazy idea to do a pancreas transplant for patients with type 2 diabetes? Based on the known mechanisms of hyperglycemia in these patients, it might seem so,” he said, noting that while individuals with type 2 diabetes usually have insulin resistance, many also have relative or absolute deficiency of insulin production.

“So by replacing beta-cell mass, pancreas transplantation addresses this beta-cell defect mechanism,” he explained when discussing the topic during a symposium held June 26 at the virtual American Diabetes Association (ADA) 81st Scientific Sessions.

Arguments in favor of simultaneous pancreas-kidney transplant in people with type 2 diabetes and CKD include the fact that type 2 diabetes is the leading cause of kidney disease in the United States – roughly 50-60% of candidates on the kidney transplant waiting list also have type 2 diabetes – and that kidney transplant alone tends to worsen diabetes control due to the required immunosuppression.

Moreover, due to a 2014 allocation policy change that separates simultaneous pancreas-kidney from kidney transplant–alone donor organs, waiting times are shorter for the former, and kidney quality is generally better than for kidney transplant alone, unless a living kidney donor is available.

And, Dr. Odorico added, “adding a pancreas to a kidney transplant does not appear to jeopardize patient survival or kidney graft survival in appropriately selected patients with diabetes.” However, he also noted that because type 2 diabetes is so heterogeneous, ideal candidates for simultaneous pancreas-kidney transplant are not yet clear.

Currently, people with type 2 diabetes account for about 20% of those receiving simultaneous pancreas-kidney transplants and about 50% of pancreas after kidney transplants. Few pancreas transplants alone are performed in type 2 diabetes because those individuals rarely experience severe life-threatening hypoglycemia, Dr. Odorico explained.
 

Criteria have shifted over time, C-peptide removed in 2019

In an interview, symposium moderator Peter G. Stock, MD, PhD, surgical director of the Kidney and Pancreas Transplant Program at the University of California, San Francisco, said he agreed that “it’s a surprising trend. It doesn’t make intuitive sense. In type 1 diabetes, it makes sense to replace the beta cells. But type 2 is due to a whole cluster of etiologies ... The view in the public domain is that it’s not due to the lack of insulin but problems with insulin resistance and obesity. So it doesn’t make a whole lot of sense to give you more insulin if it’s a receptor problem.”

But Dr. Stock noted that because in the past diabetes type wasn’t always rigorously assessed using C-peptide and antibody testing, which most centers measure today, “a number of transplants were done in people who turned out to have type 2. Our perception is that everybody who has type 2 is obese, but that’s not true anymore.”

Once it became apparent that some patients with type 2 diabetes who received pancreas transplants seemed to be doing well, the pancreas transplantation committee of the United Network for Organ Sharing (UNOS) established general criteria for the procedure in people with diabetes. They had to be taking insulin and have a C-peptide value of 2 ng/mL or below or taking insulin with a C-peptide greater than 2 ng/mL and a body mass index less than or equal to the maximum allowable BMI (28 kg/m² at the time).

Dr. Stock, who chaired that committee from 2005 to 2007, said: “We thought it was risky to offer a scarce pool of donor pancreases to people with type 2 when we had people with type 1 who we know will benefit from it. So initially, the committee decided to limit pancreas transplantation to those with type 2 who have fairly low insulin requirements and BMIs that are more in the range of people with type 1. And lo and behold the results were comparable.”

Subsequent to Dr. Stock’s tenure as chair, the UNOS committee decided that the BMI and C-peptide criteria for simultaneous pancreas-kidney were no longer scientifically justifiable and were potentially discriminatory both to minority populations with type 2 diabetes and people with type 1 diabetes who have a high BMI, so in 2019, they removed them.

Individual transplant centers must follow UNOS rules, but they can also add their own criteria. Some don’t perform simultaneous pancreas-kidney transplants in people with type 2 diabetes at all.

At Dr. Odorico’s center, which began doing so in 2012, patients with type 2 diabetes account for nearly 40% of all simultaneous pancreas-kidney transplants. Indications there include age 20-60 years, insulin dependent with requirements less than 1 unit/kg/day, CKD stage 3-5, predialysis or on dialysis, and BMI <33 kg/m².

“They are highly selected and a fairly fit group of patients,” Dr. Odorico noted.

Those who don’t meet all the requirements for simultaneous pancreas-kidney transplants may still be eligible for kidney transplant alone, from either a living or deceased donor, he said.

Dr. Stock’s criteria at UCSF are even more stringent for both BMI and insulin requirements.

SPK outcomes similar for type 1 and type 2 diabetes: Emerging data

Data to guide this area are accumulating slowly. Thus far, all studies have been retrospective and have used variable definitions for diabetes type and for graft failure. However, they’re fairly consistent in showing similar outcomes by diabetes type and little impact of C-peptide level on patient survival or survival of either kidney or pancreas graft, particularly after adjustment for confounding factors between the two types.

