Integrating buprenorphine and harm eduction tools into primary care may improve clinical outcomes, increase costs only modestly, and be cost effective in health systems, authors conclude in an original investigation in JAMA Network Open.

A team led by Raagini Jawa, MD, MPH, with the Center for Research on Healthcare, University of Pittsburgh, set out to analyze costs of the interventions versus increased benefit in extending life expectancy.

Their analysis found that, compared with the status quo, integrating buprenorphine and harm reduction kits (syringes, wound care supplies, etc.) reduced drug use–related deaths by 33% and was cost effective.

“Our results suggest that integrated addiction care in primary care has the potential to save lives and increase nonemergency health care use, which is consistent with prior literature,” the authors write. “Colocated addiction services within primary care is pragmatic and effective and has comparable quality to specialty care. We found that onsite BUP [buprenorphine prescribing] plus HR [harm reduction] provides better outcomes than BUP alone at a lower cost.”
 

Three strategies compared

Using a microsimulation model of 2.25 million people in the United States who inject opioids, with an average age of 44 (69% of them male), the researchers tested three strategies:

• Status quo. PCP refers to addiction care.
• BUP. PCP services plus onsite buprenorphine prescribing with referral to off-site harm reduction kits.
• BUP plus HR. PCP services plus on-site buprenorphine prescribing and harm reduction kits.

The model is the Reducing Infections Related to Drug Use Cost-Effectiveness (REDUCE) microsimulation model, which tracks serious injection-related infections, overdose, hospitalization, and death.

The status quo (referral for treatment) resulted in 1,162 overdose deaths per 10,000 people (95% credible interval, 1,144-2,303), whereas both BUP and BUP plus HR resulted in about 160 fewer deaths per 10,000 people (95% Crl for BUP, 802-1718; 95% CrI for BUP plus HR, 692-1,810).

Compared with the status quo strategy, life expectancy was lengthened with the BUP strategy by 2.65 years and BUP plus HR by 2.71 years.

Researchers found the average discounted lifetime cost per person of both the BUP strategy and the BUP plus HR strategy were higher than the average status quo.

“The dominating strategy was BUP plus HR,” the authors write. “Compared with status quo, BUP plus HR was cost effective (incremental cost-effectiveness ratio [ICER], $34,400 per life year).”
 

Cost for primary care practices

Comparatively, over a 5-year period, BUP plus HR was found to cost an individual PCP practice approximately $13,000.

That cost includes direct costs for resources and opportunity costs, the authors write. These costs could be offset by health care system savings.

“These costs included those for X-waiver training, which has been eliminated; thus, we expect this to cost less. Put another way, our findings inform ways to reinvest health care dollars as financial incentives for PCPs to adopt this new paradigm. Public health departments could provide grants or harm reduction kit supplies directly to PCPs to offset these costs as they do in some places with syringe service programs and/or increase Medicaid reimbursements for providing addiction care in primary care,” they write.
 

Data help make the case

Dinah Applewhite, MD, a primary care physician and addiction medicine specialist at Massachusetts General Hospital in Boston, who was not part of the study, said clinicians there have seen the benefits of integrating various aspects of addiction medicine into primary care but these data on outcomes and cost-effectiveness can help make the case to hospital leaders, legislators, and grant providers.

The primary care setting also provides a chance to engage patients around their injection practice and explore ways to minimize risk, she said.

“By offering them these kits, it lets them know your priority is their safety and well-being,” Dr. Applewhite said.

She noted that the linkage to primary care was low for patients who inject drugs, which speaks to the need for models in addition to this one, such as bringing primary care clinicians into syringe service programs.

“The medical establishment has a lot to learn from these programs,” she said.
 

Practices need support

She said it’s important to note that primary care practices need support from administrative leaders, philanthropists, and grant providers to help cover the costs.

“It’s one of the barriers to doing this,” she said. “There isn’t a mechanism to pay for this.”

Sarah Bagley, MD, a primary care physician at Boston Medical Center and medical director of BMC’s Center for Addiction Treatment for Adolescents/Young Adults Who Use Substances told this publication she was excited to see that the addition of harm reduction kits to buprenorphine seemed to have the optimal effect in improving outcomes. People with substance abuse disorders should feel they are welcome in primary care even if they are not yet ready to stop drug use, she said.

She said she was also glad to see increased life expectancy with these interventions. The news of overdose deaths contributing to a decrease in life expectancy can be overwhelming, she said.

But this study, she says, offers a road map for addressing the overdose crisis “by including harm reduction in the substance abuse care we provide.”

She pointed out that the study showed that costs increase per patient with both interventions, compared with the status quo. The study found that health care costs per person during a lifetime increased, compared with the status quo, by 69.1% for BUP and 74.3% for BUP plus HR.

But it’s important to understand the reason for that, she said: “The cost was higher because people were staying alive.”

She said it may help to compare giving optimal care to people who have substance abuse disorders with giving optimal care to people with other chronic conditions, such as diabetes, who may not always adhere to recommended diets or treatment regimens.

“We still invite those patients in and work with them based on where they are,” she said.

Growing epidemic

The researchers point to the urgent need for solutions given the U.S. opioid epidemic, which has led to increasing numbers of overdoses and injection drug use–related infections, such as infective endocarditis, and severe skin and soft tissue infections.

They point out that primary care providers are the largest clinical workforce in the United States, but few of their practices offer comprehensive addiction care onsite.

“Primary care practices are a practical place to integrate addiction services, where PCPs can prescribe buprenorphine and deliver harm reduction kits,” they write.

Coauthor Dr. Kimmel reports personal fees from Massachusetts Department of Public Health, Bureau of Substance Addiction Services Overdose Education and Prevention Program, and American Academy of Addiction Psychiatry, Opioid Response Network for harm reduction education outside the submitted work and previous consulting with Abt Associates on a Massachusetts Department of Public Health–funded project to improve access to medications for opioid use disorder treatment. Dr. Applewhite and Dr. Bagley report no relevant financial relationships.

Integrating buprenorphine and harm eduction tools into primary care may improve clinical outcomes, increase costs only modestly, and be cost effective in health systems, authors conclude in an original investigation in JAMA Network Open.

A team led by Raagini Jawa, MD, MPH, with the Center for Research on Healthcare, University of Pittsburgh, set out to analyze costs of the interventions versus increased benefit in extending life expectancy.

Their analysis found that, compared with the status quo, integrating buprenorphine and harm reduction kits (syringes, wound care supplies, etc.) reduced drug use–related deaths by 33% and was cost effective.

“Our results suggest that integrated addiction care in primary care has the potential to save lives and increase nonemergency health care use, which is consistent with prior literature,” the authors write. “Colocated addiction services within primary care is pragmatic and effective and has comparable quality to specialty care. We found that onsite BUP [buprenorphine prescribing] plus HR [harm reduction] provides better outcomes than BUP alone at a lower cost.”
 

Three strategies compared

Using a microsimulation model of 2.25 million people in the United States who inject opioids, with an average age of 44 (69% of them male), the researchers tested three strategies:

• Status quo. PCP refers to addiction care.
• BUP. PCP services plus onsite buprenorphine prescribing with referral to off-site harm reduction kits.
• BUP plus HR. PCP services plus on-site buprenorphine prescribing and harm reduction kits.

The model is the Reducing Infections Related to Drug Use Cost-Effectiveness (REDUCE) microsimulation model, which tracks serious injection-related infections, overdose, hospitalization, and death.

The status quo (referral for treatment) resulted in 1,162 overdose deaths per 10,000 people (95% credible interval, 1,144-2,303), whereas both BUP and BUP plus HR resulted in about 160 fewer deaths per 10,000 people (95% Crl for BUP, 802-1718; 95% CrI for BUP plus HR, 692-1,810).

Compared with the status quo strategy, life expectancy was lengthened with the BUP strategy by 2.65 years and BUP plus HR by 2.71 years.

Researchers found the average discounted lifetime cost per person of both the BUP strategy and the BUP plus HR strategy were higher than the average status quo.

“The dominating strategy was BUP plus HR,” the authors write. “Compared with status quo, BUP plus HR was cost effective (incremental cost-effectiveness ratio [ICER], $34,400 per life year).”
 

Cost for primary care practices

Comparatively, over a 5-year period, BUP plus HR was found to cost an individual PCP practice approximately $13,000.

That cost includes direct costs for resources and opportunity costs, the authors write. These costs could be offset by health care system savings.

“These costs included those for X-waiver training, which has been eliminated; thus, we expect this to cost less. Put another way, our findings inform ways to reinvest health care dollars as financial incentives for PCPs to adopt this new paradigm. Public health departments could provide grants or harm reduction kit supplies directly to PCPs to offset these costs as they do in some places with syringe service programs and/or increase Medicaid reimbursements for providing addiction care in primary care,” they write.
 

Data help make the case

Dinah Applewhite, MD, a primary care physician and addiction medicine specialist at Massachusetts General Hospital in Boston, who was not part of the study, said clinicians there have seen the benefits of integrating various aspects of addiction medicine into primary care but these data on outcomes and cost-effectiveness can help make the case to hospital leaders, legislators, and grant providers.

The primary care setting also provides a chance to engage patients around their injection practice and explore ways to minimize risk, she said.

“By offering them these kits, it lets them know your priority is their safety and well-being,” Dr. Applewhite said.

She noted that the linkage to primary care was low for patients who inject drugs, which speaks to the need for models in addition to this one, such as bringing primary care clinicians into syringe service programs.

“The medical establishment has a lot to learn from these programs,” she said.
 

Practices need support

She said it’s important to note that primary care practices need support from administrative leaders, philanthropists, and grant providers to help cover the costs.

“It’s one of the barriers to doing this,” she said. “There isn’t a mechanism to pay for this.”

Sarah Bagley, MD, a primary care physician at Boston Medical Center and medical director of BMC’s Center for Addiction Treatment for Adolescents/Young Adults Who Use Substances told this publication she was excited to see that the addition of harm reduction kits to buprenorphine seemed to have the optimal effect in improving outcomes. People with substance abuse disorders should feel they are welcome in primary care even if they are not yet ready to stop drug use, she said.

She said she was also glad to see increased life expectancy with these interventions. The news of overdose deaths contributing to a decrease in life expectancy can be overwhelming, she said.

But this study, she says, offers a road map for addressing the overdose crisis “by including harm reduction in the substance abuse care we provide.”

She pointed out that the study showed that costs increase per patient with both interventions, compared with the status quo. The study found that health care costs per person during a lifetime increased, compared with the status quo, by 69.1% for BUP and 74.3% for BUP plus HR.

But it’s important to understand the reason for that, she said: “The cost was higher because people were staying alive.”

She said it may help to compare giving optimal care to people who have substance abuse disorders with giving optimal care to people with other chronic conditions, such as diabetes, who may not always adhere to recommended diets or treatment regimens.

“We still invite those patients in and work with them based on where they are,” she said.

Growing epidemic

The researchers point to the urgent need for solutions given the U.S. opioid epidemic, which has led to increasing numbers of overdoses and injection drug use–related infections, such as infective endocarditis, and severe skin and soft tissue infections.

They point out that primary care providers are the largest clinical workforce in the United States, but few of their practices offer comprehensive addiction care onsite.

“Primary care practices are a practical place to integrate addiction services, where PCPs can prescribe buprenorphine and deliver harm reduction kits,” they write.

Coauthor Dr. Kimmel reports personal fees from Massachusetts Department of Public Health, Bureau of Substance Addiction Services Overdose Education and Prevention Program, and American Academy of Addiction Psychiatry, Opioid Response Network for harm reduction education outside the submitted work and previous consulting with Abt Associates on a Massachusetts Department of Public Health–funded project to improve access to medications for opioid use disorder treatment. Dr. Applewhite and Dr. Bagley report no relevant financial relationships.

Integrating buprenorphine and harm eduction tools into primary care may improve clinical outcomes, increase costs only modestly, and be cost effective in health systems, authors conclude in an original investigation in JAMA Network Open.

A team led by Raagini Jawa, MD, MPH, with the Center for Research on Healthcare, University of Pittsburgh, set out to analyze costs of the interventions versus increased benefit in extending life expectancy.

Their analysis found that, compared with the status quo, integrating buprenorphine and harm reduction kits (syringes, wound care supplies, etc.) reduced drug use–related deaths by 33% and was cost effective.

“Our results suggest that integrated addiction care in primary care has the potential to save lives and increase nonemergency health care use, which is consistent with prior literature,” the authors write. “Colocated addiction services within primary care is pragmatic and effective and has comparable quality to specialty care. We found that onsite BUP [buprenorphine prescribing] plus HR [harm reduction] provides better outcomes than BUP alone at a lower cost.”
 

Three strategies compared

Using a microsimulation model of 2.25 million people in the United States who inject opioids, with an average age of 44 (69% of them male), the researchers tested three strategies:

• Status quo. PCP refers to addiction care.
• BUP. PCP services plus onsite buprenorphine prescribing with referral to off-site harm reduction kits.
• BUP plus HR. PCP services plus on-site buprenorphine prescribing and harm reduction kits.

The model is the Reducing Infections Related to Drug Use Cost-Effectiveness (REDUCE) microsimulation model, which tracks serious injection-related infections, overdose, hospitalization, and death.

The status quo (referral for treatment) resulted in 1,162 overdose deaths per 10,000 people (95% credible interval, 1,144-2,303), whereas both BUP and BUP plus HR resulted in about 160 fewer deaths per 10,000 people (95% Crl for BUP, 802-1718; 95% CrI for BUP plus HR, 692-1,810).

Compared with the status quo strategy, life expectancy was lengthened with the BUP strategy by 2.65 years and BUP plus HR by 2.71 years.

Researchers found the average discounted lifetime cost per person of both the BUP strategy and the BUP plus HR strategy were higher than the average status quo.

“The dominating strategy was BUP plus HR,” the authors write. “Compared with status quo, BUP plus HR was cost effective (incremental cost-effectiveness ratio [ICER], $34,400 per life year).”
 

Cost for primary care practices

Comparatively, over a 5-year period, BUP plus HR was found to cost an individual PCP practice approximately $13,000.

That cost includes direct costs for resources and opportunity costs, the authors write. These costs could be offset by health care system savings.

“These costs included those for X-waiver training, which has been eliminated; thus, we expect this to cost less. Put another way, our findings inform ways to reinvest health care dollars as financial incentives for PCPs to adopt this new paradigm. Public health departments could provide grants or harm reduction kit supplies directly to PCPs to offset these costs as they do in some places with syringe service programs and/or increase Medicaid reimbursements for providing addiction care in primary care,” they write.
 

Data help make the case

Dinah Applewhite, MD, a primary care physician and addiction medicine specialist at Massachusetts General Hospital in Boston, who was not part of the study, said clinicians there have seen the benefits of integrating various aspects of addiction medicine into primary care but these data on outcomes and cost-effectiveness can help make the case to hospital leaders, legislators, and grant providers.

The primary care setting also provides a chance to engage patients around their injection practice and explore ways to minimize risk, she said.

“By offering them these kits, it lets them know your priority is their safety and well-being,” Dr. Applewhite said.

She noted that the linkage to primary care was low for patients who inject drugs, which speaks to the need for models in addition to this one, such as bringing primary care clinicians into syringe service programs.

“The medical establishment has a lot to learn from these programs,” she said.
 

Practices need support

She said it’s important to note that primary care practices need support from administrative leaders, philanthropists, and grant providers to help cover the costs.

“It’s one of the barriers to doing this,” she said. “There isn’t a mechanism to pay for this.”

Sarah Bagley, MD, a primary care physician at Boston Medical Center and medical director of BMC’s Center for Addiction Treatment for Adolescents/Young Adults Who Use Substances told this publication she was excited to see that the addition of harm reduction kits to buprenorphine seemed to have the optimal effect in improving outcomes. People with substance abuse disorders should feel they are welcome in primary care even if they are not yet ready to stop drug use, she said.

She said she was also glad to see increased life expectancy with these interventions. The news of overdose deaths contributing to a decrease in life expectancy can be overwhelming, she said.

But this study, she says, offers a road map for addressing the overdose crisis “by including harm reduction in the substance abuse care we provide.”

She pointed out that the study showed that costs increase per patient with both interventions, compared with the status quo. The study found that health care costs per person during a lifetime increased, compared with the status quo, by 69.1% for BUP and 74.3% for BUP plus HR.

But it’s important to understand the reason for that, she said: “The cost was higher because people were staying alive.”

She said it may help to compare giving optimal care to people who have substance abuse disorders with giving optimal care to people with other chronic conditions, such as diabetes, who may not always adhere to recommended diets or treatment regimens.

“We still invite those patients in and work with them based on where they are,” she said.

Growing epidemic

The researchers point to the urgent need for solutions given the U.S. opioid epidemic, which has led to increasing numbers of overdoses and injection drug use–related infections, such as infective endocarditis, and severe skin and soft tissue infections.

They point out that primary care providers are the largest clinical workforce in the United States, but few of their practices offer comprehensive addiction care onsite.

“Primary care practices are a practical place to integrate addiction services, where PCPs can prescribe buprenorphine and deliver harm reduction kits,” they write.

Coauthor Dr. Kimmel reports personal fees from Massachusetts Department of Public Health, Bureau of Substance Addiction Services Overdose Education and Prevention Program, and American Academy of Addiction Psychiatry, Opioid Response Network for harm reduction education outside the submitted work and previous consulting with Abt Associates on a Massachusetts Department of Public Health–funded project to improve access to medications for opioid use disorder treatment. Dr. Applewhite and Dr. Bagley report no relevant financial relationships.

Early detection and management of sleep disorders could reduce asthma incidence, according to a large-scale prospective study that included nearly half a million participants. The study was published in BMJ Open Respiratory Research.

The population-attributable risk analysis indicated that 19% of asthma cases could be prevented through improving sleep traits. The investigators took into consideration polygenic risk scores (PRSs) for asthma and comprehensive sleep scores encompassing five sleep traits.

Sleep quality is generally recognized as a nongenetic driver of asthma. Poor sleep quality and obstructive sleep apnea have been reported particularly among those with severe disease. In addition, asthma is known to adversely affect sleep duration, sleep quality, napping, and daytime sleepiness.

The researchers suggest that the relationship between sleep and asthma is bidirectional, given that sleep disorders (sleep of short duration, insomnia, evening chronotype [“night owl”], snoring, excessive daytime sleepiness) are associated with specific chronic inflammatory reactions. It has remained unclear, however, whether poor sleep reflects a higher risk of early asthma progression.

Genetic factors also contribute to asthma risk, but highly variable heritability suggests that the nongenetic exposures play an important role. “However, whether healthy nongenetic exposure could decrease the risk of asthma and mitigate the adverse effect of genetic risk remains largely unknown,” the authors state. They hypothesize that healthier sleep could decrease future asthma risk and mitigate the hazards of genetic effects.

Using data from the UK Biobank, a national large, prospective cohort drawn from 22 U.K. assessment centers, they investigated the independent and combined effects of sleep pattern and PRSs on asthma incidence.

In the UK Biobank cohort (455,405 adults aged 38-73 years, who were enrolled from 2006 to 2010), 17,836 were diagnosed with asthma over 10 years of follow-up. PRSs were constructed for each participant on the basis of their having any of 17 single-nucleotide polymorphisms that are significantly associated with asthma. Participants were stratified into three groups: those at high genetic risk, those at intermediate genetic risk, and those at low genetic risk. Around 1 in 3 participants were classified as being at high genetic risk (150,429), and another third (151,970) were classified as being at intermediate risk. The remainder were classified as being at low risk. Some 7,105 people at high genetic risk and 5,748 at intermediate genetic risk were diagnosed with asthma during the monitoring period.

Comprehensive sleep scores, which ranged from 0 to 5, were constructed on the basis of self-reported sleep traits. Higher scores represented healthier sleep patterns. A healthy sleep pattern was defined as early chronotype; getting from 7 to 9 hours of sleep every night; never or rare insomnia; no snoring; and no frequent daytime sleepiness. On the basis of their responses, 73,223 people met the criteria for a healthy sleep pattern; 284,267, an intermediate sleep pattern; and 97,915, a poor sleep pattern.

“Compared with non-cases, asthma cases were more likely to have lower education levels, unhealthy sleep traits and patterns, obesity, higher PRS, more smoking, more alcohol consumption, hypertension, diabetes, depression, gastroesophageal reflux. and more air pollution exposure,” the authors report. All five healthy sleep traits were independently associated with lower risk for asthma. Never/rare insomnia and sleep duration of 7-9 hours a night were seemingly the most influential; they were associated with risk reductions of 25% and 20%, respectively.

Analysis showed that, compared with the low-risk group, the hazard ratios and 95% confidence intervals for the highest PRS group and the poor sleep pattern group were 1.47 (95% CI, 1.41-1.52) and 1.55 (95% CI, 1.45-1.65), respectively.

Risk was twofold higher in the presence of a combination of poor sleep and high genetic susceptibility (HR, 2.22; 95% CI, 1.97-2.49; P < .001). Conversely, a healthy sleep pattern was associated with a lower risk of asthma in the low (HR, 0.56; 95% CI, 0.50-0.64), intermediate (HR, 0.59; 95% CI, 0.53-0.67), and high genetic susceptibility groups (HR, 0.63; 95% CI, 0.57-0.70). A population-attributable risk analysis indicated that improving these sleep traits would prevent 19% of asthma cases. Also, a subset analysis suggested that a healthy sleep pattern might reduce the risk of asthma among those at high genetic risk by 37%.

The study findings suggest that analysis of sleep patterns is warranted for all asthma patients, said coauthor Qing Wang, PhD, Cheeloo College of Medicine, Shandong University, Jinan, China, in an interview. “In our results, the effects of sleep and genetics were independent. Therefore, what we learned about the effects of sleep on asthma could be applied to all the patients, including those with a high or low genetic predisposition. In addition, we believe that intervening among those with high genetic predisposition could be more beneficial since they are more likely to have asthma. However, because this study is observational, a large clinical trial is absolutely needed to provide causal evidence, especially before guidelines modifications can be considered.”
 

Complex and multifactorial

“Addressing relevant asthma comorbid conditions continues to be an integral part of asthma care,” commented Diego J. Maselli, MD, associate professor of medicine and interim chief, division of pulmonary diseases and critical care, UT Health, San Antonio, in an interview. “There is mounting evidence that sleep patterns and obstructive sleep apnea may influence asthma control. This association is complex and multifactorial. It is important to remember that obstructive sleep apnea may coexist with other conditions, such as obesity and gastroesophageal reflux disease, that in turn can also worsen asthma control and influence clinical outcomes.

CHEST

“Yet, even after controlling for these factors, sleep disturbances have been associated with poor asthma outcomes. It is reasonable, particularly in patients with uncontrolled and/or severe asthma, to screen for sleep disturbances. There are multiple questionnaires and clinical tools that can be employed to screen for coexisting sleep apnea and other conditions. Although genetic testing has shown some promise in identifying individuals at risk, these assays are not widely available and are not ready yet for routine clinical practice. Therefore, sleep studies should be reserved for patients that have symptoms and test positive for screening questionnaires and other tools.

“The study by Xiang and colleagues adds to the field of study, but further evidence is required to change practice guidelines at this time. Fortunately, sleep studies are readily available now with more widespread use of home testing, so patients can be easily tested. The majority third-party payers have identified that diagnosing these disorders is cost-effective and are able to reimburse sleep studies,” Dr. Maselli concluded.

The research was funded by the Future Program for Young Scholars and National Key Research and Development Program. The study authors and Dr. Maselli have disclosed no relevant financial relationships.
 

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

Early detection and management of sleep disorders could reduce asthma incidence, according to a large-scale prospective study that included nearly half a million participants. The study was published in BMJ Open Respiratory Research.

The population-attributable risk analysis indicated that 19% of asthma cases could be prevented through improving sleep traits. The investigators took into consideration polygenic risk scores (PRSs) for asthma and comprehensive sleep scores encompassing five sleep traits.

Sleep quality is generally recognized as a nongenetic driver of asthma. Poor sleep quality and obstructive sleep apnea have been reported particularly among those with severe disease. In addition, asthma is known to adversely affect sleep duration, sleep quality, napping, and daytime sleepiness.

The researchers suggest that the relationship between sleep and asthma is bidirectional, given that sleep disorders (sleep of short duration, insomnia, evening chronotype [“night owl”], snoring, excessive daytime sleepiness) are associated with specific chronic inflammatory reactions. It has remained unclear, however, whether poor sleep reflects a higher risk of early asthma progression.

Genetic factors also contribute to asthma risk, but highly variable heritability suggests that the nongenetic exposures play an important role. “However, whether healthy nongenetic exposure could decrease the risk of asthma and mitigate the adverse effect of genetic risk remains largely unknown,” the authors state. They hypothesize that healthier sleep could decrease future asthma risk and mitigate the hazards of genetic effects.

Using data from the UK Biobank, a national large, prospective cohort drawn from 22 U.K. assessment centers, they investigated the independent and combined effects of sleep pattern and PRSs on asthma incidence.

In the UK Biobank cohort (455,405 adults aged 38-73 years, who were enrolled from 2006 to 2010), 17,836 were diagnosed with asthma over 10 years of follow-up. PRSs were constructed for each participant on the basis of their having any of 17 single-nucleotide polymorphisms that are significantly associated with asthma. Participants were stratified into three groups: those at high genetic risk, those at intermediate genetic risk, and those at low genetic risk. Around 1 in 3 participants were classified as being at high genetic risk (150,429), and another third (151,970) were classified as being at intermediate risk. The remainder were classified as being at low risk. Some 7,105 people at high genetic risk and 5,748 at intermediate genetic risk were diagnosed with asthma during the monitoring period.

Comprehensive sleep scores, which ranged from 0 to 5, were constructed on the basis of self-reported sleep traits. Higher scores represented healthier sleep patterns. A healthy sleep pattern was defined as early chronotype; getting from 7 to 9 hours of sleep every night; never or rare insomnia; no snoring; and no frequent daytime sleepiness. On the basis of their responses, 73,223 people met the criteria for a healthy sleep pattern; 284,267, an intermediate sleep pattern; and 97,915, a poor sleep pattern.

“Compared with non-cases, asthma cases were more likely to have lower education levels, unhealthy sleep traits and patterns, obesity, higher PRS, more smoking, more alcohol consumption, hypertension, diabetes, depression, gastroesophageal reflux. and more air pollution exposure,” the authors report. All five healthy sleep traits were independently associated with lower risk for asthma. Never/rare insomnia and sleep duration of 7-9 hours a night were seemingly the most influential; they were associated with risk reductions of 25% and 20%, respectively.

Analysis showed that, compared with the low-risk group, the hazard ratios and 95% confidence intervals for the highest PRS group and the poor sleep pattern group were 1.47 (95% CI, 1.41-1.52) and 1.55 (95% CI, 1.45-1.65), respectively.

Risk was twofold higher in the presence of a combination of poor sleep and high genetic susceptibility (HR, 2.22; 95% CI, 1.97-2.49; P < .001). Conversely, a healthy sleep pattern was associated with a lower risk of asthma in the low (HR, 0.56; 95% CI, 0.50-0.64), intermediate (HR, 0.59; 95% CI, 0.53-0.67), and high genetic susceptibility groups (HR, 0.63; 95% CI, 0.57-0.70). A population-attributable risk analysis indicated that improving these sleep traits would prevent 19% of asthma cases. Also, a subset analysis suggested that a healthy sleep pattern might reduce the risk of asthma among those at high genetic risk by 37%.

The study findings suggest that analysis of sleep patterns is warranted for all asthma patients, said coauthor Qing Wang, PhD, Cheeloo College of Medicine, Shandong University, Jinan, China, in an interview. “In our results, the effects of sleep and genetics were independent. Therefore, what we learned about the effects of sleep on asthma could be applied to all the patients, including those with a high or low genetic predisposition. In addition, we believe that intervening among those with high genetic predisposition could be more beneficial since they are more likely to have asthma. However, because this study is observational, a large clinical trial is absolutely needed to provide causal evidence, especially before guidelines modifications can be considered.”
 

Complex and multifactorial

“Addressing relevant asthma comorbid conditions continues to be an integral part of asthma care,” commented Diego J. Maselli, MD, associate professor of medicine and interim chief, division of pulmonary diseases and critical care, UT Health, San Antonio, in an interview. “There is mounting evidence that sleep patterns and obstructive sleep apnea may influence asthma control. This association is complex and multifactorial. It is important to remember that obstructive sleep apnea may coexist with other conditions, such as obesity and gastroesophageal reflux disease, that in turn can also worsen asthma control and influence clinical outcomes.

CHEST

“Yet, even after controlling for these factors, sleep disturbances have been associated with poor asthma outcomes. It is reasonable, particularly in patients with uncontrolled and/or severe asthma, to screen for sleep disturbances. There are multiple questionnaires and clinical tools that can be employed to screen for coexisting sleep apnea and other conditions. Although genetic testing has shown some promise in identifying individuals at risk, these assays are not widely available and are not ready yet for routine clinical practice. Therefore, sleep studies should be reserved for patients that have symptoms and test positive for screening questionnaires and other tools.

“The study by Xiang and colleagues adds to the field of study, but further evidence is required to change practice guidelines at this time. Fortunately, sleep studies are readily available now with more widespread use of home testing, so patients can be easily tested. The majority third-party payers have identified that diagnosing these disorders is cost-effective and are able to reimburse sleep studies,” Dr. Maselli concluded.

The research was funded by the Future Program for Young Scholars and National Key Research and Development Program. The study authors and Dr. Maselli have disclosed no relevant financial relationships.
 

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

Early detection and management of sleep disorders could reduce asthma incidence, according to a large-scale prospective study that included nearly half a million participants. The study was published in BMJ Open Respiratory Research.

The population-attributable risk analysis indicated that 19% of asthma cases could be prevented through improving sleep traits. The investigators took into consideration polygenic risk scores (PRSs) for asthma and comprehensive sleep scores encompassing five sleep traits.

Sleep quality is generally recognized as a nongenetic driver of asthma. Poor sleep quality and obstructive sleep apnea have been reported particularly among those with severe disease. In addition, asthma is known to adversely affect sleep duration, sleep quality, napping, and daytime sleepiness.

The researchers suggest that the relationship between sleep and asthma is bidirectional, given that sleep disorders (sleep of short duration, insomnia, evening chronotype [“night owl”], snoring, excessive daytime sleepiness) are associated with specific chronic inflammatory reactions. It has remained unclear, however, whether poor sleep reflects a higher risk of early asthma progression.

Genetic factors also contribute to asthma risk, but highly variable heritability suggests that the nongenetic exposures play an important role. “However, whether healthy nongenetic exposure could decrease the risk of asthma and mitigate the adverse effect of genetic risk remains largely unknown,” the authors state. They hypothesize that healthier sleep could decrease future asthma risk and mitigate the hazards of genetic effects.

Using data from the UK Biobank, a national large, prospective cohort drawn from 22 U.K. assessment centers, they investigated the independent and combined effects of sleep pattern and PRSs on asthma incidence.

In the UK Biobank cohort (455,405 adults aged 38-73 years, who were enrolled from 2006 to 2010), 17,836 were diagnosed with asthma over 10 years of follow-up. PRSs were constructed for each participant on the basis of their having any of 17 single-nucleotide polymorphisms that are significantly associated with asthma. Participants were stratified into three groups: those at high genetic risk, those at intermediate genetic risk, and those at low genetic risk. Around 1 in 3 participants were classified as being at high genetic risk (150,429), and another third (151,970) were classified as being at intermediate risk. The remainder were classified as being at low risk. Some 7,105 people at high genetic risk and 5,748 at intermediate genetic risk were diagnosed with asthma during the monitoring period.

Comprehensive sleep scores, which ranged from 0 to 5, were constructed on the basis of self-reported sleep traits. Higher scores represented healthier sleep patterns. A healthy sleep pattern was defined as early chronotype; getting from 7 to 9 hours of sleep every night; never or rare insomnia; no snoring; and no frequent daytime sleepiness. On the basis of their responses, 73,223 people met the criteria for a healthy sleep pattern; 284,267, an intermediate sleep pattern; and 97,915, a poor sleep pattern.