In a study from Dr. Odorico’s center of 284 type 1 and 39 type 2 diabetes patients undergoing simultaneous pancreas-kidney transplant between 2006 and 2017, pretransplant BMI and insulin requirements did not affect patient or graft survival in either type. There was a suggestion of greater risk for post-transplant diabetes with very high pretransplant insulin requirements (>75 units/day) but the numbers were too small to be definitive.  

“It’s clear we will be doing more pancreas transplants in the future in this group of patients, and it’s ripe for further investigation,” Dr. Odorico concluded.
 

Beta cells for all?

Dr. Stock added one more aspect. While of course whole-organ transplantation is limited by the shortage of human donors, stem cell–derived beta cells could potentially produce an unlimited supply. Both Dr. Stock and Dr. Odorico are working on different approaches to this.

“We’re really close,” he said, noting, “the data we get for people with type 2 diabetes undergoing solid organ pancreas transplant could also be applied to cellular therapy ... We need to get a better understanding of which patients will benefit. The data we have so far are very promising.”

Dr. Odorico is scientific founder, stock equity holder, scientific advisory board chair, and a prior grant support recipient from Regenerative Medical Solutions. He has reported receiving clinical trial support from Veloxis Pharmaceuticals, CareDx, Natera, and Vertex Pharmaceuticals. Dr. Stock has reported being on the scientific advisory board of Encellin and receives funding from the California Institute of Regenerative Medicine and National Institutes of Health.

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

Most U.S. adults (77%) ages 50 and older in the United States rated their overall health as good, very good, or excellent in an online survey conducted by WebMD and Capital Caring Health (CCH), a nonprofit hospice/advanced illness care organization based in Virginia.

Among the respondents, 41% said their health was very good or excellent.

However, the ratings differed largely by race, employment status, and income.

Employment status was also associated with a significant difference in the way people viewed their health at the top tier and bottom tier.

The middle tier (“good” health) was reported similarly (from 33% to 37%) whether a person was employed, retired, or not employed. However, employed respondents were much more likely to report they had “excellent” or “very good” health (51% vs. 44% for retirees and 21% for the not employed).

Conversely, those who were not employed were far more likely to report “fair” or “poor” health (45%) than those who were employed (13%) or retired (20%).

Similarly, respondents with incomes of less than $50,000 were three times more likely to report their health as “fair” or “poor” than were those with incomes of more than $100,000 (36% vs. 12%).

WebMD/CCH surveyed 3,464 U.S. residents ages 50 and older between Aug. 13 and Nov. 9, 2020.  WebMD.com readers were randomly invited to take a 10-minute online survey.
 

Aging at home a priority

The survey also highlighted a strong preference for aging in place, says Steve Cone, chief of communications and philanthropy at CCH.

“More now than ever before, thanks to the COVID experience, baby boomers and their children really believe that’s the holy grail,” he says.

Mr. Cone notes that the quick spread of COVID-19 through some nursing homes early in the pandemic likely has strengthened people’s resolve to live out their lives in their own homes.

The survey indicated that 85% of people aged 50+ who are living in their own home, a family member’s home, or a loved one’s home responded that it is “very important” or “important” to stay in their home as they age.

When asked what services they would need to continue their living situation, the most common responses were housekeeping, home repair services, and transportation (listed as needs by 35% to 45% of respondents). Regarding changes they would have to make to feel safe in their home as they age, installing grab bars and/or safety rails in the bath/shower was the most popular answer (50%).
 

Use of telemedicine

Respondents were also asked about their acceptance of telemedicine, and 62% said they would be likely or very likely to engage in virtual visits with a doctor it in the future.

However, the likelihood varied by income level. Specifically, respondents with incomes over $100,000 were significantly more likely to say they would use telemedicine in the future than were those with incomes below $50,000 (74% vs. 60%).  They were also more likely to already have used telemedicine.

Although respondents generally embraced telemedicine, they are less confident about some types of monitoring, according to Mr. Cone.

Emergency response (64%) was the leading type of remote monitoring respondents ages 50 and older would allow. Only a minority of respondents would allow the other types of monitoring asked about in the survey.

Close to one-quarter of respondents would not allow any type of monitoring.

Fewer than one-third would allow tracking of medication compliance, refrigerator use, sleep habits, or bathroom use.

People see monitoring of some movements as “Orwellian,” Mr. Cone says.
 

Knowledge of hospice

The survey findings support the need for more widespread use of hospice so people can stay in their homes as they age, Mr. Cone says.

When illness gets severe, “There’s no reason you have to get rushed to the emergency room or wind up in a hospital,” Mr. Cone says.

He notes that hospice and palliative care can come to patients wherever they reside – in their home, an assisted living center, a nursing home, or even a hospital room.

“That doesn’t mean the physician isn’t involved,” he says. “But working as a team, we can keep them in their homes and their lifestyle intact.”

Patients whose doctors attest that they are likely to live a maximum 6 months are eligible for hospice. But most families wait too long to long to start hospice or palliative care for a patient, Mr. Cone says, and may not be aware of what these services typically cover, including meal preparation and pet care.