“Compared with non-cases, asthma cases were more likely to have lower education levels, unhealthy sleep traits and patterns, obesity, higher PRS, more smoking, more alcohol consumption, hypertension, diabetes, depression, gastroesophageal reflux. and more air pollution exposure,” the authors report. All five healthy sleep traits were independently associated with lower risk for asthma. Never/rare insomnia and sleep duration of 7-9 hours a night were seemingly the most influential; they were associated with risk reductions of 25% and 20%, respectively.

Analysis showed that, compared with the low-risk group, the hazard ratios and 95% confidence intervals for the highest PRS group and the poor sleep pattern group were 1.47 (95% CI, 1.41-1.52) and 1.55 (95% CI, 1.45-1.65), respectively.

Risk was twofold higher in the presence of a combination of poor sleep and high genetic susceptibility (HR, 2.22; 95% CI, 1.97-2.49; P < .001). Conversely, a healthy sleep pattern was associated with a lower risk of asthma in the low (HR, 0.56; 95% CI, 0.50-0.64), intermediate (HR, 0.59; 95% CI, 0.53-0.67), and high genetic susceptibility groups (HR, 0.63; 95% CI, 0.57-0.70). A population-attributable risk analysis indicated that improving these sleep traits would prevent 19% of asthma cases. Also, a subset analysis suggested that a healthy sleep pattern might reduce the risk of asthma among those at high genetic risk by 37%.

The study findings suggest that analysis of sleep patterns is warranted for all asthma patients, said coauthor Qing Wang, PhD, Cheeloo College of Medicine, Shandong University, Jinan, China, in an interview. “In our results, the effects of sleep and genetics were independent. Therefore, what we learned about the effects of sleep on asthma could be applied to all the patients, including those with a high or low genetic predisposition. In addition, we believe that intervening among those with high genetic predisposition could be more beneficial since they are more likely to have asthma. However, because this study is observational, a large clinical trial is absolutely needed to provide causal evidence, especially before guidelines modifications can be considered.”
 

Complex and multifactorial

“Addressing relevant asthma comorbid conditions continues to be an integral part of asthma care,” commented Diego J. Maselli, MD, associate professor of medicine and interim chief, division of pulmonary diseases and critical care, UT Health, San Antonio, in an interview. “There is mounting evidence that sleep patterns and obstructive sleep apnea may influence asthma control. This association is complex and multifactorial. It is important to remember that obstructive sleep apnea may coexist with other conditions, such as obesity and gastroesophageal reflux disease, that in turn can also worsen asthma control and influence clinical outcomes.

CHEST

“Yet, even after controlling for these factors, sleep disturbances have been associated with poor asthma outcomes. It is reasonable, particularly in patients with uncontrolled and/or severe asthma, to screen for sleep disturbances. There are multiple questionnaires and clinical tools that can be employed to screen for coexisting sleep apnea and other conditions. Although genetic testing has shown some promise in identifying individuals at risk, these assays are not widely available and are not ready yet for routine clinical practice. Therefore, sleep studies should be reserved for patients that have symptoms and test positive for screening questionnaires and other tools.

“The study by Xiang and colleagues adds to the field of study, but further evidence is required to change practice guidelines at this time. Fortunately, sleep studies are readily available now with more widespread use of home testing, so patients can be easily tested. The majority third-party payers have identified that diagnosing these disorders is cost-effective and are able to reimburse sleep studies,” Dr. Maselli concluded.

The research was funded by the Future Program for Young Scholars and National Key Research and Development Program. The study authors and Dr. Maselli have disclosed no relevant financial relationships.
 

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

As you may have seen in the February issue, in my year serving as President of the American College of Chest Physicians, I will be periodically contributing to CHEST Physician with the latest updates and to serve as a touchpoint for what we are currently working on.

For this contribution, I want to share and reflect upon the recent Nurse Work Environment study published by the American Association of Critical-Care Nurses (AACN). Deployed in 2021, the now-published study concluded that there is serious need for “bold, intentional, and relentless” efforts to create and sustain healthy work environments that foster excellence in patient care and optimal outcomes for patients, nurses, and other members of the health care team.

CHEST

To achieve this, AACN recommends adhering to the Healthy Work Environments (HWE) Standards created in 2005 but that are more pertinent than ever in 2023.

As close partners of the AACN through the Critical Care Societies Collaborative, the CHEST organization applauds and vehemently supports the need for increased efforts to support nurses and other members of the care team.

In a previous article for CHEST Physician, I spoke about my goals for 2023 and one of those goals was to focus on increasing the membership of a variety of providers who help care for patients, including advanced practice providers, respiratory therapists, registered nurses, and others. CHEST is already an inclusive organization to a variety of health care providers, but we can do more, and this is a great time to reemphasize the importance of the care team by showing our support of the AACN and the working conditions of nurses.

Beyond supporting other organizations, the CHEST Board of Regents will focus on new ways to make the organization a valuable resource to every member at every level of their career and with every designation.

The (HWE) Standards that I encourage all CHEST members to support include:

• Skilled communication and true collaboration between doctors, nurses and other clinicians.
• Effective decision-making that includes nurses in the process for input and expertise.
• Appropriate staffing that ensures an effective match between patient needs and the skills of the nurse.
• Meaningful recognition by rewarding and appreciating the value that everyone brings to the team.
• Authentic leadership that embraces a healthy work environment and is supportive of every member of the care team.

Let’s all make a dedicated effort to be intentional in our support of our care team colleagues to improve the working environment and overall patient care.

Think of one thing you can do at your own institution or in your practice to improve the work environment for all those on your team. And then make it happen!

Please reach out with ideas or questions.

As you may have seen in the February issue, in my year serving as President of the American College of Chest Physicians, I will be periodically contributing to CHEST Physician with the latest updates and to serve as a touchpoint for what we are currently working on.

For this contribution, I want to share and reflect upon the recent Nurse Work Environment study published by the American Association of Critical-Care Nurses (AACN). Deployed in 2021, the now-published study concluded that there is serious need for “bold, intentional, and relentless” efforts to create and sustain healthy work environments that foster excellence in patient care and optimal outcomes for patients, nurses, and other members of the health care team.

CHEST

To achieve this, AACN recommends adhering to the Healthy Work Environments (HWE) Standards created in 2005 but that are more pertinent than ever in 2023.

As close partners of the AACN through the Critical Care Societies Collaborative, the CHEST organization applauds and vehemently supports the need for increased efforts to support nurses and other members of the care team.

In a previous article for CHEST Physician, I spoke about my goals for 2023 and one of those goals was to focus on increasing the membership of a variety of providers who help care for patients, including advanced practice providers, respiratory therapists, registered nurses, and others. CHEST is already an inclusive organization to a variety of health care providers, but we can do more, and this is a great time to reemphasize the importance of the care team by showing our support of the AACN and the working conditions of nurses.

Beyond supporting other organizations, the CHEST Board of Regents will focus on new ways to make the organization a valuable resource to every member at every level of their career and with every designation.

The (HWE) Standards that I encourage all CHEST members to support include:

• Skilled communication and true collaboration between doctors, nurses and other clinicians.
• Effective decision-making that includes nurses in the process for input and expertise.
• Appropriate staffing that ensures an effective match between patient needs and the skills of the nurse.
• Meaningful recognition by rewarding and appreciating the value that everyone brings to the team.
• Authentic leadership that embraces a healthy work environment and is supportive of every member of the care team.

Let’s all make a dedicated effort to be intentional in our support of our care team colleagues to improve the working environment and overall patient care.

Think of one thing you can do at your own institution or in your practice to improve the work environment for all those on your team. And then make it happen!

Please reach out with ideas or questions.

As you may have seen in the February issue, in my year serving as President of the American College of Chest Physicians, I will be periodically contributing to CHEST Physician with the latest updates and to serve as a touchpoint for what we are currently working on.

For this contribution, I want to share and reflect upon the recent Nurse Work Environment study published by the American Association of Critical-Care Nurses (AACN). Deployed in 2021, the now-published study concluded that there is serious need for “bold, intentional, and relentless” efforts to create and sustain healthy work environments that foster excellence in patient care and optimal outcomes for patients, nurses, and other members of the health care team.

CHEST

To achieve this, AACN recommends adhering to the Healthy Work Environments (HWE) Standards created in 2005 but that are more pertinent than ever in 2023.

As close partners of the AACN through the Critical Care Societies Collaborative, the CHEST organization applauds and vehemently supports the need for increased efforts to support nurses and other members of the care team.

In a previous article for CHEST Physician, I spoke about my goals for 2023 and one of those goals was to focus on increasing the membership of a variety of providers who help care for patients, including advanced practice providers, respiratory therapists, registered nurses, and others. CHEST is already an inclusive organization to a variety of health care providers, but we can do more, and this is a great time to reemphasize the importance of the care team by showing our support of the AACN and the working conditions of nurses.

Beyond supporting other organizations, the CHEST Board of Regents will focus on new ways to make the organization a valuable resource to every member at every level of their career and with every designation.

The (HWE) Standards that I encourage all CHEST members to support include:

• Skilled communication and true collaboration between doctors, nurses and other clinicians.
• Effective decision-making that includes nurses in the process for input and expertise.
• Appropriate staffing that ensures an effective match between patient needs and the skills of the nurse.
• Meaningful recognition by rewarding and appreciating the value that everyone brings to the team.
• Authentic leadership that embraces a healthy work environment and is supportive of every member of the care team.

Let’s all make a dedicated effort to be intentional in our support of our care team colleagues to improve the working environment and overall patient care.

Think of one thing you can do at your own institution or in your practice to improve the work environment for all those on your team. And then make it happen!

Please reach out with ideas or questions.

The Food and Drug Administration on April 13 cleared the first patch to reduce excessive underarm sweating for adults with primary axillary hyperhidrosis.

The single-use, disposable, prescription-only patch will be marketed as Brella. It consists of a sodium sheet with an adhesive overlay. A health care provider applies it to the patient’s underarm for up to 3 minutes and then repeats the process on the other underarm.

The developer, Candesant Biomedical, says the patch uses the company’s patented targeted alkali thermolysis (TAT) technology, which was built on the principle that heat is generated when sodium reacts with water in sweat. “The thermal energy created by the sodium sheet is precisely localized, microtargeting sweat glands to significantly reduce sweat production,” according to the company’s press release announcing the FDA decision.

FDA clearance was based on data from the pivotal randomized, double-blind, multicenter SAHARA study, which indicated that the product is effective and well tolerated.

Patients experienced a reduction in sweat that was maintained for 3 months or longer, according to trial results.

The SAHARA trial results were reported in a late-breaking abstract at the annual meeting of the American Academy of Dermatology in March.

The trial enrolled 110 individuals with Hyperhidrosis Disease Severity Scale (HDSS) scores of 3 or 4 (indicating frequent sweating or sweating that always interferes with daily activities). Trial participants were randomly assigned to receive either an active TAT or a sham patch, which was applied for up to 3 minutes.

At the meeting, lead investigator David M. Pariser, MD, a dermatologist practicing in Norfolk, Va., reported that at 4 weeks, 63.6% of patients in the active patch group achieved an HDSS score of 1 or 2, compared with 44.2% of those in the sham treatment group (P = .0332). Also, 43.2% of those in the active-patch group achieved an improvement of 2 points or greater on the HDSS, as compared with 16.3% of those in the sham treatment group (P = .0107) .

In addition, 9.1% of those in the active-patch group achieved a 3-point improvement on the HDSS, compared with none in the sham group. “That’s an amazing improvement; you’re basically going from moderate or severe to none,” Dr. Pariser said at the meeting.

As for adverse events (AEs), 13 patients in the active-patch group experienced AEs at the treatment site. Six patients experienced erythema; four experienced erosion; two experienced burning, itching, or stinging; and one had underarm odor.

“The two procedure-related AEs in the TAT-treated group were compensatory sweating and irritant contact dermatitis due to the adhesive,” Dr. Pariser said. He noted that most AEs resolved in fewer than 2 weeks, and all AEs were mild to moderate.

According to the International Hyperhidrosis Society, about 1.3 million people in the United States have axillary hyperhidrosis, and about a third report that sweating is barely tolerable and frequently interferes with daily activities or is intolerable and always interferes with daily activities.

The patch will be available within months in select U.S. markets beginning in late summer. The company says the markets will be listed on its website.

A company representative told this news organization that because it is an in-office procedure, pricing will vary, depending on the practice. “With that said, Candesant expects doctors will charge about the same for one session of the Brella SweatControl Patch as they would for a high-end, in-office facial or chemical peel,” the representative said.

Dr. Pariser is a consultant or investigator for Bickel Biotechnology, Biofrontera AG, Bristol-Myers Squibb, the Celgene Corporation, Novartis Pharmaceuticals, Pfizer, Regeneron, and Sanofi.

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

The Food and Drug Administration on April 13 cleared the first patch to reduce excessive underarm sweating for adults with primary axillary hyperhidrosis.

The single-use, disposable, prescription-only patch will be marketed as Brella. It consists of a sodium sheet with an adhesive overlay. A health care provider applies it to the patient’s underarm for up to 3 minutes and then repeats the process on the other underarm.

The developer, Candesant Biomedical, says the patch uses the company’s patented targeted alkali thermolysis (TAT) technology, which was built on the principle that heat is generated when sodium reacts with water in sweat. “The thermal energy created by the sodium sheet is precisely localized, microtargeting sweat glands to significantly reduce sweat production,” according to the company’s press release announcing the FDA decision.

FDA clearance was based on data from the pivotal randomized, double-blind, multicenter SAHARA study, which indicated that the product is effective and well tolerated.

Patients experienced a reduction in sweat that was maintained for 3 months or longer, according to trial results.

The SAHARA trial results were reported in a late-breaking abstract at the annual meeting of the American Academy of Dermatology in March.

The trial enrolled 110 individuals with Hyperhidrosis Disease Severity Scale (HDSS) scores of 3 or 4 (indicating frequent sweating or sweating that always interferes with daily activities). Trial participants were randomly assigned to receive either an active TAT or a sham patch, which was applied for up to 3 minutes.

At the meeting, lead investigator David M. Pariser, MD, a dermatologist practicing in Norfolk, Va., reported that at 4 weeks, 63.6% of patients in the active patch group achieved an HDSS score of 1 or 2, compared with 44.2% of those in the sham treatment group (P = .0332). Also, 43.2% of those in the active-patch group achieved an improvement of 2 points or greater on the HDSS, as compared with 16.3% of those in the sham treatment group (P = .0107) .

In addition, 9.1% of those in the active-patch group achieved a 3-point improvement on the HDSS, compared with none in the sham group. “That’s an amazing improvement; you’re basically going from moderate or severe to none,” Dr. Pariser said at the meeting.

As for adverse events (AEs), 13 patients in the active-patch group experienced AEs at the treatment site. Six patients experienced erythema; four experienced erosion; two experienced burning, itching, or stinging; and one had underarm odor.

“The two procedure-related AEs in the TAT-treated group were compensatory sweating and irritant contact dermatitis due to the adhesive,” Dr. Pariser said. He noted that most AEs resolved in fewer than 2 weeks, and all AEs were mild to moderate.

According to the International Hyperhidrosis Society, about 1.3 million people in the United States have axillary hyperhidrosis, and about a third report that sweating is barely tolerable and frequently interferes with daily activities or is intolerable and always interferes with daily activities.

The patch will be available within months in select U.S. markets beginning in late summer. The company says the markets will be listed on its website.

A company representative told this news organization that because it is an in-office procedure, pricing will vary, depending on the practice. “With that said, Candesant expects doctors will charge about the same for one session of the Brella SweatControl Patch as they would for a high-end, in-office facial or chemical peel,” the representative said.

Dr. Pariser is a consultant or investigator for Bickel Biotechnology, Biofrontera AG, Bristol-Myers Squibb, the Celgene Corporation, Novartis Pharmaceuticals, Pfizer, Regeneron, and Sanofi.

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

The Food and Drug Administration on April 13 cleared the first patch to reduce excessive underarm sweating for adults with primary axillary hyperhidrosis.

The single-use, disposable, prescription-only patch will be marketed as Brella. It consists of a sodium sheet with an adhesive overlay. A health care provider applies it to the patient’s underarm for up to 3 minutes and then repeats the process on the other underarm.

The developer, Candesant Biomedical, says the patch uses the company’s patented targeted alkali thermolysis (TAT) technology, which was built on the principle that heat is generated when sodium reacts with water in sweat. “The thermal energy created by the sodium sheet is precisely localized, microtargeting sweat glands to significantly reduce sweat production,” according to the company’s press release announcing the FDA decision.

FDA clearance was based on data from the pivotal randomized, double-blind, multicenter SAHARA study, which indicated that the product is effective and well tolerated.

Patients experienced a reduction in sweat that was maintained for 3 months or longer, according to trial results.

The SAHARA trial results were reported in a late-breaking abstract at the annual meeting of the American Academy of Dermatology in March.

The trial enrolled 110 individuals with Hyperhidrosis Disease Severity Scale (HDSS) scores of 3 or 4 (indicating frequent sweating or sweating that always interferes with daily activities). Trial participants were randomly assigned to receive either an active TAT or a sham patch, which was applied for up to 3 minutes.

At the meeting, lead investigator David M. Pariser, MD, a dermatologist practicing in Norfolk, Va., reported that at 4 weeks, 63.6% of patients in the active patch group achieved an HDSS score of 1 or 2, compared with 44.2% of those in the sham treatment group (P = .0332). Also, 43.2% of those in the active-patch group achieved an improvement of 2 points or greater on the HDSS, as compared with 16.3% of those in the sham treatment group (P = .0107) .

In addition, 9.1% of those in the active-patch group achieved a 3-point improvement on the HDSS, compared with none in the sham group. “That’s an amazing improvement; you’re basically going from moderate or severe to none,” Dr. Pariser said at the meeting.

As for adverse events (AEs), 13 patients in the active-patch group experienced AEs at the treatment site. Six patients experienced erythema; four experienced erosion; two experienced burning, itching, or stinging; and one had underarm odor.

“The two procedure-related AEs in the TAT-treated group were compensatory sweating and irritant contact dermatitis due to the adhesive,” Dr. Pariser said. He noted that most AEs resolved in fewer than 2 weeks, and all AEs were mild to moderate.

According to the International Hyperhidrosis Society, about 1.3 million people in the United States have axillary hyperhidrosis, and about a third report that sweating is barely tolerable and frequently interferes with daily activities or is intolerable and always interferes with daily activities.

The patch will be available within months in select U.S. markets beginning in late summer. The company says the markets will be listed on its website.

A company representative told this news organization that because it is an in-office procedure, pricing will vary, depending on the practice. “With that said, Candesant expects doctors will charge about the same for one session of the Brella SweatControl Patch as they would for a high-end, in-office facial or chemical peel,” the representative said.

Dr. Pariser is a consultant or investigator for Bickel Biotechnology, Biofrontera AG, Bristol-Myers Squibb, the Celgene Corporation, Novartis Pharmaceuticals, Pfizer, Regeneron, and Sanofi.

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

Electroconvulsive therapy appears to have a small advantage over ketamine for improving depressive symptoms in adults with a major depressive episode, results of a new review show.

“Although ECT is superior to ketamine for patients with a major depressive episode, our findings suggest that the therapeutic advantage may be smaller than what was demonstrated in prior analyses,” first author Vikas Menon, MD, department of psychiatry, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India, told this news organization.

“This supports a recommendation for a trial of ketamine before a trial of ECT for patients with MDE, though this recommendation is limited by the small size and number of existing trials,” Dr. Menon said.

The study was published online in JAMA Psychiatry.
 

Questions remain

The meta-analysis included five trials of 278 adults with MDE (141 treated with ketamine and 137 with ECT).

In the main analysis, posttreatment depression ratings showed a trend for lower scores with ECT, compared with ketamine (standardized mean difference, −0.39; 95% confidence interval, −0.81 to 0.02). 

In a sensitivity analysis of the two methodologically stronger trials, ECT was superior to ketamine (pooled SMD, −0.45; 95% CI, −0.75 to −0.14).

ECT was also superior to ketamine in terms of response rates (risk ratio, 1.27; 95% CI, 1.06-1.53) and remission rates (RR, 1.43; 95% CI, 1.12-1.82).

There were no significant between-group differences for number of sessions to response and remission and for cognitive outcomes.

Key limitations of the analysis were the small number of studies with limited sample sizes and a high risk of bias in all trials.

“There is a need for more comparative studies with adequate sample size in non-inferiority designs, examining a wider range of benefits and side effects and followed up for longer durations to answer clinically relevant questions about the nature and durability of observed benefits with ketamine,” said Dr. Menon.

“In patients with MDE for whom the administration of ECT is limited by restricted availability of the treatment, concerns about its cognitive adverse effects, negative patient attitudes, and other issues, clinicians may consider a trial of ketamine,” he added.
 

‘Important research’

Several experts offered perspective on the analysis in a statement from the U.K.-based nonprofit Science Media Centre, which was not involved with the conduct of this study.

Rupert McShane, MD, psychiatrist at the University of Oxford (England), noted that ECT and ketamine are both “potent” treatments for depression, and this meta-analysis shows that they are, “broadly speaking, equally as good as each other with perhaps a slight advantage for ECT.”

“Whether or not there is a difference depends on exactly how you define it and how you cut the data. Despite the slight advantage for ECT in this analysis, the authors support using ketamine before ECT, especially in patients who are worried about the cognitive risks of ECT. This seems sensible,” Dr. McShane said.

Allan Young, MBChB, clinical psychiatrist at King’s College London, noted that both ketamine and ECT have been shown to help some patients with treatment-resistant depression.

“Clearly the relative benefits of these two treatments need to be understood better, but this review of the existing literature suggests that ECT may benefit some more than ketamine,” said Mr. Young.

“There is evidence that ketamine with ECT may add little extra benefit, but much more work needs to be done to fully understand how these treatments fit best into the treatment pathway for major depressive episodes. However, based on this evidence, ECT clearly still merits a place in the treatment pathway,” Mr. Young added.

George Kirov, PhD, clinical professor, division of psychological medicine and clinical neurosciences, Cardiff University (England), said while the study is conducted well, most of the evidence is coming from one large trial conducted in Sweden.

“The other studies add small numbers of patients and the authors even present a sensitivity analysis after removing studies of poor quality, thus leaving only two studies and exposing even further the dependence of the results on one single study,” Dr. Kirov noted. 

“The small studies should not be blamed for their size, as this is very difficult research to perform. On the other hand, the trends were in the same direction,” he added.

With those caveats in mind, Dr. Kirov said he still thinks this is “important research. It establishes the superiority of ECT against an active comparator (ketamine) which is very popular now and accepted to be quite effective.”

The study had no specific funding. Dr. Menon reports no relevant financial relationships. Dr. McShane is former chair of the ECT and Related Treatments Committee, Royal College of Psychiatrists and runs a ketamine clinic and an ECT service. Mr. Young has received compensation for lectures and advisory boards for AstraZeneca, Eli Lilly, Lundbeck, Sunovion, Servier, Livanova, Janssen, Allergan, Bionomics, Sumitomo Dainippon Pharma, COMPASS, and Sage, and has served as principal investigator on a trial of intranasal esketamine in treatment-resistant depression. Dr. Kirov has no interest to declare other than running the ECT service in Cardiff.

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

Electroconvulsive therapy appears to have a small advantage over ketamine for improving depressive symptoms in adults with a major depressive episode, results of a new review show.

“Although ECT is superior to ketamine for patients with a major depressive episode, our findings suggest that the therapeutic advantage may be smaller than what was demonstrated in prior analyses,” first author Vikas Menon, MD, department of psychiatry, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India, told this news organization.

“This supports a recommendation for a trial of ketamine before a trial of ECT for patients with MDE, though this recommendation is limited by the small size and number of existing trials,” Dr. Menon said.

The study was published online in JAMA Psychiatry.
 

Questions remain

The meta-analysis included five trials of 278 adults with MDE (141 treated with ketamine and 137 with ECT).

In the main analysis, posttreatment depression ratings showed a trend for lower scores with ECT, compared with ketamine (standardized mean difference, −0.39; 95% confidence interval, −0.81 to 0.02). 

In a sensitivity analysis of the two methodologically stronger trials, ECT was superior to ketamine (pooled SMD, −0.45; 95% CI, −0.75 to −0.14).

ECT was also superior to ketamine in terms of response rates (risk ratio, 1.27; 95% CI, 1.06-1.53) and remission rates (RR, 1.43; 95% CI, 1.12-1.82).

There were no significant between-group differences for number of sessions to response and remission and for cognitive outcomes.

Key limitations of the analysis were the small number of studies with limited sample sizes and a high risk of bias in all trials.

“There is a need for more comparative studies with adequate sample size in non-inferiority designs, examining a wider range of benefits and side effects and followed up for longer durations to answer clinically relevant questions about the nature and durability of observed benefits with ketamine,” said Dr. Menon.

“In patients with MDE for whom the administration of ECT is limited by restricted availability of the treatment, concerns about its cognitive adverse effects, negative patient attitudes, and other issues, clinicians may consider a trial of ketamine,” he added.
 

‘Important research’

Several experts offered perspective on the analysis in a statement from the U.K.-based nonprofit Science Media Centre, which was not involved with the conduct of this study.

Rupert McShane, MD, psychiatrist at the University of Oxford (England), noted that ECT and ketamine are both “potent” treatments for depression, and this meta-analysis shows that they are, “broadly speaking, equally as good as each other with perhaps a slight advantage for ECT.”

“Whether or not there is a difference depends on exactly how you define it and how you cut the data. Despite the slight advantage for ECT in this analysis, the authors support using ketamine before ECT, especially in patients who are worried about the cognitive risks of ECT. This seems sensible,” Dr. McShane said.

Allan Young, MBChB, clinical psychiatrist at King’s College London, noted that both ketamine and ECT have been shown to help some patients with treatment-resistant depression.

“Clearly the relative benefits of these two treatments need to be understood better, but this review of the existing literature suggests that ECT may benefit some more than ketamine,” said Mr. Young.

“There is evidence that ketamine with ECT may add little extra benefit, but much more work needs to be done to fully understand how these treatments fit best into the treatment pathway for major depressive episodes. However, based on this evidence, ECT clearly still merits a place in the treatment pathway,” Mr. Young added.

George Kirov, PhD, clinical professor, division of psychological medicine and clinical neurosciences, Cardiff University (England), said while the study is conducted well, most of the evidence is coming from one large trial conducted in Sweden.

“The other studies add small numbers of patients and the authors even present a sensitivity analysis after removing studies of poor quality, thus leaving only two studies and exposing even further the dependence of the results on one single study,” Dr. Kirov noted. 

“The small studies should not be blamed for their size, as this is very difficult research to perform. On the other hand, the trends were in the same direction,” he added.

With those caveats in mind, Dr. Kirov said he still thinks this is “important research. It establishes the superiority of ECT against an active comparator (ketamine) which is very popular now and accepted to be quite effective.”

The study had no specific funding. Dr. Menon reports no relevant financial relationships. Dr. McShane is former chair of the ECT and Related Treatments Committee, Royal College of Psychiatrists and runs a ketamine clinic and an ECT service. Mr. Young has received compensation for lectures and advisory boards for AstraZeneca, Eli Lilly, Lundbeck, Sunovion, Servier, Livanova, Janssen, Allergan, Bionomics, Sumitomo Dainippon Pharma, COMPASS, and Sage, and has served as principal investigator on a trial of intranasal esketamine in treatment-resistant depression. Dr. Kirov has no interest to declare other than running the ECT service in Cardiff.

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

Electroconvulsive therapy appears to have a small advantage over ketamine for improving depressive symptoms in adults with a major depressive episode, results of a new review show.

“Although ECT is superior to ketamine for patients with a major depressive episode, our findings suggest that the therapeutic advantage may be smaller than what was demonstrated in prior analyses,” first author Vikas Menon, MD, department of psychiatry, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India, told this news organization.

“This supports a recommendation for a trial of ketamine before a trial of ECT for patients with MDE, though this recommendation is limited by the small size and number of existing trials,” Dr. Menon said.

The study was published online in JAMA Psychiatry.
 

Questions remain

The meta-analysis included five trials of 278 adults with MDE (141 treated with ketamine and 137 with ECT).

In the main analysis, posttreatment depression ratings showed a trend for lower scores with ECT, compared with ketamine (standardized mean difference, −0.39; 95% confidence interval, −0.81 to 0.02). 

In a sensitivity analysis of the two methodologically stronger trials, ECT was superior to ketamine (pooled SMD, −0.45; 95% CI, −0.75 to −0.14).

ECT was also superior to ketamine in terms of response rates (risk ratio, 1.27; 95% CI, 1.06-1.53) and remission rates (RR, 1.43; 95% CI, 1.12-1.82).

There were no significant between-group differences for number of sessions to response and remission and for cognitive outcomes.

Key limitations of the analysis were the small number of studies with limited sample sizes and a high risk of bias in all trials.

“There is a need for more comparative studies with adequate sample size in non-inferiority designs, examining a wider range of benefits and side effects and followed up for longer durations to answer clinically relevant questions about the nature and durability of observed benefits with ketamine,” said Dr. Menon.

“In patients with MDE for whom the administration of ECT is limited by restricted availability of the treatment, concerns about its cognitive adverse effects, negative patient attitudes, and other issues, clinicians may consider a trial of ketamine,” he added.
 

‘Important research’

Several experts offered perspective on the analysis in a statement from the U.K.-based nonprofit Science Media Centre, which was not involved with the conduct of this study.

Rupert McShane, MD, psychiatrist at the University of Oxford (England), noted that ECT and ketamine are both “potent” treatments for depression, and this meta-analysis shows that they are, “broadly speaking, equally as good as each other with perhaps a slight advantage for ECT.”

“Whether or not there is a difference depends on exactly how you define it and how you cut the data. Despite the slight advantage for ECT in this analysis, the authors support using ketamine before ECT, especially in patients who are worried about the cognitive risks of ECT. This seems sensible,” Dr. McShane said.

Allan Young, MBChB, clinical psychiatrist at King’s College London, noted that both ketamine and ECT have been shown to help some patients with treatment-resistant depression.

“Clearly the relative benefits of these two treatments need to be understood better, but this review of the existing literature suggests that ECT may benefit some more than ketamine,” said Mr. Young.

“There is evidence that ketamine with ECT may add little extra benefit, but much more work needs to be done to fully understand how these treatments fit best into the treatment pathway for major depressive episodes. However, based on this evidence, ECT clearly still merits a place in the treatment pathway,” Mr. Young added.

George Kirov, PhD, clinical professor, division of psychological medicine and clinical neurosciences, Cardiff University (England), said while the study is conducted well, most of the evidence is coming from one large trial conducted in Sweden.

“The other studies add small numbers of patients and the authors even present a sensitivity analysis after removing studies of poor quality, thus leaving only two studies and exposing even further the dependence of the results on one single study,” Dr. Kirov noted. 

“The small studies should not be blamed for their size, as this is very difficult research to perform. On the other hand, the trends were in the same direction,” he added.

With those caveats in mind, Dr. Kirov said he still thinks this is “important research. It establishes the superiority of ECT against an active comparator (ketamine) which is very popular now and accepted to be quite effective.”

The study had no specific funding. Dr. Menon reports no relevant financial relationships. Dr. McShane is former chair of the ECT and Related Treatments Committee, Royal College of Psychiatrists and runs a ketamine clinic and an ECT service. Mr. Young has received compensation for lectures and advisory boards for AstraZeneca, Eli Lilly, Lundbeck, Sunovion, Servier, Livanova, Janssen, Allergan, Bionomics, Sumitomo Dainippon Pharma, COMPASS, and Sage, and has served as principal investigator on a trial of intranasal esketamine in treatment-resistant depression. Dr. Kirov has no interest to declare other than running the ECT service in Cardiff.

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

“They Paused Puberty but Is There a Cost?”

“Bone Health: Puberty Blockers Not Fully Reversible.”