In the survey, nearly one-third of respondents said they did not know that palliative care is something that “can be given at any stage of a serious illness” or “provides non-medical services (e.g., patient/family communication, help with insurance issues, scheduling appointments, arranging transportation).”

He notes palliative care and hospice are covered by Medicare and Medicaid and also by most private insurance plans or by individual companies providing the service.

However, health care providers may have to overcome a general reluctance to discuss hospice when sharing options for those severely ill.

The survey showed that while 51% of those 50 and older are at least “slightly interested” in learning more about hospice, a nearly equal number say they are “not at all interested” (49%).
 

Most using hospice are White

More than 90% of those surveyed reported that aspects of hospice care, including “comfort and relief from pain at the end of patients’ lives,” providing a dedicated care team, and an alternative to other care settings, are “very important” or “important.”

However, national hospice use rates are extremely low for minorities and the LGBTQ community, according to Mr. Cone. Among Medicare hospice recipients, 82% were white, 8.2% Black, 6.7% Hispanic, and 1.8% Asian or Pacific Islander, according to the National Hospice and Palliative Care Organization.

Those numbers signal a need for outreach to those communities with information on what services are available and how to access them, he says.
 

Health costs top concern

The survey also asked about level of concern regarding matters including family, health, financials, and end-of-life directives and found adults aged 50 and older expressed the greatest amount of concern for health care costs that are not covered by insurance.

More than half (56%) said they were concerned or very concerned about those costs, which was higher than the percentage concerned about losing a spouse (49%).

Respondents were less concerned (“slightly concerned” or “not at all concerned”) about their children living far away, planning end-of life-directives, and falling or having reduced mobility.

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

Most U.S. adults (77%) ages 50 and older in the United States rated their overall health as good, very good, or excellent in an online survey conducted by WebMD and Capital Caring Health (CCH), a nonprofit hospice/advanced illness care organization based in Virginia.

Among the respondents, 41% said their health was very good or excellent.

However, the ratings differed largely by race, employment status, and income.

Employment status was also associated with a significant difference in the way people viewed their health at the top tier and bottom tier.

The middle tier (“good” health) was reported similarly (from 33% to 37%) whether a person was employed, retired, or not employed. However, employed respondents were much more likely to report they had “excellent” or “very good” health (51% vs. 44% for retirees and 21% for the not employed).

Conversely, those who were not employed were far more likely to report “fair” or “poor” health (45%) than those who were employed (13%) or retired (20%).

Similarly, respondents with incomes of less than $50,000 were three times more likely to report their health as “fair” or “poor” than were those with incomes of more than $100,000 (36% vs. 12%).

WebMD/CCH surveyed 3,464 U.S. residents ages 50 and older between Aug. 13 and Nov. 9, 2020.  WebMD.com readers were randomly invited to take a 10-minute online survey.
 

Aging at home a priority

The survey also highlighted a strong preference for aging in place, says Steve Cone, chief of communications and philanthropy at CCH.

“More now than ever before, thanks to the COVID experience, baby boomers and their children really believe that’s the holy grail,” he says.

Mr. Cone notes that the quick spread of COVID-19 through some nursing homes early in the pandemic likely has strengthened people’s resolve to live out their lives in their own homes.

The survey indicated that 85% of people aged 50+ who are living in their own home, a family member’s home, or a loved one’s home responded that it is “very important” or “important” to stay in their home as they age.

When asked what services they would need to continue their living situation, the most common responses were housekeeping, home repair services, and transportation (listed as needs by 35% to 45% of respondents). Regarding changes they would have to make to feel safe in their home as they age, installing grab bars and/or safety rails in the bath/shower was the most popular answer (50%).
 

Use of telemedicine

Respondents were also asked about their acceptance of telemedicine, and 62% said they would be likely or very likely to engage in virtual visits with a doctor it in the future.

However, the likelihood varied by income level. Specifically, respondents with incomes over $100,000 were significantly more likely to say they would use telemedicine in the future than were those with incomes below $50,000 (74% vs. 60%).  They were also more likely to already have used telemedicine.

Although respondents generally embraced telemedicine, they are less confident about some types of monitoring, according to Mr. Cone.

Emergency response (64%) was the leading type of remote monitoring respondents ages 50 and older would allow. Only a minority of respondents would allow the other types of monitoring asked about in the survey.

Close to one-quarter of respondents would not allow any type of monitoring.

Fewer than one-third would allow tracking of medication compliance, refrigerator use, sleep habits, or bathroom use.

People see monitoring of some movements as “Orwellian,” Mr. Cone says.
 

Knowledge of hospice

The survey findings support the need for more widespread use of hospice so people can stay in their homes as they age, Mr. Cone says.

When illness gets severe, “There’s no reason you have to get rushed to the emergency room or wind up in a hospital,” Mr. Cone says.

He notes that hospice and palliative care can come to patients wherever they reside – in their home, an assisted living center, a nursing home, or even a hospital room.

“That doesn’t mean the physician isn’t involved,” he says. “But working as a team, we can keep them in their homes and their lifestyle intact.”