UT Southwestern Medical Center

Headlines such as these from major national news outlets have begun to cast doubt on one of the medications used in treating gender-diverse adolescents and young adults. GnRH agonists, such as leuprorelin and triptorelin, were first approved by the Food and Drug Administration in the 1980s and have been used since then for a variety of medical indications. In the decades since, these medications have been successfully used with a generally favorable side effect profile.

GnRH agonists and puberty

In the treatment of precocious puberty, GnRH agonists are often started prior to the age of 7, depending on the age at which the affected patient begins showing signs of central puberty. These include breast development, scrotal enlargement, and so on. GnRH agonists typically are continued until age 10-12, depending on the patient and an informed discussion with the patient’s parents about optimal outcomes.¹ Therefore, it is not uncommon to see these medications used for anywhere from 1 to 4 years, depending on the age at which precocious puberty started.

GnRH agonists are used in two populations of transgender individuals. The first group is those youths who have just started their natal, or biological, puberty. The medication is not started until the patient has biochemical or physical exam evidence that puberty has started. The medication is then continued until hormones are started. This is usually 2-3 years on average, depending on the age at which the medication was started. This is essentially comparable with cisgender youths who have taken these medications for precocious puberty. The second population of individuals who use GnRH agonists is transgender women who are also on estrogen therapy. In these women, the GnRH agonist is used for androgen (testosterone) suppression.
 

Concerns over bone health

One of the main concerns recently expressed about long-term use of GnRH agonists is their effect on bone density. Adolescence is a critical time for bone mineral density (BMD) accrual and this is driven by sex hormones. When GnRH agonists are used to delay puberty in transgender adolescents, this then delays the maturation of the adult skeleton until the GnRH agonist is stopped (and natal puberty resumes) or cross-sex hormones are started. In a recent multicenter study² looking at baseline BMD of transgender youth at the time of GnRH agonist initiation, 30% of those assigned male at birth and 13% of those assigned female at birth had low bone mineral density for age (defined as a BMD z score of <–2). For those with low BMD, their physical activity scores were significantly lower than those with normal BMD. Thus, these adolescents require close follow-up, just like their cisgender peers.

There are currently no long-term data on the risk of developing fractures or osteoporosis in those individuals who were treated with GnRH agonists and then went on to start cross-sex hormone therapy. Some studies suggest that there is a risk that BMD does not recover after being on cross-sex hormones,³ while another study suggested that transgender men recover their BMD after being on testosterone.⁴ It is still unclear in that study why transgender women did not recover their BMD or why they were low at baseline. Interestingly, a 2012 study⁵ from Brazil showed that there was no difference in BMD for cisgender girls who had been off their GnRH agonist therapy for at least 3 years, as compared with their age-matched controls who had never been on GnRH agonist therapy. These conflicting data highlight the importance of long-term follow-up, as well as the need to include age-matched, cisgender control subjects, to better understand if there is truly a difference in transgender individuals or if today’s adolescents, in general, have low BMD.
 

Lingering questions

In summary, the use of GnRH agonists in transgender adolescents remains controversial because of the potential long-term effects on bone mineral density. However, this risk must be balanced against the risks of allowing natal puberty to progress in certain transgender individuals with the development of undesired secondary sex characteristics. More longitudinal studies are needed to better understand the long-term risks of osteoporosis and fractures in those who have undergone GnRH agonist therapy as part of their gender-affirming medical care, as well as any clinical interventions that might help mitigate this risk.

Dr. Cooper is assistant professor of pediatrics at UT Southwestern, Dallas, and an adolescent medicine specialist at Children’s Medical Center Dallas.

References

1. Harrington J et al. Treatment of precocious puberty. UpToDate. www.uptodate.com/contents/treatment-of-precocious-puberty.

2. Lee JY et al. J Endocr Soc. 2020;4(9):bvaa065. doi: 10.1210/jendso/bvaa065.

3. Klink D et al. J Clin Endocrinol Metab. 2015;100(2):E270-5. doi: 10.1210/jc.2014-2439.

4. Schagen SEE et al. J Clin Endocrinol Metab. 2020;105(12):e4252-e4263. doi: 10.1210/clinem/dgaa604.

5. Alessandri SB et al. Clinics (Sao Paulo). 2012;67(6):591-6. doi: 10.6061/clinics/2012(06)08.
 

“They Paused Puberty but Is There a Cost?”

“Bone Health: Puberty Blockers Not Fully Reversible.”

UT Southwestern Medical Center

Headlines such as these from major national news outlets have begun to cast doubt on one of the medications used in treating gender-diverse adolescents and young adults. GnRH agonists, such as leuprorelin and triptorelin, were first approved by the Food and Drug Administration in the 1980s and have been used since then for a variety of medical indications. In the decades since, these medications have been successfully used with a generally favorable side effect profile.

GnRH agonists and puberty

In the treatment of precocious puberty, GnRH agonists are often started prior to the age of 7, depending on the age at which the affected patient begins showing signs of central puberty. These include breast development, scrotal enlargement, and so on. GnRH agonists typically are continued until age 10-12, depending on the patient and an informed discussion with the patient’s parents about optimal outcomes.¹ Therefore, it is not uncommon to see these medications used for anywhere from 1 to 4 years, depending on the age at which precocious puberty started.

GnRH agonists are used in two populations of transgender individuals. The first group is those youths who have just started their natal, or biological, puberty. The medication is not started until the patient has biochemical or physical exam evidence that puberty has started. The medication is then continued until hormones are started. This is usually 2-3 years on average, depending on the age at which the medication was started. This is essentially comparable with cisgender youths who have taken these medications for precocious puberty. The second population of individuals who use GnRH agonists is transgender women who are also on estrogen therapy. In these women, the GnRH agonist is used for androgen (testosterone) suppression.
 

Concerns over bone health

One of the main concerns recently expressed about long-term use of GnRH agonists is their effect on bone density. Adolescence is a critical time for bone mineral density (BMD) accrual and this is driven by sex hormones. When GnRH agonists are used to delay puberty in transgender adolescents, this then delays the maturation of the adult skeleton until the GnRH agonist is stopped (and natal puberty resumes) or cross-sex hormones are started. In a recent multicenter study² looking at baseline BMD of transgender youth at the time of GnRH agonist initiation, 30% of those assigned male at birth and 13% of those assigned female at birth had low bone mineral density for age (defined as a BMD z score of <–2). For those with low BMD, their physical activity scores were significantly lower than those with normal BMD. Thus, these adolescents require close follow-up, just like their cisgender peers.

There are currently no long-term data on the risk of developing fractures or osteoporosis in those individuals who were treated with GnRH agonists and then went on to start cross-sex hormone therapy. Some studies suggest that there is a risk that BMD does not recover after being on cross-sex hormones,³ while another study suggested that transgender men recover their BMD after being on testosterone.⁴ It is still unclear in that study why transgender women did not recover their BMD or why they were low at baseline. Interestingly, a 2012 study⁵ from Brazil showed that there was no difference in BMD for cisgender girls who had been off their GnRH agonist therapy for at least 3 years, as compared with their age-matched controls who had never been on GnRH agonist therapy. These conflicting data highlight the importance of long-term follow-up, as well as the need to include age-matched, cisgender control subjects, to better understand if there is truly a difference in transgender individuals or if today’s adolescents, in general, have low BMD.
 

Lingering questions

In summary, the use of GnRH agonists in transgender adolescents remains controversial because of the potential long-term effects on bone mineral density. However, this risk must be balanced against the risks of allowing natal puberty to progress in certain transgender individuals with the development of undesired secondary sex characteristics. More longitudinal studies are needed to better understand the long-term risks of osteoporosis and fractures in those who have undergone GnRH agonist therapy as part of their gender-affirming medical care, as well as any clinical interventions that might help mitigate this risk.

Dr. Cooper is assistant professor of pediatrics at UT Southwestern, Dallas, and an adolescent medicine specialist at Children’s Medical Center Dallas.

References

1. Harrington J et al. Treatment of precocious puberty. UpToDate. www.uptodate.com/contents/treatment-of-precocious-puberty.

2. Lee JY et al. J Endocr Soc. 2020;4(9):bvaa065. doi: 10.1210/jendso/bvaa065.

3. Klink D et al. J Clin Endocrinol Metab. 2015;100(2):E270-5. doi: 10.1210/jc.2014-2439.

4. Schagen SEE et al. J Clin Endocrinol Metab. 2020;105(12):e4252-e4263. doi: 10.1210/clinem/dgaa604.

5. Alessandri SB et al. Clinics (Sao Paulo). 2012;67(6):591-6. doi: 10.6061/clinics/2012(06)08.
 

“They Paused Puberty but Is There a Cost?”

“Bone Health: Puberty Blockers Not Fully Reversible.”

UT Southwestern Medical Center

Headlines such as these from major national news outlets have begun to cast doubt on one of the medications used in treating gender-diverse adolescents and young adults. GnRH agonists, such as leuprorelin and triptorelin, were first approved by the Food and Drug Administration in the 1980s and have been used since then for a variety of medical indications. In the decades since, these medications have been successfully used with a generally favorable side effect profile.

GnRH agonists and puberty

In the treatment of precocious puberty, GnRH agonists are often started prior to the age of 7, depending on the age at which the affected patient begins showing signs of central puberty. These include breast development, scrotal enlargement, and so on. GnRH agonists typically are continued until age 10-12, depending on the patient and an informed discussion with the patient’s parents about optimal outcomes.¹ Therefore, it is not uncommon to see these medications used for anywhere from 1 to 4 years, depending on the age at which precocious puberty started.

GnRH agonists are used in two populations of transgender individuals. The first group is those youths who have just started their natal, or biological, puberty. The medication is not started until the patient has biochemical or physical exam evidence that puberty has started. The medication is then continued until hormones are started. This is usually 2-3 years on average, depending on the age at which the medication was started. This is essentially comparable with cisgender youths who have taken these medications for precocious puberty. The second population of individuals who use GnRH agonists is transgender women who are also on estrogen therapy. In these women, the GnRH agonist is used for androgen (testosterone) suppression.
 

Concerns over bone health

One of the main concerns recently expressed about long-term use of GnRH agonists is their effect on bone density. Adolescence is a critical time for bone mineral density (BMD) accrual and this is driven by sex hormones. When GnRH agonists are used to delay puberty in transgender adolescents, this then delays the maturation of the adult skeleton until the GnRH agonist is stopped (and natal puberty resumes) or cross-sex hormones are started. In a recent multicenter study² looking at baseline BMD of transgender youth at the time of GnRH agonist initiation, 30% of those assigned male at birth and 13% of those assigned female at birth had low bone mineral density for age (defined as a BMD z score of <–2). For those with low BMD, their physical activity scores were significantly lower than those with normal BMD. Thus, these adolescents require close follow-up, just like their cisgender peers.

There are currently no long-term data on the risk of developing fractures or osteoporosis in those individuals who were treated with GnRH agonists and then went on to start cross-sex hormone therapy. Some studies suggest that there is a risk that BMD does not recover after being on cross-sex hormones,³ while another study suggested that transgender men recover their BMD after being on testosterone.⁴ It is still unclear in that study why transgender women did not recover their BMD or why they were low at baseline. Interestingly, a 2012 study⁵ from Brazil showed that there was no difference in BMD for cisgender girls who had been off their GnRH agonist therapy for at least 3 years, as compared with their age-matched controls who had never been on GnRH agonist therapy. These conflicting data highlight the importance of long-term follow-up, as well as the need to include age-matched, cisgender control subjects, to better understand if there is truly a difference in transgender individuals or if today’s adolescents, in general, have low BMD.
 

Lingering questions

In summary, the use of GnRH agonists in transgender adolescents remains controversial because of the potential long-term effects on bone mineral density. However, this risk must be balanced against the risks of allowing natal puberty to progress in certain transgender individuals with the development of undesired secondary sex characteristics. More longitudinal studies are needed to better understand the long-term risks of osteoporosis and fractures in those who have undergone GnRH agonist therapy as part of their gender-affirming medical care, as well as any clinical interventions that might help mitigate this risk.

Dr. Cooper is assistant professor of pediatrics at UT Southwestern, Dallas, and an adolescent medicine specialist at Children’s Medical Center Dallas.

References

1. Harrington J et al. Treatment of precocious puberty. UpToDate. www.uptodate.com/contents/treatment-of-precocious-puberty.

2. Lee JY et al. J Endocr Soc. 2020;4(9):bvaa065. doi: 10.1210/jendso/bvaa065.

3. Klink D et al. J Clin Endocrinol Metab. 2015;100(2):E270-5. doi: 10.1210/jc.2014-2439.

4. Schagen SEE et al. J Clin Endocrinol Metab. 2020;105(12):e4252-e4263. doi: 10.1210/clinem/dgaa604.

5. Alessandri SB et al. Clinics (Sao Paulo). 2012;67(6):591-6. doi: 10.6061/clinics/2012(06)08.
 

In my most recent column, “ ‘They All Laughed When I Spoke of Greedy Doctors,’ ” I attempted to provide a global understanding of some of the economic forces that have made American medicine what it is, how that happened, and why it is still happening.

I did not propose a fix. I have been proposing fixes for more than 30 years, on the pages of JAMA until 1999 and then for this news organization, most recently in 2019 with “Healthcare for All in a Land of Special Interests.”

Where you stand depends a lot on where you sit.

Is this good news or bad news? When William Hubbard was the dean of the University of Michigan School of Medicine in 1969, he said that “an academic medical center is the most efficient energy and resource trapping device that has ever been created” (personal communication, 1969).

To me as a faculty member of an academic medical center for many years, that was great news. We could grow faculty, erect buildings, take the best care of sick people, churn out research papers, mint new physicians and specialists, and get paid well in the process for doing “the Lord’s work.” What’s not to like? At that time, the proportion of the country’s gross national product expended for medical and health care was about 7%. And the predicted life span of an American at birth was 70.5 years.

Is this good news or bad news? In 2021, the proportion of our annual gross domestic product (GDP) consumed by health care was 18.3%, totaling $4.3 trillion, or $12,914 per person. For perspective, in 2021, the median income per capita was $37,638. Because quite a few Americans have very high incomes, the mean income per capita is much higher: $63,444. Predicted life span in 2021 was 76.4 years.

Thus, in a span of 53 years (1969-2022), only 5.9 years of life were gained per person born, for how many trillions of dollars expended? To me as a tax-paying citizen and payer of medical insurance premiums, that is bad news.

Is this good news or bad news? If we compare developed societies globally, our medical system does a whole lot of things very well indeed. But we spend a great deal more than any other country for health care and objectively achieve poorer outcomes. Thus, we are neither efficient nor effective. We keep a lot of workers very busy doing stuff, and they are generally well paid. As a worker, that’s good news; as a manager who values efficiency, it’s bad news indeed.

Is this good news or bad news? We’re the leader at finding money to pay people to do “health care work.” More Americans work in health care than any other field. In 2019, the United States employed some 21,000,000 people doing “health care and social assistance.” Among others, these occupations include physicians, dentists, dental hygienists and assistants, pharmacists, registered nurses, LVNs/LPNs, nursing aides, technologists and technicians, home health aides, respiratory therapists, occupational and speech therapists, social workers, childcare workers, and personal and home care aides. For a patient, parent, grandparent, and great-grandparent, it is good news to have all those folks available to take care of us when we need it.

So, while I have cringed at the frequent exposés from Roy Poses of what seem to me to be massive societal betrayals by American health care industry giants, it doesn’t have to be that way. Might it still be possible to do well while doing good?
 

A jobs program

Consider such common medical procedures as coronary artery stents or bypass grafts for stable angina (when optimal medical therapy is as good, or better than, and much less expensive); PSAs on asymptomatic men followed by unnecessary surgery for localized cancer; excess surgery for low back pain; and the jobs created by managing the people caught up in medical complications of the obesity epidemic.

Don’t forget the number of people employed simply to “follow the money” within our byzantine cockamamie medical billing system. In 2009, this prompted me to describe the bloated system as a “health care bubble” not unlike Enron, the submarket real estate financing debacle, or the dot-com boom and bust. I warned of the downside of bursting that bubble, particularly lost jobs.