Patients whose doctors attest that they are likely to live a maximum 6 months are eligible for hospice. But most families wait too long to long to start hospice or palliative care for a patient, Mr. Cone says, and may not be aware of what these services typically cover, including meal preparation and pet care.

In the survey, nearly one-third of respondents said they did not know that palliative care is something that “can be given at any stage of a serious illness” or “provides non-medical services (e.g., patient/family communication, help with insurance issues, scheduling appointments, arranging transportation).”

He notes palliative care and hospice are covered by Medicare and Medicaid and also by most private insurance plans or by individual companies providing the service.

However, health care providers may have to overcome a general reluctance to discuss hospice when sharing options for those severely ill.

The survey showed that while 51% of those 50 and older are at least “slightly interested” in learning more about hospice, a nearly equal number say they are “not at all interested” (49%).
 

Most using hospice are White

More than 90% of those surveyed reported that aspects of hospice care, including “comfort and relief from pain at the end of patients’ lives,” providing a dedicated care team, and an alternative to other care settings, are “very important” or “important.”

However, national hospice use rates are extremely low for minorities and the LGBTQ community, according to Mr. Cone. Among Medicare hospice recipients, 82% were white, 8.2% Black, 6.7% Hispanic, and 1.8% Asian or Pacific Islander, according to the National Hospice and Palliative Care Organization.

Those numbers signal a need for outreach to those communities with information on what services are available and how to access them, he says.
 

Health costs top concern

The survey also asked about level of concern regarding matters including family, health, financials, and end-of-life directives and found adults aged 50 and older expressed the greatest amount of concern for health care costs that are not covered by insurance.

More than half (56%) said they were concerned or very concerned about those costs, which was higher than the percentage concerned about losing a spouse (49%).

Respondents were less concerned (“slightly concerned” or “not at all concerned”) about their children living far away, planning end-of life-directives, and falling or having reduced mobility.

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

Most U.S. adults (77%) ages 50 and older in the United States rated their overall health as good, very good, or excellent in an online survey conducted by WebMD and Capital Caring Health (CCH), a nonprofit hospice/advanced illness care organization based in Virginia.

Among the respondents, 41% said their health was very good or excellent.

However, the ratings differed largely by race, employment status, and income.

Employment status was also associated with a significant difference in the way people viewed their health at the top tier and bottom tier.

The middle tier (“good” health) was reported similarly (from 33% to 37%) whether a person was employed, retired, or not employed. However, employed respondents were much more likely to report they had “excellent” or “very good” health (51% vs. 44% for retirees and 21% for the not employed).

Conversely, those who were not employed were far more likely to report “fair” or “poor” health (45%) than those who were employed (13%) or retired (20%).

Similarly, respondents with incomes of less than $50,000 were three times more likely to report their health as “fair” or “poor” than were those with incomes of more than $100,000 (36% vs. 12%).

WebMD/CCH surveyed 3,464 U.S. residents ages 50 and older between Aug. 13 and Nov. 9, 2020.  WebMD.com readers were randomly invited to take a 10-minute online survey.
 

Aging at home a priority

The survey also highlighted a strong preference for aging in place, says Steve Cone, chief of communications and philanthropy at CCH.

“More now than ever before, thanks to the COVID experience, baby boomers and their children really believe that’s the holy grail,” he says.

Mr. Cone notes that the quick spread of COVID-19 through some nursing homes early in the pandemic likely has strengthened people’s resolve to live out their lives in their own homes.

The survey indicated that 85% of people aged 50+ who are living in their own home, a family member’s home, or a loved one’s home responded that it is “very important” or “important” to stay in their home as they age.

When asked what services they would need to continue their living situation, the most common responses were housekeeping, home repair services, and transportation (listed as needs by 35% to 45% of respondents). Regarding changes they would have to make to feel safe in their home as they age, installing grab bars and/or safety rails in the bath/shower was the most popular answer (50%).
 

Use of telemedicine

Respondents were also asked about their acceptance of telemedicine, and 62% said they would be likely or very likely to engage in virtual visits with a doctor it in the future.

However, the likelihood varied by income level. Specifically, respondents with incomes over $100,000 were significantly more likely to say they would use telemedicine in the future than were those with incomes below $50,000 (74% vs. 60%).  They were also more likely to already have used telemedicine.

Although respondents generally embraced telemedicine, they are less confident about some types of monitoring, according to Mr. Cone.

Emergency response (64%) was the leading type of remote monitoring respondents ages 50 and older would allow. Only a minority of respondents would allow the other types of monitoring asked about in the survey.

Close to one-quarter of respondents would not allow any type of monitoring.

Fewer than one-third would allow tracking of medication compliance, refrigerator use, sleep habits, or bathroom use.

People see monitoring of some movements as “Orwellian,” Mr. Cone says.
 

Knowledge of hospice

The survey findings support the need for more widespread use of hospice so people can stay in their homes as they age, Mr. Cone says.

When illness gets severe, “There’s no reason you have to get rushed to the emergency room or wind up in a hospital,” Mr. Cone says.

He notes that hospice and palliative care can come to patients wherever they reside – in their home, an assisted living center, a nursing home, or even a hospital room.

“That doesn’t mean the physician isn’t involved,” he says. “But working as a team, we can keep them in their homes and their lifestyle intact.”

Patients whose doctors attest that they are likely to live a maximum 6 months are eligible for hospice. But most families wait too long to long to start hospice or palliative care for a patient, Mr. Cone says, and may not be aware of what these services typically cover, including meal preparation and pet care.

In the survey, nearly one-third of respondents said they did not know that palliative care is something that “can be given at any stage of a serious illness” or “provides non-medical services (e.g., patient/family communication, help with insurance issues, scheduling appointments, arranging transportation).”

He notes palliative care and hospice are covered by Medicare and Medicaid and also by most private insurance plans or by individual companies providing the service.

However, health care providers may have to overcome a general reluctance to discuss hospice when sharing options for those severely ill.

The survey showed that while 51% of those 50 and older are at least “slightly interested” in learning more about hospice, a nearly equal number say they are “not at all interested” (49%).
 

Most using hospice are White

More than 90% of those surveyed reported that aspects of hospice care, including “comfort and relief from pain at the end of patients’ lives,” providing a dedicated care team, and an alternative to other care settings, are “very important” or “important.”

However, national hospice use rates are extremely low for minorities and the LGBTQ community, according to Mr. Cone. Among Medicare hospice recipients, 82% were white, 8.2% Black, 6.7% Hispanic, and 1.8% Asian or Pacific Islander, according to the National Hospice and Palliative Care Organization.

Those numbers signal a need for outreach to those communities with information on what services are available and how to access them, he says.
 

Health costs top concern

The survey also asked about level of concern regarding matters including family, health, financials, and end-of-life directives and found adults aged 50 and older expressed the greatest amount of concern for health care costs that are not covered by insurance.

More than half (56%) said they were concerned or very concerned about those costs, which was higher than the percentage concerned about losing a spouse (49%).

Respondents were less concerned (“slightly concerned” or “not at all concerned”) about their children living far away, planning end-of life-directives, and falling or having reduced mobility.

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

St. Jude Medical, now part of Abbott Laboratories, will pay the American government $27 million to settle allegations that it knowingly sold defective implantable cardiac defibrillators to health care facilities, which were implanted into patients, causing injuries and two deaths, the U.S. Department of Justice (DOJ) has announced.

“Medical device manufacturers have an obligation to be truthful with the Food and Drug Administration, and the U.S. government will not pay for devices that are unsafe and risk injury or death,” Jonathan F. Lenzner, Acting U.S. Attorney for the District of Maryland, said in a July 8 statement.

“The government contends that St. Jude knowingly caused the submission of false claims and failed to inform the FDA with critical information about prior injuries and a death which, had the FDA been made aware, would have led to a recall,” Mr. Lenzner added.

Those claims were submitted to the Medicare, TRICARE, and Federal Employees Health Benefits programs, according to the settlement agreement.

“The U.S. Attorney’s Office is committed to protecting Medicare and other federal health care programs from fraud, and in doing so, strengthen[ing] patient safety,” Mr. Lenzner said.
 

Premature battery depletion

The government alleges that St. Jude failed to disclose “serious adverse health events” related to premature battery depletion of certain models of its Fortify, Fortify Assura, Quadra, and Unify implantable defibrillators.

The government further alleges that, by 2013, St. Jude knew that lithium clusters could form on the batteries, causing them to short and run out of power. But it took until late 2014 for St. Jude to ask the FDA to approve a change to prevent lithium clusters from draining the battery.

And at this point, St. Jude told the FDA that “no serious injury, permanent harm, or deaths have been reported associated with this” issue, the government alleges.

However, according to the government’s allegations, St. Jude was aware at that time of two reported serious injuries and one death associated with the faulty batteries and continued to distribute devices that had been manufactured without the new design.

Not until August 2016 did St. Jude inform the FDA that the number of premature battery depletion events had increased to 729, including two deaths and 29 events associated with loss of pacing, the government alleges.

In October 2016, St. Jude issued a medical advisory regarding the battery problem, which the FDA classified as a Class I recall, the most serious type.

After the recall, St. Jude no longer sold the older devices, but thousands of them had been implanted into patients between November 2014 and October 2016.

In September 2017, as reported by this news organization, a nationwide class-action lawsuit was filed against St. Jude Medical and parent company Abbott Laboratories alleging that, despite knowing about a battery-depletion defect in some of its cardiac defibrillators as early as 2011, St. Jude failed to adequately report the risk and waited nearly 5 years before issuing a recall.

“To ensure the health and safety of patients, manufacturers of implantable cardiac devices must be transparent when communicating with the government about safety issues and incidents,” Acting Assistant Attorney General Brian Boynton, from the DOJ’s Civil Division, said in the DOJ statement announcing the settlement.