The Affordable Care Act (ACA) provided health insurance to some 35 million Americans who had been uninsured. It retarded health care inflation. But it did nothing to trim administrative costs or very high pay for nonclinical executives, or shareholder profits in those companies that were for-profit, or drug and device prices. Without the support of all those groups, the ACA would never have passed Congress. The ACA has clearly been a mixed blessing.

If any large American constituency were ever serious about reducing the percentage of our GDP expended on health care, we have excellent ways to do that while improving the health and well-being of the American people. But remember, one person’s liability (unnecessary work) is another person’s asset (needed job).
 

The MBAization of medicine

Meanwhile, back at Dean Hubbard’s voracious academic medical center, the high intellect and driven nature of those who are attracted to medicine as a career has had other effects. The resulting organizations reflect not only the glorious calling of caring for the sick and the availability of lots of money to recruit and compensate leaders, but also the necessity to develop strong executive types who won’t be “eaten alive” by the high-powered workforce of demanding physicians and the surrounding environment.

Thus, it came as no great surprise that in its 2021 determination of America’s top 25 Best Large Employers, Forbes included five health care organizations and seven universities. Beating out such giants as NASA, Cisco, Microsoft, Netflix, and Google, the University of Alabama Birmingham Hospital was ranked first. Mayo Clinic and Yale University came in third and fifth, respectively, and at the other end of the list were Duke (23), MIT (24), and MD Anderson (25).

My goodness! Well done.

Yet, as a country attempting to be balanced, Warren Buffett’s descriptive entreaty on the 2021 failure of Haven, the Amazon-Chase-Berkshire Hathaway joint initiative, remains troubling. Calling upon Haven to change the U.S. health care system, Buffet said, “We learned a lot about the difficulty of changing around an industry that’s 17% of the GDP. We were fighting a tapeworm in the American economy, and the tapeworm won.” They had failed to tame the American health care cost beast.

I am on record as despising the “MBAization” of American medicine. Unfairly, I blamed a professional and technical discipline for what I considered misuse. I hereby repent and renounce my earlier condemnations.
 

Take it all over?

Here’s an idea: If you can’t beat them, join them.

Medical care is important, especially for acute illnesses and injuries, early cancer therapy, and many chronic conditions. But the real determinants of health writ large are social: wealth, education, housing, nutritious food, childcare, climate, clean air and water, meaningful employment, safety from violence, exercise schemes, vaccinations, and so on.

Why doesn’t the American medical-industrial complex simply bestow the label of “health care” on all health-related social determinants? Take it all over. Good “health care” jobs for everyone. Medical professionals will still be blamed for the low health quality and poor outcome scores, the main social determinants of health over which we have no control or influence.

Let that tapeworm grow to encompass all social determinants of health, and measure results by length and quality of life, national human happiness, and, of course, jobs. We can do it. Let that bubble glow. Party time.

And that’s the way it is. That’s my opinion.

George Lundberg, MD, is editor-in-chief at Cancer Commons, president of the Lundberg Institute, executive advisor at Cureus, and a clinical professor of pathology at Northwestern University. Previously, he served as editor-in-chief of JAMA (including 10 specialty journals), American Medical News, and Medscape.

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

In my most recent column, “ ‘They All Laughed When I Spoke of Greedy Doctors,’ ” I attempted to provide a global understanding of some of the economic forces that have made American medicine what it is, how that happened, and why it is still happening.

I did not propose a fix. I have been proposing fixes for more than 30 years, on the pages of JAMA until 1999 and then for this news organization, most recently in 2019 with “Healthcare for All in a Land of Special Interests.”

Where you stand depends a lot on where you sit.

Is this good news or bad news? When William Hubbard was the dean of the University of Michigan School of Medicine in 1969, he said that “an academic medical center is the most efficient energy and resource trapping device that has ever been created” (personal communication, 1969).

To me as a faculty member of an academic medical center for many years, that was great news. We could grow faculty, erect buildings, take the best care of sick people, churn out research papers, mint new physicians and specialists, and get paid well in the process for doing “the Lord’s work.” What’s not to like? At that time, the proportion of the country’s gross national product expended for medical and health care was about 7%. And the predicted life span of an American at birth was 70.5 years.

Is this good news or bad news? In 2021, the proportion of our annual gross domestic product (GDP) consumed by health care was 18.3%, totaling $4.3 trillion, or $12,914 per person. For perspective, in 2021, the median income per capita was $37,638. Because quite a few Americans have very high incomes, the mean income per capita is much higher: $63,444. Predicted life span in 2021 was 76.4 years.

Thus, in a span of 53 years (1969-2022), only 5.9 years of life were gained per person born, for how many trillions of dollars expended? To me as a tax-paying citizen and payer of medical insurance premiums, that is bad news.

Is this good news or bad news? If we compare developed societies globally, our medical system does a whole lot of things very well indeed. But we spend a great deal more than any other country for health care and objectively achieve poorer outcomes. Thus, we are neither efficient nor effective. We keep a lot of workers very busy doing stuff, and they are generally well paid. As a worker, that’s good news; as a manager who values efficiency, it’s bad news indeed.

Is this good news or bad news? We’re the leader at finding money to pay people to do “health care work.” More Americans work in health care than any other field. In 2019, the United States employed some 21,000,000 people doing “health care and social assistance.” Among others, these occupations include physicians, dentists, dental hygienists and assistants, pharmacists, registered nurses, LVNs/LPNs, nursing aides, technologists and technicians, home health aides, respiratory therapists, occupational and speech therapists, social workers, childcare workers, and personal and home care aides. For a patient, parent, grandparent, and great-grandparent, it is good news to have all those folks available to take care of us when we need it.

So, while I have cringed at the frequent exposés from Roy Poses of what seem to me to be massive societal betrayals by American health care industry giants, it doesn’t have to be that way. Might it still be possible to do well while doing good?
 

A jobs program

Consider such common medical procedures as coronary artery stents or bypass grafts for stable angina (when optimal medical therapy is as good, or better than, and much less expensive); PSAs on asymptomatic men followed by unnecessary surgery for localized cancer; excess surgery for low back pain; and the jobs created by managing the people caught up in medical complications of the obesity epidemic.

Don’t forget the number of people employed simply to “follow the money” within our byzantine cockamamie medical billing system. In 2009, this prompted me to describe the bloated system as a “health care bubble” not unlike Enron, the submarket real estate financing debacle, or the dot-com boom and bust. I warned of the downside of bursting that bubble, particularly lost jobs.

The Affordable Care Act (ACA) provided health insurance to some 35 million Americans who had been uninsured. It retarded health care inflation. But it did nothing to trim administrative costs or very high pay for nonclinical executives, or shareholder profits in those companies that were for-profit, or drug and device prices. Without the support of all those groups, the ACA would never have passed Congress. The ACA has clearly been a mixed blessing.

If any large American constituency were ever serious about reducing the percentage of our GDP expended on health care, we have excellent ways to do that while improving the health and well-being of the American people. But remember, one person’s liability (unnecessary work) is another person’s asset (needed job).
 

The MBAization of medicine

Meanwhile, back at Dean Hubbard’s voracious academic medical center, the high intellect and driven nature of those who are attracted to medicine as a career has had other effects. The resulting organizations reflect not only the glorious calling of caring for the sick and the availability of lots of money to recruit and compensate leaders, but also the necessity to develop strong executive types who won’t be “eaten alive” by the high-powered workforce of demanding physicians and the surrounding environment.

Thus, it came as no great surprise that in its 2021 determination of America’s top 25 Best Large Employers, Forbes included five health care organizations and seven universities. Beating out such giants as NASA, Cisco, Microsoft, Netflix, and Google, the University of Alabama Birmingham Hospital was ranked first. Mayo Clinic and Yale University came in third and fifth, respectively, and at the other end of the list were Duke (23), MIT (24), and MD Anderson (25).

My goodness! Well done.

Yet, as a country attempting to be balanced, Warren Buffett’s descriptive entreaty on the 2021 failure of Haven, the Amazon-Chase-Berkshire Hathaway joint initiative, remains troubling. Calling upon Haven to change the U.S. health care system, Buffet said, “We learned a lot about the difficulty of changing around an industry that’s 17% of the GDP. We were fighting a tapeworm in the American economy, and the tapeworm won.” They had failed to tame the American health care cost beast.

I am on record as despising the “MBAization” of American medicine. Unfairly, I blamed a professional and technical discipline for what I considered misuse. I hereby repent and renounce my earlier condemnations.
 

Take it all over?

Here’s an idea: If you can’t beat them, join them.

Medical care is important, especially for acute illnesses and injuries, early cancer therapy, and many chronic conditions. But the real determinants of health writ large are social: wealth, education, housing, nutritious food, childcare, climate, clean air and water, meaningful employment, safety from violence, exercise schemes, vaccinations, and so on.

Why doesn’t the American medical-industrial complex simply bestow the label of “health care” on all health-related social determinants? Take it all over. Good “health care” jobs for everyone. Medical professionals will still be blamed for the low health quality and poor outcome scores, the main social determinants of health over which we have no control or influence.

Let that tapeworm grow to encompass all social determinants of health, and measure results by length and quality of life, national human happiness, and, of course, jobs. We can do it. Let that bubble glow. Party time.

And that’s the way it is. That’s my opinion.

George Lundberg, MD, is editor-in-chief at Cancer Commons, president of the Lundberg Institute, executive advisor at Cureus, and a clinical professor of pathology at Northwestern University. Previously, he served as editor-in-chief of JAMA (including 10 specialty journals), American Medical News, and Medscape.

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

In my most recent column, “ ‘They All Laughed When I Spoke of Greedy Doctors,’ ” I attempted to provide a global understanding of some of the economic forces that have made American medicine what it is, how that happened, and why it is still happening.

I did not propose a fix. I have been proposing fixes for more than 30 years, on the pages of JAMA until 1999 and then for this news organization, most recently in 2019 with “Healthcare for All in a Land of Special Interests.”

Where you stand depends a lot on where you sit.

Is this good news or bad news? When William Hubbard was the dean of the University of Michigan School of Medicine in 1969, he said that “an academic medical center is the most efficient energy and resource trapping device that has ever been created” (personal communication, 1969).

To me as a faculty member of an academic medical center for many years, that was great news. We could grow faculty, erect buildings, take the best care of sick people, churn out research papers, mint new physicians and specialists, and get paid well in the process for doing “the Lord’s work.” What’s not to like? At that time, the proportion of the country’s gross national product expended for medical and health care was about 7%. And the predicted life span of an American at birth was 70.5 years.

Is this good news or bad news? In 2021, the proportion of our annual gross domestic product (GDP) consumed by health care was 18.3%, totaling $4.3 trillion, or $12,914 per person. For perspective, in 2021, the median income per capita was $37,638. Because quite a few Americans have very high incomes, the mean income per capita is much higher: $63,444. Predicted life span in 2021 was 76.4 years.

Thus, in a span of 53 years (1969-2022), only 5.9 years of life were gained per person born, for how many trillions of dollars expended? To me as a tax-paying citizen and payer of medical insurance premiums, that is bad news.

Is this good news or bad news? If we compare developed societies globally, our medical system does a whole lot of things very well indeed. But we spend a great deal more than any other country for health care and objectively achieve poorer outcomes. Thus, we are neither efficient nor effective. We keep a lot of workers very busy doing stuff, and they are generally well paid. As a worker, that’s good news; as a manager who values efficiency, it’s bad news indeed.

Is this good news or bad news? We’re the leader at finding money to pay people to do “health care work.” More Americans work in health care than any other field. In 2019, the United States employed some 21,000,000 people doing “health care and social assistance.” Among others, these occupations include physicians, dentists, dental hygienists and assistants, pharmacists, registered nurses, LVNs/LPNs, nursing aides, technologists and technicians, home health aides, respiratory therapists, occupational and speech therapists, social workers, childcare workers, and personal and home care aides. For a patient, parent, grandparent, and great-grandparent, it is good news to have all those folks available to take care of us when we need it.

So, while I have cringed at the frequent exposés from Roy Poses of what seem to me to be massive societal betrayals by American health care industry giants, it doesn’t have to be that way. Might it still be possible to do well while doing good?
 

A jobs program

Consider such common medical procedures as coronary artery stents or bypass grafts for stable angina (when optimal medical therapy is as good, or better than, and much less expensive); PSAs on asymptomatic men followed by unnecessary surgery for localized cancer; excess surgery for low back pain; and the jobs created by managing the people caught up in medical complications of the obesity epidemic.

Don’t forget the number of people employed simply to “follow the money” within our byzantine cockamamie medical billing system. In 2009, this prompted me to describe the bloated system as a “health care bubble” not unlike Enron, the submarket real estate financing debacle, or the dot-com boom and bust. I warned of the downside of bursting that bubble, particularly lost jobs.

The Affordable Care Act (ACA) provided health insurance to some 35 million Americans who had been uninsured. It retarded health care inflation. But it did nothing to trim administrative costs or very high pay for nonclinical executives, or shareholder profits in those companies that were for-profit, or drug and device prices. Without the support of all those groups, the ACA would never have passed Congress. The ACA has clearly been a mixed blessing.

If any large American constituency were ever serious about reducing the percentage of our GDP expended on health care, we have excellent ways to do that while improving the health and well-being of the American people. But remember, one person’s liability (unnecessary work) is another person’s asset (needed job).
 

The MBAization of medicine

Meanwhile, back at Dean Hubbard’s voracious academic medical center, the high intellect and driven nature of those who are attracted to medicine as a career has had other effects. The resulting organizations reflect not only the glorious calling of caring for the sick and the availability of lots of money to recruit and compensate leaders, but also the necessity to develop strong executive types who won’t be “eaten alive” by the high-powered workforce of demanding physicians and the surrounding environment.

Thus, it came as no great surprise that in its 2021 determination of America’s top 25 Best Large Employers, Forbes included five health care organizations and seven universities. Beating out such giants as NASA, Cisco, Microsoft, Netflix, and Google, the University of Alabama Birmingham Hospital was ranked first. Mayo Clinic and Yale University came in third and fifth, respectively, and at the other end of the list were Duke (23), MIT (24), and MD Anderson (25).

My goodness! Well done.

Yet, as a country attempting to be balanced, Warren Buffett’s descriptive entreaty on the 2021 failure of Haven, the Amazon-Chase-Berkshire Hathaway joint initiative, remains troubling. Calling upon Haven to change the U.S. health care system, Buffet said, “We learned a lot about the difficulty of changing around an industry that’s 17% of the GDP. We were fighting a tapeworm in the American economy, and the tapeworm won.” They had failed to tame the American health care cost beast.

I am on record as despising the “MBAization” of American medicine. Unfairly, I blamed a professional and technical discipline for what I considered misuse. I hereby repent and renounce my earlier condemnations.
 

Take it all over?

Here’s an idea: If you can’t beat them, join them.

Medical care is important, especially for acute illnesses and injuries, early cancer therapy, and many chronic conditions. But the real determinants of health writ large are social: wealth, education, housing, nutritious food, childcare, climate, clean air and water, meaningful employment, safety from violence, exercise schemes, vaccinations, and so on.

Why doesn’t the American medical-industrial complex simply bestow the label of “health care” on all health-related social determinants? Take it all over. Good “health care” jobs for everyone. Medical professionals will still be blamed for the low health quality and poor outcome scores, the main social determinants of health over which we have no control or influence.

Let that tapeworm grow to encompass all social determinants of health, and measure results by length and quality of life, national human happiness, and, of course, jobs. We can do it. Let that bubble glow. Party time.

And that’s the way it is. That’s my opinion.

George Lundberg, MD, is editor-in-chief at Cancer Commons, president of the Lundberg Institute, executive advisor at Cureus, and a clinical professor of pathology at Northwestern University. Previously, he served as editor-in-chief of JAMA (including 10 specialty journals), American Medical News, and Medscape.

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

If you’ve worked in the ICU then you’ve worked with nurses and, if you’re lucky, you’ve worked with some great ones. Working in multiple units, you may have noticed some differences unit to unit in the dynamics of efficiency, staff retention, and interprofessional dynamics among nurses. Or as the kids would say nowadays, the “vibe” of the unit. The American Association of Critical-Care Nurses (AACN) has been studying the Nurse Work Environment since 2005 with the goal of promoting and improving a Healthy Work Environment (HWE).

There are six standards for an HWE according to the AACN, which include: Skilled Communication, True Collaboration, Effective Decision Making, Appropriate Staffing, Meaningful Recognition, and Authentic Leadership. Other than happy nurses, why is an HWE important? Multiple studies have supported that HWEs are associated with high patient satisfaction scores, shorter hospitalization time, increased patient safety, and reduction in adverse events and mortality. Hospitals that get this right can earn the Beacon Award of Excellence, which recognizes units that meet the practices of HWE.

In October 2022, the AACN released its 2021 Nurse Work Environments Status Report earlier than planned to assess how the public health crisis associated with COVID-19 has affected nurses and their work environment. Unsurprisingly, the results were dissatisfactory; 9,335 nurses from 50 states participated. Starting with the worse score, appropriate staffing, only 20% reported having appropriate and skilled staffing at least 75% of the time in 2021. That is the lowest recorded report, even lower than it was during the 2006 nursing shortage.

Less than 50% felt their organization valued their health and safety, and 72% stated they were verbally, physically, or sexually assaulted on the job. In regard to quality, only 30% of nurses felt the quality of care in their unit was excellent; however, nurse managers, being the optimists that they are, reported higher at 41%. Satisfaction took a nosedive especially in units where HWEs were not implemented. Only 34% of these nurses felt satisfied with their job, and 67% intend on leaving their employer in the next 3 years. Thirty percent of nurses would recommend their unit, and 20% would recommend their employer to others. During the last survey in 2018, 62% of nurses were very satisfied with being a nurse, but, sadly, this dropped to 40% in 2021. Of note, Beacon units did perform higher in most reported areas despite the hardships of COVID-19.

Nurses are the foundation supporting our plan of care, patient outcomes, and patient advocacy. Improving the nurse work environment benefits the entire care team and, most importantly, patient outcomes. AACN recommendations to promote an HWE would require systems to create environments where work is respected and honored, improve communication where a nursing voice is heard in regard to patient care decision making, provide staffing levels that are both appropriate and skilled, and ensure nurses feel valued. As part of the care team, we can hear our nurses and advocate for them. We can have conversations with administration regarding creating HWEs and striving for Beacon status. We can engage nurses in policy development that affects their unit. And, we can stop showing nurses how valuable they are with pizza and give them more meaningful feedback instead. In the 2021 survey, nurses reported positive feedback from patients and families was more meaningful to them than free meals. Encourage your patients and families to give that needed feedback. We could all be better stewards of the nursing profession and starting a conversation about HWEs is a great place to start.

If you’ve worked in the ICU then you’ve worked with nurses and, if you’re lucky, you’ve worked with some great ones. Working in multiple units, you may have noticed some differences unit to unit in the dynamics of efficiency, staff retention, and interprofessional dynamics among nurses. Or as the kids would say nowadays, the “vibe” of the unit. The American Association of Critical-Care Nurses (AACN) has been studying the Nurse Work Environment since 2005 with the goal of promoting and improving a Healthy Work Environment (HWE).

There are six standards for an HWE according to the AACN, which include: Skilled Communication, True Collaboration, Effective Decision Making, Appropriate Staffing, Meaningful Recognition, and Authentic Leadership. Other than happy nurses, why is an HWE important? Multiple studies have supported that HWEs are associated with high patient satisfaction scores, shorter hospitalization time, increased patient safety, and reduction in adverse events and mortality. Hospitals that get this right can earn the Beacon Award of Excellence, which recognizes units that meet the practices of HWE.

In October 2022, the AACN released its 2021 Nurse Work Environments Status Report earlier than planned to assess how the public health crisis associated with COVID-19 has affected nurses and their work environment. Unsurprisingly, the results were dissatisfactory; 9,335 nurses from 50 states participated. Starting with the worse score, appropriate staffing, only 20% reported having appropriate and skilled staffing at least 75% of the time in 2021. That is the lowest recorded report, even lower than it was during the 2006 nursing shortage.

Less than 50% felt their organization valued their health and safety, and 72% stated they were verbally, physically, or sexually assaulted on the job. In regard to quality, only 30% of nurses felt the quality of care in their unit was excellent; however, nurse managers, being the optimists that they are, reported higher at 41%. Satisfaction took a nosedive especially in units where HWEs were not implemented. Only 34% of these nurses felt satisfied with their job, and 67% intend on leaving their employer in the next 3 years. Thirty percent of nurses would recommend their unit, and 20% would recommend their employer to others. During the last survey in 2018, 62% of nurses were very satisfied with being a nurse, but, sadly, this dropped to 40% in 2021. Of note, Beacon units did perform higher in most reported areas despite the hardships of COVID-19.

Nurses are the foundation supporting our plan of care, patient outcomes, and patient advocacy. Improving the nurse work environment benefits the entire care team and, most importantly, patient outcomes. AACN recommendations to promote an HWE would require systems to create environments where work is respected and honored, improve communication where a nursing voice is heard in regard to patient care decision making, provide staffing levels that are both appropriate and skilled, and ensure nurses feel valued. As part of the care team, we can hear our nurses and advocate for them. We can have conversations with administration regarding creating HWEs and striving for Beacon status. We can engage nurses in policy development that affects their unit. And, we can stop showing nurses how valuable they are with pizza and give them more meaningful feedback instead. In the 2021 survey, nurses reported positive feedback from patients and families was more meaningful to them than free meals. Encourage your patients and families to give that needed feedback. We could all be better stewards of the nursing profession and starting a conversation about HWEs is a great place to start.

If you’ve worked in the ICU then you’ve worked with nurses and, if you’re lucky, you’ve worked with some great ones. Working in multiple units, you may have noticed some differences unit to unit in the dynamics of efficiency, staff retention, and interprofessional dynamics among nurses. Or as the kids would say nowadays, the “vibe” of the unit. The American Association of Critical-Care Nurses (AACN) has been studying the Nurse Work Environment since 2005 with the goal of promoting and improving a Healthy Work Environment (HWE).

There are six standards for an HWE according to the AACN, which include: Skilled Communication, True Collaboration, Effective Decision Making, Appropriate Staffing, Meaningful Recognition, and Authentic Leadership. Other than happy nurses, why is an HWE important? Multiple studies have supported that HWEs are associated with high patient satisfaction scores, shorter hospitalization time, increased patient safety, and reduction in adverse events and mortality. Hospitals that get this right can earn the Beacon Award of Excellence, which recognizes units that meet the practices of HWE.

In October 2022, the AACN released its 2021 Nurse Work Environments Status Report earlier than planned to assess how the public health crisis associated with COVID-19 has affected nurses and their work environment. Unsurprisingly, the results were dissatisfactory; 9,335 nurses from 50 states participated. Starting with the worse score, appropriate staffing, only 20% reported having appropriate and skilled staffing at least 75% of the time in 2021. That is the lowest recorded report, even lower than it was during the 2006 nursing shortage.

Less than 50% felt their organization valued their health and safety, and 72% stated they were verbally, physically, or sexually assaulted on the job. In regard to quality, only 30% of nurses felt the quality of care in their unit was excellent; however, nurse managers, being the optimists that they are, reported higher at 41%. Satisfaction took a nosedive especially in units where HWEs were not implemented. Only 34% of these nurses felt satisfied with their job, and 67% intend on leaving their employer in the next 3 years. Thirty percent of nurses would recommend their unit, and 20% would recommend their employer to others. During the last survey in 2018, 62% of nurses were very satisfied with being a nurse, but, sadly, this dropped to 40% in 2021. Of note, Beacon units did perform higher in most reported areas despite the hardships of COVID-19.

Nurses are the foundation supporting our plan of care, patient outcomes, and patient advocacy. Improving the nurse work environment benefits the entire care team and, most importantly, patient outcomes. AACN recommendations to promote an HWE would require systems to create environments where work is respected and honored, improve communication where a nursing voice is heard in regard to patient care decision making, provide staffing levels that are both appropriate and skilled, and ensure nurses feel valued. As part of the care team, we can hear our nurses and advocate for them. We can have conversations with administration regarding creating HWEs and striving for Beacon status. We can engage nurses in policy development that affects their unit. And, we can stop showing nurses how valuable they are with pizza and give them more meaningful feedback instead. In the 2021 survey, nurses reported positive feedback from patients and families was more meaningful to them than free meals. Encourage your patients and families to give that needed feedback. We could all be better stewards of the nursing profession and starting a conversation about HWEs is a great place to start.

Just when I thought I was out, they pull me back in. Had I known when I penned my last column for the November 2022 issue of CHEST Physician that I’d get one more crack at making a final impression, I might have saved some of my leadership tips for this month, but c’est la vie. Being the Past President is a pretty sweet gig. I liken it to being a grandparent; you get to have lots of fun, and then get to go home at the end of the day and leave the cleanup to someone else. Not that I left too much to clean up, but I have no doubt that President Doreen Addrizzo-Harris is ready to handle whatever challenges 2023 throws at her.

Today, I consider myself the luckiest man on the face of the Earth. Serving as CHEST President was an incredible privilege. The Nashville meeting seems like it was just yesterday, as does the experience of watching the work of the Scientific Program Committee, led by the amazing Dr. Subani Chandra, that put together our most ambitious annual meeting to date. And, it superseded all our expectations. It was wonderful to be back in person for the first time in 3 years, and it was even better to have the chance to share the experience with all of you who joined us. While I have every expectation that our Hawai’i meeting this October will be even bigger and better, this was the personal highlight of the year for me. There were so many other fantastic things I got to experience that it is difficult to know where to start. Sometimes the whole year seems like it went by so fast; I don’t know where we’ve been, and I’ve just been there! As a component of our organizational strategy, CHEST has been examining ways in which we can work more closely with our society partners, both domestically and abroad. During my tenure, I had the pleasure of meeting with representatives from many organizations, including the American Thoracic Society, the Canadian Thoracic Society, the European Respiratory Society, the Sociedade Brasileira de Pneumologia e Tisiologia, the Thoracic Society of Australia and New Zealand, the Indian Chest Society, the Asociación Latinoamericana de Tórax, and the Turkish Respiratory Society. Many of these groups are struggling with the same challenges as CHEST, including how best to conduct academic meetings in the context of an increasingly online world, how to better engage our junior colleagues, who may not see the value of membership in a professional society, and how to better integrate our efforts toward improving worldwide lung health. In the coming months and years, I expect that you will see the products of these international collaborations, which I hope will be the springboard from which we can mutually develop more impactful public health and educational initiatives.

CHEST

The year was certainly not without challenges; there were some definite struggles in 2022. The Networks reorganization created confusion for some, despite diligent planning and communication. Despite the challenges, however, the change ultimately permitted us to offer more leadership opportunities to our members than existed previously and created new a home for many different specialists among our membership. We have heard from some of you that the elimination of certain networks led you to feel that CHEST did not adequately value your areas of professional focus. And while we hear you and are working to develop new mechanisms for networking at the annual meeting and throughout the year, the addition of our new sections also allows us to highlight disease states and content domains that previously did not have a clear home in our prior Network structure. CHEST is still learning how to best include and engage groups who have been historically disenfranchised, for whom we want to create new opportunities. The 2021 CHEST President Dr. Steve Simpson identified this as a priority for his presidential year, and we have made strides in the area of diversity, equity, and inclusion.

We launched the First 5 Minutes^® initiative to help clinicians build trust with their patients earlier and more effectively. And CHEST hired the organization’s first Director of Diversity, Equity, Inclusion, and Belonging (DEIB), who has already built our first Value-Setting Work Group and started incorporating DEIB principles into our organizational decision-making. Naively, as we began the year, I was hoping we would make more progress in 2022 than we did. The old dreams were good dreams; they didn’t work out, but I’m glad I had them.

So although there is a great deal more work to do, I know that this is a priority for President Addrizzo-Harris in 2023, and we will continue this positive momentum in the months and years to come. I will retire now to my couch of perpetual indulgence. Yes, I’ve still got the rest of 2023 as an active member of the Board. And, while it has been a great experience, I am looking forward a bit to winding down and letting the fresh faces guide the future of this wonderful organization. Of course, I couldn’t go out without another contest (with an opportunity to win free registration to CHEST 2023!). Five of the sentences in this document come directly from movies; identify the five different sources of these quotes (the movie titles alone are sufficient) and email them to us at [email protected]. All correct responses received by May 15, 2023, will be entered into a drawing for the prize. Don’t know if there will be a next time, but ‘til then.


David

Just when I thought I was out, they pull me back in. Had I known when I penned my last column for the November 2022 issue of CHEST Physician that I’d get one more crack at making a final impression, I might have saved some of my leadership tips for this month, but c’est la vie. Being the Past President is a pretty sweet gig. I liken it to being a grandparent; you get to have lots of fun, and then get to go home at the end of the day and leave the cleanup to someone else. Not that I left too much to clean up, but I have no doubt that President Doreen Addrizzo-Harris is ready to handle whatever challenges 2023 throws at her.

Today, I consider myself the luckiest man on the face of the Earth. Serving as CHEST President was an incredible privilege. The Nashville meeting seems like it was just yesterday, as does the experience of watching the work of the Scientific Program Committee, led by the amazing Dr. Subani Chandra, that put together our most ambitious annual meeting to date. And, it superseded all our expectations. It was wonderful to be back in person for the first time in 3 years, and it was even better to have the chance to share the experience with all of you who joined us. While I have every expectation that our Hawai’i meeting this October will be even bigger and better, this was the personal highlight of the year for me. There were so many other fantastic things I got to experience that it is difficult to know where to start. Sometimes the whole year seems like it went by so fast; I don’t know where we’ve been, and I’ve just been there! As a component of our organizational strategy, CHEST has been examining ways in which we can work more closely with our society partners, both domestically and abroad. During my tenure, I had the pleasure of meeting with representatives from many organizations, including the American Thoracic Society, the Canadian Thoracic Society, the European Respiratory Society, the Sociedade Brasileira de Pneumologia e Tisiologia, the Thoracic Society of Australia and New Zealand, the Indian Chest Society, the Asociación Latinoamericana de Tórax, and the Turkish Respiratory Society. Many of these groups are struggling with the same challenges as CHEST, including how best to conduct academic meetings in the context of an increasingly online world, how to better engage our junior colleagues, who may not see the value of membership in a professional society, and how to better integrate our efforts toward improving worldwide lung health. In the coming months and years, I expect that you will see the products of these international collaborations, which I hope will be the springboard from which we can mutually develop more impactful public health and educational initiatives.

CHEST

The year was certainly not without challenges; there were some definite struggles in 2022. The Networks reorganization created confusion for some, despite diligent planning and communication. Despite the challenges, however, the change ultimately permitted us to offer more leadership opportunities to our members than existed previously and created new a home for many different specialists among our membership. We have heard from some of you that the elimination of certain networks led you to feel that CHEST did not adequately value your areas of professional focus. And while we hear you and are working to develop new mechanisms for networking at the annual meeting and throughout the year, the addition of our new sections also allows us to highlight disease states and content domains that previously did not have a clear home in our prior Network structure. CHEST is still learning how to best include and engage groups who have been historically disenfranchised, for whom we want to create new opportunities. The 2021 CHEST President Dr. Steve Simpson identified this as a priority for his presidential year, and we have made strides in the area of diversity, equity, and inclusion.

We launched the First 5 Minutes^® initiative to help clinicians build trust with their patients earlier and more effectively. And CHEST hired the organization’s first Director of Diversity, Equity, Inclusion, and Belonging (DEIB), who has already built our first Value-Setting Work Group and started incorporating DEIB principles into our organizational decision-making. Naively, as we began the year, I was hoping we would make more progress in 2022 than we did. The old dreams were good dreams; they didn’t work out, but I’m glad I had them.

So although there is a great deal more work to do, I know that this is a priority for President Addrizzo-Harris in 2023, and we will continue this positive momentum in the months and years to come. I will retire now to my couch of perpetual indulgence. Yes, I’ve still got the rest of 2023 as an active member of the Board. And, while it has been a great experience, I am looking forward a bit to winding down and letting the fresh faces guide the future of this wonderful organization. Of course, I couldn’t go out without another contest (with an opportunity to win free registration to CHEST 2023!). Five of the sentences in this document come directly from movies; identify the five different sources of these quotes (the movie titles alone are sufficient) and email them to us at [email protected]. All correct responses received by May 15, 2023, will be entered into a drawing for the prize. Don’t know if there will be a next time, but ‘til then.