“We will hold accountable those companies whose conduct violates the law and puts patients’ health at risk,” Mr. Boynton said.

The civil settlement includes the resolution of claims brought under the qui tam, or whistleblower, provisions of the False Claims Act by Debbie Burke, a patient who received one of the devices that was subject to recall.

The claims resolved by the settlement are allegations only; there has been no determination of liability, the DOJ noted. St. Jude denies the allegations raised in the lawsuit.

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

St. Jude Medical, now part of Abbott Laboratories, will pay the American government $27 million to settle allegations that it knowingly sold defective implantable cardiac defibrillators to health care facilities, which were implanted into patients, causing injuries and two deaths, the U.S. Department of Justice (DOJ) has announced.

“Medical device manufacturers have an obligation to be truthful with the Food and Drug Administration, and the U.S. government will not pay for devices that are unsafe and risk injury or death,” Jonathan F. Lenzner, Acting U.S. Attorney for the District of Maryland, said in a July 8 statement.

“The government contends that St. Jude knowingly caused the submission of false claims and failed to inform the FDA with critical information about prior injuries and a death which, had the FDA been made aware, would have led to a recall,” Mr. Lenzner added.

Those claims were submitted to the Medicare, TRICARE, and Federal Employees Health Benefits programs, according to the settlement agreement.

“The U.S. Attorney’s Office is committed to protecting Medicare and other federal health care programs from fraud, and in doing so, strengthen[ing] patient safety,” Mr. Lenzner said.
 

Premature battery depletion

The government alleges that St. Jude failed to disclose “serious adverse health events” related to premature battery depletion of certain models of its Fortify, Fortify Assura, Quadra, and Unify implantable defibrillators.

The government further alleges that, by 2013, St. Jude knew that lithium clusters could form on the batteries, causing them to short and run out of power. But it took until late 2014 for St. Jude to ask the FDA to approve a change to prevent lithium clusters from draining the battery.

And at this point, St. Jude told the FDA that “no serious injury, permanent harm, or deaths have been reported associated with this” issue, the government alleges.

However, according to the government’s allegations, St. Jude was aware at that time of two reported serious injuries and one death associated with the faulty batteries and continued to distribute devices that had been manufactured without the new design.

Not until August 2016 did St. Jude inform the FDA that the number of premature battery depletion events had increased to 729, including two deaths and 29 events associated with loss of pacing, the government alleges.

In October 2016, St. Jude issued a medical advisory regarding the battery problem, which the FDA classified as a Class I recall, the most serious type.

After the recall, St. Jude no longer sold the older devices, but thousands of them had been implanted into patients between November 2014 and October 2016.

In September 2017, as reported by this news organization, a nationwide class-action lawsuit was filed against St. Jude Medical and parent company Abbott Laboratories alleging that, despite knowing about a battery-depletion defect in some of its cardiac defibrillators as early as 2011, St. Jude failed to adequately report the risk and waited nearly 5 years before issuing a recall.

“To ensure the health and safety of patients, manufacturers of implantable cardiac devices must be transparent when communicating with the government about safety issues and incidents,” Acting Assistant Attorney General Brian Boynton, from the DOJ’s Civil Division, said in the DOJ statement announcing the settlement.

“We will hold accountable those companies whose conduct violates the law and puts patients’ health at risk,” Mr. Boynton said.

The civil settlement includes the resolution of claims brought under the qui tam, or whistleblower, provisions of the False Claims Act by Debbie Burke, a patient who received one of the devices that was subject to recall.

The claims resolved by the settlement are allegations only; there has been no determination of liability, the DOJ noted. St. Jude denies the allegations raised in the lawsuit.

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

St. Jude Medical, now part of Abbott Laboratories, will pay the American government $27 million to settle allegations that it knowingly sold defective implantable cardiac defibrillators to health care facilities, which were implanted into patients, causing injuries and two deaths, the U.S. Department of Justice (DOJ) has announced.

“Medical device manufacturers have an obligation to be truthful with the Food and Drug Administration, and the U.S. government will not pay for devices that are unsafe and risk injury or death,” Jonathan F. Lenzner, Acting U.S. Attorney for the District of Maryland, said in a July 8 statement.

“The government contends that St. Jude knowingly caused the submission of false claims and failed to inform the FDA with critical information about prior injuries and a death which, had the FDA been made aware, would have led to a recall,” Mr. Lenzner added.

Those claims were submitted to the Medicare, TRICARE, and Federal Employees Health Benefits programs, according to the settlement agreement.

“The U.S. Attorney’s Office is committed to protecting Medicare and other federal health care programs from fraud, and in doing so, strengthen[ing] patient safety,” Mr. Lenzner said.
 

Premature battery depletion

The government alleges that St. Jude failed to disclose “serious adverse health events” related to premature battery depletion of certain models of its Fortify, Fortify Assura, Quadra, and Unify implantable defibrillators.

The government further alleges that, by 2013, St. Jude knew that lithium clusters could form on the batteries, causing them to short and run out of power. But it took until late 2014 for St. Jude to ask the FDA to approve a change to prevent lithium clusters from draining the battery.

And at this point, St. Jude told the FDA that “no serious injury, permanent harm, or deaths have been reported associated with this” issue, the government alleges.

However, according to the government’s allegations, St. Jude was aware at that time of two reported serious injuries and one death associated with the faulty batteries and continued to distribute devices that had been manufactured without the new design.

Not until August 2016 did St. Jude inform the FDA that the number of premature battery depletion events had increased to 729, including two deaths and 29 events associated with loss of pacing, the government alleges.

In October 2016, St. Jude issued a medical advisory regarding the battery problem, which the FDA classified as a Class I recall, the most serious type.

After the recall, St. Jude no longer sold the older devices, but thousands of them had been implanted into patients between November 2014 and October 2016.

In September 2017, as reported by this news organization, a nationwide class-action lawsuit was filed against St. Jude Medical and parent company Abbott Laboratories alleging that, despite knowing about a battery-depletion defect in some of its cardiac defibrillators as early as 2011, St. Jude failed to adequately report the risk and waited nearly 5 years before issuing a recall.

“To ensure the health and safety of patients, manufacturers of implantable cardiac devices must be transparent when communicating with the government about safety issues and incidents,” Acting Assistant Attorney General Brian Boynton, from the DOJ’s Civil Division, said in the DOJ statement announcing the settlement.

“We will hold accountable those companies whose conduct violates the law and puts patients’ health at risk,” Mr. Boynton said.

The civil settlement includes the resolution of claims brought under the qui tam, or whistleblower, provisions of the False Claims Act by Debbie Burke, a patient who received one of the devices that was subject to recall.

The claims resolved by the settlement are allegations only; there has been no determination of liability, the DOJ noted. St. Jude denies the allegations raised in the lawsuit.

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

A standard medical face mask is more effective at preventing the wearer from inhaling aerosols without causing substantial breathing resistance than various cloth, medical, or respirator masks, new research shows.

“Medical face masks with good filtration efficacies can provide even better protective effects than KN95 respirators,” Christian Sterr, MD, from Philipps University of Marburg (Germany), and colleagues wrote. “FFP2 respirators, on the other hand, could be useful in high-risk situations but require greater breathing effort and therefore physical stress for users.”

Extensive evidence has shown that face masks are an excellent form of source control, preventing infectious people from spreading the SARS-CoV-2 virus into the environment. But evidence has been less clear about how well masks protect the wearer from inhaling particles containing the virus.

The researchers conducted three experiments to test 32 different face masks. The findings were presented at the 31st European Congress of Clinical Microbiology & Infectious Diseases and published online in PLOS One .

First they tested pressure drop, which “relates to how easily air can pass through the material,” said Chris Cappa, PhD, professor of civil and environmental engineering at the University of California, Davis, who was not involved with the study.

“Higher pressure drops mean that there is greater resistance to the air passing through. A higher pressure drop will typically mean breathing through the material will be slightly more challenging, compared to a low pressure drop. There is no relationship between pressure drop and the mask effectiveness,” he said in an interview.

Pressure drop was lowest with type II medical face masks, the typical three-ply surgical masks designed to stop large particles expelled by the wearer from entering the environment, was highest with respirators, including KN95 and FFP2 masks, and varied with the different cloth masks tested.

Next the researchers compared filtration efficacy, which “refers to how well the material removes particles from the air that passes through the mask material,” Dr. Cappa explained. They did this by placing each mask over the opening to an air collector that measured how many particles got through. “A mask that has 100% filtration efficacy will remove all particles from the air that passes through it and 0% means that no particles are removed.”

Cloth masks had the lowest filtration efficacy, at 28%. Certified face masks that met European Standards had a relatively high efficacy, at 70%; for uncertified face masks, filtration efficacy was 63%. As expected, KN95 and FFP2 masks had the highest filtration efficacy, at 94% and 98%, respectively.Finally, the researchers tested as-worn filtration efficacies. They placed each mask on a dummy head with an artificial airway that collected airborne particles. They then pumped a mixture of aerosol particles – ranging in size from 0.3 to 2.0 mcm – and particle-free pressurized air into the air-proof acrylic chamber in which the head was placed.

In this experiment, cloth masks and noncertified face masks were least effective, filtering less than 20% of aerosols. Interestingly, the cloth face mask with the highest filtration on its own (84%) had the lowest filtration efficacy (9%), apparently because of its very high pressure drop (breathing resistance). When more effort is required to breathe through a mask, more air can bypass the filtration system.

A standard medical face mask is more effective at preventing the wearer from inhaling aerosols without causing substantial breathing resistance than various cloth, medical, or respirator masks, new research shows.

“Medical face masks with good filtration efficacies can provide even better protective effects than KN95 respirators,” Christian Sterr, MD, from Philipps University of Marburg (Germany), and colleagues wrote. “FFP2 respirators, on the other hand, could be useful in high-risk situations but require greater breathing effort and therefore physical stress for users.”