David

Just when I thought I was out, they pull me back in. Had I known when I penned my last column for the November 2022 issue of CHEST Physician that I’d get one more crack at making a final impression, I might have saved some of my leadership tips for this month, but c’est la vie. Being the Past President is a pretty sweet gig. I liken it to being a grandparent; you get to have lots of fun, and then get to go home at the end of the day and leave the cleanup to someone else. Not that I left too much to clean up, but I have no doubt that President Doreen Addrizzo-Harris is ready to handle whatever challenges 2023 throws at her.

Today, I consider myself the luckiest man on the face of the Earth. Serving as CHEST President was an incredible privilege. The Nashville meeting seems like it was just yesterday, as does the experience of watching the work of the Scientific Program Committee, led by the amazing Dr. Subani Chandra, that put together our most ambitious annual meeting to date. And, it superseded all our expectations. It was wonderful to be back in person for the first time in 3 years, and it was even better to have the chance to share the experience with all of you who joined us. While I have every expectation that our Hawai’i meeting this October will be even bigger and better, this was the personal highlight of the year for me. There were so many other fantastic things I got to experience that it is difficult to know where to start. Sometimes the whole year seems like it went by so fast; I don’t know where we’ve been, and I’ve just been there! As a component of our organizational strategy, CHEST has been examining ways in which we can work more closely with our society partners, both domestically and abroad. During my tenure, I had the pleasure of meeting with representatives from many organizations, including the American Thoracic Society, the Canadian Thoracic Society, the European Respiratory Society, the Sociedade Brasileira de Pneumologia e Tisiologia, the Thoracic Society of Australia and New Zealand, the Indian Chest Society, the Asociación Latinoamericana de Tórax, and the Turkish Respiratory Society. Many of these groups are struggling with the same challenges as CHEST, including how best to conduct academic meetings in the context of an increasingly online world, how to better engage our junior colleagues, who may not see the value of membership in a professional society, and how to better integrate our efforts toward improving worldwide lung health. In the coming months and years, I expect that you will see the products of these international collaborations, which I hope will be the springboard from which we can mutually develop more impactful public health and educational initiatives.

CHEST

The year was certainly not without challenges; there were some definite struggles in 2022. The Networks reorganization created confusion for some, despite diligent planning and communication. Despite the challenges, however, the change ultimately permitted us to offer more leadership opportunities to our members than existed previously and created new a home for many different specialists among our membership. We have heard from some of you that the elimination of certain networks led you to feel that CHEST did not adequately value your areas of professional focus. And while we hear you and are working to develop new mechanisms for networking at the annual meeting and throughout the year, the addition of our new sections also allows us to highlight disease states and content domains that previously did not have a clear home in our prior Network structure. CHEST is still learning how to best include and engage groups who have been historically disenfranchised, for whom we want to create new opportunities. The 2021 CHEST President Dr. Steve Simpson identified this as a priority for his presidential year, and we have made strides in the area of diversity, equity, and inclusion.

We launched the First 5 Minutes^® initiative to help clinicians build trust with their patients earlier and more effectively. And CHEST hired the organization’s first Director of Diversity, Equity, Inclusion, and Belonging (DEIB), who has already built our first Value-Setting Work Group and started incorporating DEIB principles into our organizational decision-making. Naively, as we began the year, I was hoping we would make more progress in 2022 than we did. The old dreams were good dreams; they didn’t work out, but I’m glad I had them.

So although there is a great deal more work to do, I know that this is a priority for President Addrizzo-Harris in 2023, and we will continue this positive momentum in the months and years to come. I will retire now to my couch of perpetual indulgence. Yes, I’ve still got the rest of 2023 as an active member of the Board. And, while it has been a great experience, I am looking forward a bit to winding down and letting the fresh faces guide the future of this wonderful organization. Of course, I couldn’t go out without another contest (with an opportunity to win free registration to CHEST 2023!). Five of the sentences in this document come directly from movies; identify the five different sources of these quotes (the movie titles alone are sufficient) and email them to us at [email protected]. All correct responses received by May 15, 2023, will be entered into a drawing for the prize. Don’t know if there will be a next time, but ‘til then.


David

Planning for the CHEST Annual Meeting is no small undertaking and begins shortly after the past year’s conference concludes – if not even earlier. Each year, the members of the Scientific Program Committee are tasked with receiving hundreds of submissions and selecting the most clinically compelling ideas to build a meeting program that is both broad in scope, yet also tailored to each specific area of pulmonary, critical care, and sleep medicine.

In mid-February, the CHEST 2023 program began to take shape as the members of the committee met at CHEST Headquarters in Glenview, Illinois, to critically review each and every session. By the end of the 2-day meeting, barring last minute changes, the program was all but completed, and Hawai’i began to feel very close.

Scenic images of the destination were projected onto the walls, and the room was brimming with excitement for a CHEST meeting unlike any other. Chair of the CHEST Annual Meeting 2023, Aneesa Das, MD, FCCP, focused heavily on the educational experience the meeting will offer while also embracing the culture of Hawai’i. With two representatives from the state, CHEST 2023 looks to respectfully incorporate Hawaiian customs at every opportunity to supplement the education.

Chair of the Interstitial Lung Disease and Transplant curriculum, Debbie Levine, MD, MS, FCCP, shared that, at least for her section, it was likely the irresistible destination that contributed to the submissions. “Because this meeting is in Hawai’i, we received the most submissions our group has ever seen,” said Dr. Levine. “And these submissions were top notch – we had really excellent topics to pick from, so this is going to be our best curriculum yet. This is likely true for the other groups, too, so anyone who goes to CHEST 2023 in Hawai’i will get the best of the best in the most beautiful place in the world.”

 

Breadth of coverage

With something for everyone in chest medicine, the CHEST 2023 meeting will feature hundreds of sessions covering eight curriculum groups:

• Critical Care
• Interdisciplinary/Practice Operations/Education
• Cardiovascular/Pulmonary Vascular Disease
• Interstitial Lung Disease/Transplant
• Lung Cancer/Interventional Pulmonary/Radiology
• Chest Infections/Disaster Medicine/Systemic Disease
• Airways Disease
• Sleep

During the planning meeting, each of the curriculum chairs presented their slate to ensure diversity of content, panelist characteristics – including clinical backgrounds – and something for every level of clinician: from student to accomplished professional.

Chair of the Sleep Medicine curriculum, Carolyn D’Ambrosio, MD, MS, FCCP, said, “Our curriculum covers the typical topics like obstructive sleep apnea, but we also have sessions on difficult titrations in the sleep laboratory and how to work with noninvasive ventilation in the outpatient setting. Anyone who specializes in sleep medicine should come to CHEST 2023 because we have something for every piece of practice.”
 

The CHEST atmosphere

Chair of the Airway Disorders curriculum, Marcos Restrepo, MD, PhD, FCCP, encouraged attendees who may not be involved with the college saying, “CHEST is very welcoming to everyone, no matter what the level of knowledge or experience is; it is a very collegial group. That’s what first attracted me to CHEST from the beginning – how nice everyone was. I think this is a fantastic opportunity for all of us and particularly for those that are willing to really be part of something. And this is something really special.” In addition to the slate of programming, CHEST will host master courses before and after the annual meeting. Requiring advance registration, these will include a wide variety of problem-based learning scenarios taught by renowned experts in the field.

Returning to Hawai’i for the first time since 2011, this year’s CHEST Annual Meeting is expected to offer an unmatched educational lineup and countless other opportunities for career advancement. When asked why they are looking forward to the meeting, Chair of the Pulmonary Vascular/Cardiovascular Disease curriculum, Jean Elwing, MD, FCCP, said, “There are so many reasons I am looking forward to CHEST 2023 – I want to see my friends. I want to network. And I want to learn together in these interactive, unique ways that only CHEST can offer. From the pro/con debates to the interactive sessions we have planned in our curriculum, anyone who attends will have a great learning experience and have fun doing it. I can’t wait to see everyone there!”

Visit www.chestnet.org/Learning-and-Events/Events/CHEST-Annual-Meeting to sign up for updates about CHEST 2023 and to apply to be a moderator.

Planning for the CHEST Annual Meeting is no small undertaking and begins shortly after the past year’s conference concludes – if not even earlier. Each year, the members of the Scientific Program Committee are tasked with receiving hundreds of submissions and selecting the most clinically compelling ideas to build a meeting program that is both broad in scope, yet also tailored to each specific area of pulmonary, critical care, and sleep medicine.

In mid-February, the CHEST 2023 program began to take shape as the members of the committee met at CHEST Headquarters in Glenview, Illinois, to critically review each and every session. By the end of the 2-day meeting, barring last minute changes, the program was all but completed, and Hawai’i began to feel very close.

Scenic images of the destination were projected onto the walls, and the room was brimming with excitement for a CHEST meeting unlike any other. Chair of the CHEST Annual Meeting 2023, Aneesa Das, MD, FCCP, focused heavily on the educational experience the meeting will offer while also embracing the culture of Hawai’i. With two representatives from the state, CHEST 2023 looks to respectfully incorporate Hawaiian customs at every opportunity to supplement the education.

Chair of the Interstitial Lung Disease and Transplant curriculum, Debbie Levine, MD, MS, FCCP, shared that, at least for her section, it was likely the irresistible destination that contributed to the submissions. “Because this meeting is in Hawai’i, we received the most submissions our group has ever seen,” said Dr. Levine. “And these submissions were top notch – we had really excellent topics to pick from, so this is going to be our best curriculum yet. This is likely true for the other groups, too, so anyone who goes to CHEST 2023 in Hawai’i will get the best of the best in the most beautiful place in the world.”

 

Breadth of coverage

With something for everyone in chest medicine, the CHEST 2023 meeting will feature hundreds of sessions covering eight curriculum groups:

• Critical Care
• Interdisciplinary/Practice Operations/Education
• Cardiovascular/Pulmonary Vascular Disease
• Interstitial Lung Disease/Transplant
• Lung Cancer/Interventional Pulmonary/Radiology
• Chest Infections/Disaster Medicine/Systemic Disease
• Airways Disease
• Sleep

During the planning meeting, each of the curriculum chairs presented their slate to ensure diversity of content, panelist characteristics – including clinical backgrounds – and something for every level of clinician: from student to accomplished professional.

Chair of the Sleep Medicine curriculum, Carolyn D’Ambrosio, MD, MS, FCCP, said, “Our curriculum covers the typical topics like obstructive sleep apnea, but we also have sessions on difficult titrations in the sleep laboratory and how to work with noninvasive ventilation in the outpatient setting. Anyone who specializes in sleep medicine should come to CHEST 2023 because we have something for every piece of practice.”
 

The CHEST atmosphere

Chair of the Airway Disorders curriculum, Marcos Restrepo, MD, PhD, FCCP, encouraged attendees who may not be involved with the college saying, “CHEST is very welcoming to everyone, no matter what the level of knowledge or experience is; it is a very collegial group. That’s what first attracted me to CHEST from the beginning – how nice everyone was. I think this is a fantastic opportunity for all of us and particularly for those that are willing to really be part of something. And this is something really special.” In addition to the slate of programming, CHEST will host master courses before and after the annual meeting. Requiring advance registration, these will include a wide variety of problem-based learning scenarios taught by renowned experts in the field.

Returning to Hawai’i for the first time since 2011, this year’s CHEST Annual Meeting is expected to offer an unmatched educational lineup and countless other opportunities for career advancement. When asked why they are looking forward to the meeting, Chair of the Pulmonary Vascular/Cardiovascular Disease curriculum, Jean Elwing, MD, FCCP, said, “There are so many reasons I am looking forward to CHEST 2023 – I want to see my friends. I want to network. And I want to learn together in these interactive, unique ways that only CHEST can offer. From the pro/con debates to the interactive sessions we have planned in our curriculum, anyone who attends will have a great learning experience and have fun doing it. I can’t wait to see everyone there!”

Visit www.chestnet.org/Learning-and-Events/Events/CHEST-Annual-Meeting to sign up for updates about CHEST 2023 and to apply to be a moderator.

Planning for the CHEST Annual Meeting is no small undertaking and begins shortly after the past year’s conference concludes – if not even earlier. Each year, the members of the Scientific Program Committee are tasked with receiving hundreds of submissions and selecting the most clinically compelling ideas to build a meeting program that is both broad in scope, yet also tailored to each specific area of pulmonary, critical care, and sleep medicine.

In mid-February, the CHEST 2023 program began to take shape as the members of the committee met at CHEST Headquarters in Glenview, Illinois, to critically review each and every session. By the end of the 2-day meeting, barring last minute changes, the program was all but completed, and Hawai’i began to feel very close.

Scenic images of the destination were projected onto the walls, and the room was brimming with excitement for a CHEST meeting unlike any other. Chair of the CHEST Annual Meeting 2023, Aneesa Das, MD, FCCP, focused heavily on the educational experience the meeting will offer while also embracing the culture of Hawai’i. With two representatives from the state, CHEST 2023 looks to respectfully incorporate Hawaiian customs at every opportunity to supplement the education.

Chair of the Interstitial Lung Disease and Transplant curriculum, Debbie Levine, MD, MS, FCCP, shared that, at least for her section, it was likely the irresistible destination that contributed to the submissions. “Because this meeting is in Hawai’i, we received the most submissions our group has ever seen,” said Dr. Levine. “And these submissions were top notch – we had really excellent topics to pick from, so this is going to be our best curriculum yet. This is likely true for the other groups, too, so anyone who goes to CHEST 2023 in Hawai’i will get the best of the best in the most beautiful place in the world.”

 

Breadth of coverage

With something for everyone in chest medicine, the CHEST 2023 meeting will feature hundreds of sessions covering eight curriculum groups:

• Critical Care
• Interdisciplinary/Practice Operations/Education
• Cardiovascular/Pulmonary Vascular Disease
• Interstitial Lung Disease/Transplant
• Lung Cancer/Interventional Pulmonary/Radiology
• Chest Infections/Disaster Medicine/Systemic Disease
• Airways Disease
• Sleep

During the planning meeting, each of the curriculum chairs presented their slate to ensure diversity of content, panelist characteristics – including clinical backgrounds – and something for every level of clinician: from student to accomplished professional.

Chair of the Sleep Medicine curriculum, Carolyn D’Ambrosio, MD, MS, FCCP, said, “Our curriculum covers the typical topics like obstructive sleep apnea, but we also have sessions on difficult titrations in the sleep laboratory and how to work with noninvasive ventilation in the outpatient setting. Anyone who specializes in sleep medicine should come to CHEST 2023 because we have something for every piece of practice.”
 

The CHEST atmosphere

Chair of the Airway Disorders curriculum, Marcos Restrepo, MD, PhD, FCCP, encouraged attendees who may not be involved with the college saying, “CHEST is very welcoming to everyone, no matter what the level of knowledge or experience is; it is a very collegial group. That’s what first attracted me to CHEST from the beginning – how nice everyone was. I think this is a fantastic opportunity for all of us and particularly for those that are willing to really be part of something. And this is something really special.” In addition to the slate of programming, CHEST will host master courses before and after the annual meeting. Requiring advance registration, these will include a wide variety of problem-based learning scenarios taught by renowned experts in the field.

Returning to Hawai’i for the first time since 2011, this year’s CHEST Annual Meeting is expected to offer an unmatched educational lineup and countless other opportunities for career advancement. When asked why they are looking forward to the meeting, Chair of the Pulmonary Vascular/Cardiovascular Disease curriculum, Jean Elwing, MD, FCCP, said, “There are so many reasons I am looking forward to CHEST 2023 – I want to see my friends. I want to network. And I want to learn together in these interactive, unique ways that only CHEST can offer. From the pro/con debates to the interactive sessions we have planned in our curriculum, anyone who attends will have a great learning experience and have fun doing it. I can’t wait to see everyone there!”

Visit www.chestnet.org/Learning-and-Events/Events/CHEST-Annual-Meeting to sign up for updates about CHEST 2023 and to apply to be a moderator.