Extensive evidence has shown that face masks are an excellent form of source control, preventing infectious people from spreading the SARS-CoV-2 virus into the environment. But evidence has been less clear about how well masks protect the wearer from inhaling particles containing the virus.

The researchers conducted three experiments to test 32 different face masks. The findings were presented at the 31st European Congress of Clinical Microbiology & Infectious Diseases and published online in PLOS One .

First they tested pressure drop, which “relates to how easily air can pass through the material,” said Chris Cappa, PhD, professor of civil and environmental engineering at the University of California, Davis, who was not involved with the study.

“Higher pressure drops mean that there is greater resistance to the air passing through. A higher pressure drop will typically mean breathing through the material will be slightly more challenging, compared to a low pressure drop. There is no relationship between pressure drop and the mask effectiveness,” he said in an interview.

Pressure drop was lowest with type II medical face masks, the typical three-ply surgical masks designed to stop large particles expelled by the wearer from entering the environment, was highest with respirators, including KN95 and FFP2 masks, and varied with the different cloth masks tested.

Next the researchers compared filtration efficacy, which “refers to how well the material removes particles from the air that passes through the mask material,” Dr. Cappa explained. They did this by placing each mask over the opening to an air collector that measured how many particles got through. “A mask that has 100% filtration efficacy will remove all particles from the air that passes through it and 0% means that no particles are removed.”

Cloth masks had the lowest filtration efficacy, at 28%. Certified face masks that met European Standards had a relatively high efficacy, at 70%; for uncertified face masks, filtration efficacy was 63%. As expected, KN95 and FFP2 masks had the highest filtration efficacy, at 94% and 98%, respectively.Finally, the researchers tested as-worn filtration efficacies. They placed each mask on a dummy head with an artificial airway that collected airborne particles. They then pumped a mixture of aerosol particles – ranging in size from 0.3 to 2.0 mcm – and particle-free pressurized air into the air-proof acrylic chamber in which the head was placed.

In this experiment, cloth masks and noncertified face masks were least effective, filtering less than 20% of aerosols. Interestingly, the cloth face mask with the highest filtration on its own (84%) had the lowest filtration efficacy (9%), apparently because of its very high pressure drop (breathing resistance). When more effort is required to breathe through a mask, more air can bypass the filtration system.

A standard medical face mask is more effective at preventing the wearer from inhaling aerosols without causing substantial breathing resistance than various cloth, medical, or respirator masks, new research shows.

“Medical face masks with good filtration efficacies can provide even better protective effects than KN95 respirators,” Christian Sterr, MD, from Philipps University of Marburg (Germany), and colleagues wrote. “FFP2 respirators, on the other hand, could be useful in high-risk situations but require greater breathing effort and therefore physical stress for users.”

Extensive evidence has shown that face masks are an excellent form of source control, preventing infectious people from spreading the SARS-CoV-2 virus into the environment. But evidence has been less clear about how well masks protect the wearer from inhaling particles containing the virus.

The researchers conducted three experiments to test 32 different face masks. The findings were presented at the 31st European Congress of Clinical Microbiology & Infectious Diseases and published online in PLOS One .

First they tested pressure drop, which “relates to how easily air can pass through the material,” said Chris Cappa, PhD, professor of civil and environmental engineering at the University of California, Davis, who was not involved with the study.

“Higher pressure drops mean that there is greater resistance to the air passing through. A higher pressure drop will typically mean breathing through the material will be slightly more challenging, compared to a low pressure drop. There is no relationship between pressure drop and the mask effectiveness,” he said in an interview.

Pressure drop was lowest with type II medical face masks, the typical three-ply surgical masks designed to stop large particles expelled by the wearer from entering the environment, was highest with respirators, including KN95 and FFP2 masks, and varied with the different cloth masks tested.

Next the researchers compared filtration efficacy, which “refers to how well the material removes particles from the air that passes through the mask material,” Dr. Cappa explained. They did this by placing each mask over the opening to an air collector that measured how many particles got through. “A mask that has 100% filtration efficacy will remove all particles from the air that passes through it and 0% means that no particles are removed.”

Cloth masks had the lowest filtration efficacy, at 28%. Certified face masks that met European Standards had a relatively high efficacy, at 70%; for uncertified face masks, filtration efficacy was 63%. As expected, KN95 and FFP2 masks had the highest filtration efficacy, at 94% and 98%, respectively.Finally, the researchers tested as-worn filtration efficacies. They placed each mask on a dummy head with an artificial airway that collected airborne particles. They then pumped a mixture of aerosol particles – ranging in size from 0.3 to 2.0 mcm – and particle-free pressurized air into the air-proof acrylic chamber in which the head was placed.

In this experiment, cloth masks and noncertified face masks were least effective, filtering less than 20% of aerosols. Interestingly, the cloth face mask with the highest filtration on its own (84%) had the lowest filtration efficacy (9%), apparently because of its very high pressure drop (breathing resistance). When more effort is required to breathe through a mask, more air can bypass the filtration system.